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19812418-DS-6
| 19,812,418 | 25,812,343 |
DS
| 6 |
2126-07-21 00:00:00
|
2126-07-21 15:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
___
Extraction of teeth 3, 4, 5, 6, 12, 31, and 32
.
___
1. Aortic valve replacement with a size 19 ___
Ease tissue valve.
2. Mitral valve replacement with a 27 mm ___
tissue valve.
3. Tricuspid valve repair with a 30 size ___
ring.
.
___- PICC
History of Present Illness:
___ yo female with history of Afib, aortic stenosis, COPD, DM2
who presents with worsening SOB for several days. She initially
presented to ___ where she was found to have LLL PNA on
CXR and was initially treated with ceftriaxone and azithromycin
as well as nebulizers and prednisone due to history of COPD. She
had EKG that showed nonspecific lateral ST changes; troponins
were pending at time of transfer. She was planned for admission
at ___ for concern for CAP.
However, while awaiting a bed in the ED she became suddenly more
dyspneic, very anxious and gasping for air. Her O2 sat remained
normal during this time. However, she appeared diaphoretic and
uncomfortable. Given this and an underlying diagnosis of PNA
based on CXR, she was intubated. She was subsequently
transferred to ___.
Of note, patient has had a history of admission for SOB in ___
which was felt to be more ___nd symptomatic
aortic stenosis. She had been planned for possible TAVR for
symptomatic AS but this has not been done per report.
In the ED: T afebrile, BP in 130s/80s HR in ___ AC 400x18 PEEP 5
60%
She had CTA chest that was negative for PE but did show b/l LL
PNA as well as pulmonary edema with moderate bilateral pleural
effusion R >L
She had CT head which showed no acute intracranial process.
Initial ABG was pH 7.20/43/120; on repeat: ___
Lactate 3.6 WBC 21.5 Hgb 7.6, and platelets 230. Potassium was
5.4 and HCO3 14. BNP was 7908. Calcium was 7.7 and phos 4.9 UA
was positive for 28 RBCs and 31 WBCs. Urine culture is pending.
Trop <0.01
She had CT head that was negative for etiology of AMS
CTA chest was neg for PE but did show bilateral LLL PNA,
background pulmonary edema R > L effusion.
On arrival to the MICU, pt on pressure support ___ FiO2 40%
Past Medical History:
COPD
GERD
Hypertension
Hyperlipidemia
T2DM
Afib s/p cardioversion ___, maintained on Coumadin
AS - no prior TTE in our system
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
Vitals: T: BP: 100/50 P: 86 R: pressure support ___ FiO2 40%
GENERAL: intubated, sedated, RASS -1
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP elevated to ear
LUNGS: decreased breath sounds bilaterally in lateral lung
fields
CV: irreg irreg, no clear murmur appreciated, no rubs
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, 2+ edema bilaterally
SKIN: warm, well perfused
Pertinent Results:
ADMISSION LABS
=================
___ 03:34AM BLOOD WBC-21.5* RBC-2.78* Hgb-7.6* Hct-26.3*
MCV-95 MCH-27.3 MCHC-28.9* RDW-15.9* RDWSD-55.4* Plt ___
___ 03:34AM BLOOD ___ PTT-30.8 ___
___ 05:10AM BLOOD Ret Man-4.3* Abs Ret-0.11*
___ 03:34AM BLOOD ___ 03:34AM BLOOD Glucose-261* UreaN-19 Creat-1.0 Na-140
K-5.4* Cl-111* HCO3-14* AnGap-20
___ 05:10AM BLOOD LD(LDH)-232 TotBili-0.6
___ 03:34AM BLOOD cTropnT-<0.01
___ 03:34AM BLOOD proBNP-7908*
___ 03:34AM BLOOD Lipase-17
___ 03:34AM BLOOD Calcium-7.7* Phos-4.9* Mg-1.8
___ 05:10AM BLOOD Hapto-71
___ 03:34AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:43AM BLOOD pO2-120* pCO2-43 pH-7.20* calTCO2-18*
Base XS--10
___ 03:43AM BLOOD Glucose-245* Lactate-3.6* Na-138 K-5.0
Cl-117*
___ 03:43AM BLOOD Hgb-8.3* calcHCT-25 O2 Sat-95 COHgb-2.5
MetHgb-0.4
___ 03:43AM BLOOD freeCa-1.02*
___ 03:34AM URINE Color-Yellow Appear-Hazy Sp ___
___ 03:34AM URINE Blood-SM Nitrite-NEG Protein-600
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 03:34AM URINE RBC-28* WBC-31* Bacteri-NONE Yeast-NONE
Epi-6 TransE-1
___ 03:34AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
MICRO
======
Urine culture - no growth
Blood culture -
IMAGING
========
___ TTE
The left atrium is mildly 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.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. There are three aortic valve leaflets.
The aortic valve leaflets are moderately thickened. The aortic
valve VTI = cm. There is severe aortic valve stenosis (valve
area <1.0cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. Severe (4+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] Due to the eccentric nature of the regurgitant
jet, its severity may be significantly underestimated (Coanda
effect). Severe [4+] tricuspid regurgitation is seen. There is
severe pulmonary artery systolic hypertension. [In the setting
of at least moderate to severe tricuspid regurgitation, the
estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is a trivial/physiologic pericardial effusion.
IMPRESSION: Biatrial abnormality. Preserved biventricular
systolic function. Increased left ventricular filling pressure.
Severe aortic stenosis with mild aortic regurgitation. Severe
mitral regurgitation. Severe tricuspid regurgitation. Severe
pulmonary artery systolic hypertension.
CTA Chest
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Findings concerning for bilateral lower lobe pneumonia.
3. Background pulmonary edema with moderate bilateral pleural
effusions, right greater than left.
CT Head
IMPRESSION: No acute intracranial abnormality on noncontrast
head CT.
CXR
IMPRESSION:
In comparison with the study of ___, the monitoring and
support devices
have been removed. There is again enlargement of the cardiac
silhouette but improvement in the pulmonary vascular status with
only minimal elevation of pulmonary venous pressure.
Retrocardiac opacification with obscuration of the hemidiaphragm
is consistent with volume loss in the left lower lobe with small
pleural effusion. Elevation of the right hemidiaphragmatic
contour persists.
.
TEE ___
Conclusions
PRE-BYPASS: The left atrium is dilated. No mass/thrombus is
seen in the left atrium or left atrial appendage. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. [Intrinsic left ventricular systolic function is likely
more depressed given the severity of valvular regurgitation.]
The right ventricular cavity is dilated [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] There are simple atheroma
in the descending thoracic aorta. There are simple atheroma in
the abdominal aorta. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area <1.0cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are severely thickened/deformed. There is
moderate thickening of the mitral valve chordae. Severe (4+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Severe [4+] tricuspid regurgitation is seen.
There is no pericardial effusion. Dr. ___ was notified in person
of the results before surgical incision..
POST-BYPASS:
Patient is on milrinone, levophed, vasopressin.
Moderate to severely depressed global RV function. LVEF 45%.
Difficult views due to triple valve surgery and subsequent
shadowing.
Aortic bioprosthesis is intact with no regurgitant lesions. It
is stable and functioning well with a residual mean gradient of
11mm of Hg.
Mitral bioprosthesis is stable, functioning well, no residual
regurgitant lesion with a residual mean gradient of 4mm of Hg.
Tricuspid ring is intact and no residual stenosis.
Intact thoracic aorta.
.
___ 04:41AM BLOOD WBC-8.2 RBC-3.25* Hgb-9.2* Hct-31.5*
MCV-97 MCH-28.3 MCHC-29.2* RDW-18.4* RDWSD-65.0* Plt ___
___ 02:03AM BLOOD WBC-12.3* RBC-3.45* Hgb-9.7* Hct-32.0*
MCV-93 MCH-28.1 MCHC-30.3* RDW-19.1* RDWSD-63.5* Plt ___
___ 04:25AM BLOOD ___
___ 04:41AM BLOOD ___ PTT-30.7 ___
___ 05:28AM BLOOD ___
___ 03:32AM BLOOD ___ PTT-36.7* ___
___ 02:16PM BLOOD ___
___ 02:44AM BLOOD ___ PTT-47.7* ___
___ 02:03AM BLOOD ___ PTT-35.7 ___
___ 02:17AM BLOOD ___ PTT-38.7* ___
___ 02:29AM BLOOD ___ PTT-33.7 ___
___ 03:53AM BLOOD ___ PTT-28.1 ___
___ 01:50AM BLOOD ___ PTT-28.4 ___
___ 04:41AM BLOOD Glucose-97 UreaN-11 Creat-0.5 Na-136
K-4.5 Cl-101 HCO3-23 AnGap-17
___ 05:28AM BLOOD Glucose-109* UreaN-15 Creat-0.5 Na-136
K-4.2 Cl-100 HCO3-29 AnGap-11
___ 01:50AM BLOOD Glucose-141* UreaN-23* Creat-0.7 Na-135
K-4.2 Cl-97 HCO3-26 AnGap-16
.
Liver u/s ___
Final Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with LFTs/Bili // eval acute
choleycystitis*Portable please-rhythm/rate unstable
TECHNIQUE: Grey scale and color Doppler ultrasound images of
the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
Note is made that this ultrasound exam is limited due to the
limited
sonographic window.
LIVER: The hepatic parenchyma appears within normal limits. The
contour of the
liver is smooth. There is no focal liver mass. The main portal
vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD
measures 4 mm.
GALLBLADDER: The gallbladder is not pathologically distended.
Numerous small
gravel like stones are noted in the gallbladder. There is no
gallbladder wall
edema and no pericholecystic fluid is seen.
PANCREAS: The pancreas could not be visualized.
KIDNEYS: Limited views of the right kidney show no
hydronephrosis.
IMPRESSION:
1. Cholelithiasis. No sonographic evidence of cholecystitis.
2. Unremarkable appearance of the liver although visualization
is limited. No
biliary dilatation.
BY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN
ATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE
EXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE.
___
___, MD electronically signed on ___ 4:04
___
Imaging Lab
Report History
___ 4:04 ___
by INFORMATION,SYSTEMS
.
Brief Hospital Course:
Course on Medicine Service ___
Ms. ___ is an ___ year old female with PMH of AFib, AS,
COPD, GERD, T2DM who initially presented with acute shortness of
breath secondary to an acute on chronic HFpEF exacerbation
secondary to significant valvular disease as well as a left
lower lobe pneumonia. She was found to have aortic stenosis,
mitral regurgitation, and tricuspid regurgitation. Ms.
___ was diuresed to euvolemia and optimizing prior to
undergoing surgical valve repair after thorough pre-operative
testing. She underwent aortic valve replacement, mitral valve
replacement, and tricuspid valve repair.
# HFpEF (EF 55%) ___ Valvular Disease: Patient with volume
overload at admission likely related to valvular disease, which
improved with diuresis. Patient was initially diuresed on 10mg
and 20mg doses of torsemide with good effect. She was later
diuresed with intravenous lasix until she was euvolemic. It was
felt that her heart failure was secondary to significant
valvular disease. At that point, she was transferred to the
cardiothoracic surgery service to undergo valve replacement
surgery. She was continued on metropolol and diltiazem for
atrial fibrillation rate control. She was initially started on
captopril, but it was held in the setting of hypotension.
# Multi-valvular disease: Patient had evidence of significant
valvular disease with severe AS, severe MR, and severe TR
visualized on TEE. It was felt that heart heart failure
exacerbations were due in large part to her valvular disease and
such she was evaluated for cardiac surgery. After undergoing
carotid doppler, right heart catheterization, coronary
angiogram, she was transferred from the cardiology service to
the cardiac surgery service where she underwent aortic valve
replacement, mitral valve replacement, and tricuspid valve
repair. The surgery was uneventful and Ms. ___ did well
afterwards.
# AFib on warfarin. Patient was placed on metropol and diltiazem
for rate control of her atrial fibrillation. Initially difficult
to achieve control without adversely affecting blood pressures.
She seems to be highly sensitive to metoprolol. Her dose of
metoprolol was down-titrated and she was placed on metoprolol
and diltiazem. She was carefully titrated on these medications
due the risk of precipitating cariogenic shock in a patient who
is pre-load dependent.
# PNA. Patient presented with LLL pneumonia on CXR. She was
treated with an 8 day course of levofloxacin without event.
#Diarrhea. Patient with over 1 week of diarrhea. Her stool was
C. Diff negative and thought to be secondary to antibiotics. It
resolved by discharge.
# DM2. Patients sugars well-controlled. Her home medications
were held and she was placed on a sliding scale.
# GERD. Patient with h/o GERD, well-controlled. Maintained on PO
protons
# HLD
- Continue atorvastatin
# Depression
- Continue home meds
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
Course on Cardiac Surgery Service ___
The patient was brought to the Operating Room on ___ where
the patient underwent AVR, MVR, TVr with Dr. ___. Overall
the patient tolerated the procedure well and post-operatively
was transferred to the CVICU in stable condition for recovery
and invasive monitoring. She was initially coagulopathic
requiring multiple blood products. Hemodynamic support was
achieved with vasopressin, levophed and milrinone. She was
extubated by POD 1 and vasopressors were weaned as hemodynamics
improved.
She initially failed a swallow evaluation and was fed with tube
feeds via dob hoff.
Digoxin was started for AFib as well as amio and diltiazem.
Anti-coagulation was resumed with Warfarin. Vasopressors were
discontinued and Beta blocker initiated.
She developed a left sided pleural effusion and pig-tail drain
was placed with good effect.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. The patient was transferred to
the telemetry floor on POD 11 for further recovery.
Speech/Swallow continued to follow and diet was advanced
accordingly. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 14 the patient was ambulating with
assistance, the wound was healing and pain was controlled with
oral analgesics. The patient was discharged to ___
___ in good condition with appropriate follow up instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. RisperiDONE 0.125 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. FLUoxetine 20 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Furosemide 60 mg PO DAILY
6. Ferrous GLUCONATE 324 mg PO DAILY
7. Magnesium Oxide 400 mg PO BID
8. Metoprolol Tartrate 50 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. GlipiZIDE XL 2.5 mg PO DAILY
11. MetFORMIN XR (Glucophage XR) 750 mg PO BID
12. Vitamin D 1000 UNIT PO DAILY
13. Warfarin 1.5 mg PO 4X/WEEK (___)
14. Diltiazem Extended-Release 120 mg PO DAILY
15. Tiotropium Bromide 1 CAP IH DAILY
16. Warfarin 1 mg PO 3X/WEEK (___)
17. Asmanex HFA (mometasone) 100 mcg/actuation inhalation BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheezing
3. Aspirin 81 mg PO DAILY
4. Digoxin 0.125 mg PO DAILY
5. Diltiazem 30 mg PO QID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. GuaiFENesin 10 mL PO Q6H to thin secretions
8. Heparin 5000 UNIT SC BID
d/c when INR>2
9. Pantoprazole 40 mg PO Q24H
10. Potassium Chloride (Powder) 20 mEq PO BID
11. TraMADol 25 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*30 Tablet Refills:*0
12. TraZODone 25 mg PO QHS
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
13. Atorvastatin 40 mg PO QPM
14. Metoprolol Tartrate 12.5 mg PO BID
15. RisperiDONE 0.125 mg PO QHS
RX *risperidone [Risperdal] 0.25 mg 0.5 (One half) tablet(s) by
mouth at bedtime Disp #*30 Tablet Refills:*0
16. ___ MD to order daily dose PO DAILY16 afib
dose to change daily for goal INR ___, dx: AFib
17. Asmanex HFA (mometasone) 100 mcg/actuation inhalation BID
18. Ferrous GLUCONATE 324 mg PO DAILY
19. FLUoxetine 20 mg PO DAILY
RX *fluoxetine 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
20. Furosemide 60 mg PO DAILY
21. GlipiZIDE XL 2.5 mg PO DAILY
22. Magnesium Oxide 400 mg PO BID
23. Multivitamins 1 TAB PO DAILY
24. Tiotropium Bromide 1 CAP IH DAILY
25. Vitamin D 1000 UNIT PO DAILY
26. HELD- MetFORMIN XR (Glucophage XR) 750 mg PO BID This
medication was held. Do not restart MetFORMIN XR (Glucophage XR)
until instructed by PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Pnemonia
COPD
GERD
HDL
Depression
Afib s/p cardioversion ___, maintained on Coumadin
AS - no prior TTE in our system
difficulty swallowing no hx of swallow study
meningitis x 2 70's
Past Surgical History:
hysterectomy
T&A
bilateral catarcts
Discharge Condition:
Alert and oriented x3 non-focal
Deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema- trace
Discharge Instructions:
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
19812504-DS-26
| 19,812,504 | 29,541,380 |
DS
| 26 |
2178-07-08 00:00:00
|
2178-07-09 17:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / cefepime / Imipenem
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx of ESRD on HD (___), HTN, T2DM,
chronic subclavian DVT on warfarin, gangrenous R toe TMA w/
wound vac c/b multiple gram negative line infections and most
recently line associated bacteremia with Corynebacterium
presents to the ED from dialysis with altered mental status.
On previous admission in ___: Pt presented with fever,
leukocytosis, respiratory failure, and hypotension in the ED
concerning for shock. Initial symptoms at that time were only of
lethargy and confusion with no known localizing symptoms.
Treated empirically with vanc/meropenem. Blood grew Vanc
sensitive, Penicillin/Gent intermediate Corynebacterium from
blood in context of suspected line infection--treated with 2
weeks of vanc.
In terms of further microbiological history: Also has had Pan
sensitive Proteus in context of suspected line infection. MSSA
and Non-anthracis Clinda resistant Bacillus in context of
suspected line infection. She now is with a right tunneled IJ
that was placed ___ after her last line became infected. She
has very poor peripheral access.
Also previously had Cipro resistant E.coli and Prevotella
growing from gangrenous foot. This had been treated with right
SFA and anterior tibial stent and then a TMA which needed
multiple wound vacs.
Today she was at regularly scheduled ___ dialysis
when she was noted to be more lethargic than usual. Was AOx3,
but given prior primary presentation of lethargy, she was sent
to the ED for evaluation.
On presentation to ED initial vitals were 98 90 139/50 20 96%
4L. Temperature heightend to 100.0. Noted to have a
peau'd'orange appearance on her left breast, which is consistent
with appearance on last d/c summary. No subQ air was palpable.
Per PCP note this is a chronic issue being followed by serially
by ultrasound and mammograms. The left breast swelling was
considered secondary to more proximal (SCV) thromboses, which
have been chronic leading to congestion.
CBC of 7.1. Chem 7 with HCO3 of 17, creat to 3.4, AG of
17--otherwise unremarkable. INR 2.0 (on warfarin). VBG with pH
7.15 pCO2 72 pO2 67 HCO3 26. Three sets of blood cultures were
drawn.
CT Head showed now acute intracranial abnormality. Given
suspicion for necrotizing fasciitis, CT Torso obtained showing
extensive L chest wall cellulitis extending into the flank with
some superficial muscle involvement.
Failed EJ attempt but able to get 18 gauge in R arm. She was
given Clinda, Vanc, imipenem and 1L of NS for soft pressures to
SBP ___. On transfer to ___ her vitals were T99 P90 BP 90/37 R
12 96% on 4L.
Past Medical History:
recent proteus bacteremia admission ___ (had tunnelled
HD line RIJ pulled)
- CAD (nonobstructive on cath ___, normal ETT ___
- Moderate
- DM2
- Hypertension
- Hypercholesterolemia
- ESRD ___ HTN, DM on HD ___ years (TuThSa)
- Severe renal osteodystrophy
- H. Pylori s/p treatment in ___
- Gastritis
- Severe osteoarthritis
- Hx of Back Abscess
- Multiple HD line infections
- s/p total abdominal hysterectomy/BSO ___
- status post C-section
- s/p R knee subtotal medial meniscectomy and subtotal lateral
meniscectomy with medial femoral chondroplasty ___
- Pelvic fracture, minimally displaced, managed conservatively
___
- chronic SCL Vein thrombosis on Coumadin
Social History:
___
Family History:
CAD in mother. Several brothers and sisters with DM.
Physical Exam:
ADMISSION
General: AOx3, no acute distress, patient not sure why she's in
the hospital
Neck: supple, JVP not elevated, no LAD
SKIN: Her line in her right side appeared clean, dry, and
intact. Lignous skin change of L breast with warmth. No
surrounding erythema but hard to tell given pigmentation. L
flank nonpitting induration with warmth. Non tender to palpation
anywhere.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: obese, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE
Pertinent Results:
ADMISSION
___ 12:10PM BLOOD WBC-7.1# RBC-3.44* Hgb-10.5* Hct-37.9
MCV-110* MCH-30.6 MCHC-27.8* RDW-15.4 Plt ___
___ 06:15AM BLOOD ___
___ 12:10PM BLOOD Glucose-147* UreaN-14 Creat-3.4*# Na-134
K-4.2 Cl-100 HCO3-17* AnGap-21*
___ 12:10PM BLOOD ALT-25 AST-35 CK(CPK)-202* AlkPhos-162*
TotBili-0.3
___ 12:10PM BLOOD CK-MB-4
___ 12:10PM BLOOD cTropnT-0.10*
___ 12:10PM BLOOD Albumin-4.7 Calcium-7.9* Phos-2.8 Mg-1.7
___ 12:12PM BLOOD Glucose-134* Lactate-1.7 Na-136 K-6.3*
Cl-104 calHCO3-19*
DISCHARGE
___ 08:10AM BLOOD WBC-7.8 RBC-3.44* Hgb-10.5* Hct-35.9*
MCV-104* MCH-30.5 MCHC-29.2* RDW-15.3 Plt ___
___ 09:25AM BLOOD ___ PTT-44.6* ___
___ 08:10AM BLOOD Glucose-127* UreaN-25* Creat-3.7*# Na-138
K-4.1 Cl-99 HCO3-23 AnGap-20
___ 08:10AM BLOOD Calcium-7.6* Phos-2.2*# Mg-2.2
BLOOD GASES
___ 12:20PM BLOOD ___ Temp-37.3 pO2-67* pCO2-72*
pH-7.15* calTCO2-26 Base XS--5 Intubat-NOT INTUBA
Comment-GREENTOP
IMAGING
CT Torso w/o contrast ___:
1. Extensive cellulitis involving the deep soft tissues and
musculature of the left lateral chest wall in the left flank
without clear evidence for
intrathoracic or intra-abdominal involvement. The small focus
of gas within the left supraclavicular area is likely due to
recent instrumentation, however if no intervention has been
performed, this is concerning for necrotizing fasciitis.
2. No acute intra abdominal process.
3. Dense atherosclerotic disease with multiple collateral
vessels seen in the right chest wall and abdomen, as seen
previously.
Brief Hospital Course:
___ with PMHx of ESRD on HD (___), HTN, T2DM,
chronic subclavian DVT on warfarin, gangrenous R toe TMA w/
wound vac c/b multiple gram negative line infections and most
recently line associated bacteremia with Corynebacterium
presents to the ED from dialysis with altered mental status.
# CONCERN FOR CELLULITIS:
Patient was hemodynamically stable on admission to ICU. CT scan
concerning for cellulitis involving the deep soft tissues and
musculature of the left lateral chest, for while she received
antibiotics (see below). On further review, these skin changes
were noted as chronic and documented as so previously in the
medical record. The antibiotics were discontinued and she
remained stable off therapy.
# ANGIOEDEMA:
Noted following administration of both Imipenem and Cefepime.
Previous PCN allergy noted as hives. Treated with Famotidine,
Benadryl and Methylprednisolone to good effect. Negative TSH and
B12. Pt maintained on NIPPV briefly. patient did not require
intubation, but her code status was transiently reversed in the
MICU. She remained DNR/DNI at discharge. She was discharged on
a short course of prednisone.
# ENCEPHALOPATHY:
In context of similar presentation to prior episodes of sepsis,
but on arrival ICU, patient was AOx3 and conversing normally. CT
head shows no acute abnormality. Unclear initially etiology,
but possibly explained by fluid shifts in dialysis. As above,
initial concern was for sepsis. Her HD line appeared clean and
without evidence of infection.
# L BREAST SKIN CHANGES:
Per previous notes and discussion with PCP, these felt to be
likely chronic secondary to chronic subclavian thrombosis for
which she is on warfarin. Had previously been monitored with
serial mammograms and ultrasound.
INACTIVE ISSUES
# PERIPHERAL VASCULAR DISEASE: Secondary to diabetes, now s/p
anterior tibial stenting with TMA of gangrenous right foot.
Right foot without infection. Continued ASA/Plavix.
# DM: Had longstanding poor control previously, but has had
improved A1cs in more recent years. Latest A1c was 6.1%. At home
is only on sliding scale insulin. Per reports of prior notes,
average measured sugars at dialysis are in 100s-110s. Continued
gabapentin and maintained with HISS in-house.
# ESRD on HD: ___ schedule. Complicated by renal
osteodystrophy. Continued VitD/calc/Nephrocaps.
# ACCESS: Right tunneled IJ that was placed ___ after her
last line became infected. She has very poor peripheral access.
# GERD: Previously was H.pylori positive. Stable with regards to
GI symptoms currently. Continued omeprazole.
# CAD: Non-obstructive. Last Echo in ___ with LVEF likely >55%.
Cont ASA/Plavix/simvastatin.
TRANSITIONAL ISSUES
# Workup for sleep apnea given transient nocturnal hypoxia that
improved with waking overnight in ICU
# ALLERGY TO PENICILLINS, CEPHALOSPORINS (SIGNIFICANT
ANGIOEDEMA)
# ___ clinic
# GOALS OF CARE: Previously had been DNR/DNI in discussions with
PCP, but on prior two admissions had requested to be full code.
Was transiently made okay to intubate in context of angioedema
but subsequently confirmed DNR/DNI prior to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
8. Milk of Magnesia 30 mL PO DAILY:PRN constipation
9. Nephrocaps 1 CAP PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO TID
11. OxycoDONE (Immediate Release) 5 mg PO PRN prior to ___
12. Senna 1 TAB PO BID
13. Simethicone 80 mg PO TID
14. Simvastatin 40 mg PO QHS
15. Warfarin 3 mg PO DAILY16
16. Zinc Sulfate 220 mg PO DAILY
17. Clonazepam 0.5 mg PO BID:PRN anxiety
please hold for rr<12 or increased somnolence
18. DiphenhydrAMINE 25 mg PO BID:PRN itching
19. Gabapentin 300 mg PO HS
20. Gabapentin 100 mg PO QHD
21. Lactulose 30 mL PO DAILY:PRN constipation
22. Omeprazole 20 mg PO DAILY
23. sevelamer CARBONATE 1600 mg PO TID W/MEALS
24. Senna 1 TAB PO BID:PRN constipation
25. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
26. Tucks Hemorrhoidal Oint 1% 1 Appl PR TID discomfort from
hemhorroids
27. darbepoetin alfa in polysorbat *NF* 60 mcg/0.3 mL Injection
weekly every ___
28. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. DiphenhydrAMINE 25 mg PO BID:PRN itching
RX *diphenhydramine HCl 25 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Lactulose 30 mL PO DAILY:PRN constipation
9. Milk of Magnesia 30 mL PO DAILY:PRN constipation
10. Nephrocaps 1 CAP PO DAILY
11. Senna 1 TAB PO BID
12. Sertraline 50 mg PO DAILY
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth
three times a day with meals Disp #*90 Tablet Refills:*0
14. Simethicone 80 mg PO TID
15. Simvastatin 40 mg PO QHS
16. Tucks Hemorrhoidal Oint 1% 1 Appl PR TID discomfort from
hemhorroids
17. Zinc Sulfate 220 mg PO DAILY
18. Clonazepam 0.25 mg PO BID:PRN anxiety
19. darbepoetin alfa in polysorbat *NF* 60 mcg/0.3 mL Injection
weekly every ___
20. Gabapentin 300 mg PO HS
21. Gabapentin 100 mg PO QHD
22. Omeprazole 20 mg PO DAILY
23. Warfarin 1 mg PO DAILY16
Please hold your dose of coumadin on ___. Please have your
INR checked on ___.
RX *warfarin 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
24. PredniSONE MD to order daily dose PO DAILY
RX *prednisone 10 mg ASDIR tablet(s) by mouth once a day Disp
#*6 Tablet Refills:*0
25. OxycoDONE (Immediate Release) 5 mg PO PRN prior to ___
26. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
27. Senna 1 TAB PO BID:PRN constipation
28. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using HUM Insulin
29. OxycoDONE (Immediate Release) 5 mg PO TID
RX *oxycodone 5 mg 1 tablet(s) by mouth three times a day Disp
#*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Acute confusional state
Angioedema
ESRD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in you were care. You were
admitted after you were having some confusion. While here you
had an allergic reaction to an antibiotic. You improved
significantly and gradually became less confused. We hope you
continue to feel well.
Followup Instructions:
___
|
19812527-DS-11
| 19,812,527 | 25,999,463 |
DS
| 11 |
2170-07-18 00:00:00
|
2170-07-18 14:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ yo otherwise healthy male re-presents to emergency department
for melena. The night of ___ he drank heavily and had several
episodes of vomiting with blood streaking after his third
episode.
After discharge he had 1 melenotic stool at 0400,noted increased
thirst. He had some mild light headedness and shortness of
breath
which has now resolved.
rectal with some melenotic stools heme +
In the ED, initial vitals: 98.6 130/73 77 18 99%RA
Labs were significant for
11.2>13.8/40.9<284 to 9.3>11.___/34.5<252 over 10 hours
UA normal
Chemistry panel with bicarb 21, BUN 37, Cr 0.9
Imaging showed CXR with no acute cardiopulmonary process. No
pneumomediastinum.
GI was consulted and recommended:
___ M with multiple episodes of emesis followed by hematemesis.
H/H stable. ___ 3. No known liver disease and not on
medications, but will need to verify with patient.
He was discharged from ED, and then developed melena at home
which prompted him to return to the ED. Repeat H/H down from
13.8/40.9 -> 11.___/34.5. Otherwise HD stable
Likely ___, gastritis, vs peptic ulcer disease.
Recommend:
- Keep NPO for now
- IV BID PPI
- Will plan for EGD today in ___
In the ED, pt received IV esomeprazole 40mg at 0945
Vitals prior to transfer: 97.6 128/87 76 16 100%RA
Currently, he is asymptomatic. He recalls the above story
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in
vision or hearing, no changes in balance. No cough, no shortness
of breath, no dyspnea on exertion. No chest pain or
palpitations.
No diarrhea or constipation. No dysuria or hematuria. No
hematochezia. No numbness or weakness, no focal deficits.
Past Medical History:
h/o presumed ___ tear in ___ while intoxicated.
Reports EGD 2 weeks after hospitalization that was normal
Social History:
___
Family History:
Denies FH of GI malignancy, IBD, coronary
disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.7 120/80 78 18 100%RA
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
VS: 98.2 119/84 63 14 99%RA
GEN: Alert, sitting up in bed, no acute distress
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
===============
___ 07:48PM BLOOD WBC-11.2* RBC-4.55* Hgb-13.8 Hct-40.9
MCV-90 MCH-30.3 MCHC-33.7 RDW-12.2 RDWSD-39.9 Plt ___
___ 07:48PM BLOOD Neuts-78.0* Lymphs-16.5* Monos-3.8*
Eos-0.5* Baso-0.8 Im ___ AbsNeut-8.76* AbsLymp-1.85
AbsMono-0.43 AbsEos-0.06 AbsBaso-0.09*
___ 07:48PM BLOOD Plt ___
___ 07:48PM BLOOD Glucose-100 UreaN-19 Creat-0.9 Na-138
K-4.4 Cl-99 HCO3-24 AnGap-15
___ 07:50PM URINE Color-Straw Appear-Clear Sp ___
___ 07:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
OTHER PERTINENT/DISCHARGE LABS:
===============================
___ 12:46PM BLOOD WBC-6.1 RBC-3.38* Hgb-10.4* Hct-31.2*
MCV-92 MCH-30.8 MCHC-33.3 RDW-12.2 RDWSD-41.1 Plt ___
___ 07:47AM BLOOD WBC-5.5 RBC-3.66* Hgb-11.2* Hct-33.6*
MCV-92 MCH-30.6 MCHC-33.3 RDW-12.0 RDWSD-39.9 Plt ___
___ 06:10AM BLOOD Glucose-95 UreaN-37* Creat-0.9 Na-140
K-4.7 Cl-104 HCO3-21* AnGap-15
MICROBIOLOGY:
=============
___ 7:50 pm URINE PLAIN RED TOP.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
REPORTS:
=========
CHEST (PA & LAT) Study Date of ___ 6:30 AM
No acute cardiopulmonary process. No pneumomediastinum.
___ EGD
___ tear (endoclip)
Erythema in the antrum compatible with gastritis
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
SUMMARY:
___ had nausea/vomiting after heavy alcohol intake and developed
hematemesis followed by melena. EGD showed ___ tear,
addressed by endoclip. He remained hemodynamically stable
throughout his hospital course and had a modest initial drop in
H/H, stable at time of discharge. He will be discharged on PO
PPI BID for planned 6 week course. Recommended fluid with
advancement as tolerated to soft diet x1 week.
___ Tear
-s/p EGD showing MW-tear with visible vessel s/p endoclip
-PO PPI BID for planned 6 week course.
-counseled against alcohol intake given this is his second
___ tear in the setting of retching after EtOH intake.
TRANSITIONAL ISSUES:
[ ] Discharge H/H: 11.2/33.6. Recommend repeat CBC at PCP
___ in the next ___ days.
[ ] Patient does not have PCP. He needs to establish with one in
his home town.
[ ] Patient to be complete a 6 week course of BID PO PPI. Day 42
= ___
[ ] Recommend ongoing counseling regarding alcohol consumption
and avoidance of binge drinking, as this is the patient's second
episode of hematemesis.
[ ] Full code, presumed
[ ] HCP is wife, ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H Duration: 6 Weeks
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# Acute blood loss anemia
# ___ tear with hemorrhage
# Alcohol use disorder, high risk behavior
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 the ___
___. You were recently hospitalized after throwing up
blood and then having black stool. You underwent an upper
endoscopy study with the GI team who saw a small tear in your
esophagus and a bleeding blood vessel. This was treated with an
"endoclip" which stopped the bleeding. You will need to take a
PPI, pantoprazole, twice daily for the next 6 weeks. You should
establish with a primary care doctor in your ___. The tear
in your esophagus was caused by forceful vomiting.
Your discharge H/H (blood count) was 11.2/33.6.
You should have a soft diet for the next 5 days.
You will continue pantoprazole 40mg twice daily to complete a 6
week course. Projected end date: ___
Please take your medication as prescribed and establish with a
primary care doctor.
You should be able to view your laboratory work by signing up
with the ___ Patient Portal website: ___
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19812593-DS-21
| 19,812,593 | 28,061,658 |
DS
| 21 |
2110-04-28 00:00:00
|
2110-04-28 21:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall with headstrike
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with a h/o Afib (on Eliquis),
dementia p/w fall out of bed with head strike from ___ ___
___).
Patient was found awake and alert wedged between the bed and the
wall. Patient could not recall the fall. The patient denied
fever, chills, chest pain, and shortness of breath. He endorses
___ episodes of vomiting prior to the fall and limited PO intake
(poached egg and toast) on day prior to fall. He endorses
currently feeling hungry and dehydrated. Endorses mild headache.
In the ED, initial vital signs were: 97.3 65 149/69 16 99%RA
- Exam notable for: abrasion to R scalp and bilateral knees. no
abdominal tenderness.
- Labs were notable for Hb 11.2, Plt 117, BUN 38, Cr 1.3, PR
21.9, PTT 37.7, INR 2.0
- Studies performed include non-contrast head CT, which showed a
white matter hypodensity without evidence of acute hemorrhage.
- Neurology was consulted in the ED and suggested MRI with and
without contrast.
- Patient was given IVF (1L NS) and apixaban 5mg.
- Vitals on transfer: 98.0 66 150/74 18 96%RA
Past Medical History:
Hypothyroidism
Atrial fibrillation
BPD
Depression
Acid reflux
Iron-deficiency anemia
Social History:
___
Family History:
Unable to obtain
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
Vitals- 98.6 64 167/80 20 96% Ra
General: Deconditioned somnolent male, AOx1 (can state full name
and month but not year - thought it was ___, thought he was in
___. Perseverates on "making a huge mistake."
HEENT: Abrasions on R scalp. Opens eyes to verbal commands.
Mucous membranes dry. No palpable lymphadenopathy. No JVD
Cardiovascular: RRR. IV/VI systolic murmur, loudest LUSB, n
radiation to carotids. Large well-healed midline sternal scar.
Pulmonary: Intermittent wet-cough, but patient cannot produce
sputum. Crackles bilaterally. Intermittent expiratory wheeze.
Poor respiratory effort.
Abdominal: Soft, non-tender, non-distended, no rebound/guarding
Extremities: Warm, well-perfused. 2+ pitting edema ___ ___. No
pitting edema in upper extremities. Hairless below shins, pale.
Pulses 2+ radial and DP. Large well-healed raised scar on L
medial aspect of leg from mid-thigh to ankle.
========================
DISCHARGE PHYSICAL EXAM
========================
Vitals: T 97.6, BP 166 / 80, HR 67, RR 18, O2 96 on RA
General: Sitting upright in bed, appears chronically ill but in
NAD; A&Ox3
HEENT: Sclerae anicteric. MMM
HEART: RRR. IV/VI systolic murmur, loudest at the LUSB, with no
radiation to carotids. Large well-healed midline sternal scar.
Lung: Poor inspiratory effort. CTAB
GU: Foley in place
Abdominal: Soft, non-tender, non-distended, no rebound/guarding
Extremities: WWP. No pitting edema in the lower extremities
today. NEURO: A&Ox3, moving all extremities spontaneously
Pertinent Results:
ADMISSION LABS:
___ 01:20PM GLUCOSE-95 UREA N-38* CREAT-1.3* SODIUM-146
POTASSIUM-4.5 CHLORIDE-110* TOTAL CO2-24 ANION GAP-12
___ 01:20PM estGFR-Using this
___ 01:20PM CK-MB-6 cTropnT-0.06* ___
___ 01:20PM WBC-6.2 RBC-3.88* HGB-11.2* HCT-37.3* MCV-96
MCH-28.9 MCHC-30.0* RDW-22.6* RDWSD-79.8*
___ 01:20PM NEUTS-70.9 LYMPHS-17.5* MONOS-10.5 EOS-0.3*
BASOS-0.5 IM ___ AbsNeut-4.38 AbsLymp-1.08* AbsMono-0.65
AbsEos-0.02* AbsBaso-0.03
___ 01:20PM PLT COUNT-117*
___ 01:20PM ___ PTT-37.7* ___
PERTINENT IMAGING:
CT C-Spine (___):
1. No evidence of fracture or malalignment of the cervical
spine.
2. Bilateral diffuse ground-glass opacities may represent
infectious/inflammatory process. Partially imaged moderate right
pleural effusion.
3. Multilevel degenerative changes as described above.
CT Head (___):
1. No evidence of intracranial hemorrhage or fracture.
2. Right parieto-occipital white matter hypodensity without mass
effect, may represent white matter ischemic changes or other
prior infarct, but underlying edema is not excluded. However, a
mass with vasogenic edema cannot be excluded and if clinical
concern remains MRI may provide additional information.
PERTINENT MICRO:
___ 2:52 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS:
___ 07:40AM BLOOD WBC-7.6 RBC-4.22* Hgb-12.1* Hct-40.3
MCV-96 MCH-28.7 MCHC-30.0* RDW-21.2* RDWSD-74.0* Plt ___
___ 07:40AM BLOOD Glucose-101* UreaN-30* Creat-1.2 Na-146
K-4.0 Cl-106 HCO3-24 AnGap-16
___ 07:40AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.2
Brief Hospital Course:
Mr. ___ is an ___ with PMHx Afib (on eliquis), hypothyroidism,
and dementia who presented from his SNF due to an unwitnessed
fall from bed with possible headstrike. He has a CT head on
arrival that was negative for acute intracranial pathology.
Also noted to have volume overload on arrival, for which he was
diuresed to euvolemia. A transthoracic echocardiogram showed
new diagnoses of HFrEF. Cardiology was consulted who recommend
against beta blocker given bradycardia and no standing diuretic.
Pt was discharged to Rehab at a weight of 76.8kg.
ACTIVE ISSUES:
# STATUS POST FALL:
Unclear if syncopal episode vs. rolling out of bed, as Pt was
anamnestic. CT head without acute intra-cranial process;
notable for a R parieto-occipital mass which has been stable at
least since ___ per comparison with outside records. Pt with
loud systolic murmur and evidence of volume overload on exam
(see below), concerning for possible cardiogenic etiology of
syncope. Echocardiogram showed diffuse hypokinesis and EF of
approximately 35% (see below), and telemetry revealed no
arrhythmias concerning for possible causes. Pt was discharged
to rehab.
# R PARIETO-OCCIPITAL WHITE MATTER HYPODENSITY:
Likely some encephalomalacia, stable in appearance since ___
per neurology evaluation of images. Difficult to exclude
possibility of a brain malignancy given previous MRI done
without IV contrast. In discussion with Pt's legal guardian,
MRI of the brain was deferred as treatment of a possible brain
cancer at the patient's advanced age and frail status would not
be within his goals of care.
# VOLUME OVERLOAD with
# NEW DIAGNOSIS OF HFrEF (EF 30%) and
# SEVERE MITRAL, TRICUSPID REGURGITATION and
# SEVERE AORTIC STENOSIS and
# JUNCTIONAL RHYTHM:
Pt with lower extremity pitting edema, crackles at the bases,
small R pleural effusion, and a BNP of 21,000 on arrival -
concerning for volume overload. Diuresed to euvolemia. ECG
notable for a slow possibly junctional rhythm at 65bpm.
Transthoracic echocardiogram revealed LVEF 35%, severe aortic
stenosis, severe MR/TR, and severe pulmonary artery
hypertension. Pt was evaluated by cardiology, who recommended
no additional medications or valvular interventions, given his
age and medical frailty.
# ELEVATED CREATININE, with
# ?CHRONIC KIDNEY DISEASE:
Pt with previous creatinine 1.17 in ___, elevated to 1.3 on
arrival. Possibly within normal variation for Pt versus some
mild congestive nephropathy. Creatinine remained stable and was
1.2 at discharge.
# HYPERNATREMIA:
Mild, to 149. Improved with diuresis and restoration of PO
nutrition.
# THROMBOCYTOPENIA:
Mild, to low 100's. Possibly related to his chronically ill
state. No sequelae of bleeding noted.
# DEMENTIA:
Pt with reports of agitation and outbursts against family per
his past reports. Pt with intermittent agitation here,
nonviolent. His home olanzapine was decreased, and replaced
with low-dose Seroquel QHS.
CHRONIC/STABLE ISSUES:
# ATRIAL FIBRILLATION:
- Home apixaban
# IRON DEFICIENCY ANEMIA:
At baseline.
- Home iron supplement
# HYPOTHYROIDISM:
- Home levothyroxine
# ACID REFLUX:
- Home ranitidine
# BPH:
- Home tamsulosin
# DEPRESSION:
- Home fluoxetine
TRANSITIONAL ISSUES:
# CODE: Full, confirmed
# CONTACT: ___, court-appointed guardian
(___)
[ ] MEDICATION CHANGES:
- Added: Docusate, senna, seroquel
- Stopped: Olanzapine (added Seroquel in its place)
[ ] NEW DIAGNOSIS OF HFrEF (EF 35%):
- Discharge weight: 165.9 lb
- Discharge creatinine: 1.2
- Discharge diuretic: None.
- If patient develops hypoxia or shortness of breath, please
evaluate with chest XR and consider gentle diuresis with PO
furosemide ___ PO to start).
[ ] SEVERE VALVULAR DISEASE:
- Given ___ medical comorbidities, dementia, and progressive
frailty, cardiology recommended no further evaluation for
valvular interventions such as TAVR, TMVR. This may be
re-discussed as per goals of care.
[ ] GUARDIANSHIP:
- Pt has legally-appointed guardian ___ at the
contact information as above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FLUoxetine 10 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Ranitidine 150 mg PO DAILY
5. Apixaban 5 mg PO BID
6. Ferrous Sulfate 325 mg PO BID
7. Senna 8.6 mg PO DAILY:PRN constipation
8. melatonin 5 mg oral QHS
9. OLANZapine 5 mg PO QHS:PRN insomnia
10. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
2. Docusate Sodium 100 mg PO BID
3. QUEtiapine Fumarate 12.5 mg PO QHS
4. Apixaban 5 mg PO BID
5. Ferrous Sulfate 325 mg PO BID
6. FLUoxetine 10 mg PO DAILY
7. Levothyroxine Sodium 150 mcg PO DAILY
8. melatonin 5 mg oral QHS
9. Multivitamins 1 TAB PO DAILY
10. Ranitidine 150 mg PO DAILY
11. Senna 8.6 mg PO DAILY:PRN constipation
12. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Unwitnessed fall
New diagnosis of heart failure with reduced ejection fraction
Dementia
Hypernatremia, mild
SECONDARY DIAGNOSES:
Right parieto-occipital white matter hypodensity
History of atrial fibrillation
History of hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at the ___
___.
WHY WAS I SEEN IN THE HOSPITAL?
- You had an unwitnessed fall at your nursing home.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- We looked at your brain using a CT scan, which did not show
any damage to your brain or the bones of your skull.
- You had fluid on your lungs. We removed this with a water
pill through the IV ("Lasix").
- We got a picture of your heart, which showed that your heart
does not squeeze as well as it should. Our cardiologists did
not recommend any further medicines for you at this time.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- Please take your medicines as prescribed.
- Weigh yourself every day, and call your doctor if you weigh
more than three pounds.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
19812657-DS-5
| 19,812,657 | 23,268,497 |
DS
| 5 |
2149-07-04 00:00:00
|
2149-07-04 21:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
deep right palmar laceration
Major Surgical or Invasive Procedure:
___ - Dr. ___
1. Wound exploration, irrigation, debridement, removal of
foreign body right hand.
2. Repair flexor digitorum superficialis and flexor
digitorum profundus tendons to the long, ring and small
fingers (6 tendons, zone 3 repairs).
3. Repair common digital nerve to long and ring fingers,
common digital nerve to ring and small fingers and ulnar
digital nerve to small finger, all with AxoGen nerve
conduits (3 nerves).
4. Primary repair common digital artery to long and ring
fingers, common digital artery to ring and small
fingers, ulnar digital artery to the index finger and
ulnar digital artery to the small finger (4 arteries).
5. Right open carpal tunnel release.
History of Present Illness:
___ yo RHD F w/ PMHx of HTN, HLD, levothyroxine and IDDM who is
transferred to ___ ED from ___ with deep right
palmar laceration after falling onto a shattered ceramic bowl at
7 pm on ___. Immediate bleeding, decreased sensation in long
(ulnar side), ring and small fingers. Unable to flex long, ring
and small fingers. No other injuries.
Past Medical History:
HTN, HLD, levothyroxine, IDDM
Social History:
___
Family History:
NC
Physical Exam:
Gen: NAD, AxOx3
MSK:
splint clean and dry
all digits well perfused
tingling in digits ___, some mild sensation in index, thumb
normal,
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery Hand team. The patient was
found to have
1. Complex laceration right hand 9 cm length.
2. Laceration flexor digitorum superficialis tendons to digits
3, 4 and 5.
3. Laceration flexor digitorum profundus tendons to digits 3, 4
and 5.
4. Laceration common digital nerves to digits 3, 4 and digits 4,
5 ___s ulnar digital nerve to the small finger.
5. Laceration common digital arteries to digits 3 and 4, 4 and
5, ulnar digital artery to the index finger and ulnar digital
artery to the small finger.
She was taken emergently to the operating room on ___ for:
1. Wound exploration, irrigation, debridement, removal of
foreign body right hand.
2. Repair flexor digitorum superficialis and flexor digitorum
profundus tendons to the long, ring and small fingers (6
tendons, zone 3 repairs).
3. Repair common digital nerve to long and ring fingers,common
digital nerve to ring and small fingers and ulnar digital nerve
to small finger, all with AxoGen nerve conduits (3 nerves).
4. Primary repair common digital artery to long and ring
fingers, common digital artery to ring and small fingers, ulnar
digital artery to the index finger and ulnar digital artery to
the small finger (4 arteries).
5. Right open carpal tunnel release.
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 TICU for q1hour pulse checks to her R digits
for the first 24hours. She was transferred to the floor on
POD#2. 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.
___ was consulted to assist in her diabetes management. The
patient worked with OT who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the RUE, and will be discharged on ASA 325mg 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:
Atorvastatin
Lisinopril
Levothyroxine
Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*28
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h to q6h prn Disp
#*60 Tablet Refills:*0
6. Senna 17.2 mg PO HS
7. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Levothyroxine Sodium 112 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1. Complex laceration right hand 9 cm length.
2. Laceration flexor digitorum superficialis tendons to
digits 3, 4 and 5.
3. Laceration flexor digitorum profundus tendons to digits
3, 4 and 5.
4. Laceration common digital nerves to digits 3, 4 and
digits 4, 5 ___s ulnar digital nerve to the small
finger.
5. Laceration common digital arteries to digits 3 and 4, 4
and 5, ulnar digital artery to the index finger and
ulnar digital artery to the small finger.
Discharge Condition:
Stable
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing R upper extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin 325mg daily for 2 weeks
WOUND CARE:
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Followup Instructions:
___
|
19812722-DS-2
| 19,812,722 | 28,845,899 |
DS
| 2 |
2127-01-09 00:00:00
|
2127-01-09 17:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin / Ceclor / prednisone
Attending: ___.
Chief Complaint:
cough, confusion
Major Surgical or Invasive Procedure:
bronchoscopy ___
extubation ___
History of Present Illness:
___ year old woman with PMHx COPD on home O2 at night, long
standing tobacco use transferred from ___ with worsening
confusion, cough, fever.
Patient lives at home with brother, worsening confusion over 4
days, today more confusion, more altered en route to CT,
intubated, CT Head / Abd showed mild intrahepatic parenchymal
disease, diffuse anasarca. LP negative, urine negative. Covered
with vanc / ___ / cipro, transferred on Propofol, good BP on
arrival, transitioned to fent/versed for pressures that
softened, got some fluids, CXR with LLL PNA (here). No rashes.
Lactate 2.5, pressures holding on fent / versed. Access 2 PIVs
At ___:
Tmax 100.9, +1800 I/O, labs: WBC 9.6, Hgb 17, Plt 222, Cr 0.5,
BNP 928, TP 3.8, Alb 2.5, Lactate 2.3, LP: WBC 3, RBC 341, Glu
93, protein 27, gram: negative, CSF Strep Pneumo: negative, Flu
A/B negative, ABG 7.31/78.2/33.4/39.7
Given: APAP 1000mg, Cipro 400mg, Meropenem 1gm, Vancomycin
1000mg
In ED initial VS: 99.8 67 135/99 16 100% vented
Labs significant for: Stox/Utox negative, lactate 2.5, ABG 7.55
/ 37 / ___ / ___
Patient was given: 1L NS, midazolam, fentanyl for sedation
Imaging notable for: CXR: LLL collapse
VS prior to transfer: 69 ___ 98% Vent
On arrival to the MICU, patient is intubated and sedated
REVIEW OF SYSTEMS: unable to obtain
Past Medical History:
COPD, history of intubation ___
Hip fracture, Rt, non-operative ___
MVA ___, resultant chronic neck / back pain from disk problem
HTN
Afib on apixaban: new onset in the setting of critical illness
___
Social History:
___
Family History:
M: alive, healthy
F: tobacco, emphysema, COPD
Sibs: alive, alcoholism
Children: alive and well
Physical Exam:
Admission exam:
VITALS: 99 73 136/103 18 98% CMV 380/20/5/35%
GENERAL: intubated and sedated
HEENT: pupils pinpoint bilaterally, MOM, no elevated JVD, ~ 1cm
corneal opacity, horizontal, OS
LUNGS: occasional coarse rales LLL, diffuse end expiratory
wheezing
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
GU: foley in place draining dark yellow urine
EXT: Warm, well perfused, 2+ pulses BUE, cool BLE with 1+ pulses
b/l, no cyanosis or edema
SKIN: warm, dry
NEURO: intubated and sedated, no hyper-reflexia, clonus
Discharge exam:
Vitals: 98.7 84 120/81 14 90% 50L 40% HF NC
GENERAL: aaox3
HEENT: MMM no elevated JVD, ~ 1cm corneal opacity, horizontal,
OS
LUNGS: diffuse rhochi without rales or wheezing
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: Warm, well perfused, 2+ pulses BUE, cool BLE with 1+ pulses
b/l, no cyanosis or edema
SKIN: warm, dry
NEURO: alert, interactive, face symmetric, MAE
Pertinent Results:
Admission and notable labs:
___ 07:25AM BLOOD WBC-8.3 RBC-5.81* Hgb-18.0* Hct-55.1*
MCV-95 MCH-31.0 MCHC-32.7 RDW-18.9* RDWSD-59.9* Plt ___
___ 07:25AM BLOOD Neuts-67.4 Lymphs-17.9* Monos-13.6*
Eos-0.2* Baso-0.4 NRBC-0.2* Im ___ AbsNeut-5.57
AbsLymp-1.48 AbsMono-1.12* AbsEos-0.02* AbsBaso-0.03
___ 07:25AM BLOOD ___ PTT-25.6 ___
___ 07:25AM BLOOD Glucose-80 UreaN-14 Creat-0.6 Na-141
K-5.1 Cl-96 HCO3-30 AnGap-15
___ 07:25AM BLOOD ALT-56* AST-59* CK(CPK)-44 AlkPhos-118*
TotBili-0.7
___ 07:25AM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:03PM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:00AM BLOOD Calcium-7.0* Phos-4.3 Mg-1.5*
___ 07:25AM BLOOD VitB12-1443*
___ 05:03PM BLOOD TSH-5.6*
___ 01:00AM BLOOD Free T4-1.4
___ 07:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-8*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:38AM BLOOD ___ pO2-35* pCO2-50* pH-7.46*
calTCO2-37* Base XS-9 ___ TOP
___ 07:38AM BLOOD Lactate-2.5*
___ 05:17PM BLOOD Lactate-0.6
___ 07:45AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-NEG
___ 07:45AM URINE RBC-13* WBC-6* Bacteri-NONE Yeast-NONE
Epi-<1
___ 07:45AM URINE Color-Yellow Appear-Clear Sp ___
___ 07:45AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
MICROBIOLOGY:
___ 7:45 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
REPORTS:
CXR ___
IMPRESSION:
Left lower lobe collapsed. Chronicity and explanation
uncertain. Careful
radiographic follow-up advised including chest CT if atelectasis
does not
resolve quickly.
TEE ___:
IMPRESSION: This is an abnormal continuous video EEG monitoring
study because of a generalized slowing indicative of mild to
moderate encephalopathy. Toxic/metabolic disturbances and
medication effects are among the most common causes of such
findings. Generalized epileptiform discharges, often with a
triphasic morphology, are indicative of diffuse cortical
irritability. This study captured no pushbutton activations and
no electrographic seizures.
EEG ___:
IMPRESSION: This is an abnormal continuous video EEG monitoring
study because of a generalized slowing indicative of mild to
moderate encephalopathy. Toxic/metabolic disturbances and
medication effects are among the most common causes of such
findings. Generalized epileptiform discharges, often with a
triphasic morphology, are indicative of diffuse cortical
irritability. This study captured no pushbutton activations and
no electrographic seizures.
___ CXR
Small bilateral pleural effusions right greater than left are
unchanged.
Parenchymal opacity in the right lower lobe is stable.
Cardiomediastinal
silhouette is unchanged. Main pulmonary artery is enlarged,
most likely
secondary to pulmonary arterial hypertension. Right perihilar
opacity in the right middle lobe is unchanged. No pneumothorax
is seen.
DISCHARGE LABS:
___ 02:56AM BLOOD WBC-8.0 RBC-5.83* Hgb-17.5* Hct-53.1*
MCV-91 MCH-30.0 MCHC-33.0 RDW-18.4* RDWSD-57.2* Plt ___
___ 02:56AM BLOOD ___ PTT-35.7 ___
___ 02:56AM BLOOD Glucose-84 UreaN-16 Creat-0.4 Na-145
K-3.8 Cl-96 HCO3-35* AnGap-14
___ 02:56AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.8
___ 06:17AM BLOOD Type-ART Temp-36.7 FiO2-40 O2 Flow-50
pO2-59* pCO2-60* pH-7.42 calTCO2-40* Base XS-11 Intubat-NOT
INTUBATED
Brief Hospital Course:
___ year old woman with PMHx COPD on home O2 at night, long
standing tobacco, afib on apixaban, transferred from ___
with worsening confusion, found to have encephalopathy in
setting of hypoxemia
# Acute on chronic hypercarbic hypoxemic respiratory failure:
requiring intubation in ICU. Etiology felt to be due to
multifactorial contributors including worsening of her chronic
COPD in setting of ongoing smoking, URI, PNA (although neg
bronchoscopy but significant secretions noted), COPD
exacerbation, and small amount of volume overload. PE unlikely
given CTA neg at OSH prior to arrival. Respiratory infection is
likely given poor baseline, fevers, wheezing and chronic cough.
No evidence of volume overload / CHF exacerbation overlty. CXR
with LLL abnormality but chest CT without reported severe
parenchymal process. Blood gasses show chronic compensation for
respiratory acidosis from severe COPD and polycythemia likely
reflective of chronic hypoxemia. Patient was intubated ___ and
eventually extubated ___ to BIPAP. She was placed on broad
spectrum abx with vancomycin ___ - ___, meropenem ___
planned), azithromycin (___) for HCAP coverage as well as
methylprednisolone given concern for COPD exacerbation. Also
received duonebs, albuterol. She will complete meropenem through
___ and will be on a steroid taper with methylprednisolone
through ___. Discharge dose 32mg QD (taper every 3 days
decreasing by 8mg, ___ taper ___, last day of steroids ___
# Encephalopathy: likely from steroids and hypoxemia. ___ be due
to hypercarbic respiratory failure vs sepsis (?HCAP) vs less
likely Wernickes. CT head neg. EEG neg. MRI head deferred given
improvement in MS. ___ minimally elevated but normal FT4. B12
elevated. Received IV thiamine 500mg Q8H x 2 days followed by
250mg IV QD x 5 days, started on folic acid, thiamine. Her
mental status improved with improved oxygenation on high flow
NC.
# Interstitial keratitis: Ophtho consulted given L corneal
clouding on exam. Per family, left eye finding is newer over the
last few weeks without known history of trauma or exposure but
worrisome that these may be unreported in the setting of
progressive confusion. No reported visual changes or eye pain
but family also admits that patient rarely complains of any
symptoms. Started on prednisolone acetate 1% 1 drop in left eye
6x/day (shake well before using) per ophtho consult this
admission as well as acyclovir 400 mg bid. On follow up
evaluation, patient thought to have chronic keratitis and
medication was discontinued.
CHRONIC
# Afib w RVR: CHADS2VASC = 1, R/C = diltiazem, A/C = apixaban.
New onset during critical illness ___, questionable
compliance per family members. No arrhythmia on admission EKGs.
Negative ICH on head CT. Restarted on home diltiazem ER 180 mg
QD with ___fter extubation requiring IV
diltiazem. Dose increased to 240mg ER. Continued on apixaban.
# Depression: initially held home bupropion SR 150 mg QD and
mirtazapine 15 mg QHS iso encephalopathy; resumed over hospital
course.
TRANSITIONAL ISSUES
===================
[ ] complete meropenem through ___
[ ] taper methylprednisolone by 8mg every 3 days starting ___,
last day of steroids should be ___
[ ] furosemide and potassium held on discharge, add back as
necessary
[ ] encourage smoking cessation
[ ] consider palliative care discussions about reintubation and
hospitalization given primary goal to stay home
Communication: Brother: ___, ___ Daughter: ___
___, ___, HCP: ___ ___ (daughter)
Code: Full, confirmed
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Multivitamins 1 TAB PO DAILY
2. Diltiazem Extended-Release 180 mg PO DAILY
3. Potassium Chloride 20 mEq PO DAILY
4. Apixaban 5 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Furosemide 20 mg PO BID
7. Mirtazapine 15 mg PO QHS
8. Vitamin D 3000 UNIT PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. BuPROPion (Sustained Release) 150 mg PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheeze / SOB
2. FoLIC Acid 1 mg PO DAILY
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
4. Meropenem 500 mg IV Q6H
5. Methylprednisolone 32 mg PO DAILY
through ___
Tapered dose - DOWN
6. Methylprednisolone 24 mg PO DAILY Duration: 3 Days
___
Tapered dose - DOWN
7. Methylprednisolone 16 mg PO DAILY Duration: 3 Days
___
Tapered dose - DOWN
8. Methylprednisolone 8 mg PO DAILY Duration: 3 Days
___
Tapered dose - DOWN
9. Thiamine 100 mg PO DAILY
10. Diltiazem Extended-Release 240 mg PO DAILY
11. Apixaban 5 mg PO BID
12. BuPROPion (Sustained Release) 150 mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Mirtazapine 15 mg PO QHS
15. Multivitamins 1 TAB PO DAILY
16. Pantoprazole 40 mg PO Q24H
17. Vitamin D 3000 UNIT PO DAILY
18. HELD- Furosemide 20 mg PO BID This medication was held. Do
not restart Furosemide until your doctor says it is ok
19. HELD- Potassium Chloride 20 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until your doctor
says it is ok
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Encephalopathy
Secondary
# Respiratory failure
# chronic keratitis, left eye
# Afib
# polycythemia in setting of COPD
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 ___ for
confusion and low oxygen levels. You had a breathing tube in
place and there was concern for seizures. Fortunately, there
were no seizures and you were able to come off the breathing
machine with treatment for COPD and pneumonia. To keep your
oxygen levels up and your confusion down, you will need a high
amount of oxygen for a while and you are going to rehab to work
towards getting stronger.
Please take your medications as prescribed and make your best
effort to participate in rehab so you don't need as much oxygen.
You should not smoke as this will likely lead to another
hospitalization
Followup Instructions:
___
|
19812827-DS-10
| 19,812,827 | 22,502,149 |
DS
| 10 |
2177-05-20 00:00:00
|
2177-05-20 15:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Tetanus&Diphtheria Toxoid
Attending: ___.
Chief Complaint:
R hip pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ yo woman in her USOH until the day of presentation
when she sustained a mechanica fall onto her right lower
extremity with immediate pain worsened by an attempt to
ambulate. The patient denies LOC, premonitory symptoms and ROS
is otherwise at baseline.
Past Medical History:
HLD
Social History:
Denies EtOH, tobacco or illicits.
Physical Exam:
admit:
A&O x 3
Calm and comfortable
Pelvis stable to AP and lateral compression with pain on lateral
compression in right groin.
BLE skin clean and intact
RLE w/ pain on active flexion of hip. No pain with passive
internal/external rotation, axial loading, or active
flexion/extension of knee. No shortened, not rotated.
Thighs and leg compartments soft
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
___ FHS ___ TA Peroneals Fire
1+ ___ and DP pulses
d/c:
A&O x 3
Calm and comfortable
Pelvis stable to AP and lateral compression with pain on lateral
compression in right groin.
BLE skin clean and intact
RLE w/ minimal pain on active flexion of hip.
Thighs and leg compartments soft
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
Q H ___ ___ ___ TA Peroneals Fire
1+ ___ and DP pulses
Pertinent Results:
___ 04:45PM URINE HOURS-RANDOM
___ 04:45PM URINE UHOLD-HOLD
___ 04:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:45PM URINE RBC-6* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 04:45PM URINE HYALINE-1*
___ 03:40PM GLUCOSE-107* UREA N-13 CREAT-0.7 SODIUM-142
POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-23 ANION GAP-17
___ 03:40PM estGFR-Using this
___ 03:40PM WBC-9.7 RBC-4.28 HGB-13.4 HCT-41.4 MCV-97
MCH-31.3 MCHC-32.4 RDW-12.4
___ 03:40PM NEUTS-85.3* LYMPHS-7.5* MONOS-6.4 EOS-0.2
BASOS-0.6
___ 03:40PM PLT COUNT-332
___ 03:40PM ___ PTT-28.6 ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R superior ramus fx and was admitted to the orthopedic
surgery service. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is PWB in the RLE, and will be
discharged on lovenox 40mg x2wks for DVT prophylaxis. The
patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Atorvastatin 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Senna 1 TAB PO BID:PRN constipation
5. Enoxaparin Sodium 40 mg SC DAILY Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg subq daily Disp #*14 Syringe
Refills:*0
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q6hrs Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right superior rami fx
Discharge Condition:
stable
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
ACTIVITY AND WEIGHT BEARING:
- PWB RLE
Physical Therapy:
Activity: Activity: Activity as tolerated
Right lower extremity: Partial weight bearing
Treatments Frequency:
n/a
Followup Instructions:
___
|
19812995-DS-8
| 19,812,995 | 20,436,641 |
DS
| 8 |
2130-09-26 00:00:00
|
2130-09-26 13:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Endoscopic ultrasound
History of Present Illness:
___ with a history of biliary colic, s/p cholecystectomy in
___, presents with abdominal pain. She developed post-prandial
right upper quadrant colicky pain about 5 days ago. She endorses
slight nausea although no vomiting. The pain has become
increasingly frequent, and now occurs each time she eats. She
last ate at 2am after she finished a shift that went until
midnight.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies vomiting, diarrhea,
constipation. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Ten point review of
systems is otherwise negative.
Past Medical History:
s/p CCY- ___, Dr. ___: "At time of operation, she had a
nondistended, noninflamed gallbladder which was filled with
hundreds of 1 to 3 mm small black stones." GB Path: "mixed type
cholelithiasis"
Social History:
___
Family History:
No family history of gallstones.
Physical Exam:
VS:
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric, o/p
clear, MMM.
Neck: Supple, no JVD, no thyromegaly.
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, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: Cranial nerves ___ grossly intact, muscle strength ___
in all major muscle groups, sensation to light touch intact,
non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
___ 06:30AM BLOOD WBC-8.4# RBC-4.25 Hgb-13.0 Hct-38.9
MCV-92 MCH-30.6 MCHC-33.4 RDW-11.8 Plt ___
___ 06:30AM BLOOD Glucose-86 UreaN-14 Creat-0.8 Na-139
K-4.2 Cl-103 HCO3-25 AnGap-15
___ 06:30AM BLOOD ___ PTT-31.8 ___
___ 06:30AM BLOOD Albumin-5.0 Calcium-10.1 Phos-3.7 Mg-2.1
___ 06:30AM BLOOD Lipase-32
___
06:28a Liver Or Gallbladder Us (Single Organ) -- Preliminary
Result
Mildly prominent common bile duct, similar to prior. Possible
mild layering
sludge in the common bile duct without stones.
___ Endoscopic ultrasound report
Impression: No obvious abnormalities that could explain Ms.
___ pain were seen endoscopically in the stomach and
duodenum (no ulcers, erosions, erythema, lesions etc)
CBD was normal. No stones, sludge, dilation or other
abnormalities noted.
Pancreatic parenchyma was normal (homogenous, with a normal
salt and pepper appearance).
The pancreas duct was normal..
Ampulla appeared normal both endoscopically and sonographically.
Recommendations: Ms ___ can return to floor for ongoing care
for pain control.
No ERCP was performed because there was no biliary dilation,
stones or sludge seen.
If symptoms persist, follow up with Dr. ___ in clinic in a
few months
Brief Hospital Course:
___ yo F with history of cholelithiasis presents with biliary
colic. The pain resolved by the time she arrived on the floor.
Endoscopic ultrasound revealed normal caliber bile ducts. She
may have had a gallstone that passed. She felt well on
discharge.
Medications on Admission:
None.
Discharge Disposition:
Home
Discharge Diagnosis:
Biliary colic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain that developed after
eating. You had an ultrasound that raised questions about
biliary dilation, but on endoscopic ultrasound there was no
evidence of biliary dilation. You may have had a gallstone that
passed prior to the ultrasound evaluation.
Followup Instructions:
___
|
19813103-DS-17
| 19,813,103 | 26,518,874 |
DS
| 17 |
2164-04-28 00:00:00
|
2164-04-29 01:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o COPD who is coming in from clinic with SOB and
hypoxia. The patient said that over the last few days he has
been having increasing SOB. He felt SOB at rest and it worsened
w/ minimal exertion. He ran out of his symbicort
(budesonide/formoterol) 5 days ago and has only 1 more dose of
spiriva (tiotropium) left. He was unable to refill the
prescriptions because of financial issues and lack of insurance.
He sleeps on 2 pillows and wakes up often at night, but denies
PND and orthopnea. He denies cough or sputum production. Denies
fevers, chills, URI symptoms, lower extremity edema. Reports no
difficulty eating and swallowing, but has difficulty with some
foods due to edentulous. He presented to ___
because of progressive symptoms and was sent to the ED due to O2
sat of low ___ w/ exertion and high ___ at rest which improved
w/ neb and 1 L O2.
.
Initial VS in the ED: 98.3 105 152/98 24 94% 3l. Comfortable,
but tachypneic. Labs notable for D-dimer ___. CTA done that
showed secretions within the right mainstem and left lower lobe
bronchus with ___ opacities in the right middle, lower
and left lower lobes as well as lingula concerning for
aspiration. There was also concern for intra-abdominal free air,
but CT Abd showed air within the lumen of the colon. Pt was
given Prednisone 40mg, fluticasone-salmeterol, and ipratroprium
with good effect and able to wean off O2.
.
On the floor, pt was breathing comfortably on room air. Didn't
complain of SOB.
Review of systems:
(+) Per HPI
(-) fever, chills, night sweats, recent weight loss or gain,
recent sleep changes, headache, vision changes, syncope, sinus
tenderness, rhinorrhea, congestion, sore throat, cough, chest
pain or tightness, palpitations, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria, recent change in bowel or bladder habits,
arthralgias or myalgias.
Past Medical History:
COPD
GERD
BPH
Social History:
___
Family History:
No history of heart disease or heart attacks, HTN, HLD.
Uncle had asthma.
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.1 BP: 155/100 P: 99 R: 18 O2: 95% RA
General: WD WN AAOx3 comfortable in NAD. Thin man, speaking full
sentences, no use of accessory muscles.
HEENT: NC/AT PERRL EOMI, sclera anicteric, MMM OP clear,
edentulous
Neck: supple, no LAD, no JVD, no thyromegaly
CV: RRR, S1, S2, no m/r/g
Chest: scoliosis. barrel chest
Lungs: CTAB bilaterally
Abdomen: soft NT ND +BS can palpate liver and spleen a few cm
below ribs
Ext: WWP no c/c/e 2+ radial DP, ___, strength ___ BUE and BLE
Neuro: CN I-XII intact
Skin: no rashes, excoriations
Discharge Physical Exam:
Vitals: T: 98.9 BP: 137-163/88-100 P: ___ R: 22 O2: 100%/2L
General: WD WN AAOx3 comfortable in NAD. Thin man, speaking full
sentences, no use of accessory muscles.
HEENT: NC/AT PERRL EOMI, sclera anicteric, MMM OP clear,
edentulous
Neck: supple, no LAD, no JVD
CV: RRR, S1, S2, no m/r/g
Chest: scoliosis. barrel chest
Lungs: difficult to hear lung sounds bilaterally
Abdomen: soft NT ND +BS can palpate liver and spleen a few cm
below ribs
Ext: WWP no c/c/e 2+ radial DP, ___, strength ___ BUE and BLE
Neuro: CN I-XII intact
Skin: no rashes
Pertinent Results:
Admission
___ 11:00AM BLOOD WBC-7.7 RBC-4.84 Hgb-13.4* Hct-41.7
MCV-86 MCH-27.6 MCHC-32.0 RDW-12.5 Plt ___
___ 11:00AM BLOOD Neuts-52.5 ___ Monos-7.4 Eos-5.3*
Baso-0.4
___ 11:00AM BLOOD Plt ___
___ 11:00AM BLOOD Glucose-99 UreaN-15 Creat-0.9 Na-140
K-4.1 Cl-99 HCO3-30 AnGap-15
___ 11:00AM BLOOD ___ 11:19AM BLOOD Lactate-1.8
CHEST (PA & LAT) (___)
No acute cardiopulmonary process.
CTA CHEST (___)
1. No pulmonary embolism or acute aortic pathology.
2. Secretions within the right mainstem and left lower lobe
bronchus with
___ opacities in the right middle, lower and left lower
lobes as well as lingula concerning for aspiration.
3. Pocket of air in the left upper quadrant which is not
definitely within a bowel loop. Correlate with symptoms and
consider CT abdomen for more evaluation.
CT ABD & PELVIS W/O CONTRAST (___)
1. No evidence of perforated viscus. Pocket of air was within
the splenic
flexure.
2. Prostatic hyperplasia
Discharge:
___ 08:10AM BLOOD WBC-6.7 RBC-4.37* Hgb-12.5* Hct-36.9*
MCV-85 MCH-28.5 MCHC-33.7 RDW-12.6 Plt ___
Brief Hospital Course:
Mr. ___ is a ___ yo M with PMH of COPD who is coming in from
clinic with SOB and hypoxia in the setting of not taking his
medications for COPD.
# COPD flare/SOB: Pt has a 50 pack year smoking hx who presented
with respiratory distress and hypoxia in the absence of cough,
increased sputum production or fever in the setting of not
taking his COPD meds due running out and not being able to
refill them due to inadequate insurance. His increased SOB is
likely caused by lack of inhaled corticosteroids, long acting
anticholinergics and possibly complicated by chronic aspiration
which was seen on CT scan. The patient has ___ criteria for COPD
exacerbation (acute increase in dyspnea, no increase in cough or
sputum) so likely a minor flare even in the setting of hypoxia
due to lack of meds. Once started on his medications again in
the hospital he improved quickly with 95% O2 sat/RA at rest.
Upon ambulation, his O2 sat dropped to low ___. He was started
on 2L of O2 and prednisone burst and his O2 sat has been
100%/2L. Since the chest CT showed opacities in RM, RL, LL, and
lingula, there was concern for aspiration so was treated with
Augmentin for 7 days. His ambulatory O2 sats continued to be in
low to mid ___ on RA so he was set up with home O2. His O2 sats
at rest were low 90's on RA. We discharged him on fluticasone,
ipratroprium, and albuterol. He will also finish prednisone 40mg
PO daily for 5 days (D1: ___ burst.
His baseline PFTs are unkown and he should have PFTs several
weeks after this acute exacerbation resolves. If he is not
hypoxic on RA in the future than ambulatory 02 therapy can be
discontinued. We changed his medications in order for him to
have an affordable co-pay.
# GERD: We continued Omeprazole 20 mg PO daily.
# BPH: We continued finasteride 5mg PO daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Finasteride 5 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation BID
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/Wheezing
Discharge Medications:
1. Finasteride 5 mg PO DAILY
RX *finasteride 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
2. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule,delayed ___ by
mouth Daily Disp #*30 Capsule Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/Wheezing
RX *albuterol 2 Puffs INH every four (4) hours Disp #*1 Inhaler
Refills:*0
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth every twelve (12) hours Disp #*12 Tablet
Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Col-Rite] 100 mg 1 capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
6. PredniSONE 40 mg PO DAILY Duration: 5 Days
RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*8 Tablet
Refills:*0
7. Home O2
Home ___ L to maintain O2 sat >90 to be used for ambulation.
Ambulatory Sat 80-84%on RA
Please provide portable tank
DDx: COPD
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
RX *fluticasone [Flovent HFA] 110 mcg/actuation 2 PUFF IH twice
a day Disp #*1 Inhaler Refills:*0
9. Ipratropium Bromide MDI 2 PUFF IH QID
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 2 PUFF
IH four times a day Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
COPD exacerbation
Shortness of Breath
Secondary:
GERD
BPH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - doesn't require assistance or aid
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You came to the
hospital because you were having increased shortness of breath
and decreased oxygen in your blood. You were unable to take some
of your COPD medications at home because you couldn't afford
them. We treated your symptoms with the medications you usually
take at home and others (steroids and antibiotics for a possible
infection). You were seen by a representative from Social Work.
Wishing you the best.
Followup Instructions:
___
|
19813103-DS-19
| 19,813,103 | 26,669,689 |
DS
| 19 |
2166-06-26 00:00:00
|
2166-06-26 16:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
BiPAP
History of Present Illness:
Mr. ___ is ___ man with Gold ___ III COPD (FEV1
0.67L in ___, no prior intubations, intermittent home O2),
GERD, and BPH who presents with shortness of breath and is being
admitted to the ___ for hypercarbic respiratory failure.
Per report, patient developed dyspnea about 3 days ago. He also
reports a cough with increased quantity of brown/greenish sputum
production. Also notes fatigue and poor appetite for the past
___ days. His daughter called EMS. Patient was noted to have
diffuse wheezing. Patient was given Solumedrol 125 mg IV and
DuoNebs en route.
In the ED, initial vital signs were 98.4, 105, 145/84, 28, 100%
12L. Labs were remarkable for WBC 10.7, H/H 12.4/40.2, Plt 224,
BUN/Cr ___, lactate 1.6, VBG ___, UA bland. Patient
was given albuterol and ipratropium nebs, 1g IV Ceftriaxone,
500mg IV Azithromycin, and 1 L of IVF. GOC were discussed with
interpreter. Confirmed that he is DNR/DNI. Patient was placed on
BiPAP immediately prior to transfer and he was admitted to the
___ for further management.
In the FICU, he is awake and alert. He denies chest pain,
headache, dysuria, hematuria, and diarrhea.
Past Medical History:
COPD
GERD
BPH
Social History:
___
Family History:
No history of heart disease or heart attacks, HTN, HLD. Uncle
had asthma.
Physical Exam:
Admission Exam:
Vitals: Temp 97.9, HR 112, BP 161/91, RR 20, O2 sat 100% on 40%
Aerosol
GENERAL: Fatigued-appearing older gentleman, laying in bed, in
no acute distress.
HEENT: EOMI, PERRLA, moist mucous membranes, clear oropharnyx,
no teeth.
NECK: Supple, no JVD, no lymphadenopathy.
LUNGS: Poor air movement bilaterally, no wheezes auscultated.
CV: Tachycardic, regular rhythm, normal s1/s2, no m/r/g.
ABD: Soft, non-distended, mild epigastric tenderness to
palpation, no rebound or guarding, normoactive bowel sounds, no
masses palpated.
EXT: Warm, well-perfused, no edema.
SKIN: No rashes.
NEURO: A&Ox3, CNII-XII intact, gross motor and sensory intact
bilaterally.
Pertinent Results:
=============
Admission Labs
=============
___ 09:00AM BLOOD WBC-10.7* RBC-4.50* Hgb-12.4* Hct-40.2
MCV-89 MCH-27.6 MCHC-30.8* RDW-13.1 RDWSD-42.4 Plt ___
___ 09:00AM BLOOD Neuts-66 Bands-2 ___ Monos-11 Eos-1
Baso-1 ___ Myelos-0 AbsNeut-7.28* AbsLymp-2.03
AbsMono-1.18* AbsEos-0.11 AbsBaso-0.11*
___ 09:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+
___ 09:00AM BLOOD Glucose-98 UreaN-17 Creat-0.8 Na-136
K-4.4 Cl-97 HCO3-30 AnGap-13
___ 09:00AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.7
___ 09:06AM BLOOD ___ pO2-25* pCO2-73* pH-7.29*
calTCO2-37* Base XS-4 Intubat-NOT INTUBA
___ 09:06AM BLOOD Lactate-1.6
=============
Microbiology
=============
Sputum cx (___): GRAM NEGATIVE ROD(S). SPARSE GROWTH OF TWO
COLONIAL MORPHOLOGIES.
=============
Imaging
=============
# CXR (___): 1. Opacities at bilateral lung bases may represent
infection, aspiration, or pulmonary edema in the proper clinical
setting. 2. Severe underlying chronic obstructive pulmonary
disease.
# TTE (___): EF 70-75%, mild LAE, dilated IVC (estimated RA
pressure > 15), indeterminate PA pressure. E/A 0.85, E decel
time 213, mild functional mitral stenosis
Brief Hospital Course:
___ man with Gold ___ IV COPD (FEV1 0.67L in ___,
no prior intubations, intermittent home O2), GERD, and BPH who
presents with shortness of breath and is being admitted to the
FICU for hypercarbic respiratory failure.
# Hypercarbic Respiratory Failure/COPD Exacerbation: Mr. ___
has history ___ COPD with intermittent home O2. He was
admitted with acute hypercarbic respiratory failure with pCO2 73
(VBG) on admission. He required BiPAP in the ICU temprorarily -
with improvement after treatment with antibiotics and steroids
and nebulizers. The possible triggers would include pneumonia
as well as medication non-compliance as ran out of inhalers
several days PTA.
There was likely pneumonia given leukocytosis, increased
sputum production, and question of bilateral infiltrates on CXR.
Because he had no recent hospitalizations, he was initially
treated as if her had community acquired pneumonia with
ceftriaxone, azithromycin. He was also given prednisone,
duonebs standing, albuterol nebs PRN, and Advair. Ultimately he
was switched to PO levoflox on ___ for a planned total 8 day
course.
Without oxygen, he desaturated to 80% particularly with
exertion. He was intstructed to have oxygen on at all time
given this consideration. The family also reported that he did
much better with nebulizers (and did not work with inhalers well
at home). For this reason, he was placed on Oxygen, given
prescription for nebulizers. He can restart Tiotropium at
discharge
# Tachycardia: irreg/irreg: during this admission, Mr. ___ had
episodes of significant tachycardia - with heart rates as high
ast 170s with exertion. EKG revealed afib (vs. MAT). There was
no hypotension during these events. His oxygenation was
optimized and he was placed on escalating dose of diltiazem.
Ultimately, he was placed on 360 mg/day of diltiazem with good
response. His HR was largely ___ at rest, although would
increase to 150 with exertion. The tachycardia was likely
contributed by nebs and possible compouned by recent infection.
The hope is that the afib is transient in the acute setting and
that long-term anticoagulation can be avoided altogether (also
fall risk).
# BPH: Mr. ___ had an episode of urinary retention with BS
650cc. This was possibly compounded by constipation. He was
placed on flomax, in addition to the finateride. he was also
treated for his constipation. With this, regimen, he had good
urine output with PVR in low 100 range. This can be followed up
as an outpt.
# Glaucoma
- Continue home eye drops
BUNDLE
# Prophylaxis: Heparin SQ
# Access: PIV
# Communication: Etlelgi___ (daughter) ___, ___
(___) ___
# Code: DNR/DNI but BiPAP ok (confirmed with patient and
daughter)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. Finasteride 5 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. fluticasone-salmeterol 115-21 mcg/actuation inhalation BID
5. Tiotropium Bromide 1 CAP IH DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
Discharge Medications:
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
2. Finasteride 5 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Diltiazem Extended-Release 360 mg PO DAILY
RX *diltiazem HCl [Cardizem CD] 360 mg 1 capsule(s) by mouth
Daily Disp #*30 Capsule Refills:*1
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 amp
NEB every six (6) hours Disp #*60 Ampule Refills:*1
6. Levofloxacin 750 mg PO Q48H
RX *levofloxacin 750 mg 1 tablet(s) by mouth Q48H Disp #*2
Tablet Refills:*0
7. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*1
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. fluticasone-salmeterol 115-21 mcg/actuation INHALATION BID
11. Tiotropium Bromide 1 CAP IH DAILY
12. Outpatient Physical Therapy
Walker
Diagnosis: COPD, pneumonia
Length of need: 13 months
Prognosis: good
___: ___
13. Nebulizer
Nebulizer and Supplies
Length of need: 13 months
Diagnosis: COPD
Inhalation Drug: Duoneb 1 neb Q6 PRN
14. Oxygen
O2 portable device, O2 tank, and supplies (nasal cannula)
2L NC continuous (maintain O2 sats>90%)
Diagnosis: severe COPD, hypoxia
Length of Need: 13 months
Prognosis: Good
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
COPD exacerbation
Pneumonia
Atrial fibrillation
Urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure looking after you, Mr. ___. As you know, you
were admitted for shortness of breath. You were found to have
acute respiratory problems due to emphysema exacerbation along
with a pneumonia. You were treated with antibiotics and
medications to help you breathe. Over time, your breathing
improved. You would need to receive oxygen all the time, since
without it, your oxygen levels decrease significantly.
You were also found to have a rapid heart rate attributed to
something called atrial fibrillation. For this you were given
medications to help control the heart rate.
You are provided with some new medications and equipment:
these include
- Diltiazem (for control of heart rate)
- Levofloxacin (antibiotic to be taken for an additional 3
days)
- Prednisone (steroids for an additional 2 days)
- Tamsulosin (to help you urinate)
- nebulizer (a way to deliver breathing medications with a
steam-like method)
- ___
Followup Instructions:
___
|
19813144-DS-22
| 19,813,144 | 29,303,079 |
DS
| 22 |
2171-02-02 00:00:00
|
2171-02-02 18:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
bee venom (honey bee)
Attending: ___
Chief Complaint:
abdominal pain, fevers
Major Surgical or Invasive Procedure:
diagnostic paracentesis
History of Present Illness:
___ with history of cirrhosis secondary to alcoholic liver
disease and hep C who presents with worsening ascites and lower
extremity swelling. Pt reports that he began having cough with
subjective fevers/chills on ___, associated with pain
underneath his shoulder blades bilaterally and shortness of
breath. His cough was productive of green mucous. Pt reports a
Tmax at home of 103.3 on ___. That afternoon, he presented
to ___ for a therapeutic tap, where 3
liters of ascitic fluid was reportedly removed. Pt told staff
there that he was feeling unwell, but was told that his blood
work was normal and he was discharged home. He presented again
to the ___ ED on ___ and was reportedly
diagnosed wtih pneumonia and started on azithromycin. He reports
no improvement since starting on azithro. Since ___, he notes
worsening of his lower extremity edema and abdominal distension,
associated with diffuse abdominal tenderness. Pt called Dr.
___ for an appointment but stated that he needed to
be seen today, so presented to the ED.
.
Pt was hospitalized ___ for hematemesis with negative EGD.
Bleeding was attributed to epistaxis. No evidence of variceal
bleed. He was discharged on 7 day course of ciprofloxacin.
.
ED Course: Initial Vitals 97.7 57 ___ 99% ra. CXR showed
stable persistent patchy L basilar opacity wo acute findings. He
underwent diagnostic paracentesis which showed WBC 140, RBC 845,
tot protein 1.3, gluc 126, 7% PMN. Labs notable for lactate 1.8,
wbc 6.8 (wo L shift), Hct 40.7, Plt 70, chem 7 wnl, AST 109, ALT
45, tbili 1.3, alb 2.8. He received ceftriaxone 1g IV to broaden
for presumed pna, IV morphine, and zofran. Vitals prior to
transfer 97.8 °F (36.6 °C), Pulse: 62, RR: 18, BP: 110/79,
O2Sat: 97, O2Flow: ra, Pain: ___. Access: PIV 20g.
.
On the floor, pt reports feeling improved since getting
ceftriaxone in the ED. He states that his leg and abdominal
swelling is only mildly increased and his biggest concern has
been his cough, nasal congestion and headaches. He also note 1
day of diarrhea and vomitting last ___. Pt reports that he
has been compliant with medications, and compliant with a low
salt diet. He has been requiring therapeutic taps every 2.5
weeks.
Past Medical History:
Cirrhosis
Hepatitis C
Esophageal varices
Ascites
HTN
Myocardial infarction in setting of cocaine use (age ___
b/l hip replacement
Social History:
___
Family History:
Hypertension; Mother, father and brothers with alcoholism;
sister former drug addict, now sober
Physical Exam:
ADMISSION EXAM:
VS: 98.0 122/81 60 22 98% RA
___: Well appearing ___ yo M/F who appears stated age.
Comfortable, appropriate and in good humor.
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, S1 S2 clear without murmurs, rubs or gallops. No
S3 or S4 appreciated.
LUNGS: Resp were unlabored, no accessory muscle use, moving air
well and symmetrically, upper airway noises transmitted
throughout, mildly rhonchous, no crackles, wheezes.
ABDOMEN: soft, mild distension, diffusely tender to light touch,
worse over spleen and abdominal hernia, splenomegaly. Dullness
to percussion over dependent areas but tympanic anteriorly.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
___ ___ bilaterally to knees.
.
DISCHARGE EXAM:
VS: Tm 98.5 Tc97.9 ___ 20 97/RA
I/O: ___ overnight BM x5
___: Well appearing ___ yo M/F who appears stated age.
Comfortable, appropriate and in good humor.
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, S1 S2 clear without murmurs, rubs or gallops. No
S3 or S4 appreciated.
LUNGS: Resp were unlabored, no accessory muscle use, moving air
well and symmetrically, upper airway noises transmitted
throughout, mildly rhonchous, no crackles, wheezes.
ABDOMEN: soft, mild distension, diffusely tender to light touch,
worse over spleen and abdominal hernia, splenomegaly. Dullness
to percussion over dependent areas but tympanic anteriorly.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
___ ___ bilaterally to knees.
Pertinent Results:
ADMISSION LABS:
___ 12:02PM BLOOD WBC-6.8# RBC-4.14* Hgb-13.0* Hct-40.7
MCV-99* MCH-31.4 MCHC-31.9 RDW-17.3* Plt Ct-70*
___ 12:02PM BLOOD Neuts-67.5 ___ Monos-5.3 Eos-2.3
Baso-0.8
___ 12:02PM BLOOD Glucose-136* UreaN-8 Creat-0.7 Na-133
K-4.1 Cl-100 HCO3-26 AnGap-11
___ 12:02PM BLOOD ALT-45* AST-109* AlkPhos-91 TotBili-1.3
___ 12:02PM BLOOD Albumin-2.8*
.
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-6.8 RBC-4.12* Hgb-12.8* Hct-40.6
MCV-99* MCH-31.2 MCHC-31.6 RDW-17.4* Plt Ct-93*
___ 06:25AM BLOOD ___ PTT-35.7 ___
___ 06:25AM BLOOD Glucose-116* UreaN-6 Creat-0.6 Na-134
K-4.6 Cl-102 HCO3-25 AnGap-12
___ 06:25AM BLOOD ALT-45* AST-106* AlkPhos-99 TotBili-1.1
___ 06:25AM BLOOD Calcium-8.4 Phos-4.2 Mg-1.6
.
URINALYSIS/URINE TOX:
___ 05:14PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.5 Leuks-NEG
___ 05:14PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
.
DIAGNOSTIC PARACENTESIS:
___ 02:54PM ASCITES WBC-140* RBC-845* Polys-7* Lymphs-32*
Monos-4* Mesothe-5* Macroph-52*
___ 02:54PM ASCITES TotPro-1.3 Glucose-126
.
MICROBIOLOGY
___ 2:54 pm PERITONEAL FLUID
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
.
Blood culture x 2 pending
.
Urine culture pending
.
CHEST (PA & LAT) Study Date of ___
FINDINGS: The heart is normal in size. The mediastinal and hilar
contours
appear within normal limits. There is a persistent patchy left
basilar opacity. Given the lack of change, the appearance may be
chronic. More
generally, there is mild interstitial prominence, perhaps due to
slight fluid overload or congestion, but not specific; other
possibilities include atypical infection, airway inflammation,
or possibly interstitial lung disease.
IMPRESSION: Mild suspected background interstitial abnormality
and unchanged focal left infrahilar opacity, accordingly
suggestive of longer chronicity. Clinical correlation is
recommended. If shortness of breath were to continue and the
possibility of an underlying interstitial process is of
potential clinical concern, dedicated chest CT could be
considered.
.
CT ABD & PELVIS WITH CONTRAST Study Date of ___
CT ABDOMEN: There are no pleural effusions. The lung bases
appear clear.
The liver is nodular consistent with fibrosis. The caudate and
left lateral segments are markedly enlarged. The entire left
lobe is shrunken with predominantly central areas of relative
hypodensity suggesting fibrosis. Because monophasic technique
was used, screening for hepatocellular carcinoma is limited, but
there are no suspicious focal lesions identified. The spleen is
moderately enlarged, measuring up to 17.3 cm in length.
Esophageal, paraesophageal and short gastric varices are
apparent. The gallbladder shows mild wall thickening which can
be seen in cirrhosis but it does not appear distended. The
adrenal glands, pancreas and adrenal glands appear within normal
limits.
Along the anterior abdominal wall there is a fat-containing
paraumbilical
hernia with omental contents. Its neck is wide, measuring up to
nearly 26 mm in diameter; the sac measures up to 49 mm in
diameter. There is congestive change suggested by high
attenuation in the fat as well as a small amount of peripheral
fluid, which are findings that can be seen with incarceration
but which are highly nonspecific particularly in the setting of
generalized cirrhosis and ascites with portal hypertension.
The stomach, small and large bowel appear within normal limits.
The appendix appears normal.
CT PELVIS: Moderate-to-large ascites layers in the pelvis.
Streak artifact
from bilateral hip replacements makes evaluation of lower pelvic
structures such as the prostate and seminal vesicles and lower
part of the bladder difficult, but no definite abnormality is
identified. The bladder is poorly delineated and probably mostly
empty. There are patchy vascular
calcifications without any aneurysm. There are slightly
prominent celiac and periportal lymph nodes but none enlarged by
size criteria. The main portal vein and its major branches
appear patent, although segmental branches of the portal vein
are markedly attenuated in keeping with portal hypertension.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
Mild
degenerative changes are present along the lower lumbar facets.
Patient is
status post right hip hemiarthroplasty and left total hip
replacement.
IMPRESSION:
1. Cirrhosis with findings consistent with portal hypertension
including
splenomegaly and varices.
2. Moderate-to-large quantity of ascites.
3. Fat-containing ventral hernia with a fairly wide neck.
Although there is
increased attenuation of fat as well as a small quantity of
peripheral fluid,
which can be seen with incarceration, findings are highly
nonspecific in this
setting.
Brief Hospital Course:
___ man with a history of cirrhosis secondary to
hepatitis C and alcohol use who was admitted with fever and
abdominal pain. Pt remained afebrile throughout his stay and his
abdominal exam and imaging were not concerning for any acute
process.
.
ACTIVE ISSUES:
# Fever: Pt was admitted with reports of 4 days of fever,
however he remained afebrile throughout his hospitalization. He
reportedly was diagnosed with pneumonia at an outside facility,
however his chest xray here was not concerning for any acute
pathology, and radiographic findings were consistent with prior
chest xrays. His abdominal pain was concerning for SBP but his
diagnostic paracentesis showed only 140 WBC, 7% PMN. His
transaminases were at baseline. He had blood and urine cultures
sent, both of which were pending at time of discharged, but his
UA was not concerning for an infectious process. He had an
abdominal CT scan to evaluation for possible perforation or
incarcerated hernia, neither of which were evident. He was
continued on his azithromycin and was discharged with
instructions to complete a 5 day course.
.
# abdominal pain: His abdominal pain was concerning for SBP but
his diagnostic paracentesis showed only 140 WBC, 7% PMN. His
transaminases were at baseline. He had blood and urine cultures
sent, both of which were pending at time of discharged, but his
UA was not concerning for an infectious process. He had an
abdominal CT scan to evaluation for possible perforation or
incarcerated hernia, neither of which were evident and no source
of his pain was identified. His pain was well controlled on his
home oxycodone dose and he was able to tolerate a full diet
prior to discharge.
.
# Ascites: Pt is s/p therapeutic tap for recurrent ascites on
___ at ___. He requires therapeutic taps
every ___ weeks at baseline. His report of increasing ascites
was concerning for possible intraabdominal infectious etiology
for abdominal pain, though his CT scan was not concerning and
his diagnostic paracentesis was not concerning for SBP. He did
not require a therapeutic paracentesis during this admission.
.
CHRONIC ISSUES:
# Cirrhosis: Pt has history of cirrhosis secondary to alcohol
use and hepatitis C. He reports being sober since ___.
His cirrhosis has been complicated by varices and recurrent
ascites. He is status post recent therapeutic tap on ___ (3L)
at ___, and is requiring therapeutic taps every ___
weeks per his baseline. His home nadolol was continued. His
diuretic regimen was initially held given concern for infectious
process, but was resumed prior to discharge as pt was clinically
stable.
.
# CAD: Pt was not on antiplatelet, statin or antihypertensives
as an outpatient.
.
# Chronic pain: he was continued on his home dose oxycodone and
cyclobenzaprine
.
# Varices: There was no evidence of bleeding during this
admission with his hematocrit at baseline. He was continued on
his home dose PPI and Carafate.
.
# tobacco use: Pt received a nicotine patch.
.
TRANSITIONAL ISSUES:
# Pt is being discharged with close follow-up with his PCP ___
___ and hepatology on ___.
.
# He should complete a 5 day course of azithromycin, which was
started at an OSH.
.
# Pt had blood, urine, and peritoneal cultures pending at time
of discharged. This should be followed as an outpatient.
Medications on Admission:
# nadolol 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
# omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
# sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a
day.
# hydroxyzine HCl 50 q HS
# zinc sulfate 220 mg Tablet Sig: One (1) Tablet PO twice a
day.
# furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
# spironolactone 150 mg Tablet Sig: One (1) Tablet PO once a
day.
# ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for nausea.
# oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
# flovent inhaler 2 puffs BID
# flonase daily
# vitamin B complex
# MVI
# Vit D
Discharge Medications:
1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
2. nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
4. hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
8. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed for nausea.
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
10. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
11. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
12. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days: Please complete 2 more doses, last
dose ___.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
abdominal pain
SECONDARY:
hepatitis C
Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted with abdominal pain. You had a
CT scan done, which did not show any abnormalities. There was no
evidence of infection.
Please make the following changes to your medications:
# CONTINUE azithromycin 250 mg daily for 2 more days
Continue all other medications as prescribed.
Followup Instructions:
___
|
19813160-DS-15
| 19,813,160 | 21,965,027 |
DS
| 15 |
2176-09-26 00:00:00
|
2176-09-26 19:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
clonidine
Attending: ___.
Chief Complaint:
confusion
weakness
lethargy
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ female with prior tobacco
abuse, hypertension, atrial fibrillation on apixaban, likely
COPD, and metastatic squamous cell lung cancer complicated by
right malignant pleural effusion s/p right TPC on
carboplatin/paclitaxel/pembrolizumab who presents with weakness
and chills.
Patient reports 2 days of chills, weakness, confusion, and
lethargy. Per ED report, family notes she has become more
agitated and has been hallucinating. She also notes worsening
shortness of breath with exertion and pain over her Pleurx
drain.
She has also had worsening back pain over the past 2 days for
which she has been taking Tylenol and oxycodone. She has not
been
eating and has been very weak. Her daughter had to lift her out
of bed to get her to the commode. She has been using ___ of
home
O2.
On arrival to the ED, initial vitals were 99.1 82 125/71 20 98%
6L. Exam was notable for decreased breath sounds over the right
base and 1 cm x 4 cm region of warmth and erythema the tissue
surrounding the Pleur-evac dressing. Labs were notable for WBC
2.4 (___ 1800), H/H 6.9/23.5, Plt 95, INR 2.2, Na 132, K 6.3,
BUN/Cr ___, LFTs wnl, lactate 0.8, and positive UA. Urine and
blood cultures were sent. CXR showed moderate right pleural
effusion and no evidence of pneumonia. Patient was given Zosyn
4.5g IV, vancomycin 1g IV, insulin/D50, Lasix 20mg IV, and 1L
LR.
Repeat K was 5.1. IP was consulted and recommended to connect
pleurx to pleurvac and keep to water seal. Prior to transfer
vitals were 98.6 70 117/68 18 93% 4L.
On arrival to the floor, patient reports ___ pain at her pleurX
site. She also reports occasional dizziness. She denies fevers,
headache, vision changes, weakness/numbness, cough, hemoptysis,
chest pain, palpitations, abdominal pain, nausea/vomiting,
diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria,
and new rashes.
Past Medical History:
Hypertension
Hyperlipidemia
CKD stage III (Cr 1.28 - 1.51)
RT lung mass
Legally blind ___ macular degeneration
Hypercalcemia thought ___ HCTZ
Uterovaginal prolapse
Colonic adenoma
Tobacco dependence
Vitamin D deficiency
Tremor
PVD (posterior vitreous detachment)
Proximal humerus fracture
Anemia
Diverticulosis
Social History:
___
Family History:
Family history significant for 2 brothers with MIs, an aunt and
sister w/ CHF, her father with HTN
Physical Exam:
ADMISSION EXAM
=====================
VS: Temp 97.8, BP 136/74, HR 98, RR 20, O2 sat 92% 4L.
GENERAL: Pleasant woman, ___ no distress, lying ___ bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, no murmurs.
LUNG: Not cooperative with exam but decreased breath sounds at
right base.
ABD: Soft, non-tender, non-distended, normal bowel sounds.
BACK: Erythema around PleurX site. No spinal or paraspinal
tenderness to palpation.
EXT: Warm, well perfused, 2+ bilateral lower extremity edema.
NEURO: A&Ox3, forgetful, CN II-XII intact. Strength full
throughout. Sensation to light touch intact. Able to state ___
backwards.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
DISCHARGE EXAM
=====================
VITALS: T:98.7 PO BP:118/68 HR:73 RR:20 O2:96 3.5L NC
GENERAL: NAD
HEENT: Anicteric, OP with white plaques on tongue
CARDIAC: RRR, no murmurs.
LUNG: decreased breath sounds at right base. possibly mild
bibasilar rales.
ABD: Soft, non-tender, non-distended, normal bowel sounds.
BACK: Erythema at former ___ site. non-tender. No spinal or
paraspinal tenderness to palpation.
EXT: Warm, well perfused, trace lower extremity edema.
NEURO: A&Ox3, forgetful, CN II-XII intact. Strength full
throughout. Sensation to light touch intact. Able to state ___
backwards.
SKIN: erythematous surrounding skin of TPC with some purulence
ACCESS: Right chest wall port without erythema.
Pertinent Results:
ADMISSION LABS
=======================
___ 09:10PM BLOOD WBC-2.4* RBC-2.61* Hgb-6.9* Hct-23.5*
MCV-90 MCH-26.4 MCHC-29.4* RDW-16.3* RDWSD-53.1* Plt Ct-95*
___ 09:10PM BLOOD Neuts-71 Bands-4 Lymphs-17* Monos-8
Eos-0* Baso-0 AbsNeut-1.80 AbsLymp-0.41* AbsMono-0.19*
AbsEos-0.00* AbsBaso-0.00*
___ 09:10PM BLOOD Poiklo-1+* Polychr-1+* Ovalocy-1+*
___ 09:10PM BLOOD ___ PTT-38.8* ___
___ 09:10PM BLOOD Plt Smr-LOW* Plt Ct-95*
___ 09:10PM BLOOD Glucose-101* UreaN-27* Creat-0.7 Na-132*
K-6.3* Cl-93* HCO3-28 AnGap-11
___ 09:10PM BLOOD ALT-38 AST-37 AlkPhos-129* TotBili-0.4
___ 09:10PM BLOOD Lipase-8
___ 09:10PM BLOOD Albumin-2.5*
___ 09:24PM BLOOD ___ pO2-30* pCO2-59* pH-7.32*
calTCO2-32* Base XS-1
___ 09:24PM BLOOD K-5.8*
___ 09:24PM BLOOD K-5.8*
PERTINENT LABS
=======================
___ 01:40AM BLOOD Hapto-325*
___ 05:00AM BLOOD CRP-191.5*
___ 05:00AM BLOOD CRP-119.3*
___ 06:00AM BLOOD CRP-116.2*
___ 04:32AM BLOOD CRP-91.5*
___ 06:13PM BLOOD Vanco-23.6*
___ 06:00AM BLOOD Vanco-23.7*
DISCHARGE LABS
=======================
___ 04:53AM BLOOD WBC-6.4 RBC-2.77* Hgb-7.3* Hct-25.4*
MCV-92 MCH-26.4 MCHC-28.7* RDW-16.8* RDWSD-53.5* Plt ___
___ 04:53AM BLOOD Plt ___
___ 04:53AM BLOOD Glucose-90 UreaN-12 Creat-0.6 Na-137
K-4.2 Cl-95* HCO3-32 AnGap-10
___ 04:53AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.6
___ 04:53AM BLOOD CRP-77.0*
STUDIES
=======================
___ CXR
IMPRESSION:
Moderate right pleural effusion, with overlying atelectasis. No
radiographic evidence of pneumonia.
___ CHEST CT W/ CONTRAST
IMPRESSION:
1. Moderately motion degraded study.
2. Ground-glass and consolidative opacities with heterogeneous
attenuation of the right middle and lower lobe pulmonary
parenchyma is concerning for
pneumonia.
3. Increased loculation of a small right pleural effusion with
right posterior approach pleural drainage catheter ___ place.
Air is seen encompassing the periphery of the catheter tract
with locules of air seen within the pleural collection at the
right lung base. Superimposed infection of the pleural fluid is
not entirely excluded.
4. Interval decrease ___ size of a previously seen right
mediastinal mass, now measuring up to 8.2 cm ___ maximum
dimension, previously 13.3 cm on exam performed ___.
5. Mild pulmonary interstitial edema.
6. Trace left pleural effusion.
7. Multiple small foci of air are seen along the subcutaneous
course of the right pleural catheter. No organized collection
is identified.
___ CXR PORTABLE
IMPRESSION:
Interval removal the pleural catheter. There is no
pneumothorax. There is
increased opacity ___ the right lower lobe which may represent
extension of the empyema or a new infectious process. The left
pleural effusion is
predominantly unchanged.
MICROBIOLOGY
=======================
___ 6:25 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:44 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 11:25 am PLEURAL FLUID PLEURAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
Reported to and read back by ___ MD (___)
ON ___
AT 18:03.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 11:00 am TISSUE Source: skin.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Brief Hospital Course:
SUMMARY
=====================
Ms. ___ is a ___ female with prior tobacco
abuse, hypertension, atrial fibrillation on apixaban, likely
COPD, and metastatic squamous cell lung cancer complicated by
right malignant pleural effusion s/p right TPC on
carboplatin/paclitaxel/pembrolizumab who presents with weakness
and chills.
TRANSITIONAL ISSUES
=====================
[] Please ensure that she has continued her Cefazolin 2g q8h IV
until time of outpatient appointment. Scheduled to go until
___ and conditionally stop or continue based on clinical
picture.
[] Please follow-up weekly antibiotic monitoring labs: CBC w/
diff, BUN/Cr.
[] Patient will hold apixaban on morning of ___ for possible
placement of TPC ___ ___ clinic on ___. Please instruct
patient on when to re-start.
[] Please follow-up repeat CXR and re-evaluate for TPC.
[] She was retaining urine close to time of discharge and
required straight catheterization. She has some incontinence at
baseline and family was fine with being discharged without
having adequate UOP. Please follow-up regarding her urinary
status.
ACTIVE ISSUES
=====================
# Chronic Hypoxemic Respiratory Failure:
# Right Malignant Pleural Effusion:
# Empyema
Ms. ___ has had previous malignant pleural effusions and is
s/p tunneled pleural catheter who presented with a moderate
sized R pleural effusion. Patient uses baseline ___ home O2 and
did not have an increased requirement. Interventional
Pulmonology was consulted for catheter management. Pleural
effusion was sampled and was found to have elevated TNC and RBC.
Cultures came back positive for GPCs ___ pairs and she was given
vancomycin X3 days. The culture speciated to MSSA and she was
transitioned to Cefazolin 2g q8h on ___. Infectious disease was
consulted to discuss IV vs PO antibiotics. Given her TPC and
recurrent effusions it was decided she would be best served with
at least 3 weeks of IV Cefazolin to end on ___. Her apixaban was
held as she was given 2 days of fibrinolytic agents through the
catheter ___ an effort to break-up the pockets of exudative
fluid. The catheter was accidentally removed on ___. Bedside US
showed small pockets of fluid and a decision was made to not
replace the catheter ___ the tract nor create a new tract. She
was discharged with a plan to treat the empyema with IV Abx and
follow-up ___ ___ clinic ___ one week. She was also discharged with
plan to follow-up with infectious disease to determine further
antibiotic requirements.
# PleurX Erythema
She presented with erythema and around PleurX site with
associated exudative drainage
concerning for cellulitis. A wound culture was obtained and came
back positive for GPCs ___ pairs. As stated above, she received 3
days of vancomycin until culture speciated to MSSA. She was
transitioned to Cefazolin and will receive at home for at least
3 weeks until seen ___ ___ clinic.
# Asymptomatic bacturia
# Retention
She presented with a grossly positive UA ___ absence of symptoms.
She had been started on cefepime for possible lung/skin
infection and decided to give her a 3 day course of ceftriaxone
to cover for UTI. She had a purewick catheter and had adequate
UOP. On ___ had some urinary retention and was straight-cath'd
for 550cc. Repeat UA neg for infection. She was not on
medications that might induce retention. Per patient, she has
incontinence and wears adult diapers. She may just have overflow
incontinence with increased filling pressures. Family was not
concerned about her continuing to retain and she was discharged.
# Acute on Chronic HFpEF
She has restrictive filling pattern on ___s
mild-mod MR/TR. She presented with some dyspnea likely iso
right-sided pleural effusion, however, there was evidence of
left-sided effusion on CXR as well. She was overloaded on exam.
She was diuresed with IV Lasix and saw improvement ___ dyspnea.
She was discharged on home diuretic regimen.
# Cancer-Related Fatigue/Weakness:
# Malnutrition:
# Hypoalbuminemia:
This was thought to be likely ___ setting of malignancy and
recent chemotherapy. She has had poor PO. Nutrition saw and she
has moderate malnutrition given 8% weight loss ___ 2 months. Will
continue to encourage PO given increased requirements.
# Metastatic Squamous Cell Lung Cancer
# Secondary Neoplasm of Lymph Node
Status-post cycle 2 of carboplatin/paclitaxel/pembrolizumab. Has
follow-up with Dr. ___ on ___.
# Anemia ___ Malignancy
# Thrombocytopenia
Likely from chemotherapy. C2D1 was on ___. She remained
asymptomatic. She required 1u pRBC on ___. She showed no signs
of bleeding. Her apixaban was held for 72 hours for lytic
therapy via catheter.
# Esophagitis
This is secondary to radiation therapy. She was continued on her
home PPI and sucralfate.
# Hyponatremia
This has been stable likely ___ poor nutritional status and
lasix. Improved to 137 by discharge.
# Paroxysmal Atrial Fibrillation
She has PAF and is on apixaban 5mg BID. She was at increased
risk of bleeding ___
the setting of her right-sided tumor which was found to be
invading the
right pulmonary artery. Her apixaban was held for 72 hours ___
order to receive 2 doses of tpa/dornase through TPC. It was
re-started on ___.
# Fasciculations/Tremor
Continued home propranolol
# Hyperlipidemia
Continued home atorvastatin
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Apixaban 5 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Diltiazem Extended-Release 60 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Propranolol 10 mg PO TID
6. Sucralfate 1 gm PO TID
7. Atorvastatin 20 mg PO QPM
8. Vitamin D ___ UNIT PO DAILY
9. Furosemide 20 mg PO EVERY OTHER DAY
10. Ondansetron ODT 8 mg PO Q8H:PRN nausea/vomiting
11. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
12. OxyCODONE Liquid 5 mg PO Q8H:PRN Pain - Moderate
13. Potassium Chloride 20 mEq PO DAILY
14. Magnesium Oxide 200 mg PO BID
Discharge Medications:
1. CeFAZolin 2 g IV Q8H
RX *cefazolin ___ dextrose (iso-os) 2 gram/50 mL 2 grams IV every
eight (8) hours Disp #*28 Intravenous Bag Refills:*0
2. Apixaban 5 mg PO BID
3. Atorvastatin 20 mg PO QPM
4. Diltiazem Extended-Release 60 mg PO DAILY
5. Furosemide 20 mg PO EVERY OTHER DAY
6. Magnesium Oxide 200 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Ondansetron ODT 8 mg PO Q8H:PRN nausea/vomiting
9. OxyCODONE Liquid 5 mg PO Q8H:PRN Pain - Moderate
10. Pantoprazole 40 mg PO Q24H
11. Potassium Chloride 20 mEq PO DAILY
12. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
13. Propranolol 10 mg PO TID
14. Sucralfate 1 gm PO TID
15. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=========================
Catheter-induced empyema
Cellulitis
SECONDARY DIAGNOSIS
=========================
metastatic squamous cell lung cancer
Anemia
HFpEF
Esophagitis
UTI
Afib
HLD
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 Ms. ___,
It was a pleasure caring for you here at ___
___!
WHY WAS I ___ THE HOSPITAL?
===================================
- You came to the hospital because you were experiencing
weakness, confusion and chills and you had redness around your
catheter site.
WHAT HAPPENED ___ THE HOSPITAL?
===================================
- Imaging showed that you had some fluid building up ___ your
lung. Cultures from the fluid and from the catheter site were
sent to the lab and you were found to have a bacterial
infection.
- Antibiotic treatment was started for you and the infectious
disease team felt you were going to need at least 3 weeks of
antibiotics.
- The interventional pulmonology team also tried to break up
some of the fluid collections so that it might drain more
easily.
- The catheter accidentally came out on ___. We decided not
to re-insert another catheter or drain.
- You were also treated for a UTI with antibiotics early on
during your stay.
WHAT SHOULD I DO WHEN I LEAVE?
===================================
- You will be going home and receiving intravenous antibiotics
at home. A visiting nurse ___ help you receive these
medications.
- You will also have close follow-up appointments with
interventional pulmonology, oncology, and infectious disease.
Please attend these appointments.
- If you start to experience fevers and chills or worsening
weakness, confusion please reach out to your healthcare
provider.
- Please do not take your apixaban starting on ___.
Discuss re-starting with interventional pulmonologist at your
appointment on ___.
We wish you the very best!
Your ___ care team
Followup Instructions:
___
|
19813245-DS-19
| 19,813,245 | 27,658,852 |
DS
| 19 |
2140-02-13 00:00:00
|
2140-02-13 14:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
PICC ___
History of Present Illness:
Ms. ___ is a ___ year old woman with a past medical history of
vascular dementia, heart failure with preserved EF, asthma, CKD,
HTN who is BIBA from nursing home for unresponsiveness.
She is a resident at ___. One night prior to admission
patient was noted to be SOB by her god-daughter and HCP. She
denies having pain or being lightheaded. Patient was noted to be
breathing heavily at RR ___. 98% on 2L.
Last known well 430 am. at 530 am came in to do vitals, baseline
is usually answering yes/no questions. She was staring off into
space, not responding. CVA in ___ with residual right sided
deficits. Rhonchorous throughout past few days RA sats of 83%,
sounded rhonchorous to midline per EMS. She was not responding
to verbal commands initially but began responding to verbal
commands en route here answering yes and no. Blood sugar 166 for
ems. BP 128/72.
In the ED, code status was discussed with daughter and agrees
that patient is full code and would like everything to be done.
Patient has not been in the hospital for over ___ years and has
been doing though is bedbound in ___. Reports she has
never been intubated before.
In ED initial VS: 97.3 54 . 119/99 . 18 . 100% RA
Labs significant for:
- K 6.7 (hemolysed), Na 152, elevated BUN/Cr (55/0.8)
- ALT83, AST 117
- proBNP 8239
- Troponin 0.07
- D-Dimer 1697
- VBG: 7.19/123 -> 7.19/107 -> ___
Patient was given:
___ 08:40IVFNSWhitehead,NealStarted 125 mL/hr
___ 08:40IHAlbuterol 0.083% Neb Soln 1 NEB
___ 08:40IHIpratropium Bromide Neb 1 NEB
___ 09:21IVCefTRIAXone (1 g ordered)
___ 09:21IVFurosemide 40 mg
Imaging notable for:
___ CXR
IMPRESSION:
Mild central pulmonary vascular congestion and possible
bilateral small pleural effusions. No evidence of pneumonia.
Bipap trial despite she was altered, Co2 came down to 99. Now
opens eyes to voice, knows her name and daughter's name. Was not
oriented to hospital. Remains on BIPAP.
VS prior to transfer: T 97.0 HR 63 BP 149/64 RR24 SaO2 98%
Bipap
On arrival to the MICU, the patient opens her eyes but is
otherwise not following commands. On arrival the patient
idenfied her HCP (god-daughter) and said she was in the
hospital. In discussion with the HCP, the patient is normally
very sharp and often reminds her to pay her bills. She has a
decreased appetite over the past month or two. She has not been
in the hospital for ___ years.
On review of records, the patient had a creatinine of 1.71 with
BN 95 on ___ and ACE and Lasix were discontinued. Creatienine
improved to 1.21 on ___. In ___, symbicort was stopped
for questionable diagnosis of asthma. Enalapril stopped in ___. Lasix decreased from 60mg daily to 20mg daily in ___
then stopped in ___.
Past Medical History:
Hypertension
Heart failure with preserved EF
Osteoarthritis s/p ORIF
Glaucoma
Chronic kidney disease stage 3
Vascular dementia (TIA vs. stroke in ___ with R neglect, R
tremor and some apraxia)
Social History:
___
Family History:
Not obtained
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: Afebrile, BP 156/93 HR 70 SaO2 99% on 2LNC with BIPAP
GENERAL: Arousable to voice, answers questions, chronically ill
appearing but nontoxic
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP difficult to visualize given habitus
LUNGS: Clear to auscultation bilaterally, no wheezes, good air
movement.
CV: Regular rate and rhythm, normal S1 S2, loud holosystolic
murmur heard across the precordium
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.
Trace edema
SKIN: No rashes.
NEURO: Oriented to person and to hospital. Identifies her
god-daughter. ___. Moves extremities without much effort.
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 2350)
Temp: 98.2 (Tm 98.5), BP: 142/84 (138-174/78-86), HR: 85
(65-85), RR: 18, O2 sat: 96% (92-99), O2 delivery: fm 3L
GEN: chronically ill appearing obese female, sitting up in bed.
Drowsy but interactive.
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Poor inspiratory effort, but no visible respiratory
distress. Few bibasilar crackles, lungs otherwise clear.
CAR: +JVD. RRR. ___ systolic ejection murmur best heard at left
sternal border.
ABD: Soft, non-tender, non-distended
EXTREM: Coarse RUE tremor; LUE clenched fist, increased tone.
B/l
feet deviated towards L; atrophic.
NEURO: slow to respond, but answering appropriately. Able to
wiggle toes. LUE clench fist increased tone.
Pertinent Results:
ADMISSION LABS:
===============
___ 07:41AM BLOOD WBC-6.2 RBC-4.22 Hgb-11.3 Hct-38.9 MCV-92
MCH-26.8 MCHC-29.0* RDW-17.7* RDWSD-57.7* Plt ___
___ 07:41AM BLOOD Neuts-63.8 ___ Monos-11.1 Eos-1.3
Baso-0.5 NRBC-0.3* Im ___ AbsNeut-3.97 AbsLymp-1.41
AbsMono-0.69 AbsEos-0.08 AbsBaso-0.03
___ 07:41AM BLOOD ___ PTT-29.5 ___
___ 07:41AM BLOOD Glucose-101* UreaN-55* Creat-0.8 Na-152*
K-6.7* Cl-105 HCO3-36* AnGap-11
___ 07:41AM BLOOD ALT-83* AST-117* CK(CPK)-85 AlkPhos-72
TotBili-0.3
___ 07:41AM BLOOD CK-MB-3 proBNP-8239*
___ 07:41AM BLOOD cTropnT-0.07*
___ 07:41AM BLOOD Albumin-3.6 Calcium-9.7 Phos-5.2* Mg-3.2*
___ 07:59AM BLOOD D-Dimer-1697*
___ 01:35PM BLOOD TSH-4.0
___ 07:47AM BLOOD ___ pO2-29* pCO2-123* pH-7.16*
calTCO2-46* Base XS-8
PERTINENT LABS:
==============
___ 10:45AM BLOOD Glucose-96 UreaN-53* Creat-0.8 Na-151*
K-6.5* Cl-105 HCO3-32 AnGap-14
___ 01:35PM BLOOD Glucose-91 UreaN-52* Creat-0.7 Na-153*
K-4.6 Cl-105 HCO3-36* AnGap-12
___:25AM BLOOD Glucose-113* UreaN-48* Creat-0.7 Na-150*
K-4.4 Cl-105 HCO3-34* AnGap-11
___ 09:58AM BLOOD ___ pO2-25* pCO2-107* pH-7.19*
calTCO2-43* Base XS-7
___ 11:57AM BLOOD ___ Rates-/30 FiO2-40 pO2-21*
pCO2-99* pH-7.25* calTCO2-46* Base XS-10 Intubat-NOT INTUBA
___ 03:34PM BLOOD ___ pO2-55* pCO2-66* pH-7.38
calTCO2-41* Base XS-10 Comment-GREEN TOP
IMAGING STUDIES:
================
___ CXR
Mild central pulmonary vascular congestion and possible
bilateral small
pleural effusions. No evidence of pneumonia.
___ LUE DOPPLER ULTRASOUND
No evidence of deep vein thrombosis in the left upper extremity.
Superficial
edema in the left arm is incidentally noted.
___ CXR
The tip of the right PICC line projects over the distal
brachiocephalic vein
in the region of its confluence with the SVC. No pneumothorax.
___ TTE
The left atrial volume index is normal. The visually estimated
left ventricular ejection fraction is 70%.Normal right
ventricular cavity size with normal free wall motion. The aortic
sinus diameter is normal with normal ascending aorta diameter.
The aortic valve leaflets are moderately thickened. There is
mild
aortic valve stenosis (valve area 1.5-1.9 cm2). There is trace
aortic regurgitation. The mitral leaflets are mildly thickened.
There is severe mitral annular calcification. There is no mitral
valve stenosis. There is moderate [2+] mitral regurgitation. Due
to acoustic shadowing, the severity of mitral regurgitation
could be UNDERestimated. There is mild pulmonic regurgitation.
The tricuspid valve leaflets appear .structurally normal. There
is mild [1+] tricuspid regurgitation. There is SEVERE pulmonary
artery systolic hypertension.
DISCHARGE LABS:
===============
___ 09:15AM BLOOD Glucose-124* UreaN-17 Creat-0.7 Na-146
K-3.7 Cl-100 HCO3-34* AnGap-12
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a past medical history of
vascular dementia, heart failure with preserved EF, asthma, CKD,
HTN who is BIBA from nursing home for unresponsiveness found to
have markedly elevated CO2 and respiratory acidosis, acute on
chronic CHF exacerbation, improved with BIPAP, and UTI.
# Hypercarbic respiratory failure
# Acute on chronic respiratory acidosis
Etiology likely secondary to heart failure exacerbation probably
triggered in the setting of UTI and stopping diuretics. Given
the elevated bicarbonate, she likely has a chronic respiratory
acidosis but the rapid improvement on BIPAP suggests also an
acute component. Her mental status markedly improved after BIPAP
with CO2 improvement from 123 to 65. Plan to continue BIPAP
nightly at rehab as tolerated and continue treatment of heart
failure as below.
# Volume overload
# Heart failure with preserved EF
BNP at 8239 on admission with clinical and radiographic evidence
of volume overload. TTE showed preserved EF with moderate MR and
severe pulmonary artery hypertension. Diuresed initially with IV
Lasix, then transitioned to PO torsemide 10 mg prior to
discharge.
# UTI
Positive UA. No clear symptoms but this may have triggered her
heart failure exacerbation and contributed to altered mental
status. She is not currently septic appearing. She was started
on ceftriaxone on ___ and urine speciated to E. coli,
pan-sensitive. She completed her antibiotic course on ___.
# Hypernatremia
Na 153 likely from decreased free water intake in the setting of
altered mental status. She was given D5W with improvement. Na+
day prior to discharge had normalized to 146.
# Elevated troponin
Troponin to 0.07 on admission without ischemic changes on EKG,
stable on repeat. Likely demand in the setting of heart failure
exacerbation.
TRANSITIONAL ISSUES:
====================
[] BIPAP nightly as tolerated.
[] Started on torsemide 10mg daily for diastolic heart failure
[] Please repeat BMP on ___ while on torsemide 10mg daily. If
worsening hypernatremia or creatinine elevation, consider
decreasing dose of torsemide.
[] Patient made DNR/DNI on this admission. MOLST in chart.
[] Discontinued amlodipine during admission, given acute heart
failure exacerbation and addition of torsemide. Would tolerate
higher BP goal given frailty. Please follow up blood pressure at
rehab facility.
# Communication: HCP: ___ ___ (daughter)
# Code: DNR/DNI, OK to hospitalize, MOLST in chart
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing/sob
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
3. Metoprolol Tartrate 25 mg PO BID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Senna 17.2 mg PO BID
6. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
7. Aspirin 81 mg PO DAILY
8. Lactulose 15 mL PO DAILY
9. Norco (HYDROcodone-acetaminophen) ___ mg oral BID:PRN
10. amLODIPine 7.5 mg PO HS
11. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Torsemide 10 mg PO DAILY
2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing/sob
4. Aspirin 81 mg PO DAILY
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
6. Lactulose 15 mL PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Metoprolol Tartrate 25 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 17.2 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Hypercarbic respiratory failure
#Diastolic heart failure
#Urinary tract infection
#Hypernatremia
#Dementia
#Hypertension
#Goals of Care
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you were confused and lethargic at
home.
What happened while I was in the hospital?
- You were found to have excess fluid in your lungs, which was
treated with medications.
- You were also treated with an oxygen mask to help your
breathing.
What should I do after leaving the hospital?
- Please continue to wear your mask overnight.
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
19813403-DS-11
| 19,813,403 | 27,971,821 |
DS
| 11 |
2156-02-26 00:00:00
|
2156-02-26 14:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___ Laparoscopic appendectomy
History of Present Illness:
___ female on fertility treatments (currently Clomid,
day #5) presents to ED from OSH with c/o abdominal pain, nausea
and vomiting that started 6 pm yesterday. The pain is described
as sharp, constant in the lower abdomen mainly in the RLQ. She
was seen at OSH, with lab work notable for WBC 17.7. She had a
CT abdomen/pelvis that identified a thickened appendix with
___ fat stranding as well as a 6.2 x 3.7-cm cyst in
the right adnexa with a small amount of pelvic free fluid. She
was given Cefoxitin at 03:00am and transferred to ___. She
last had something to eat around 18:00. ACS was consulted for
further evaluation and treatment. she denies any change in
appetite, N&V, diarrhea, dysuria, vaginal bleeding or discharge,
fevres, chils, chest pain, SOB.
Past Medical History:
PMH:
Papilledema
PSH:
DNC ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical exam
VS: t:98.7 HR: 64 BP: 112/68 RR: 18 O(2)Sat: 99 RA
General: No acute distress
HEENT: PERRL
Heart: RRR, no m/r/g
Chest: CTA bilaterally
Abdomen: Obese, abdomen soft, focally tender in RLQ, no rebound
or guarding
EXT: WWP
Discharge Physical Exam:
98.4
PO 113 / 74 89 98
Pertinent Results:
Imaging:
CT st OSH: showed:
thickened appendix with ___ fat stranding as well
as
a 6.2 x 3.7-cm cyst in the right adnexa with a small amount of
pelvic free fluid.
Ultrasound:
Normal appearing uterus. Normal vascular flow in both ovaries.
The right ovary is enlarged and demonstrates multiple
thick-walled anechoic cysts, measuring up to 6.3 cm. While
active
torsion was not demonstrated on this exam, sporadic torsion
cannot be completely excluded. Trace pelvic fluid, which is in
within normal limits.
___ 05:40AM BLOOD WBC-14.0* RBC-3.74* Hgb-11.2 Hct-33.6*
MCV-90 MCH-29.9 MCHC-33.3 RDW-13.1 RDWSD-42.7 Plt ___
___ 05:00AM BLOOD WBC-19.3* RBC-4.05 Hgb-11.9 Hct-36.4
MCV-90 MCH-29.4 MCHC-32.7 RDW-12.8 RDWSD-42.2 Plt ___
___ 05:40AM BLOOD Glucose-96 UreaN-4* Creat-0.7 Na-141
K-3.9 Cl-105 HCO3-23 AnGap-13
___ 05:00AM BLOOD Glucose-128* UreaN-9 Creat-0.8 Na-141
K-4.5 Cl-106 HCO3-17* AnGap-18
___ 06:10AM BLOOD ___ PTT-27.8 ___
___ 05:09AM BLOOD Lactate-2.6*
Brief Hospital Course:
Ms. ___ is a ___ yo F in good health on fertility treatment
(Clomid, day #5) who presented to outside hospital with
abdominal pain and CT scan concerning for acute appendicitis as
well as a 6.2 x 3.7-cm cyst in the right adnexa with a small
amount of pelvic free fluid. She underwent transvaginal ultra
sound that showed multiple cysts in the right ovary with
appearances consistent with multiple follicles. Informed consent
was obtained and she was taken to the operating room and
underwent laparoscopic appendectomy. Please see operative report
for details. After a brief, uneventful stay in the PACU, the
patient arrived on the floor tolerating clears and on IV fluids.
The patient was hemodynamically stable.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
Clomiphene 100mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
Hold for loose stool.
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*5 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
Acute nonperforated appendicitis.
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 Acute Care Surgery Service on ___
with abdominal pain and found to have an infection in your
appendix. You were taken to the operating room and had it
removed laparoscopically. You tolerated the procedure well and
are now ready to be discharged to home with the following
discharge instructions:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
19813532-DS-19
| 19,813,532 | 22,498,809 |
DS
| 19 |
2141-10-19 00:00:00
|
2141-10-20 14:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Bilateral leg pain and numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with ETOH cirrhosis c/b portal HTN, ascites, and esophageal
varices, recently admitted ___ for decompensated cirrhosis
and alcoholic hepatitis precipitated by viral URI who presented
with severe bilateral anterior thigh pain, hyperesthesia,
paresthesia, and swelling to the groin since ___ this
morning. He has been feeling well since discharge until this
morning when he awoke with severe bilateral swelling, with
severe
pain in the anterior thighs. He also endorses mild SOB worse
with
lying down. Otherwise, no CP, fevers, chills, abdominal pain,
n/v/d. Denies ETOH. He has a h/o opiate use d/o and was supposed
to start methadone on d/c but has not started it yet.
- In the ED, initial vitals were: 98.3 HR 79 BP 155/79 RR20 100%
RA
- Exam was notable for: c/o pain in bilateral thighs. Pitting
edema to groin bilaterally. Able to raise hips, no swelling,
erythema. No point tenderness. Normal strength.
- Labs were notable for: Na 126, Serum glucose 602, Bicarb 26,
AP
300, ALT 34, AST 74, Tbili 4.1, INR: 2.1, Hb 9.2, U/A with
Glucose 1000, Mod Leuks, Nitr neg, no bacteria, WBC 2
- Studies were notable for: CXR No pneumonia or acute
cardiopulmonary process.
- The patient was given: Insulin 10U Regular x2, dilaudid .5,
ketorolac 15mg, alb 25% 50g
- No consults
On arrival to the floor, patient complaining of numbness in
bilateral legs (right leg worse than right). He states the pain
started acutely this morning. He noticed the swelling since
night
prior to admission. He does endorse drinking of lot of fluids.
He
sniffed heroine yesterday (no IVDU). He has yet to start
methadone at home. He endorses chills, headache, chronic back
pain.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
T2DM
HTN
Alcohol use disorder
Tobacco abuse
Opioid Use Disorder
Social History:
___
Family History:
Father - deceased - alcohol use disorder, polysubtance abuse
Mother - T2DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.5 150/75 HR 82 RR18 100% on RA
GENERAL: Alert and interactive. Intermittently in severe
distress
from muscle spasms
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, mildly distended, non-tender to
deep palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing or cyanosis. +Diffuse anasarca (right
>left) up to scrotum and thighs. Strong pulses on Doppler
bilaterally. No asterixis.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 752)
Temp: 98.5 (Tm 98.7), BP: 133/71 (117-147/57-79), HR: 74
(73-85), RR: 18, O2 sat: 98% (97-98), O2 delivery: RA, Wt: 193.4
lb/87.73 kg
Fluid Balance (last updated ___ @ 619)
Last 24 hours Total cumulative -1373.4ml
IN: Total 1526.6ml, PO Amt 1460ml, IV Amt Infused 66.6ml
OUT: Total 2900ml, Urine Amt 2900ml
GENERAL: Alert and interactive. No apparent distress
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, mildly distended, non-tender to
deep palpation in all four quadrants. No organomegaly.
EXTREMITIES: WWP, 1+ bilateral lower extremity edema to knees.
MSK: Pain reproduced w/ ___ maneuver bilaterally
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Sensation in tact
throughout
Pertinent Results:
ADMISSION LABS:
===============
___ 02:45PM BLOOD WBC-3.8* RBC-2.67* Hgb-9.2* Hct-28.1*
MCV-105* MCH-34.5* MCHC-32.7 RDW-14.6 RDWSD-56.6* Plt Ct-98*
___ 02:45PM BLOOD Neuts-46.2 ___ Monos-14.5*
Eos-1.3 Baso-1.1* Im ___ AbsNeut-1.76 AbsLymp-1.39
AbsMono-0.55 AbsEos-0.05 AbsBaso-0.04
___ 02:45PM BLOOD ___ PTT-31.6 ___
___ 02:45PM BLOOD Glucose-602* UreaN-9 Creat-1.0 Na-126*
K-4.3 Cl-89* HCO3-26 AnGap-11
___ 02:45PM BLOOD ALT-34 AST-74* CK(CPK)-111 AlkPhos-300*
TotBili-4.1*
___ 02:45PM BLOOD Lipase-38
___ 02:45PM BLOOD Albumin-2.6*
___ 06:37AM BLOOD Calcium-8.8 Phos-2.2* Mg-1.3*
___ 02:05PM URINE Color-Straw Appear-Clear Sp ___
___ 02:05PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5
Leuks-MOD*
___ 02:05PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
___ 02:05PM URINE CastHy-1*
___ 02:05PM URINE Hours-RANDOM Creat-11 Na-98
___ 02:05PM URINE Osmolal-323
DISCHARGE LABS:
===============
___ 09:40AM BLOOD WBC-4.3 RBC-2.78* Hgb-9.4* Hct-29.6*
MCV-107* MCH-33.8* MCHC-31.8* RDW-14.9 RDWSD-59.3* Plt Ct-87*
___ 09:40AM BLOOD Glucose-297* UreaN-10 Creat-1.1 Na-137
K-4.3 Cl-99 HCO3-26 AnGap-12
___ 09:40AM BLOOD ALT-31 AST-78* LD(LDH)-219 AlkPhos-226*
TotBili-3.7*
___ 09:40AM BLOOD Calcium-8.7 Phos-2.3* Mg-1.6
MICROBIOLOGY:
=============
___ 2:05 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION
IMAGING/STUDIES:
================
CXR ___:
IMPRESSION:
No pneumonia or acute cardiopulmonary process.
___ US:
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Duplex RUQ US ___:
IMPRESSION:
1. Cirrhotic appearance of the liver with signs of portal
hypertension
demonstrated by moderate amount of ascites, recanalization of
the umbilical
vein and splenomegaly.
2. Patent hepatic vasculature with appropriate direction of
flow.
Lumbar Spine X-Ray ___:
IMPRESSION:
No compression fracture. Severe degenerative changes of the
right hip, and
mild to moderate multilevel degenerative disc changes.
Brief Hospital Course:
SUMMARY:
========
Mr. ___ is a ___ with history of EtOH cirrhosis who presented
with decompenstated cirrhosis and bilateral
hyperesthesia/paresthesia bilateral lower extremeties
(right>left). Differential for his hyperesthesia and
paresthesias were initially broad. Possibility that presentation
related to worsening ascites compressing lateral femoral
cutaneous nerves causing neurogenic pain, pain from hip
osteoarthritis, diabetic neuropathy. Acute spinal cord etiology
of pain ruled out with normal lumbar spine x-ray. However, x-ray
did show severe degenerative changes of bilateral hips
consistent with osteoarthritis. Patient was given methadone,
gabapentin, Tylenol, tramadol for pain control. Pain resolved
morning of ___. Notably, patient was net -1.4 L ___,
after resuming home diuretic regimen of Lasix and
spironolactone. Presenting symptoms ultimately most likely
multifactorial in the setting of nerve compression, hip
osteoarthritis. Patient was noted to have difficult to control
hyperglycemia throughout admission without evidence of DKA.
Required insulin drip twice to control blood sugars. ___ was
consulted who assisted with insulin regimen. Ultimately patient
discharged on 40 units of Lantus at night, units of Humalog with
each meal. Patient also with history of opioid use disorder,
last heroin use ___. Seen by addiction medicine this
admission and during prior recent admission. We will set up to
initiate treatment at ___ clinic at ___ at discharge.
Patient did not follow-up at ___ prior to this
admission. States he will initiate care with them after
discharge this time.
TRANSITIONAL ISSUES:
====================
-Follow Up Appointments: PCP, ___ weight 88.4kg
-Discharge diabetes regimen: 40 units Lantus nightly, 12 units
Humalog with each meal, holding home metformin and glipizide at
discharge pending ___ follow-up
[] Patient's leg pain was of unclear etiology. If pain
controlled and patient's weight at baseline consider tapering
off gabapentin.
[] Please assess for further illicit opioid use. Encourage
patient to initiate services at ___.
[] Will need ongoing insulin/antihyperglycemic medication
titration as patient's blood sugars were elevated and difficult
to control throughout admission.
[] Will need repeat CBD imaging to evaluate etiology of
dilation, ultrasound versus ERCP
[] Blood pressures were mildly elevated throughout much of
admission into 130s to 140s systolic. Would likely benefit from
initiation of antihypertensive therapy
[] Encourage continued alcohol abstinence, tobacco cessation
[] Severe bilateral hip osteoarthritis noted on x-ray. ___
benefit from orthopedic evaluation.
ACUTE/ACTIVE ISSUES:
====================
#Bilateral lower extremity parethesia and hyperesthesia
Differential for symptoms relatively broad. However, pain and
hyperesthesia now improved. Unclear etiology, possibly
secondary to severe bilateral hip osteoarthritis arthritis as
seen on lumbar spine x-ray. Possible contribution from diabetic
neuropathy given neurologic quality to the pain described by
patient. Also possible that abdominal distention due to ascites
was causing lateral femoral cutaneous nerve compression. Pain
has now resolved after resuming home diuretic regimen ___.
Patient was net -1.4 L ___. Patient was given methadone 5
mg daily, Tylenol, tramadol, initiated gabapentin uptitrated to
600 mg 3 times daily.
# EtOH Cirrhosis
# Ascites
ETOH cirrhosis previously c/b portal HTN, ascites, esophageal
varices, HE. Formerly followed at ___ however patient states he
wants to transfer all care to ___. Volume overloaded on
admission, no asterixis on exam, no evidence of bleeding. Was
initially diuresed with IV Lasix then transition to home
diuretics of Lasix 20 mg daily, spironolactone 50 mg daily.
Continued home pantoprazole 40 mg twice daily, home propranolol
12 mg twice daily for variceal prophylaxis. Continued home
lactulose 30 mg every 6 encephalopathy prophylaxis. Meld at
discharge 24.
# T2DM - Uncontrolled hyperglycemia
Patient admitted on regimen of metformin 500 mg daily, glipizide
10 mg daily which were held. Blood sugars uncontrolled and
required insulin drip twice during admission. No evidence of DKA
throughout admission. ___ consulted due to difficult to
control hyperglycemia. Felt patient likely glucotoxic. Glucose
control improved with increasing doses of long-acting Lantus,
prandial insulin standing, insulin sliding scale Humalog.
Patient will follow-up with ___ after discharge.
#Opioid use disorder
Patient with history of opioid use disorder disorder. Active use
by snorting, last use ___. Has ___ clinic at ___
during recent admission but did not initiate services. States
that he is still set up with to start with them at any time. He
is unsure if he
will, but notes that it is an important step towards opioid
abstinence. Addiction medicine was consulted during this
admission and encouraged patient to initiate services with his
___ clinic. Patient given 5 mg methadone daily while
admitted
STABLE/CHRONIC ISSUES:
=======================
# Biliary Ductal Dilation:
Initially concerning for cholangitis given elevated AP and Tbili
w/CBD dilation, however no e/o systemic infection. MRCP
demonstrated mild dilation but no CBD stones or conclusive
evidence of cholangitis. He will need outpatient follow up for
endoscopic
ultrasound vs. ERCP to evaluate his CBD
# EtOH Use Disorder:
No EtOH since ___. Patient required phenobarbital during last
hospitalization. No evidence of withdrawal throughout admission
Continued Thiamine 100 mg QD, folate 1g QD, MVA daily
# Macrocytic Anemia:
Hemoglobin stable and at baseline, likely associated w/
cirrhosis. Continue folate supplementation
# Hyponatremia:
Admitted with mild stable hyponatremia, likely hypervolemic iso
cirrhosis.
# Coagulopathy
Likely secondary to underlying liver dysfunction and
malnutrition. Stable throughout admission.
- CTM
# Thrombocytopenia
Likely secondary to underlying liver dysfunction. Stable
throughout admission, no evidence of bleeding
# HTN
Has not filled any antihypertensives in our system since ___.
SBP ranged from 110s to 130s throughout admission,
antihypertensive medications were not initiated. Would likely
benefit from blood pressure control as an outpatient.
# Tobacco Use
Offered nicotine patch on admission but patient declined.
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. GlipiZIDE XL 10 mg PO DAILY
2. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
3. Spironolactone 50 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Lactulose 30 mL PO TID Daily BM
6. Methadone 5 mg PO DAILY
7. Thiamine 100 mg PO DAILY
8. Propranolol 20 mg PO BID
9. Phosphorus 500 mg PO QID
10. Pantoprazole 40 mg PO Q12H
11. Multivitamins 1 TAB PO DAILY
12. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
2. Glargine 40 Units Lunch
Humalog 12 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
RX *blood sugar diagnostic [FreeStyle Test] Check blood sugar
as directed 4 times daily Disp #*100 Strip Refills:*5
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) AS DIR 40 Units at bedtime Disp #*5 Syringe Refills:*2
RX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR
12 Units before BKFT; 12 Units before LNCH; 12 Units before
DINR; Disp #*5 Syringe Refills:*2
3. Pen Needle (pen needle, diabetic) 32 gauge x ___
miscellaneous QID:PRN
RX *pen needle, diabetic 32 gauge X ___ Use as directed to
deliver insulin four times a day Disp #*100 Each Refills:*2
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Lactulose 30 mL PO TID Daily BM
7. Methadone 5 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Propranolol 20 mg PO BID
11. Spironolactone 50 mg PO DAILY
12. Thiamine 100 mg PO DAILY
13. HELD- GlipiZIDE XL 10 mg PO DAILY This medication was held.
Do not restart GlipiZIDE XL until you are told to do so by your
physician
14. HELD- MetFORMIN XR (Glucophage XR) 500 mg PO DAILY This
medication was held. Do not restart MetFORMIN XR (Glucophage XR)
until you are told to do so by your physician
15. HELD- Phosphorus 500 mg PO QID This medication was held. Do
not restart Phosphorus until You are told to do so by a
physician
___:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Bilateral lower extremity pain
Paresthesias
Volume overload
Alcoholic cirrhosis
Uncontrolled type 2 diabetes
Bilateral hip osteoarthritis
Opioid use disorder
SECONDARY DIAGNOSIS:
====================
alcohol use disorder
chronic anemia
Hyponatremia
Coagulopathy
Thrombocytopenia
Hypertension
Tobacco use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
-You were admitted to the hospital because you are having severe
pain and swelling in both of your legs
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- Imaging was obtained on admission of your legs, abdomen, and
chest. None of which showed a reason for your pain.
-It was felt that you were likely carrying too much water in
your abdomen which may have been pressing on nerves that run
into your leg causing your symptoms. We gave you medications by
IV and then resumed your home medications by mouth to help you
pee out this extra fluid.
We gave you pain medications including gabapentin and tramadol
which seemed to help your pain
Your blood sugars were very high while you are admitted. We had
our diabetes specialist evaluate you who helped us develop an
insulin regimen for you to take.
-An x-ray of your lower back was obtained to ensure that there
is nothing wrong with your spine to cause your symptoms. This
x-ray did not show anything abnormal in your spine, but did show
severe osteoarthritis in both your hips. It is possible that
some of your pain may be coming from your hip osteoarthritis.
-We gave you low-dose methadone while you were here. Our
addiction specialist met with you. You are already set up to
initiate treatment at a ___ clinic. Please follow-up with
this clinic at discharge.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
-Please weigh yourself daily and call your physician if your
weight increases by more than 3 pounds in 1 day
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19813532-DS-21
| 19,813,532 | 29,518,537 |
DS
| 21 |
2141-12-21 00:00:00
|
2141-12-21 16:49:00
|
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
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of EtOH cirrhosis complicated by portal
hypertension, ascites, hepatic encephalopathy, and esophageal
varices, type II diabetes mellitus, and opioid use disorder, who
presented to the ED with altered mental status.
Unfortunately history is limited due to patient encephalopathy,
as such information is primarily obtained from the ED dash.
Patient was in his usual state of health until this morning,
when
he developed several episodes of non-bloody, non-bilious
vomiting
and altered mental status. Symptoms were associated with mild
headache, photophobia, and sensation of the room spinning around
him. Also reported chills, but did not check his temperature.
Denied chest pain, shortness of breath, palpitations, abdominal
pain, hematemesis, melena, or BRBPR. Of note, patient reported
developing similar symptoms in the past when his blood sugars
were elevated. Given his symptoms, decision was made to call
___.
When EMS arrived, patient was confused and having difficulty
following commands. His blood glucose was elevated to 313.
In the ED, initial VS were notable for;
Temp 97.9 HR 73 BP 145/82 RR 16 SaO2 100% RA
Examination notable for;
Waxing and waning level of consciousness, clear lungs
bilaterally, distended abdomen, heme negative rectal examination
Labs were notable for;
WBC 3.8 Hgb 9.5 Plt 82
___ 21.9 PTT 34.3 INR 2.0
Na 134 K 4.4 Cl 98 HCO3 25 BUN 12 Cr 1.1 Gluc 296 AnGap
11
ALT 14 AST 31 ALP 360 Lipase 20 Tbili 1.9 Alb 2.8
Ca 8.7 Mg 1.7 Phos 1.9
Trop-T <0.01
Serum and urine tox screen negative
VBG: 7.40/44/45 Lactate 1.7
Urine studies unremarkable with the exception of 300 glucose.
Peritoneal studies with 945 WBC (7 polys), 799 RBC, protein 1.9,
and glucose 307.
ECG demonstrated sinus rhythm at 69 bpm, normal axis, normal
intervals, non-specific ST abnormalities, otherwise
unremarkable,
similar when compared to previous.
CXR demonstrated no acute cardiopulmonary process. RUQUS with
cirrhotic liver morphology with moderate ascites and
splenomegaly, patient portal vasculature, and gallbladder wall
thickening. CT head demonstrated no acute intracranial
abnormality. CT abdomen/pelvis with contrast showed cirrhotic
liver with splenomegaly, moderate volume ascites, and upper
abdominal varices, mildly dilated CBD of 1cm (similar to
previous) without evidence of obstructing stone, and otherwise
no
acute findings.
Hepatology were consulted; recommended infectious work-up,
diagnostic paracentesis, and admission to ET.
Patient was given;
- IV ceftriaxone 1g
- lactulose 30ml
- IV olanzapine 5mg
Transfer vital signs were notable for;
HR 66 BP 100/62 RR 12 SaO2 100% RA
Upon arrival to the floor, patient is confused and unable to
provide much history. Initially stated he was not taking any
medications recently, but subsequently stated he last took his
medications on the day prior to admission. Denied any specific
symptoms currently.
10-point review of systems unable to be obtained secondary to
mental status.
Past Medical History:
- EtOH cirrhosis complicated by ascites, HE, esophageal varices
- Type II diabetes mellitus
- Alcohol use disorder
- Opioid use disorder
Social History:
___
Family History:
Father with a history of alcohol and polysubstance abuse. Mother
with a history of type II diabetes mellitus.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: Temp 97.4 BP 152/88 HR 82 RR 18 SaO2 100% RA
GENERAL: initially somnolent but subsequently awake and alert
HEENT: AT/NC, no conjunctival pallor, anicteric sclera, MMM
NECK: supple, non-tender, no JVP elevation
CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops
RESP: CTAB, no wheezes/crackles
___: soft, non-tender, distended, BS normoactive
EXTREMITIES: warm, well perfused, trace lower extremity edema
NEURO: A/O x1-2, moving all four extremities with purpose, CNs
grossly intact, + asterixis
DISCHARGE PHYSICAL EXAMINATION:
PHYSICAL EXAMINATION:
VS: Temp 98.0 BP 121/72 HR 54 RR 18 SaO2 100% RA
GENERAL: Awake and alert, interactive with examiner
HEENT: AT/NC, no conjunctival pallor, anicteric sclera, MMM
NECK: supple, non-tender, no JVP elevation
CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops
RESP: CTAB, no wheezes/crackles
___: soft, non-tender, distended, BS normoactive
EXTREMITIES: warm, well perfused, trace lower extremity edema
NEURO: A/O x4, moving all four extremities with purpose, CNs
grossly intact, no asterixis
Pertinent Results:
ADMISSION LABS:
___ 12:50AM BLOOD WBC-3.8* RBC-3.08* Hgb-9.5* Hct-29.5*
MCV-96 MCH-30.8 MCHC-32.2 RDW-16.2* RDWSD-56.6* Plt Ct-82*
___ 12:50AM BLOOD Neuts-52.7 ___ Monos-9.3 Eos-1.9
Baso-0.8 Im ___ AbsNeut-1.99 AbsLymp-1.32 AbsMono-0.35
AbsEos-0.07 AbsBaso-0.03
___ 12:50AM BLOOD ___ PTT-34.3 ___
___ 12:50AM BLOOD Glucose-296* UreaN-12 Creat-1.1 Na-134*
K-4.4 Cl-98 HCO3-25 AnGap-11
___ 12:50AM BLOOD ALT-14 AST-31 AlkPhos-360* TotBili-1.9*
___ 12:50AM BLOOD Albumin-2.8* Calcium-8.7 Phos-1.9* Mg-1.7
___ 12:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:01AM BLOOD ___ pO2-45* pCO2-44 pH-7.40
calTCO2-28 Base XS-1 Comment-GREEN TOP
___ 01:01AM BLOOD Lactate-1.7
___ 12:50AM BLOOD cTropnT-<0.01
___ 12:50AM BLOOD Lipase-20
DISCHARGE LABS:
___ 07:09AM BLOOD WBC-6.4 RBC-3.30* Hgb-10.1* Hct-31.5*
MCV-96 MCH-30.6 MCHC-32.1 RDW-16.2* RDWSD-56.6* Plt ___
___ 07:09AM BLOOD ___ PTT-32.9 ___
___ 07:09AM BLOOD Glucose-296* UreaN-10 Creat-1.1 Na-137
K-4.6 Cl-101 HCO3-27 AnGap-9*
___ 07:09AM BLOOD ALT-19 AST-43* AlkPhos-295* TotBili-2.0*
___ 07:09AM BLOOD Albumin-2.7* Calcium-8.5 Phos-2.9 ___
MICRO:
STUDIES:
CT HEAD W/O CONTRAST Study Date of ___
Normal study.
CT ABD & PELVIS WITH CONTRAST Study Date of ___
1. Cirrhotic liver morphology with sequelae of portal
hypertension including
splenomegaly, moderate volume ascites, and abdominal varices.
2. Mildly dilated common bile duct up to 1.0 cm, similar to
prior MRCP
performed ___. No evidence of an obstructing stone.
3. Moderate to severe degenerative changes of the bilateral hip
joints.
4. Otherwise, no acute findings in the abdomen or pelvis to
account for
patient's symptoms.
CHEST (PA & LAT) Study Date of ___
No acute cardiopulmonary process.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
1. Cirrhotic liver morphology with moderate volume ascites and
splenomegaly.
2. Patent portal vasculature with hepatopetal flow.
3. Similar degree of wall thickening of the gallbladder compared
to ___, likely secondary to contracted state or underlying
liver disease.
4. Stable dilatation of the common bile duct up to 10 mm
compared to ___.
Brief Hospital Course:
___ with a history of EtOH cirrhosis complicated by portal
hypertension, ascites, hepatic encephalopathy, and esophageal
varices, type II diabetes mellitus, and opioid use disorder, who
presented with altered mental status concerning for HE.
ACTIVE ISSUES:
# Hepatic encephalopathy
Presented with one day of altered mental status. Examination
notable for lethargy and asterixis. CT head within normal limits
and infectious work-up was negative. Suspect hepatic
encephalopathy is the most likely etiology for altered mental
status, triggered by apparent noncompliance with lactulose at
home. This admission, his mental status improved rapidly with
lactulose. He was also started on rifAXIMin 550 mg PO BID. Home
gabapentin was stopped given possible contribution to somnolence
and AMS on presentation.
# EtOH cirrhosis
MELD-Na 21, Child's class C, on admission. Complicated by
esophageal varices, hepatic encephalopathy, and ascites. RUQUS
with no evidence of portal vein thrombosis, and overall liver
function tests improved when compared to prior. Diagnostic
paracentesis was negative for SBP this admission; he was treated
for HE with lactulose and rifaximin to good effect, as above.
- HE: Lactulose 30mL tid; started rifaximin BID
- VARICES: continue propranolol 20mg BID
- ASCITES: continue furosemide 40mg/spironolactone 100mg daily
- HCC: next abdominal imaging in ___
# Type II diabetes mellitus
# Hypoglycemia
Presented with elevated blood sugars to ~300, without evidence
of DKA or HHS. Patient does have a history of difficult to
control diabetes complicated by poor medical literacy. Overnight
this admission he had an episode of hypoglycemia to 27, after
which his insulin regimen was adjusted and downtitrated in
discussion with ___ consult. His BG subsequently became
elevated to the 300-400s and he was restarted on his home
insulin regimen with plan for close follow up with ___. He
was discharged on glargine 40 Units at lunch and Humalog 12
units with meals.
CHRONIC ISSUES:
# Anemia (baseline ___: stable
# Opioid use disorder: restarted home Methadone dose 5mg, dose
confirmed with providing ___ clinic, once mental status
improved.
# Leg pain: Stopped home gabapentin 600mg TID given presenting
encephalopathy. patient did not have leg pain this admission.
======================
TRANSITIONAL ISSUES:
======================
[] Patient has suboptimally controlled DM, please ensure follow
up with ___
[] Emphasize medication compliance, especially with lactulose
and rifaximin
#CODE STATUS: Full (presumed)
#CONTACT: ___ ___
___ - ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. FoLIC Acid 1 mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Lactulose 30 mL PO TID Daily BM
4. Propranolol 20 mg PO BID
5. Spironolactone 100 mg PO DAILY
6. Thiamine 100 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Magnesium Oxide 200 mg PO DAILY
10. Phosphorus 500 mg PO QID
11. Furosemide 40 mg PO DAILY
12. Glargine Unknown Dose
Humalog 12 Units Breakfast
Humalog 12 Units Dinner
13. Methadone 5 mg PO DAILY
Discharge Medications:
1. rifAXIMin 550 mg PO BID
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Glargine 40 Units Lunch
Humalog 12 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
5. Lactulose 30 mL PO TID Daily BM
Take extra doses as needed to have ___ bowel movements per day.
6. Magnesium Oxide 200 mg PO DAILY
7. Methadone 5 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Phosphorus 500 mg PO QID
11. Propranolol 20 mg PO BID
12. Spironolactone 100 mg PO DAILY
13. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Hepatic encephalopathy
SECONDARY DIAGNOSIS:
Cirrhosis
Type 2 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at ___
___.
WHY WERE YOU ADMITTED?
- You were confused and feeling very tired.
WHAT HAPPENED IN THE HOSPITAL?
- You receive the medication lactulose, which cleared up your
confusion. Your confusion was caused by your liver disease.
- Your insulin medications were adjusted because your blood
sugars were very high.
WHAT SHOULD YOU DO AT HOME?
- Go to follow up appointments as scheduled.
- Take your medications as prescribed.
- It is extremely important that you take lactulose as
instructed to have a minimum of ___ bowel movements each day to
prevent confusion.
- It is also very important that you keep your appointment with
the ___ for better control of your diabetes.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
19813532-DS-23
| 19,813,532 | 29,807,490 |
DS
| 23 |
2142-04-13 00:00:00
|
2142-04-13 22:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal distention
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo man with T2DM, opioid use disorder on methadone, EtOH
cirrhosis (MELD 33) c/b portal HTN, grade II esophageal varices
s/p banding ___, ascites, and hepatic encephalopathy who
presents with 2 days of worsening abdominal pain and distention
and scrotal edema.
He was recently admitted (___) with an upper GI bleed.
He
presented with abdominal pain and hematemesis and was intubated
for airway protection. He required transfusions with pRBCs, FFP,
platelets. EGD ___ showed distal esophageal varices and antral
peptic ulcers with no active bleeding. He had a therapeutic
paracentesis with 2L fluid removed on ___. Hgb was stable and
he was discharged on ___.
After discharge, he reports he was taking all of his medications
including home furosemide. Over the past ___ days, he developed
worsening BLE and scrotal edema which has become increasingly
uncomfortable especially when he needs to bend over. He has also
had leakage of clear fluid from his paracentesis site from last
admission.
In the ED:
- Initial vital signs were notable for: T 98.5 HR 78 BP 115/67
RR
18 O2 98% RA
- Exam notable for: abdominal distention, diffuse TTP, no
rebound, scrotal swelling, BLE 2+ pitting edema
- Labs were notable for: Hgb 8.6, plt 78, INR 2.1, TBili 1.8,
Alb
2.4
- Studies performed include: RUQUS - cirrhosis, moderate
ascites,
CBD 1.0 cm similar to prior
- Patient was given: IV furosemide 80mg, acetaminophen 500mg
- Consults: Hepatology - insufficient ascites to tap, favor
increase in outpatient oral diuretics rather than IV diuresis,
recommend against empiric abx, favor discharge and outpatient
follow up
Vitals on transfer: HR 56 BP 101/57 RR 16 O2 96% RA
Upon arrival to the floor, he reports discomfort in his lower
abdomen into his back and worsening edema.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
EtOH Cirrhosis
Type II diabetes
Osteoarthritis
Tobacco abuse
Alcohol use disorder
Opioid use disorder
Social History:
___
Family History:
Father with a history of alcohol and polysubstance abuse.
Mother with a history of type II diabetes mellitus.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VITALS: T 97.7 BP 127/67 HR 61 RR 18 O2 100 Ra
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: MMM. 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.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
MSK: No spinous process tenderness. No CVA tenderness. 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.
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL EXAM
========================
VITALS: ___ 0720 Temp: 98.7 PO BP: 108/62 L Sitting HR: 72
RR: 18 O2 sat: 98% O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Scleral icterus.
CARDIAC: RRR, ___ systolic murmur, no rubs or gallops, no JVD
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: soft, BS+, abdominal distention, non-tender
throughout
EXTREMITIES: 1+ edema bilaterally up to knees with compression
stockings, dependent edema in thighs, scrotal swelling improved
with no TTP
SKIN: Warm. No rash.
NEUROLOGIC: AOx3, no asterixis, speech clear and fluent
Pertinent Results:
ADMISSION LABS
================
___ 12:40PM BLOOD WBC-3.4* RBC-2.83* Hgb-8.6* Hct-27.0*
MCV-95 MCH-30.4 MCHC-31.9* RDW-15.8* RDWSD-54.3* Plt Ct-78*
___ 12:40PM BLOOD Neuts-46.5 ___ Monos-12.9 Eos-2.1
Baso-0.6 Im ___ AbsNeut-1.58* AbsLymp-1.28 AbsMono-0.44
AbsEos-0.07 AbsBaso-0.02
___ 12:40PM BLOOD ___ PTT-32.9 ___
___ 12:40PM BLOOD Glucose-269* UreaN-9 Creat-0.9 Na-135
K-4.5 Cl-100 HCO3-30 AnGap-5*
___ 12:40PM BLOOD ALT-69* AST-68* AlkPhos-268* TotBili-1.8*
___ 12:40PM BLOOD Albumin-2.4* Calcium-8.2* Phos-2.4*
Mg-1.4*
___ 12:41PM BLOOD Lactate-1.6
DISCHARGE LABS
================
___ 06:10AM BLOOD WBC-3.8* RBC-2.75* Hgb-8.4* Hct-26.0*
MCV-95 MCH-30.5 MCHC-32.3 RDW-15.7* RDWSD-54.3* Plt Ct-79*
___ 06:10AM BLOOD ___ PTT-38.1* ___
___ 06:10AM BLOOD Glucose-147* UreaN-11 Creat-1.0 Na-138
K-4.2 Cl-97 HCO3-28 AnGap-13
___ 06:10AM BLOOD ALT-48* AST-61* AlkPhos-243* TotBili-2.3*
___ 06:10AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.6
PERTINENT IMAGING
===================
Liver/Gallbladder Ultrasound (___)
IMPRESSION:
1. Cirrhotic hepatic morphology with secondary signs of portal
hypertension, including patent paraumbilical vein, moderate
ascites and splenomegaly.
2. Patent portal vein with normal hepatopetal flow.
3. Mildly dilated common bile duct, measuring up to 1.0 cm,
similar to prior CT scan from ___.
Brief Hospital Course:
SUMMARY:
========================
___ yo man with T2DM, opioid use disorder on methadone, EtOH
cirrhosis (MELD 33) c/b portal HTN, grade II esophageal varices
s/p banding ___, ascites, and hepatic encephalopathy who
presents with 2 days of abdominal distention, worsening lower
extremity swelling and scrotal edema. Patient reported adherence
with home diuretics, however had significant response to
slightly higher doses of Lasix than home dose likely due to
outpatient sodium intake variation as a contributor. Patient
elected to leave against medical advice on ___ before his
discharge diuretic was finalized.
TRANSITIONAL ISSUES
======================
[ ] Please ensure patient is not using NSAIDS to help manage
chronic hip pain and consider additional work up of pain as
needed
[ ] Please follow up to ensure patient is not using alcohol and
help facilitate connection to community resources if amenable
[ ] Patient next requires ___ screening in ___
[ ] Please follow up patient glycemic control following
discharge given uncertainty of home regimen prior to admission.
Discharged on Lantus 20 U qAM.
[ ] Please weigh patient at next visit and adjust diuretic prn.
Discharged on Furosemide 60mg PO daily and Spironolactone 100mg
daily.
[ ] Please ensure patient follows up in liver clinic
[ ] Please ensure patient undergoes repeat endoscopy in 11 weeks
time to monitor for improvement in known ulcer
[ ] Please repeat chemistry on week of ___ or
___
___: ___
ACUTE ISSUES:
=============
# BLE/scrotal edema
# AMA
Presented with worsening scrotal and lower extremity edema
causing worsening discomfort. Discharged on PO furosemide 40mg
on ___ but inconsistent in reports about whether he was taking
this medication. TTE wnl ___. EKG wnl ___. During
admission, patient received IV Lasix and diuresed significantly.
Lasix was transitioned to PO 60mg and patient continued to
diurese and was negative several liters per day. Sodium
restriction was removed to reflect what patient's home diet is
mostly like and was continued on 60mg Lasix. Patient was
recommended to stay another day to monitor his response, however
patient elected to leave the hospital against medical advice on
___ before his diuretic dose could be finalized.
#EtOH cirrhosis
MELD-Na 33, Child's class C. Has history of hepatic
encephalopathy, not encephalopathic this admission. Patient was
continued on rifaximin and lactulose TID with goal of ___ BMs
per day. Has history of grade B varices, last seen on EGD
___ and history of variceal bleed. Pt was continued on
home propranolol this admission. Decompensated by ascites, with
last paracentesis ___ last admission with 2L fluid removed.
Patient was diuresed as above and continued on home
spironolactone. Continued on home thiamine, folic acid and
multivitamins.
CHRONIC ISSUES:
===============
# T2DM
Patient was hyperglycemic during this admission. Lantus was
uptitrated from 10U to 20U daily and was discharged with 20U
daily.
# CKD - Cr at baseline 0.9-1.0.
# Opioid use disorder - continued on methadone 15mg daily.
# EtOH use disorder - Last drink > 1 week ago per patient. Seen
by SW 1 week ago during admission, did not desire tx programs.
Was continued on thiamine this admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Lactulose 30 mL PO TID Daily BM
4. Methadone 15 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Propranolol 20 mg PO BID
8. Spironolactone 100 mg PO DAILY
9. Thiamine 100 mg PO DAILY
10. rifAXIMin 550 mg PO BID
11. Magnesium Oxide 200 mg PO DAILY
12. Phosphorus 500 mg PO QID
13. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Furosemide 60 mg PO DAILY
RX *furosemide 20 mg 3 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
2. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. FoLIC Acid 1 mg PO DAILY
4. Lactulose 30 mL PO TID Daily BM
5. Magnesium Oxide 200 mg PO DAILY
6. Methadone 15 mg PO DAILY
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Phosphorus 500 mg PO QID
10. Propranolol 20 mg PO BID
11. rifAXIMin 550 mg PO BID
12. Spironolactone 100 mg PO DAILY
13. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
-Volume Overload
-Decompensated alcoholic cirrhosis
SECONDARY DIAGNOSIS:
===================
Type II Diabetes
Alcohol Use Disorder
Opioid Use Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear. Mr. ___,
WHY WAS I HERE?
-You were admitted to the hospital with fluid in your legs and
in your scrotum.
WHAT HAPPENED WHILE I WAS HERE?
-You were given medications to help remove fluid from your body
WHAT SHOULD I DO WHEN LEAVING THE HOSPITAL?
-Please take all of your medications as prescribed
-Please limit the amount of sodium in your diet
-Continue to take your diuretics (water pills) and wear
compression stockings
-Please continue to avoid using Advil or any medication similar
to it ("NSAIDs") for pain given your recent stomach bleed. You
make Tylenol up to 2 grams a day if needed for pain.
-Please continue to follow up with your liver doctor and primary
care doctor
___ was a pleasure taking care of you at ___. We wish you the
best.
Followup Instructions:
___
|
19813574-DS-11
| 19,813,574 | 22,665,969 |
DS
| 11 |
2162-05-03 00:00:00
|
2162-05-03 16:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending: ___
Chief Complaint:
weakness and fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with Crohn's s/p colectomy and end ileostomy, cirrhosis and
presumed HCC, T2DM who presents with lethargy and AMS. For the
past week, he has experienced progressive fatigue and weakness.
He has had difficulty caring for himself at home, including
difficulty with his ostomy management. He feels that he has been
too tired to do anything and has been sleeping most of the day.
Reports chronic productive cough, no change recently. Denies
fevers, chills, sick contacts. Reports slow urination over the
past few months, but no dysuria or frequency. Poor PO intake
recently. Denies significant change in quantity of ostomy
output.
Notably, the patient was found to have a liver mass concerning
for HCC on CT and confirmed on subsequent abd MRI in ___. He
was seen in the liver clinic and was offered RF ablation,
however the patient decided that he did not want to pursue
further work-up or treatment for this mass given that it was not
bothering him. Patient has periodic imaging with CT and US over
the past few years which has shown that the mass is getting
larger with additional lesions noted to appear in the liver.
In the ED intial vitals were: 97.9 105 143/56 16 94%. Labs were
significant for AST/ALT 171/108 (above baseline), Tbili 3.9, AP
321, Cr 1.8 (baseline 1.3-1.4), lactate 3.1. CT chest showed
innumerable masses and lymphadenopathy. CT head unremarkable.
Patient was given no meds. Vitals prior to transfer were: 97.7
104 154/75 16 94% RA.
On the floor, patient continues to feel weak and tired, but has
no other complaints. He denies any pain or dyspnea.
Past Medical History:
- T2DM
- Alcoholic cirrhosis
- Known enlarging liver masses thought to be HCC, pt has
declined further work-up or treatment
- Ulcerative colitis - ___ wtih end ileostomy
- ___ fistulous tract noted on the stoma ?Crohn's
- GERD
- h/o malaria
- ___ peroneal resection
- cataract surgeries
Social History:
___
Family History:
Mother is deceased, age ___, stomach cancer
Father is deceased, age ___ "old age"
3 brothers, all deceased, one with cancer unknown type, one
brother had cirrhosis secondary to etOH and the other brother
had
an MI
One sister, deceased, Cancer of some type.
Physical Exam:
On admission:
Vitals- T 97.8 BP 166/85 HR 106 RR 20 SpO2 96/RA
General- Awake, alert
HEENT- Icteric sclera, Mildly dry MM
Lungs- CTAB
CV- RRR, no m/r/g
Abdomen- +BS, soft/NT/ND. Normal-appearing ostomy in the RLQ.
Ext- 2+ ___ edema to the knee bilaterally with chronic venous
stasis changes
Neuro- Awake, oriented and appropriate. No focal deficits.
On discharge:
Vitals- 98.0 116/46 82 18 93%RA
General- Awake, alert, oriented, appropriately interactive
HEENT- Icteric sclera, Mildly dry MM
Lungs- Crackles at bases bilaterally
CV- RRR, +systolic murmur
Abdomen- +BS, soft/NT/ND. Normal-appearing ostomy in the RLQ.
Ext- 2+ ___ edema to the knee bilaterally
Pertinent Results:
==================
Labs:
==================
___ 01:30AM BLOOD WBC-8.0 RBC-4.02* Hgb-12.3* Hct-40.2
MCV-100* MCH-30.5 MCHC-30.5* RDW-17.2* Plt ___
___ 09:00AM BLOOD WBC-6.1 RBC-3.97* Hgb-12.1* Hct-39.5*
MCV-99* MCH-30.6 MCHC-30.8* RDW-16.9* Plt ___
___ 01:30AM BLOOD Neuts-78* Bands-0 Lymphs-15* Monos-6
Eos-1 Baso-0 ___ Myelos-0
___ 01:30AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-3+ Microcy-NORMAL Polychr-NORMAL
___ 01:30AM BLOOD ___ PTT-30.9 ___
___ 09:00AM BLOOD ___ PTT-31.0 ___
___ 09:00AM BLOOD Glucose-113* UreaN-31* Creat-1.8* Na-143
K-4.7 Cl-106 HCO3-25 AnGap-17
___ 01:30AM BLOOD ALT-108* AST-171* AlkPhos-321*
TotBili-3.9*
___ 09:00AM BLOOD ALT-101* AST-141* LD(LDH)-320*
AlkPhos-308* TotBili-3.9* DirBili-2.4* IndBili-1.5
___ 01:30AM BLOOD Lipase-17
___ 01:30AM BLOOD Albumin-2.9* Calcium-9.7 Phos-3.1 Mg-2.1
___ 09:00AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0
___ 01:41AM BLOOD Lactate-3.1*
==================
Micro:
==================
___ 1:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 5:58 pm URINE Source: ___.
URINE CULTURE (Pending):
==================
Imaging:
==================
CT CHEST W/O CONTRAST Study Date of ___ 2:10 AM
IMPRESSION:
1. Innumerable pulmonary masses consistent with metastases,
most likely from metastatic HCC. There is also mediastinal and
hilar lymphadenopathy.
2. Cirrhosis of the liver with what appears to be a large mass
involving a significant portion of the right hepatic lobe,
partially visualized and not fully evaluated due to lack of IV
contrast.
3. Moderate perihepatic and perisplenic ascites.
CHEST (PA & LAT) Study Date of ___ 1:52 AM
IMPRESSION: Multiple masses throughout the lungs bilaterally
consistent with metastases.
CT HEAD W/O CONTRAST Study Date of ___ 1:31 AM
FINDINGS: There is no evidence of acute hemorrhage, edema,
mass, mass effect or acute territorial infarction. The
ventricles and sulci are prominent consistent with atrophy.
There are periventricular ___ matter hypodensities consistent
with the sequelae of chronic small vessel ischemic disease.
There is a small amount of fluid in the left sphenoid sinus,
otherwise the visualized paranasal sinuses and mastoid air cells
are well aerated.
IMPRESSION: No acute intracranial process.
ECG Study Date of ___ 1:42:08 AM
Consider multifocal atrial tachycardia and occasional
ventricular ectopy. Left bundle-branch block. Compared to the
previous tracing of ___ multifocal atrial tachycardia and
occasional ventricular ectopy is recorded.
Brief Hospital Course:
___ with cirrhosis and presumed HCC - not treated, Crohn's s/p
colectomy and end ileostomy, T2DM who presents with lethargy and
weakness now found to have innumerable masses in the lungs,
likely metastatic disease.
#Likely metastatic cancer, lung nodules on CT: Pt with weight
loss as well as increasing fatigue and lethargy. No pain
reported. ___ likely primary given known liver mass many years
ago which was suggestive of ___ on MRI. Now with elevated
transaminases and bilirubin with jaundice. No focal neuro
deficits or lesions on CT to suggest metastatic disease to
brain. Overall low suspicion for infection contributing to
symptoms. UA unremarkable. C diff sent given loose stools. Pt
refused RUQ ultrasound, and indicated he did not want further
imaging, or aggressive workup or treatment. Palliative care saw
patient, and patient and family opted for home hospice care.
___, likely pre-renal: Likely the result of poor PO intake
given decreased appetite. Received IV fluids during admission.
Home lisinopril, lasix, and glyburide were discontinued and not
restarted on discharge given poor prognosis and goals of care.
#HTN: As per above, lisinopril and lasix were held on admission
given ___ not restarted given poor prognosis and goals of care.
#T2DM: Home glyburide held in setting ___ and not restarted
given poor prognosis and goals of care. Treated with insulin
sliding scale during admission.
#Crohn's s/p colectomy: Stable, not any home meds. Given loose
stools, c diff was sent.
Transitional issues:
-follow up c diff, treat if returns positive
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tylenol-Codeine #4 (acetaminophen-codeine) 300-60 mg oral qHS
2. Furosemide 40 mg PO DAILY
3. GlyBURIDE 2.5 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. LOPERamide 2 mg PO BID:PRN diarrhea
7. Multivitamins 1 TAB PO DAILY
8. urea 25 % topical daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN pain
RX *acetaminophen 325 mg 1 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
2. Tylenol-Codeine #4 (acetaminophen-codeine) 300-60 mg oral qHS
3. LOPERamide 2 mg PO BID:PRN diarrhea
4. TraZODone 25 mg PO HS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth hs Disp
#*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary: metastatic cancer presumed from ___
secondary: UC, cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You came to the hospital because of weakness and weight loss.
You had a CT scan which showed that the cancer has progressed
and this is likely what is causing you to feel weak and have
little appetite. We had a long talk and you made it clear you
wanted no more imaging or workup to be done. We spoke with your
primary care doctor who recommended that we remove all of the
unnecesary medications. There was a family meeting and the
decision was for you to go home with your family and have what
is called home hospice, where a nurse ___ come in to care for
you weekly.
Followup Instructions:
___
|
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| 19,813,794 | 23,203,623 |
DS
| 25 |
2155-05-11 00:00:00
|
2155-05-11 14:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
swollen legs
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: ___ with h/o CHF, COPD, DM with
worsening shortness of breath and edema. Pt states syx have been
going on for a number of days. Diuretic dose was doubled 10 days
ago, no improvement in syx so pcp sent him to ED for admission.
SOB worse with walking, laying flat, bending over. Also has
cough productive of yellow sputum. Also reports "kidney pain" in
the AM. Denies fevers, chills, N/V, diarrhea, consitpation. Has
occasional abdominal soreness. ___ edema is chronic but worse
than usual, especially on the left.
I spoke with the patient and his sign language interpreter who
has been with him for ___ years. Per the interpreter, the patient
went to his doctor for swollen legs. He denied pain, discomfort,
or any other symptoms. Per the interpreter, the docter has
recently tried increasing torsemide dose, but to no avail. The
patient was sent for admission for diuretic therapy.
On speaking with the patient, he denies any difficulty breathing
at an angle, but states that he becomes SOB on laying flat. He
has a nasal cannula in place which he states he does not use at
home and it is helping him right now. He denies any pain or
discomfort. He states that he has been trying to urinate all
day, but has been unable to do so. He states that he feels
distended. He states that this happened once in the past, and
they straight cathed him to relieve him. He otherwise is doing
well and is proud to report this his ___ birthday is on
___. He has a normal appetite and feels fine otherwise.
.
In the ED, initial vitals were 96.8 62 119/70 20 93%. Labs
notable for BNP 7466 (baseline ___, creatinine 2.2 (baseline
1.7-2.0), BUN 56, INR 2.0, lactate 1.9. CXR showed (my read)
bilateral pulmonary edema, significantly increased from prior.
ECG showed v-pacing at 60bpm, left axis, no concerning ST/T
changes. He was given 20mg IV lasix. Most recent vitals:
98.2po, 68, 123/64, 13, 94% 2L NC.
.
Cardiac review of systems is notable for dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema.
.
Past Medical History:
-Type 2 Diabetes Mellitus, diet controlled
-Hypertension
-Hyperlipidemia
-Coronary Artery Disease
-CHF EF 40-45% in ___
-Atrial arrhythmias/PAF, not on anticoagulation
-CKD (Baseline creatinine 1.5)
-Chronic Obstructive Pulmonary Disease
-H/O Pulmonary Nodule: Stable right middle lobe and diffuse
nodules followed on serial CT scans
-DVT
-Lymphedema
-Senorineural Hearing Loss since age ___ (adept at sign language
-and can read lips when you speak very slowly)
-Chronic venous stasis with recurrent cellulitis
-Osteoarthritis
-Cataracts ___
-BPH s/p TURP
Social History:
___
Family History:
Father and Mother died of MI (unknown age).
Physical Exam:
On admission:
VS: T= 96 BP= 141/84 HR= 66 RR= 22 O2 sat= 100 on 2L
GENERAL: NAD.Very pleasant. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: diminished at the bases, difficult to take full
inspirations, some crackles bilaterally.
ABDOMEN: very distended but soft, NTTP, no masses, no rebound or
guarding
EXTREMITIES: extremely edematous legs bilaterally, greater in
left leg, with severe stasis dermatitis on shins. Edema extends
to buttocks area and included testicles, penis, and groin area.
Pitting. Pulses unappreciable but legs are warm and well
perfused. No tenderness on pressing.
.
On Discharge:
VS: Tm= 98.6, 65, 102/52, 22, 93 RA
I/O- 24 hr: 1169/3200 net negative 2 liters
weight 81.7 KG(90kg on admission)
GENERAL: NAD.Very pleasant. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: diminished at the bases, difficult to take full
inspirations, some crackles bilaterally.
ABDOMEN: very distended but soft, NTTP, no masses, no rebound or
guarding
EXTREMITIES: leg edema improving bilaterally, greater in left
leg, with severe stasis dermatitis on shins. Legs are warm and
well perfused. No tenderness on pressing.
Pertinent Results:
On admission:
___ 03:30PM BLOOD WBC-5.8 RBC-4.08* Hgb-12.6* Hct-39.7*
MCV-97 MCH-30.8 MCHC-31.7 RDW-17.4* Plt ___
___ 03:30PM BLOOD Neuts-77.2* Lymphs-15.8* Monos-4.2
Eos-1.7 Baso-1.1
___ 03:30PM BLOOD ___ PTT-30.0 ___
___ 01:51PM BLOOD UreaN-55* Creat-2.1* Na-143 K-4.5 Cl-105
HCO3-31 AnGap-12
___ 06:00AM BLOOD ALT-15 AST-21 CK(CPK)-44* AlkPhos-85
TotBili-0.9
___ 06:00AM BLOOD Albumin-3.6 Calcium-9.1 Phos-4.1 Mg-2.4
.
Cardiac ECHO
The left atrium is markedly dilated. The left atrium is
elongated. The right atrium is markedly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is moderately depressed
(LVEF= ___. The right ventricular cavity is moderately
dilated with moderate global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Mild to moderate (___)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric LVH. Global left ventricular
hypokinesis (the septum is near-akinetic). The right ventricle
is moderately dilated with moderate hypokinesis, evidence of
pressure-volume overload and moderate pulmonary artery
hypertension. Mild to moderate mitral regurgitation.
Compared with the prior report of ___, biventricular function
has worsened. The right ventricle is more dilated (may have been
mildly so on prior). The degrees of mitral regurgitation and
pulmonary hypertension have increased.
.
Renal U/S.
IMPRESSION:
1. Bilateral renal cysts. No hydronephrosis.
2. Collapsed bladder with Foley catheter in situ.
3. Trace Ascites.
.
PA and Lateral CXR
IMPRESSION: New moderate-to-large right pleural effusion with
bibasilar
atelectasis. Mild pulmonary vascular engorgement.
.
Regular ventricular pacing with probable underlying atrial
fibrillation.
Compared to the previous tracing of ___ ventricular pacing
is now present.
Read by: ___.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
60 0 ___ 0 0 0
.
Discharge labs:
___ 08:10AM BLOOD WBC-6.0 RBC-4.02* Hgb-12.2* Hct-38.7*
MCV-96 MCH-30.4 MCHC-31.6 RDW-17.6* Plt ___
___ 08:10AM BLOOD ___
___ 08:10AM BLOOD Glucose-104* UreaN-56* Creat-1.8* Na-145
K-3.7 Cl-103 HCO3-32 AnGap-14
___ 08:10AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.4
Brief Hospital Course:
Patient was admitted from PCP for swollen legs to the groin,
distended abdomen, and other signs/symptoms of CHF
.
#CHF- patient was initially started on IV lasix, but his urine
output response was not aggressive enough for what our goals
were. The patient was then started on a lasix drip. The patient
was having urinary retention symptoms, and on admission, was
straight cathed and put out 900cc urine. He was unable to void
on his own. The decision was made to give the patient a foley.
On looking back at his previous admissions, the patient has had
foleys placed for urinary retention, with follow up as an
outpatient. The patient diuresed well with IV lasix. The patient
was also started on spironolactone to help with the diuresis.
The patient was admitted with a weight of 90KG and left with a
weight of 81.7 KG. The patient was sent with a torsemide dose
of 60 BID and a foley in place, and is to follow up with his
PCP, ___, and his cardiologist
.
#Urinary retention - the patient was given a foley catheter for
urinary retention. Urology was consulted for the patient and
they told us to give him a size 22 foley. The patient initially
had some hematuria with the foley, but urology stated that this
is to be expected for someone of this age. The patient had one
episode of clot in his foley. It was irrigated and the problem
did not return. The patient was given a size 22 foley and
discharged with follow up with urology later this week.
.
#CAD/HTN - the patient was continued on his home meds and
maintained adequate blood pressure. The patient had
spironolactone added to his regimen to aid with heart failure
management
.
#CKD - The patient's creatinine was monitored during diuresis.
His creatinine remained stable at his baseline level throughout
his admission. No interventions were required
.
#Chronic AFIB - given the patient's fall risk ,the patient is on
aspirin rather than coumadin. We continued the patient's aspirin
dose.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs(s) Four times daily as needed for COUGH or WHEEZING
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth daily
DIABETIC SNEAKERS - - As directed Daily Pt with DM, peripheral
neuropathy and peripheral vascular disease
FINASTERIDE [PROSCAR] - 5 mg Tablet - one Tablet(s) by mouth
daily
ISOSORBIDE DINITRATE - 40 mg Tablet Extended Release - 1
Tablet(s) by mouth daily
___ T. E.D ANTI EMBOLISM 100% LATEX FREE - (Not
Taking as Prescribed: per VN pt does not wear in the summer) -
- As directed Daily Fax: 1 ___ Patient with PVD,
venous stasis
LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth daily
METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth twice daily
METRONIDAZOLE - 0.75 % Cream - Apply to affected skin Once or
twice daily
NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - 1
Tablet(s) sublingually every five(5) minutes as needed for chest
pain.
POLYETHYLENE GLYCOL 3350 - 17 gram/dose Powder - 1 cap by mouth
daily
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth Daily -
evening
is preferable
TAMSULOSIN - 0.4 mg Capsule, Ext Release 24 hr - one Capsule(s)
by mouth daily
TORSEMIDE - 20 mg Tablet - ___ Tablet(s) by mouth once a day
ACETAMINOPHEN - (Prescribed by Other Provider: ___
discharge meds) - 500 mg Tablet - 1 Tablet(s) by mouth every six
hours as needed for pain Do not take more than 3 grams daily.
AMMONIUM LACTATE [AMLACTIN] - 12 % Lotion - Apply to affected
skin Twice daily
ASPIRIN, BUFFERED [BUFFERIN] - (OTC) - 325 mg Tablet -
Tablet(s)
by mouth
.
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation three times a day as needed for shortness of
breath or wheezing.
2. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. isosorbide dinitrate 40 mg Tablet Extended Release Sig: One
(1) Tablet Extended Release PO DAILY (Daily).
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. metronidazole 1 % Gel Sig: One (1) Appl Topical BID (2 times
a day) as needed for affected area.
8. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
9. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
11. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
12. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
14. torsemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Acute systolic CHF exacerbation
Urinary retention - secondary to BPH
.
Secondary Diagnoses:
Central retinal vein and artery occlusion right eye.
Chronic kidney disease
Hx of chronic venous stasis, recurrent left leg cellulitis
Remote DVT
COPD
Hx of stable pulmonary nodules
Hx of lymphedema left leg
Arthritis
Cataracts
BPH s/p TURP
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___, you came to us because your primary care physician
was concerned with the amount of fluid you were retaining in
your body. When you arrived to our service, your legs were very
swollen and the swelling extended up to the upper thighs and
groin area. Your abdomen was also filled with fluids. This fluid
accumulation was due to your heart failure. We were able to
determine that you have been having difficulty urinating for
some time. When you came to our service, your bladder was
retaining almost one liter of fluid, and you were unable to
clear the fluids. We decided to put a foley catheter into your
bladder to drain the fluid. You will be sent home with the foley
catheter. You will need to follow up with urologists for care of
this foley.
Weigh yourself every morning, call Dr. ___ weight goes up
more than 3 lbs.
The following changes have been made to your medications:
-Start spironolactone 25mg daily
-Increase Torsemide to 60mg twice daily
Followup Instructions:
___
|
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| 19,813,794 | 29,978,568 |
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| 26 |
2156-08-30 00:00:00
|
2156-08-30 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:
cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with hx of pneumonia, copd, CHF, pacer, afib, CKD
here with cough.
Pt is deaf and signs, son at bedside interpreting.
Pt developed a cold about a week ago with intermittent coughing.
However, yesterday he had poor appetite and increase in cough.
He developed thick yellow sputum that was quite profuse with
coughing and nasal drainage. Pt also began to have shortness of
breath, severe with walking, present also at rest. pt denies
CP, palp. pt became quite weak and could not get up unassisted
and therefore family called EMS.
Pt reports that he is feeling much better with the oxygen on and
is already coughing less. denies n/v/d, denies changes to
chronic ___ edema.
In regards to COPD hx, breathing greatly improved with use of
spiriva over the past year. has been given steroids with
pneumonia in the past, never exascerbated without infection.
ROS - 10 systems reviewed and are negative except for arthritis
pain with weather changes
Past Medical History:
-Type 2 Diabetes Mellitus, diet controlled
-Hypertension
-Hyperlipidemia
-Coronary Artery Disease
-CHF EF 40-45% in ___
-Atrial arrhythmias/PAF, not on anticoagulation
-CKD (Baseline creatinine 1.5)
-Chronic Obstructive Pulmonary Disease
-H/O Pulmonary Nodule: Stable right middle lobe and diffuse
nodules followed on serial CT scans
-DVT
-Lymphedema
-Senorineural Hearing Loss since age ___ (adept at sign language
-and can read lips when you speak very slowly)
-Chronic venous stasis with recurrent cellulitis
-Osteoarthritis
-Cataracts ___
-BPH s/p TURP
Social History:
___
Family History:
Father and Mother died of MI (unknown age).
Physical Exam:
Vitals:afeb 77 120/61 24 94% 4LNC
Cons: NAD, lying in bed
Eyes: PERRL, EOMI, no sclera icterus
ENT: MMM, +roseacea changes
Neck: nl ROM, no goiter
Lymph: no cervical LAD
Cardiovasc: rrr, distant heart sounds, mild ___ edema, left worse
than right, chronic per pt
Resp: decreased BS at bases, no crackles, +upper airway
congestion, no resp distress, but prolonged exp phase and mildly
tachynpic
GI: +bs, soft,nt, mildly distended
MSK: mild kyphosis noted
Skin: no rashes but severe B venostasis changes ___
Neuro: no facial droop
Psych: normal range of affect, very pleasant
Pertinent Results:
___ 06:15AM GLUCOSE-203* UREA N-52* CREAT-1.8* SODIUM-142
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-27 ANION GAP-17
___ 06:27AM LACTATE-1.8
___ 06:15AM ___ PTT-29.0 ___
___ 06:15AM PLT COUNT-162
___ 06:15AM NEUTS-91.5* LYMPHS-4.1* MONOS-4.0 EOS-0.1
BASOS-0.4
___ 06:15AM WBC-13.2*# RBC-3.98* HGB-13.2* HCT-41.2
MCV-104* MCH-33.1* MCHC-32.0 RDW-14.7
___ 06:15AM CK-MB-3 ___
___ 06:15AM cTropnT-0.10*
___ 06:15AM estGFR-Using this
Brief Hospital Course:
CXR: I personally viewed pts CXR and I find: CM, +pulm edema,
RLL infiltrate
___ male with copd, CHF here with cough, SOB and found to have
pneumonia.
Pt did well throughout his hospitalization and quickly improved.
He is returning to home with his wife and will have ___ visiting
home RN set up as well.
Pneumonia-
--treat with oxygen, levofloxacin
--pt did quite well clinically with improvement in his shortness
of breath, decrease in cough, improvement in appetite.
--he was initially on 2 L oxygen and this was weaned off
--he continued to have some cough which is expected givne his
pneumonia.
COPD-
--treat for acute exascerbation in setting of pneumonia
--spiriva, albuterol nebs
--prednisone 40 qd-will give a burst of 5 days total
acute on chronic systolic heart failure exascerbation
--exacerbation noted due to pulm edema on CXR
--BNP elevated from baseline as well
--pt feeling well on home meds, no crackles on exam, satting
well, ___ edema at baseline
CKD-
Cr at baseline around ___
monitor, avoid toxins
CAD, pacer, HL-- chronic issues, continued home meds
afib- rate controlled at this time, pt not on anticoag
coagulopathy with chronically elevated INR, no intervention at
this time
DM, diet controlled-- pt has somewhat elevated BS, but will not
require home insulin
BPH- continue home meds
OA, chronic venostasis changes-at baseline
I spoke with pt and son about code status, full code at this
time
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB
3. Isosorbide Dinitrate ER 40 mg PO DAILY
Do not crush
4. Metoprolol Tartrate 12.5 mg PO BID
5. Simvastatin 20 mg PO HS
6. Spironolactone 25 mg PO DAILY
7. Tiotropium Bromide 1 CAP IH DAILY
8. tamsuLOSIN *NF* 0.4 mg Oral daily
9. Torsemide 20 mg PO BID
10. Aspirin 325 mg PO DAILY
11. Vitamin D ___ UNIT PO DAILY
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Senna 1 TAB PO BID
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Finasteride 5 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Isosorbide Dinitrate ER 40 mg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO BID
7. Senna 1 TAB PO BID
8. Simvastatin 20 mg PO HS
9. Spironolactone 25 mg PO DAILY
10. tamsuLOSIN *NF* 0.4 mg Oral daily
11. Tiotropium Bromide 1 CAP IH DAILY
12. Torsemide 20 mg PO BID
13. Vitamin D ___ UNIT PO DAILY
14. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q6H:PRN
cough
15. Levofloxacin 500 mg PO Q24H
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth daily
Disp #*3 Tablet Refills:*0
16. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
17. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB
18. Allopurinol ___ mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
pneumonia with also mild copd exascerbation
also has heart failure, copd, afib
Discharge Condition:
improved
Discharge Instructions:
return to your regular home routine, but take it easy for a few
days with lots of rest.
Be sure to get plenty of rest as you recover from the pneumonia
Continue the antibiotic (levaquin) once a day until gone (3 more
days)
Continue the prednisone for tomorrow morning and then it is
finished
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
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2157-03-10 15:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
flank / abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ gentleman with CAD s/p CABG, CHF w/ EF
40-45%, paroxysmal afib, CKD, COPD, BPH s/p TURP, and recurrent
urinary retention who presents with flank and abomdinal pain.
Pt. ___ night of admission with significant b/l flank pain.
The pain then radiated around to his abdomen and into his limbs
as well. Pt. frequently has flank pain in the morning that is
relieved by voiding. He has a history of urinary retention
requiring foley at one time. He actually has straight catheters
for use at home but rarely uses them. Pt. also reports
constipation with no BM in 2 days, though he is passing gas.
Pt. denies fevers, night sweats, chills. Of note, he was seen in
the ED due to mechanical fall last week - CT head was negative.
On arrival to the ED, 98.4 57 125/68 18 93% RA. CT
Chest/Ab/Pelvis showed no acute intrabdominal pathology. It did,
however, incidentally note a left lower lobe mass and persistent
lung nodules. Pt. was given morphine, 500cc fluid, and admitted
to the floor.
On arrival to the floor, pt. was comfortable. Bladder scan
demonstrated 1000cc of retained urine. He was easily straight
catheterized with good relief.
ROS:
(+) per HPI; constipation; urinary retention; ab and flank pain
(-) fevers, night sweats chills, changes in weight, HA, nausea,
vomiting, diarrrhea, dysuria, hematuria
Past Medical History:
-Type 2 Diabetes Mellitus, diet controlled
-Hypertension
-Hyperlipidemia
-Coronary Artery Disease
-CHF EF 40-45% in ___
-Atrial arrhythmias/PAF, not on anticoagulation
-CKD (Baseline creatinine 1.5)
-Chronic Obstructive Pulmonary Disease
-H/O Pulmonary Nodule: Stable right middle lobe and diffuse
nodules followed on serial CT scans
-DVT
-Lymphedema
-Senorineural Hearing Loss since age ___ (adept at sign language
-and can read lips when you speak very slowly)
-Chronic venous stasis with recurrent cellulitis
-Osteoarthritis
-Cataracts ___
-BPH s/p TURP
Social History:
___
Family History:
Father and Mother died of MI (unknown age).
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS - 97.4, 61, 132/76, 95 on RA
Gen - elderly but pleasant gentleman lying in bed comfortable in
NAD
HEENT - head atraumatic; MMM; neck supple
CV - RRR; no m/r/g
Pulm - breathing comfortably; moving air well; wheezing
throughout all lung fields b/l
Ab - soft; distended; nontender; normoactive bowel sounds; no
HSM appreciated
Ext - 2+ pitting edema to knees b/l; signs of chronic venous
stasis including hyperpigmentation, lichenification
DISCHARGE PHYSICAL EXAM:
========================
VS - 98.5 101/56 66 22 100% on 3L
Gen - elderly pleasant gentleman lying in bed, NAD
HEENT - MMM
CV - RRR; no m/r/g
Pulm - Ronchorous breath sounds bilaterally, but no crackles
appreciated. No wheeze
Ab - soft non-tender; less distended than yesterday, +BS; mild
TTP over left rib cage today; no hematoma obvious
GU - foley in placed draining clear yellow urine
Ext - 2+ pitting edema to knees b/l, appears improved from
prior, signs of chronic venous stasis including
hyperpigmentation, lichenification
Pertinent Results:
ADMISSION LABS:
===============
___ 03:55AM BLOOD WBC-7.5 RBC-3.89* Hgb-13.1* Hct-40.8
MCV-105* MCH-33.5* MCHC-32.0 RDW-15.8* Plt ___
___ 03:55AM BLOOD Neuts-79.5* Lymphs-12.1* Monos-6.2
Eos-1.2 Baso-1.0
___ 03:56PM BLOOD UreaN-79* Creat-3.5*# Na-137 K-5.4*
Cl-101 HCO3-23 AnGap-18
___ 03:59AM BLOOD Lactate-1.5 K-5.4*
PERTINENT LABS:
===============
___ 01:15PM BLOOD ___
___ 03:15PM BLOOD WBC-11.4* RBC-3.48* Hgb-11.6* Hct-36.9*
MCV-106* MCH-33.2* MCHC-31.4 RDW-16.0* Plt ___
___ 03:15PM BLOOD Neuts-91.1* Lymphs-3.9* Monos-4.4 Eos-0.3
Baso-0.3
___ 06:33AM BLOOD Glucose-119* UreaN-88* Creat-2.4* Na-136
K-5.4* Cl-101 HCO3-24 AnGap-16
PERTINENT IMAGING:
==================
CT Chest/Abd/Pelvis (___):
IMPRESSION:
1. No evidence of traumatic injury to the spine, solid organs
or ribs
2. 3.4 cm left lower lobe mass concerning for primary
malignancy. Additional scattered 4 mm nodules.
3. Atherosclerotic disease and severely enlarged heart.
CXR (___):
IMPRESSION:
1. Worsening bibasilar opacities, suggestive of aspiration or
atlectasis
given rapid change from recent CT of ___.
2. Stable pulmonary vascular congestion and interstitial edema.
3. Small bilateral pleural effusions.
Abdomen XR (___):
IMPRESSION: Nonobstructive bowel gas pattern with mild gaseous
distention of the stomach and moderate amount of stool
throughout the colon.
CXR portable (___):
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Moderate cardiomegaly. Tortuosity of the thoracic
aorta. Small
bilateral pleural effusions and mild-to-moderate pulmonary
edema. Unchanged alignment of sternal wires and clips of the
CABG. Left pectoral pacemaker is unchanged.
CXR PA + Lateral (___):
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. The severity of pulmonary edema has minimally
decreased. Unchanged massive cardiomegaly. Calcified thoracic
aorta. Sternal wires in situ. Likely small right pleural
effusion with right basal atelectasis. Calcified descending
aorta. The left pectoral pacemaker is constant in appearance.
PERTINENT MICRO:
================
___ 12:32 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS:
===============
___ 06:33AM BLOOD WBC-7.9 RBC-3.53* Hgb-11.5* Hct-37.1*
MCV-105* MCH-32.5* MCHC-30.9* RDW-15.6* Plt ___
___ 06:33AM BLOOD Glucose-119* UreaN-88* Creat-2.4* Na-136
K-5.4* Cl-101 HCO3-24 AnGap-16
___ 06:33AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.4
Brief Hospital Course:
Mr. ___ is a ___ gentleman with CAD s/p CABG, CHF w/ EF
40-45%, paroxysmal afib, CKD, COPD, BPH s/p TURP, and recurrent
urinary retention who presents with urinary retention and new L
sided mass concerning for cancer.
ACTIVE ISSUES:
==============
# Pulmonary mass:
Nodules seen on prior imaging, though left lower mass is new on
imaging and concerning for malignancy. Pt. does not have
significant smoking history. Patient informed of mass and
indicated that he would not want surgery or chemotherapy. After
significant discussion with son and pt. about risks of biopsy
esp. if no treatment would occur, it was decided not to biopsy
and to pursue palliative care. Outpatient palliative care
follow-up was arranged, and the patient was discharged to a SNF
with a new Rx for home oxygen.
# Urinary retention:
Likely source of flank and abdominal pain given 1000cc urine on
bladder acan and hx of BPH s/p TURP and chronic urinary
retention. Pt. has had difficulties with urinary retention for
the past year and has even been prescribed straight caths at
home. Unfortunately, it does not seem he has been using his
straight caths at home given his significant retention on
admission to the floor. Cause of urinary retention is unclear.
Most likelyy due to BPH as he is already on finasteride and
furosemide and CT confirmed enlarged prostate. Urethral
obstruction less likely given ease of foley placement. No signs
of cord compression as sensation and mobility intact per son's
report. Constipation may also be exacerbating retention. Foley
placed on admission with good effect. The patient was
discharged to a SNF with a foley in place, and outpatient
urology follow-up was arranged.
# A-on-CKD:
Likely due to combination of urinary retention and hypovolemia
given poor PO and sig post-obstructive diuresis. His Cr
improved from 3.5 to 2.3 with foley placement and PO hydration.
He was also diuresed for a CHF exacerbation and his Cr bumped to
2.8; diuresis was held and his Cr trended back down to 2.4 at
discharge. His home torsemide 20 mg PO BID was restarted at
discharge.
# Pneumonia
Given intermittent hypoxemia and SOB, cough productive of tan
sputum, and new RLL infiltrate on CXR, patient was started on
Levofloxacin 500 mg Q48H (renally dosed) for a total of 7 days
of antibiotics. His cough and respiratory status improved with
ABx and his WBC downtrended.
# CHF exacerbation
Patient was intermittently hypoxemic on this admission to the
low ___ on 3L, whereas he had previously not been on oxygen.
BNP was 23,000 on ___, CXR w/ pulmonary edema, worsening ___
edema and ronchorous breath sounds. He was diuresed and put out
well with IV Lasix. Diuresis was stopped when his Cr bumped to
2.8. His respiratory status improved and at discharge he was
satting 100% on 3L NC. He was provided with compression
stockings to alleviate ___ edema, and was instructed to keep his
legs elevated when in chair.
# Constipation:
Patient experiences chronic constipation, which was thought to
be contributing to his abdominal pain on admission. He was
continued on an aggressive bowel regimen and was given including
miralax, lactulose, bisacodyl suppositories, and a tap water
enema. Manual disimpaction was attempted, but there was no
stool in the rectal vault. KUB revealed stool higher up in the
colon. He finally had a large bowel movement after receiving PO
Magnesium Citrate, and was discharged with a new Rx for weekly
magnesium citrate.
CHRONIC ISSUES:
===============
# COPD:
Pt. with significant wheezing on admission. He was continued on
home spiriva and started on Advair as well as albuterol
nebulizers. He required nebulizers intermittently throughout
this hospitalization, and by discharge his respiratory status
had improved significantly.
# PACEMAKER:
Patient missed his outpatient pacemaker check for ___
___ ___ being hospitalized. EP interrogated his
pacemaker in-house and found no abnormalities; 3 month follow-up
in device clinic was recommended and arranged.
# CAD s/p CABG and CHF:
Continued home ASA, metoprolol, torsemide, and simvastatin.
Spironolactone initially held given hyperkalemia; this was
restarted prior to discharge
TRANSITIONAL ISSUES:
====================
- Patient will need to have a potassium level checked on ___ to
ensure it is not uptrending (was 5.4 at discharge)
- Patient started on once weekly Magnesium Citrate for chronic
constipation, with an addittional PRN Rx for interval
constipation during the week
- Patient is being discharged with a foley for urinary retention
and will require routine foley care. Urology follow-up was
arranged.
- Outpatient palliative care follow-up was set up regarding the
patient's lung mass that likely represents a primary malignancy.
Patient and family aware and elected not to pursue further
diagnosis or treatment.
- Patient discharged on levofloxacin for a total of a 7 day
course of ABx for PNA.
- Please coordindinate follow-up with the patient's new PCP, ___.
___ at ___ to establish care.
- It is unclear if the patient will need home O2 long-term; if
his oxygen stauration tolerates, he may be weaned off.
- Ongoing discussion with PCP regarding utility of repeat
imaging for lung mass
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Finasteride 5 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Isosorbide Dinitrate ER 40 mg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO BID
7. Senna 1 TAB PO BID
8. Spironolactone 25 mg PO DAILY
9. tamsuLOSIN 0.4 mg Oral daily
10. Tiotropium Bromide 1 CAP IH DAILY
11. Torsemide 20 mg PO BID
12. Vitamin D ___ UNIT PO DAILY
13. Allopurinol ___ mg PO DAILY
14. Nitroglycerin SL 0.3 mg SL PRN chest pain
15. Simvastatin 10 mg PO HS
16. Acetaminophen 500 mg PO Q6H:PRN pain
17. Polyethylene Glycol 17 g PO DAILY constipation
18. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
19. naftifine 1 % topical daily
20. mineral oil-hydrophil petrolat topical twice daily
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
8. Isosorbide Dinitrate ER 40 mg PO DAILY
9. Metoprolol Tartrate 12.5 mg PO BID
10. Polyethylene Glycol 17 g PO DAILY constipation
11. Senna 1 TAB PO BID
12. Simvastatin 10 mg PO HS
13. Spironolactone 25 mg PO DAILY
14. tamsuLOSIN 0.4 mg Oral daily
15. Tiotropium Bromide 1 CAP IH DAILY
16. Vitamin D ___ UNIT PO DAILY
17. mineral oil-hydrophil petrolat 0 dose TOPICAL TWICE DAILY
18. naftifine 1 % topical daily
19. Nitroglycerin SL 0.3 mg SL PRN chest pain
20. Torsemide 20 mg PO BID
21. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
2 puffs twice daily
RX *budesonide-formoterol [Symbicort] 80 mcg-4.5 mcg/actuation 2
puffs inhalation twice daily Disp #*1 Inhaler Refills:*5
22. Bisacodyl 10 mg PR HS:PRN constipation
Take this medication daily if you have not had a large bowel
movement that day.
RX *bisacodyl 10 mg 1 suppository(s) rectally at bedtime Disp
#*30 Suppository Refills:*5
23. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
24. Levofloxacin 750 mg PO Q48H Duration: 7 Days
First dose was on ___ at 5pm
25. Magnesium Citrate 300 mL PO 1X/WEEK (TH)
If not having regular bowel movements.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Post-Obstructive nephropathy, Acute kidney
injury
Secondary Diagnosis: acute diastolic CHF exacerbation, BPH,
Diabetes, new lung mass suspicious for malignancy
Discharge Condition:
Mental Status: Clear and coherent, but demented (significant
short term memory loss).
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Walks only a short distance.
Discharge Instructions:
Dear Mr. ___,
It was a true pleasure to take care of you during this admission
and I'm glad we are able to get you back to your wife. You came
in with bladder obstruction which caused kidney injury. While
you were here we placed a foley catheter into your bladder to
allow your urine to drain. You will need to keep the foley in
place until you see Urology in follow up. Your kidney function
is much improved with the catheter in place. On imaging of your
chest a tumor was noted in your lungs which likely represents
lung cancer. After discussions with you, your family and the
diagnostic specialists at internventional radiology it was
decided that we would not pursue a biopsy of the tissue given
the high risks associated with the procedure. We have scheduled
an appointment with palliative care for you, so that any
symptoms you have going forward can be managed and so that you
remain comfortable and cared for going forward. While you were
here you had extra fluid on your body, which we removed with
intravenous medications. Your breathing is much more comfortable
and so you can resume your home regimen of torsemide upon
discharge. Lastly, you developed a pneumonia during your stay
here and so are being discharged with an antibiotic you will
need to take for the next 6 days. You are already improving in
the short time that you've been taking it.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19813796-DS-15
| 19,813,796 | 24,008,052 |
DS
| 15 |
2172-01-13 00:00:00
|
2172-01-13 17:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
verapamil / spironolactone / nifedipine / diltiazem / lisinopril
Attending: ___
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old with history of diabetes, hypertension,
ESRD on TTS who presents from home with headache. Patient
reports for several weeks she has been having headaches. Of
note, she has had embolization of prior aneurysmal disease in
the past but she reports that this is the worst headache she has
experienced. The headaches were accompanied by left facial pain
and pain
behind her left eye.
In the ED, initial vitals:
98.4 74 128/76 18 95% RA
- Exam was not documented.
- Labs notable for:
UA with lg ___, 146 WBCs and many bacteria
Trop 0.06
WBC 10.6
- Imaging notable for:
___ MRI/MRA brain
Left cavernous ICA aneurysm measures 2.1 x 2.0 cm, larger
compared to ___ (previously measured 2.0 x 1.9 cm).
There is new acute hematoma within the aneurysm layering
posteriorly in the aneurysm sac.
No evidence of acute infarct is identified. New T2
hyperintensity involving the right posterior parietal occipital
region may reflect subacute infarct.
Major intracranial arteries are patent including bilateral
cavernous ICA stents.
- Neurosurgery was consulted and recommended:
pain control for HA:
- Recommend 5mg IV dexamethasone once, followed by 2mg TID for
48 hours with concomitant script for zantac.
- Patient should follow up in outpatient clinic with Dr. ___.
She can call ___ to make this appointment and his
administrative staff will be made aware of need for appointment.
- Given positive troponin and increased Creatinine, patient may
require admission to Medicine
- Pt given:
___ 01:29 IV Morphine Sulfate 2 mg
___ 01:29 IV Ondansetron 4 mg
___ 02:15 IV DRIP NiCARdipine (0.5-3 mcg/kg/min ordered)
___ 04:33 IV Ondansetron 4 mg
___ 07:22 IV CeftriaXONE
___ 08:37 PO/NG ClonazePAM .5 mg
___ 08:37 PO CloNIDine .1 mg Partial Administration
___ 08:37 PO/NG GlipiZIDE 5 mg
___ 08:37 PO/NG HydrALAZINE 50 mg
___ 08:37 PO Metoprolol Succinate XL 50 mg
___ 08:44 oral felodipine *NF* 10 mg
___ 08:58 IV DRIP NiCARdipine Stopped
___ 13:13 PO Acetaminophen 1000 mg
___ 14:39 IV Dexamethasone 5 mg
- Vitals prior to transfer:
97.8 74 118/94 20 100% RA
Past Medical History:
CHF
Dyslipidemia
Asthma
Arthritis
CKD stage 4
DM type II
L adrenal nodule-hyoercortisolism
Social History:
___
Family History:
N/A
Physical Exam:
Vitals: 98.0 168/85 80 18 100 Ra
General: Alert, oriented x3, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear. Left eye
lateral does not move laterally Right eye ocular movements in
tact
Lungs: CTAB no wheezes, rales, rhonchi
CV: Irregularly irregular, soft systolic murmur
Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly, no suprapubic tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Left eye does not move latearally, otherwise CN2-12
intact. ___ strength throughout, normal sensation to light
touch, symmetric patellar and biceps reflexes
Pertinent Results:
ADMISSION LABS
___ 01:26AM BLOOD WBC-10.6* RBC-4.56 Hgb-12.1 Hct-39.5
MCV-87 MCH-26.5 MCHC-30.6* RDW-16.2* RDWSD-50.8* Plt ___
___ 01:26AM BLOOD Neuts-61.4 ___ Monos-13.3*
Eos-2.0 Baso-0.8 Im ___ AbsNeut-6.50* AbsLymp-2.33
AbsMono-1.40* AbsEos-0.21 AbsBaso-0.08
___ 01:26AM BLOOD Glucose-120* UreaN-49* Creat-5.7*# Na-137
K-5.1 Cl-94* HCO3-26 AnGap-22*
___ 01:26AM BLOOD CK(CPK)-80
___ 01:26AM BLOOD CK-MB-2
___ 01:26AM BLOOD cTropnT-0.06*
___ 01:55AM BLOOD ___ pO2-118* pCO2-35 pH-7.51*
calTCO2-29 Base XS-5 Comment-GREEN TOP
___ 01:55AM BLOOD Lactate-1.9
DISCHARGE LABS
___ 07:40AM BLOOD WBC-13.5* RBC-4.33 Hgb-11.6 Hct-36.9
MCV-85 MCH-26.8 MCHC-31.4* RDW-15.8* RDWSD-48.7* Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-174* UreaN-44* Creat-5.3* Na-132*
K-5.1 Cl-90* HCO3-27 AnGap-20
___ 07:40AM BLOOD Calcium-9.7 Phos-4.2 Mg-2.1
MICROBIOLOGY
___ 4:18 am URINE
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 CFU/mL.
REPORTS
___ CXR
IMPRESSION:
No acute cardiopulmonary process. Unchanged cardiomegaly.
___ CT Head
IMPRESSION:
1. 2.3 x 1.8 cm hyperdensity at the left cavernous sinus is
consistent with known left cavernous internal carotid artery
aneurysm. Comparison is difficult between different modalities,
however it measures slightly larger compared to prior MRI from
___ (previously 2.1 x 1.7 cm).
___ MRI Brain
IMPRESSION:
1. Right parietal and occipital lobe subacute infarction, with a
small right parietal lobe hemorrhage.
2. Left ICA aneurysm status post pipeline embolization, with
interval increase in size of the aneurysm, with new layering
acute to subacute hemorrhage posteriorly.
3. The right ophthalmic aneurysm is no longer seen
Brief Hospital Course:
___ with ESRD, HTN, embolization of a left ICA aneurysm on
___ presenting from home with the worst headache of her
life, found to have UTI and altered mental status.
#Headache
#Aneurysm:
Patient was evaluated by neurosurgery, who did not feel that any
intervention was warranted based on her imaging findings. She
was given dexamethasone 5mg IV followed by 2mg PO TID for her
headache with ranitidine for GI prophylaxis based on
neurosurgery recommendations. Her headache resolved on the day
of discharge. Neurosurgery will see her for follow up in clinic
after discharge
#UTI: UA consistent with infection. Delirium witnessed in ED is
likely secondary to infection as below. She was started on
ceftriaxone. She was discharged with one day of ciprofloxacin to
complete her 3 day course. Her Urine gram stain showed >100,000
GNRs. Culture was pending at the time of discharge.
#Altered mental status: Patient was confused overnight in the
ER. Presumed to be toxic/metabolic secondary to UTI. Not felt to
be related to headache or aneurysm. Mental status was normal
throughout her time on the medical floor.
#ESRD: Patient was initiated on TTS HD during hospitalization at
___ for pneumonia 2 weeks ago. She received HD in house on
___ according to her usual schedule.
#HTN:
-Continue home clonidine, hydralazine, metoprolol
#Chronic diastolic heart failure:
-Continue home metoprolol, furosemide
#Type 2 diabetes: Reports that she was started on insulin during
recent hospitalization, but is still waiting for ___ teaching to
start it at home. She was treated with lantus and HISS in place
of home levemir and novolog during this admission. Glipizide was
held and will presumably be discontinued when insulin starts.
#HLD:
-Continued home simvastatin
TRANSITIONAL ISSUES:
#Per Neurosurgery, following recent ICA stent placement, patient
should be on aspirin 325mg daily, not 81mg daily as noted in
___ and ___ records. Ticagrelor was stopped in ___.
#Ensure that patient follows up with neurosurgery, Dr. ___,
___ week
#Patient was given 1 day of ciprofloxacin for UTI
#Urine culture pending at discharge, please f/u as outpatient
#Patient was given 5 doses of dexamethasone per neurosurgery
recommendation for headache
#Patient was given prescription for ranitidine as GI prophylaxis
while on dexamethasone
#Patient was recently discharged from another hospital and
reports changes to her medications that were not reflected in
the ___ record. We did our best to identify those changes and
reflect them in our discharge med list. Recommend confirming the
changes made at her last hospitalization at ___, which may be
different from your current list and our discharge med list.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. levemir 8 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
3. HydrALAZINE 25 mg PO Q8H
4. CloNIDine 0.1 mg PO Q12H
5. ClonazePAM 0.5 mg PO TID
6. Calcium Acetate 667 mg PO TID W/MEALS
7. TiCAGRELOR 90 mg PO BID
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
9. Vitamin D ___ UNIT PO DAILY
10. Allopurinol ___ mg PO DAILY
11. Epoetin Alfa 1000 mg SC Q2WEEKS
12. Simvastatin 40 mg PO QPM
13. Felodipine 10 mg PO DAILY
14. Nystatin Cream 1 Appl TP BID
15. nystatin 100,000 unit/gram topical BID
16. Asmanex Twisthaler (mometasone) 220 mcg (120 doses)
inhalation BID
17. Senna 8.6 mg PO BID:PRN constipation
18. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 250 mg PO Q12H
Please take in the morning and the evening on ___
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*2 Tablet Refills:*0
3. Dexamethasone 2 mg PO Q8H Duration: 48 Hours
RX *dexamethasone 2 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*5 Tablet Refills:*0
4. Ranitidine 150 mg PO DAILY
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth once a day Disp
#*7 Capsule Refills:*0
5. Aspirin 325 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
7. Allopurinol ___ mg PO DAILY
8. Asmanex Twisthaler (mometasone) 220 mcg (120 doses)
inhalation BID
9. Calcium Acetate 667 mg PO TID W/MEALS
10. ClonazePAM 0.5 mg PO TID
11. CloNIDine 0.1 mg PO Q12H
12. Epoetin Alfa 1000 mg SC Q2WEEKS
13. Felodipine 10 mg PO DAILY
14. HydrALAZINE 25 mg PO Q8H
15. levemir 8 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
16. Metoprolol Succinate XL 100 mg PO DAILY
17. Nystatin Cream 1 Appl TP BID
18. nystatin 100,000 unit/gram topical BID
19. Senna 8.6 mg PO BID:PRN constipation
20. Simvastatin 40 mg PO QPM
21. TiCAGRELOR 90 mg PO BID
22. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
UTI
Cerebral aneurysm
Headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital because of a severe headache. We
performed an MRI that showed an aneurysm and contacted the
neurosurgeons to evaluate you. They did not feel that there was
any need to for any surgical treatment right now. The would like
to see you in a few weeks to follow up in the office. While you
were in the emergency room, they found that you had a urinary
tract infection. We gave you antibiotics to treat that
infection. You will need to take one more day of antibiotics at
home. You also had dialysis on ___ at your usual time. We
are sending you home with a prescription for a few more doses of
dexamethasone, which is the medicine the neurosurgeons
recommended we give you to treat your headache. You should take
the medication as directed and finish all of the pills.
Best wishes,
Your ___ Care Team
Followup Instructions:
___
|
19813796-DS-18
| 19,813,796 | 22,899,206 |
DS
| 18 |
2174-09-20 00:00:00
|
2174-09-20 20:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
verapamil / spironolactone / nifedipine / diltiazem / lisinopril
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
___ 12:11AM BLOOD WBC-7.5 RBC-3.95 Hgb-11.1* Hct-36.3
MCV-92 MCH-28.1 MCHC-30.6* RDW-18.2* RDWSD-60.9* Plt ___
___ 12:11AM BLOOD Neuts-55.6 ___ Monos-11.0 Eos-2.0
Baso-0.8 Im ___ AbsNeut-4.16 AbsLymp-2.26 AbsMono-0.82*
AbsEos-0.15 AbsBaso-0.06
___ 12:11AM BLOOD ___ PTT-35.6 ___
___ 12:11AM BLOOD Glucose-146* UreaN-71* Creat-9.8*# Na-138
K-8.2* Cl-94* HCO3-29 AnGap-15
___ 11:00AM BLOOD Calcium-9.1 Phos-5.8* Mg-2.2
PERTINENT LABS:
___ 12:11AM BLOOD CK(CPK)-347*
___ 03:05AM BLOOD CK(CPK)-285*
___ 12:11AM BLOOD CK-MB-3
___ 12:11AM BLOOD cTropnT-0.08*
___ 03:05AM BLOOD CK-MB-3 cTropnT-0.09*
___ 11:00AM BLOOD ___
___ 11:00AM BLOOD TSH-1.2
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-5.8 RBC-3.38* Hgb-9.4* Hct-31.1*
MCV-92 MCH-27.8 MCHC-30.2* RDW-17.2* RDWSD-57.7* Plt ___
___ 06:35AM BLOOD ___ PTT-36.1 ___
___ 06:35AM BLOOD Glucose-97 UreaN-52* Creat-9.3*# Na-141
K-4.9 Cl-96 HCO3-29 AnGap-16
___ 06:35AM BLOOD Calcium-9.0 Phos-5.0* Mg-2.2
IMAGING AND PROCEDURES:
CHEST X-RAY: ___
IMPRESSION:
No acute cardiopulmonary findings. No pulmonary edema.
Brief Hospital Course:
SUMMARY STATEMENT:
Ms. ___ is a ___ woman with a history of HTN, HLD,
T2DM, HFpEF, atrial fibrillation on warfarin (CHADSVASC 8) and
amiodarone, moderate AS, as well as bilateral ICA aneurysms
status post coiling, COPD, ESRD on HD ___ who presented
with chest pain likely in setting of increased rates ___ atrial
fibrillation/flutter, admitted with initial plan for TEE and
cardioversion. Spontaneously converted back to sinus rhythm on
___ at 0700 and remained in sinus until discharge. She was
managed for subtherapeutic INR, with no other active issues. She
was discharged home in stable condition.
TRANSITIONAL ISSUES:
==================
[ ] Weight at discharge 201.06 lb (91.2 kg)
[ ] Hemoglobin at discharge 9.4 and stable in 9s-10s range
[ ] INR at discharge: 1.8 (please see warfarin dosing sheet.
Patient was discharged with rising INR. She was otherwise well
and so discharged with plan to follow up with PCP for INR
monitoring. INR goal ___
[ ] ___ consider need for atrial ablation for atrial
fibrillation/ flutter in this patient if rhythm control
continues to be challenging.
[ ] Please follow-up medication adherence as patient was
confused about whether she should be on amiodarone. She was
restarted while inpatient.
[ ] She was trialed on metoprolol though this was discontinued
due to bradycardia
[ ] Offered ___ services for medication improvement prior to
discharge, patient declined. Recommend ongoing discussion to
improve medication compliance.
ACTIVE ISSUES:
==============
# Atrial flutter/fibrillation
The patient was noted to be in and out of atrial
fibrillation/flutter while in the ED. She reportedly had not
been taking her amiodarone due to confusion about whether she
should be taking the medication, which was thought to be the
likely instigating factor. There was no evidence of hemodynamic
instability and volume status was euvolemic after dialysis.
Ischemia was considered unlikely with flat troponins. The
patient remained in a-fib/flutter on telemetry on the floor
(maximum rates in the 130s), and was relatively asymptomatic
with occasional sensation of palpitations, no chest pain, SOB or
lightheadedness. She was given fractionated metoprolol for rate
control and started on a heparin drip for anticoagulation for a
sub-therapeutic INR of 1.5 at presentation. She was noted to
spontaneously convert to sinus rhythm on ___ at 0700,
where she remained until discharge.
- Resumed amiodarone 200mg daily
- Discontinued metoprolol tartrate on ___ due to bradycardia;
the patient noted that she had been on Toprol in the outpatient
setting which was discontinued for low heart rates.
- INR was 1.8 at discharge, heparin gtt was continued until d/c.
Patient was instructed to follow-up with her PCP who monitors
her INR
- Will need close follow-up for INR check
- Notably, INR was therapeutic until ___ last check at ___,
not therapeutic on admission
- ___ consider ablation in future
- TSH was checked and was normal at 1.2 on admission
# Chest pain, resolved
The patient noted a history of chest pain that had been
intermittent for a somewhat extended period of time, most likely
related to her rates related to a-fib/ flutter with RVR. In
___ she had a that showed stress w/ infarct, no
reversible findings. She had normal HRs at recent office visit
and was reporting similar CP, unclear if paroxysmal fib resulted
in CP vs underlying vascular disease. The patient has
significant risk factors for CAD, so this must remain on the
differential, although there was no concern for ischemia this
admisison. Could also be microvascular vs atypical. Of note, CP
resolved with rate control and troponins remained stable.
- Resumed amiodarone prior to discharge, d/c'd metoprolol
- Home BP meds were continued as per below
- Consider repeat nuclear stress test at future time if patient
has repeat symptoms
================
CHRONIC ISSUES:
================
# ESRD on HD
The patient was seen by the Nephrology HD consult service during
hospitalization and received HD on ___ per her usual
HD schedule.
- Medications were dosed by HD guidelines and nephrotoxins were
avoided
- Home Velphoro non-formulary, was given sevelamer inpatient
# HTN
- Home felodipine was held and patient was given amlodipine
while inpatient
- Continued home hydralazine
- Continued home clonidine
# HLD
- Continued home atorvastatin
# T2DM
- Home glipizide was held during hospitalization and resumed at
discharge
- ISS given while in-house
# COPD
- Continued home albuterol inhaler
# PTSD
- Continued home clonazepam
# Gout
- Continued home allopurinol
#CODE: Full Code
#CONTACT: HCP: ___, Daughter, Home: ___,
Cell: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO TID
2. HydrALAZINE 10 mg PO TID
3. Albuterol Inhaler 1 PUFF IH BID:PRN shortness of breath
4. Amiodarone 200 mg PO DAILY
5. Warfarin 5 mg PO 2X/WEEK (MO,FR)
6. Warfarin 6.25 mg PO 5X/WEEK (___)
7. Atorvastatin 40 mg PO QPM
8. CloNIDine 0.1 mg PO BID
9. GlipiZIDE 5 mg PO DAILY
10. Nystatin Cream 1 Appl TP BID
11. Lidocaine-Prilocaine 1 Appl TP PRN prior to dialysis
12. Dialyvite 800 with Zinc 15 (vitamin B complx-C-FA-zinc cit)
0.8-15 mg oral DAILY
13. Velphoro (sucroferric oxyhydroxide) 1000 mg oral TID W/MEALS
14. Felodipine 10 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH BID:PRN shortness of breath
2. Amiodarone 200 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. ClonazePAM 0.5 mg PO TID
5. CloNIDine 0.1 mg PO BID
6. Dialyvite 800 with Zinc 15 (vitamin B complx-C-FA-zinc cit)
0.8-15 mg oral DAILY
7. Felodipine 10 mg PO DAILY
8. GlipiZIDE 5 mg PO DAILY
9. HydrALAZINE 10 mg PO TID
10. Lidocaine-Prilocaine 1 Appl TP PRN prior to dialysis
11. Nystatin Cream 1 Appl TP BID
12. Velphoro (sucroferric oxyhydroxide) 1000 mg oral TID
W/MEALS
13. Warfarin 6.25 mg PO 5X/WEEK (___)
14. Warfarin 5 mg PO 2X/WEEK (MO,FR)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Atrial fibrillation/ atrial flutter with rapid ventricular
response
Sub-therapeutic INR
Secondary Diagnosis:
End-stage renal disease on hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were having chest pain and shortness of breath
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
- The function of your heart was monitored and you were given
medications to control your fast heart rate
- You were given a medication to help thin your blood
- While you were monitored your heart rhythm changed-back to
normal and you felt improvement in your chest pain, shortness of
breath and palpitations
- Your home medications for hypertension were continued
WHAT SHOULD BE DONE WHEN I GET HOME FROM THE HOSPITAL?
- Please be sure to take all of your medications as prescribed
- Please keep all of your follow-up appointments, and see you
primary doctor within 1-week to check your INR.
- If you have dizziness, chest pain, shortness of breath or
heart palpitations, trouble breathing or generally feel unwell
please call your doctor or go to the emergency room.
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
19814293-DS-33
| 19,814,293 | 26,145,963 |
DS
| 33 |
2184-11-22 00:00:00
|
2184-11-22 17:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Diltiazem / Terazosin
Attending: ___
Chief Complaint:
Chills, nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ F with history of stiff person syndrome,
DM1, HTN, hypothyrodism, migraines and chronic venous stasis who
presents with shaking and subjective fevers/chills since 11pm
yesterday. This was characterized as sudden, full body shaking,
subjective fevers and chills then approximately 15 episodes of
non-bilious/nonbloody N/V. Her home health aide found
temperature of 99.8 during this episode. She denies any
associated neck pain, headache, abdominal pain or dysuria. Her
suprapubic catheter site was without surrounding redness per
patient. Patient denies sore throat, rhinorrhea, sinus pressure,
earache. No exacerbating or relieving factors. Last bowel
movement was this morning with continued flatus.
.
In the ED, initial VS: 99.9, 120, 126/73, 18, 99%. She had an
ABG which showed 7.47/33/124/25 and labs were notable for
hyperglycemia with hyponatremia. Her UA was positive, and her
suprapubic catheter was changed. CXR was read as normal and EKG
showed sinus tachycardia. She received 3L NS, vanc, zosyn,
tylenol and ativan. Vitals on transfer were Temp: 100.3, Pulse:
118, RR: 20, BP: 106/49, O2Sat: 97% on 2L NC.
.
Currently, she reports feeling better. She was in her normal
state of health prior to last evening at 11pm.
.
ROS: Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
1. Stiff person syndrome: "Diagnosed in ___ symptoms began in
___ when she presented with foot cramps. She was diagnosed by
CSF and serum analysis. She was first started on Valium which
initially helped. She was then treated with IVIG in ___ and
plasmaphereis in ___ with last IVIG in ___ with minimal
improvement. Started weekly Rituxan and qowk Cytoxan starting on
___ and last dose on ___
2. DM type 1
3. Hypertension
4. Graves disease s/p thyroidectomy
5. Urinary retention
6. Migraines
7. Hyponatremia
Social History:
___
Family History:
Noncontributory
Physical Exam:
On admission:
VS - Temp ___ F, BP 145/76, HR 112, R 18, O2-sat 95% 1L NC
GENERAL - Well nourished female in NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, ok air movement, resp unlabored,
no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, bilateral ___ with 1+ pitting edema L>R, 2+
DPs
SKIN - erythematous face
NEURO - awake, A&Ox3, CNs II-XII grossly intact
On discharge:
VS - Tmax 99.2 Tc 97.1, BP 176/87 (130's-170's/___s-___), HR 80
(___'s-100's), R 18, O2-sat 96% 2L NC
GENERAL - Well nourished female in NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, ok air movement, resp unlabored,
no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, bilateral ___ with 1+ pitting edema L>R, 2+
DPs
SKIN - erythematous face
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Admission labs:
___ 01:35PM BLOOD WBC-10.3# RBC-3.57*# Hgb-10.9*#
Hct-31.2*# MCV-87# MCH-30.6 MCHC-35.1*# RDW-13.0 Plt ___
___ 01:35PM BLOOD Neuts-88.1* Lymphs-6.4* Monos-3.4 Eos-2.0
Baso-0.1
___ 01:35PM BLOOD ___ PTT-26.6 ___
___ 01:35PM BLOOD Glucose-276* UreaN-4* Creat-0.5 Na-128*
K-4.3 Cl-95* HCO3-24 AnGap-13
___ 01:35PM BLOOD ALT-19 AST-20 AlkPhos-98 TotBili-0.2
___ 01:42PM BLOOD Lactate-0.9
___ 01:42PM BLOOD Type-ART pO2-124* pCO2-33* pH-7.47*
calTCO2-25 Base XS-1 Intubat-NOT INTUBA Comment-GREEN TOP
Discharge Labs:
___ 06:25AM BLOOD WBC-7.5 RBC-4.13* Hgb-12.3 Hct-36.2
MCV-88 MCH-29.9 MCHC-34.1 RDW-12.7 Plt ___
___ 06:25AM BLOOD Glucose-217* UreaN-5* Creat-0.5 Na-129*
K-4.2 Cl-91* HCO3-29 AnGap-13
___ 06:25AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ F with history of stiff person syndrome,
DM1, HTN, hypothyrodism, migraines and chronic venous stasis who
presents with shaking and subjective fevers/chills and found to
have UTI.
Active issues:
# Pyelonephritis: Her presentation of fever, rigors, and UTI
(positive nitrites) were concerning for possible pyelonephritis.
Her suprapubic catheter was changed in the ED, and blood and
urine cultures were sent. She was initially treated with broad
spectrum antibiotics with rapid resolution of symptoms. She was
transititioned to empiric ciprofloxacin 500 mg bid for 10 days
on the day prior to discharge as urine cultures grew mixed
bacterial flora. This was not actually thought to be contaminant
since the patient reports that she frequents has episodes of
fecal incontinence, which is the likely source of her UTI and
pyelonephritis.
# Anemia: On admission, she had relatively new anemia with hct
of 31 from recent baseline of high ___, which was thought to be
dilutional. Hct slowly trended back upward to a normal level of
36.2 on discharge.
# Hyponatremia: Sodium improved after volume repletion in the ED
but remained low, within recent baseline. After hyperglycemia
correction, her sodium was still low. This should be followed
as an outpatient.
Inactive issues:
# Stiff-person syndrome: She is followed by neurology as an
outpatient for this and is supposed to take diazepam for
spasticity. However, she has not been taking this due to
medication shortage. Pt experienced some relief with ativan in
the ED but this resulted in somnolence. Her diazepam and keppra
were continued while she was inpatient.
# Type 1 DM: She was on a renal diet with lantus and humalog
sliding scales while inpatient.
# Depression: Her home buproprion was continued.
# HTN: Home losartan was continued.
# Grave's disease s/p thyroidectomy: Recent free T4 was normal
at beginning of ___ and her home levothyroxine was continued.
# Code status: She wished to be DNR/DNI this admission.
Medications on Admission:
BUPROPION HCL - 150 mg Tablet Extended Release - 1 Tablet(s) by
mouth qam
CONJUGATED ESTROGENS [PREMARIN] - 0.625 mg/gram Cream - apply to
vagina 2x week
DIAZEPAM - 10 mg Tablet - 16 Tablet(s) by mouth In four divided
doses; 40 mg q3AM, 40 mg q9AM, 30 mg q3PM, 50 mg q7PM
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - sc 6 units in
the morning and 4 units in the evening - No Substitution
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - use per your
sliding scale; up to 6 units four times a day or as directed -
No Substitution
LACTULOSE - (Dose adjustment - no new Rx) - 10 gram/15 mL
Solution - 30 ml by mouth up to tid prn changed by rehab
LEVETIRACETAM - 500 mg Tablet - ___ Tablet(s) by mouth twice
daily take one tablet in morning and two tablet in the evening
LEVOTHYROXINE [SYNTHROID] - 225 mcg daily
LOSARTAN - 25 mg Tablet - 1 (One) Tablet(s) by mouth once a day
TRAZODONE - 100 mg Tablet - 1 Tablet(s) by mouth each evening at
7:30pm or later as needed for insomnia
ASPIRIN [ASPIRIN LOW DOSE] - (Prescribed by Other Provider) -
81 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by
mouth once a day
CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D] - (OTC) - 315 mg-200
unit Tablet - 1 (One) Tablet(s) by mouth once a day
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - (OTC) - 1,000 unit
Tablet, Chewable - 1 (One) Tablet(s) by mouth once a day
MULTIVITAMIN - (OTC) - Tablet - 1 (One) Tablet(s) by mouth
once a day
PRUNE LAXATIVE (CONTAINS SENNA) - (OTC) - Dosage uncertain
SENNOSIDES [SENNA] 8.6 mg Capsule - 4 Capsule(s) by mouth daily
Discharge Medications:
1. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
2. diazepam 10 mg Tablet Sig: Four (4) Tablet PO Q3AM ().
3. diazepam 10 mg Tablet Sig: Four (4) Tablet PO Q9AM ().
4. diazepam 10 mg Tablet Sig: Three (3) Tablet PO Q3PM ().
5. diazepam 10 mg Tablet Sig: Five (5) Tablet PO Q7PM ().
6. levothyroxine 112 mcg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. calcium citrate-vitamin D3 315-200 mg-unit Tablet Sig: One
(1) Tablet PO once a day.
9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
13. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QPM (once
a day (in the evening)).
14. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
15. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
16. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. insulin glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: please take 6 units in the am and 4
units in the evening.
18. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: please take your regular sliding scale
humalog.
19. ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*44 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Urinary Tract infection
Secondary:
Stiff person syndrome
Diabetes Mellitus type I
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your
hospitalization at ___. You
were admitted with fever, chills and nausea with vomiting at
home. We found that you had an infection in your urine that was
likely the cause of you not feeling well. We treated your
infection with antibiotics. You felt much better and are now
ready for discharge.
Please note the following medcation changes:
- STARTED CIPROFLOXACIN 500 MG TWICE A DAY FOR THE NEXT ___ DAYS
Followup Instructions:
___
|
19814293-DS-36
| 19,814,293 | 20,842,781 |
DS
| 36 |
2185-02-19 00:00:00
|
2185-02-22 14:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Diltiazem / Terazosin
Attending: ___.
Chief Complaint:
Vomiting and Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o F with PMH notable for stiff person
syndrome, neurogenic bladder w/ suprapubic catheter and IDDM who
presented ___ w/ worsening total body edema. The patient has
been reporting total body edema over the past 6 months which has
acutely worsened over the past 2 weeks. Unclear etiolgoy despite
work-up that has included echocardiogram, abdominal CT scan, and
search for central thrombosus. Prior admission for edema in
___ that was attributed to excessive water intake and
immobility. That episode improved with compression stockings and
water restriction alone. Recent worsening edema has been managed
on an outpatient basis with escalating doses of oral diuretic.
The patient reports no increase in urination with this
medication. She denies other Sx including SOB or CP. No recent
lifestyle changes or major shifts in diet. From outpatient notes
it appears the patient has been violating her home 1.5L water
restriction recently.
.
In the ED, 97.4 68 167/82 16 100% A UA was consistent with a UTI
and she was given IV ciprofloxacin. BNP was checked which was
WNL and CXR revealed no pulmonary edema. She was admitted for IV
diuresis. Vitals at the time of transfer are 97.4 68 167/82 16
100%.
Past Medical History:
-Stiff Person Syndrome, first symptoms in ___ with left foot
cramps, GAD Ab positive in both serum and CSF, s/p treatment
with IVIg, plasmapheresis, Rituxan and Cytoxan (___), baclofen
pump, Botox injections, Diazepam, Keppra, Neurontin, and
tizanidine; wheelchair bound, followed by Dr. ___ in the
movement disorders clinic
-Hypertension
-Insulin dependent diabetes mellitus, since ___
-Grave's disease s/p subtotal thyroidectomy
-Depression
-Insomnia
-hyponatremia
-Migraine headaches
-Chronic venous stasis
-s/p suprapubic catheter
-s/p excision of right index finger mucocyst and osteophyte ___
Social History:
___
Family History:
There is no family history of Stiff Person
Syndrome. Her maternal aunt and father have insulin-dependent
diabetes mellitus. Her maternal uncle had lung cancer, but was a
smoker.
Physical Exam:
On Admission:
S - 97.7 124/70 90 18 96%RA
GENERAL - lying in bed, in NAD alert, appropriate, pleasant
HEENT - PERRL, MMM, OP clear, mild facial edema
HEART - RRR, normal S1 and S2, no m/r/g
LUNGS - unlabored respirations, CTAB anteriorly (unable to
listen to posterior fields)
ABDOMEN - BS+, no organomegaly, palpable baclofen pump, no
rebound or guarding
GU - suprapubic tube in place, site clean and moist. Urine
draining.
EXTREMITIES - WWP, ACE bandage on ___ b/l. 1+ edema of ___. Mild
edema off ace and UE. JVP at ~6cm.
NEURO - Awake, alert and oriented. CN II-XII intact. Able to
raise legs off bed but is weak in ___ b/l. This is reported as
baseline for her.
On Discharge:
VS - 98.4 136/60 104 16 95%RA
I/O - Unfortunately, urine spilt on floor overnight. No accurate
output data
___ - ___
GENERAL - lying in bed, in NAD alert, appropriate, pleasant
HEENT - PERRL, MMM, OP clear, mild facial edema
HEART - RRR, normal S1 and S2, no m/r/g
LUNGS - unlabored respirations, CTAB anteriorly (unable to
listen to posterior fields)
ABDOMEN - BS+, no organomegaly, palpable baclofen pump, no
rebound or guarding
GU - suprapubic tube in place, site clean and moist. Urine
draining.
EXTREMITIES - WWP, ACE bandage on ___ b/l. Edema in extrimities
is considerably improved from exam yesterday
NEURO - Awake, alert and oriented. CN II-XII intact. Able to
raise legs off bed but is weak in ___ b/l. This is reported as
baseline for her.
Pertinent Results:
On Admission:
___ 09:35PM BLOOD WBC-4.5 RBC-4.06* Hgb-12.2 Hct-38.8
MCV-95# MCH-30.1 MCHC-31.6 RDW-13.6 Plt ___
___ 09:35PM BLOOD Glucose-207* UreaN-6 Creat-0.7 Na-126*
K-4.5 Cl-93* HCO3-21* AnGap-17
___ 09:35PM BLOOD ALT-16 AST-23 AlkPhos-111* TotBili-0.2
___ 09:35PM BLOOD TotProt-6.6 Albumin-3.9 Globuln-2.7
Calcium-8.9 Phos-3.9 Mg-2.0
___ 09:35PM BLOOD TSH-3.3
___ 09:35PM BLOOD T4-7.3
On Discharge:
___ 06:00AM BLOOD WBC-6.1 RBC-3.96* Hgb-12.4 Hct-37.4
MCV-95 MCH-31.4 MCHC-33.3 RDW-13.6 Plt ___
___ 12:35PM BLOOD Glucose-467* UreaN-11 Creat-1.0 Na-127*
K-3.9 Cl-87* HCO3-24 AnGap-20
___ 06:00AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.0
Studies:
Liver US - IMPRESSION: Patent hepatic vasculature with
appropriate waveforms and directional flow. Limited assessment
of the liver parenchyma due to a suboptimal acoustic window.
CXR - IMPRESSION: Basilar atelectasis/scarring without definite
focal
consolidation.
Brief Hospital Course:
Ms. ___ is a ___ y/o female with stiff person syndrome,
neurogenic bladder s/p suprapubic catheter, hypertension and
IDDM who presented with worsening total body edema.
#. Total body edema: The patient had developed worsening edema
over the 2 weks leading up to admission. This was not improved
by oral lasix. In the hospital the patient received intravenous
lasix and had brisk urinary output. She was also placed on a
strict 1.5L fluid restriction. The patient's edema drastically
improved over the subsequent days. Amytriptiline was stopped as
this may have been contributing to increased thirst. The patient
was discharged on torsemide 20mg daily and encouraged to
maintain a strict fluid restriction. Will follow closely with
her primary care physician.
# Hyponatremia: Chronic in nature although was slightly below
baseline on admission. Improved with fluid restriction. Should
be monitored with ongoing diuresis and plans were made for
patient to have laboratory work done on an outpatient basis.
# Bacteuria: The patient was noted to have an abnormal UA on
admission. Started on antimicrobial therapy but this was stopped
as paient reported no Sx c/w UTI and has indwelling cath, so
some pyuria and bacteriuria is expected. A urine culture was
(-).
#. IDDM: Stable. Continued on home glargine and ISS>
#. Stiff Person Syndrome: The patient complained of back spasm
due to the bed shape. Also did not have wheelchair in-house so
was not able to be mobile. Continued high dose diazepam, keppra,
baclofen pump.
#. Hypothyroidism: Stable. Continued Levothyroxine.
#. Hypertension: Stable. Continued Losartan.
Transitional Issus:
- Titrate torsemide to maintain euvolemia
- Monior serum sodium while diuresing
Medications on Admission:
1. Baclofen Intrathecal
2. Bupropion HCl ER 150 mg PO QAM
3. Diazepam 40 mg PO Q1AM
4. Diazepam 40 mg PO Q6AM
5. Diazepam 30 mg PO Q1PM
6. Diazepam 50 mg PO Q7PM
7. Glargine 100 6 units SC QAM and 5 unit SC QPM
8. Levetiracetam 500 mg PO QAM
9. Levetiracetam 500 mg PO QPM
10. Levothyroxine 225 mcg PO DAILY
11. Mupirocin calcium 2% Cream TP BID
12. Trazodone 125.5 mg PO HS insomnia (Patient swears this is
her dose!)
13. Cholecalciferol (vitamin D3) 800 unit PO daily
14. Multivitamin PO daily
15. Senna 8.6 mg PO daily
16. Conjugated estrogens 0.625 mg/gram Intravaginally ___
17. Losartan 25 mg PO daily
18. Docusate sodium 100 mg PO BID
19. Bisacodyl 10 mg PO daily PRN constipation
20. Humalog 100 unit/mL SC QIDACHS per sliding scale
21. Aspirin 81 mg PO ___
22. Amitryptiline 10mg qHS
Discharge Medications:
1. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
2. diazepam 5 mg Tablet Sig: Eight (8) Tablet PO Q1AM ().
3. diazepam 10 mg Tablet Sig: Four (4) Tablet PO Q6AM ().
4. diazepam 10 mg Tablet Sig: Three (3) Tablet PO Q1PM ().
5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. diazepam 10 mg Tablet Sig: Five (5) Tablet PO Q7PM ().
11. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Lantus 100 unit/mL Solution Sig: Five (5) Units Subcutaneous
In the ___.
13. Lantus 100 unit/mL Solution Sig: Six (6) Units Subcutaneous
In the AM.
14. mupirocin calcium 2 % Cream Sig: One (1) Capful Topical
twice a day.
15. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. conjugated estrogens 0.625 mg/gram Cream Sig: One (1)
Application Vaginal Every ___ and ___.
18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for Constipation.
20. baclofen Intrathecal
21. compression socks, medium Misc Sig: One (1)
Miscellaneous While in bed.
22. Outpatient Lab Work
Please check chem 10 on ___ and fax results to Dr
___ (Fax: ___
23. levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a
day: to be taken with 25mcg tablet for a total of 225mcg daily.
24. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a
day: to be taken with 200mcg tablet for a total of 225mcg daily.
25. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous QIDACHS: per sliding scale.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Edema/Anasarca
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:
It was a pleasure taking care of you at ___!
You were admitted due to worsening swelling of your arms, legs
and face. In the hospital you were kept on a fluid restiction
and given intravenous diuretic. Your swelling greatly improved
and you are now ready for discharge home. You will be started on
a new diuretic pill called torsemide. You will need to have
your labs (electrolytes) checked when you see Dr ___ on
___. Please remember not to drink excessive fluids at home
(no more than 1500mL daily).
See below for changes made to your home medication regimen:
1) Please STOP Furosemide (Lasix)
2) Please START Torsemide 20mg daily
3) Please START wearing compression stockings while in bed
4) Please STOP Amitryptiline
See below for instructions regarding follow-up care
Followup Instructions:
___
|
19814315-DS-10
| 19,814,315 | 22,114,692 |
DS
| 10 |
2165-06-17 00:00:00
|
2165-06-17 17:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Avandia / Bactrim
Attending: ___.
Chief Complaint:
dyspnea, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with past medical history of
ckd III, htn, poorly controlled DMII, ?CHF; who presents with
shortness of breath and abdominal pain. This began last night.
Patient reports burning pain of the lower abdomen. He describes
this as a volcano. He had a cup of coffee this morning when a
friend noted he looked pale. He had a transient episode of chest
pain but this resolved. He then proceeded to the hospital.
Of note, patient seen by podiatry in ED on ___ due to a
worsening right foot wound. He developed lesions over the top of
his foot in setting of Epsom salt baths for the wound on the
ball of the foot. In the emergency department at that time he
received vanc and zosyn. The blisters on the top of his foot
were opened and patient was started on Bactrim PO.
Past Medical History:
DM with nephropathy and neuropathy
HTN
HLD
Gout
Anemia
Chronic renal insufficiency (recent baseline ~1.7)
Anal fissures
Alcohol use
B12 deficiency
Social History:
___
Family History:
Mother with IDDM passed away in ___.
Father died of lung cancer at age ___.
Younger brother living with DM.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
GENERAL: Alert, oriented, no acute distress
HEENT: Poor dentition, Sclera anicteric, MMM, oropharynx clear
NECK: excess soft tissue ,JVP appears at midneck, no clear
hepatojugular no LAD
LUNGS: Distant heart sounds, crackles bilaterally, no wheezing
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, distended, bowel sounds present, bandlike tenderness
of lower abdomen, some tenderness of RUQ
EXT: warm legs, cool feet, palpable pulses, has wound on right
ball of foot with erythema, open blisters along top of the foot
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: Alert and interactive, sitting on edge of bed
comfortably, in no acute distress.
HEENT: NCAT, (-) scleral icterus. L medial subconjunctival
hemorrhage present, EOMI.
CARDIAC: RRR, normal S1/S2, no m/r/g
LUNGS: Decreased breath sounds, otherwise CTAB, no increased
work
of breathing
ABDOMEN: Soft, non-tender, non-distended, normoactive BS
EXTREMITIES: Warm. Dressing in place on R foot, appears
clean/dry/intact, no bleeding noted. Varicose veins present on
lower extremities bilaterally, no peripheral edema
NEUROLOGIC: CN grossly intact, spontaneously moving all
extremities
Pertinent Results:
ADMISSION LABS
===============
___ 01:14AM BLOOD WBC-14.5* RBC-4.21* Hgb-12.1* Hct-37.4*
MCV-89 MCH-28.7 MCHC-32.4 RDW-13.9 RDWSD-44.6 Plt ___
___ 01:14AM BLOOD ___ PTT-25.3 ___
___ 01:14AM BLOOD Glucose-369* UreaN-49* Creat-2.7* Na-134*
K-7.4* Cl-97 HCO3-22 AnGap-15
___ 01:14AM BLOOD cTropnT-0.03* proBNP-___*
___ 05:18PM BLOOD cTropnT-0.03*
___ 04:44AM BLOOD CK-MB-7 cTropnT-0.04*
___ 01:14AM BLOOD Calcium-9.8 Phos-4.5 Mg-2.2
___ 11:58AM BLOOD ___ O2 Flow-10 pO2-29* pCO2-62*
pH-7.26* calTCO2-29 Base XS--1 Intubat-NOT INTUBA
___ 01:33PM BLOOD Comment-ADDED TO G
___ 03:49PM BLOOD pO2-43* pCO2-50* pH-7.34* calTCO2-28 Base
XS-0
___ 09:31PM BLOOD ___ pO2-37* pCO2-44 pH-7.42
calTCO2-30 Base XS-3
___ 01:33PM BLOOD K-6.9*
DISCHARGE LABS
===============
___ 07:02AM BLOOD WBC-9.0 RBC-4.34* Hgb-12.2* Hct-37.1*
MCV-86 MCH-28.1 MCHC-32.9 RDW-13.5 RDWSD-41.9 Plt ___
___ 07:02AM BLOOD Plt ___
___ 07:02AM BLOOD ___ PTT-28.5 ___
___ 07:02AM BLOOD Glucose-198* UreaN-31* Creat-2.0* Na-138
K-5.6* Cl-102 HCO3-19* AnGap-17
___ 07:02AM BLOOD Calcium-9.5 Phos-4.6* Mg-2.2
Brief Hospital Course:
================
PATIENT SUMMARY
================
Mr. ___ is a ___ year-old man w/ PMH of CKD Stage III, HTN,
poorly controlled DMII, distant 25-pack year smoking history &
recent R foot cellulitis on Bactrim, who presented to the ___
ED on ___ with abdominal pain & shortness of breath. Course c/b
acute hypoxic & hypercarbic respiratory failure, hyperkalemia,
acute-on-chronic ___, & bradycardia, now resolved.
================
ACUTE ISSUES
================
#Acute hypoxic respiratory failure, resolved
#Acute hypercarbic respiratory failure, resolved
#Acute on chronic diastolic heart failure
On presentation (___), Mr. ___ had shortness of breath, and
an initial ED O2 sat in the ___, with VBG concerning for hypoxic
respiratory failure. He had a CXR showing pulmonary edema. He
was transferred to the MICU, and treated with BiPAP, nitro, 2x
IV Lasix bolus, & duonebs. His respiratory status significantly
improved to baseline. He received an TTE, showing no systolic
dysfunction and an enlarged left ventricle. Etiology of
respiratory failure was thought to be multifactorial w/ likely
heart failure decompensation in the setting of diastolic
dysfunction with longstanding HTN. Other possible contributor
was potential acute COPD exacerbation, given significant past
smoking history & wheezing on initial exam with improvement on
duonebs, though he has never had a formal diagnosis. CT abdomen
and pelvis showed few inflammatory nodules w/ small effusion and
there was high suspicion for COPD exacerbation, so Mr. ___
was started on azithromycin and prednisone. Upon transfer to the
medicine floor on ___, he had no symptoms of shortness of
breath and had no respiratory distress. Additionally, Mr.
___ had no sputum production or cough, so antibiotics and
prednisone were stopped, with low suspicion for underlying
infection. Leukocytosis was likely related to stress in the
setting of hypoxic respiratory failure, and downtrended to
within normal limits over hospital course. On day of discharge,
Mr. ___ had no signs of volume overload or respiratory
distress on exam and he had an O2 sat of 91-96% on RA.
#Acute-on-chronic kidney injury
#Hx of CKD III
Mr. ___ was thought to have a baseline Cr of 1.6-1.8 but
upon further chart review it appears he may have a new baseline
of 2.0. On admission, his initial Cr was elevated to 2.7. His
FEUrea was calculated to be 31.4%, which supported a pre-renal
etiology. He maintained good urine output and renal ultrasound
showed no signs of hydronephrosis, making obstructive etiology
unlikely. UA showed moderate blood, high protein and glucose,
trace leuks, which was likely due to underlying T2D and the use
of foley catheter in the MICU. Urine sediment showed no casts.
The most likely etiology ___ was cardiorenal syndrome in the
setting of volume overload and venous congestion, with
improvement after aggressive furosemide diuresis. Upon transfer
to the general medicine floor, Mr. ___ was re-started on his
home diuretic regimen. Cr initially downtrended with diuresis,
subsequently rising and then improved after fluids. Will plan to
hold home diuretic on discharge with close follow up with PCP to
restart it. Of note, Mr. ___ was taking bactrim for his
right foot wound; however this was stopped on admission due to
suspicion for intrinsic AIN. Nephrology was curbsided, and AIN
was deemed unlikely, give lack of RBC and WBC casts, and no
eosinophilia. Over the course of his hospitalization, Mr.
___ BUN and creatinine improved, and was ___ on day of
discharge.
#Hyperkalemia
On admission, Mr. ___ had hyperkalemia to 6.9 that resolved
with calcium gluconate and insulin therapy. Most likely etiology
of hyperkalemia was ___. As Mr. ___ kidney function
improved with diuresis, his potassium downtrended and remained
stable. His EKG was stable, and he had no arrhythmias during
admission. Additionally, he denied any symptoms of hyperkalemia
such as nausea, weakness, palpitations. Per past records,
patient has baseline high K. Plan to have patient recheck his
labs prior to his PCP appointment on ___ to ensure
stability.
#Right foot wound, stable
#Right foot cellulitis, resolved
Mr. ___ initially presented to ___ on ___ for worsening R
foot ulcer. Podiatry evaluated, debrided the wound, and
prescribed a 5-day cellulitis treatment with Bactrim. His wound
culture from ___ grew polymicrobial organisms. On admission,
his Bactrim was discontinued in the setting of an ___. Podiatry
was consulted to re-evaluate his wound, and approved holding
antibiotic given that there was no acute process on evaluation,
and the right foot appeared stable, with resolution of
cellulitis. Blood cultures showed no growth to date. Plan was
made for Mr. ___ to follow-up in ___ clinic on
discharge to re-evaluate his foot ulcer.
===============
CHRONIC ISSUES:
===============
#Diabetes Mellitus, poorly controlled
#Glucosuria:
Last HgbA1c 10.4 on ___. Per patient, he is only taking
metformin at home, and does not want to take insulin because of
anxiety with self-insulin injections. He is in close follow-up
with PCP ___, and has been having ongoing discussions
to explore alternatives to insulin shots. He was maintained on
insulin sliding scale with nightly glargine for basal control.
#Hypertension:
BPs were stable over admission. His labetolol was stopped in the
setting of isolated episodes of bradycardia in the MICU, however
was resumed once transferred to the general medicine floor. He
was discharged with stable BP and HR, stable on home labetolol
and amolidipine.
#Bradycardic to ___, resolved
Mr. ___ had isolated episodes of bradycardia to the ___
while in the MICU. This was likely secondary to hyperkalemia,
but resolved w/ improvement in potassium and kidney function.
Patient has been mentating well. His heart rates were closely
monitored over the remainder of his admission and continued to
be stable.
#Abdominal Pain, resolved
Mr. ___ initially presented to ED with burning lower
abdominal pain; however collateral discussion with his sister
revealed that it was his shortness of breath that initiated his
visit to the ED. His abdominal pain resolved after a watery
bowel movement on the morning of ___, and was likely secondary
constipation or viral gastroenteritis. Abdominal CT w/ contrast
did not show an acute process, and he did not experience any
abdominal pain throughout the rest of his admission.
#Troponinemia iso CKD, stable
While in the ED, Mr. ___ had two reads of 0.03, 0.04, with
no concerns for acute changes on EKG. His troponinemia was
likely chronically elevated in the setting o CKD.
===================
TRANSITIONAL ISSUES
===================
New Meds: None
Stopped/Held Meds: Bactrim, Lasix
Changed Meds: None
Follow-up appointments: as per above
Post-Discharge Follow-up Labs Needed: BUN, creatinine, K
[] Patient's home Lasix was held on discharge due to
hypovolemia. We feel these should be restarted if his Cr
demonstrates stability on his repeat check.
[] Has close PCP ___ for ongoing optimal mgmt. of diabetes and
to reassess starting Lasix
[] Patient will have BUN, Cr, K checked prior to PCP appointment
on ___
[] Diabetic Foot Ulcer: Schedule 1 week ___ appointment after
discharge with Dr. ___, ___
[] Recommend PFT evaluation for possible COPD
[] Follow-up blood cultures, currently show no growth to date
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. CloNIDine 0.1 mg PO BID
5. Fenofibrate 54 mg PO DAILY
6. Furosemide 40 mg PO BID
7. Gabapentin 800 mg PO BID
8. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN Pain
- Moderate
9. Labetalol 200 mg PO BID
10. Aspirin 81 mg PO DAILY
11. Cyanocobalamin 1000 mcg PO DAILY
12. GlipiZIDE 10 mg PO TID
13. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. CloNIDine 0.1 mg PO BID
6. Cyanocobalamin 1000 mcg PO DAILY
7. Fenofibrate 54 mg PO DAILY
8. Gabapentin 800 mg PO BID
9. GlipiZIDE 10 mg PO TID
10. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN
Pain - Moderate
11. Labetalol 200 mg PO BID
12. MetFORMIN (Glucophage) 500 mg PO BID
13. HELD- Furosemide 40 mg PO BID This medication was held. Do
not restart Furosemide until you discuss with your provider.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
#Acute hypercarbic respiratory failure
#Acute-on-chronic kidney injury
#Hyperkalemia
#Right foot wound and cellulitis
#Abdominal Pain
SECONDARY DIAGNOSES
===================
#Diabetes Mellitus
#Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
================================================
MEDICINE Discharge Worksheet
================================================
Dear ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for shortness of breath, abdominal pain, and
injury to your kidneys.
What happened in the hospital?
- While in the hospital, your shortness of breath was treated
with a special machine (Bipap) until it got better.
- You were given medications to help remove excess fluid backed
up in your lungs and kidneys.
- The podiatry doctors ___ your ___ foot ulcer, which
showed signs of good healing, so your antibiotics were stopped.
- We gave you medications to treat your high levels of
potassium.
What should I do when I leave the hospital?
- Please attend all scheduled upcoming appointments and take
your medications as prescribed.
- Please do not take NSAID medications such as aleve, ibuprofen,
or motrin.
- Do not take your Lasix (diuretic) until you discuss with your
primary care doctor on ___.
- On ___ morning before your primary care appointment,
please go to your clinic to have labs drawn.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19814315-DS-7
| 19,814,315 | 21,577,571 |
DS
| 7 |
2159-12-04 00:00:00
|
2159-12-12 16:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Dyspnea and weight gain, DOE for one day
Major Surgical or Invasive Procedure:
Cardiac stress perfusion study
History of Present Illness:
___ is a ___ year old man with known of diabetes
mellitus, diasolic HF with prior LVEF >55%, CKD, hypertension,
hyperlipidemia, gout, and prior lower extremity DVT who presents
with swelling of hands and sudden onset of exertional dyspnea
the day prior to admission. Patient was taking his normal ___nd acutely became short of breath with associated
chest pain in L chest. He stopped walking and the DOE and chest
pain stopped. He tried to continue but the same symptoms
recurred. Afterward he noted possible fevers, chills, and
sweats, no nausea and vomiting. Pt called his PCP who
recommended evaluation in the ED. No recent PND, orthopnea.
Of note, patient mentions 23 lb weight gain in last few months,
hand swelling, belly distension, and worsening leg swelling. He
also reports intermittent RUQ abdominal pains that last for a
few seconds and tie his stomach in knots then recede. Patient
also has history of DVT in the past that was treated for 2
weeks, per patient.
In the ED, initial VS were 98.2 77 149/61 20 96% ra. Labs were
notable for Cr 1.4 (baseline 1.5), K 5.6, trop 0.03, BNP 351,
negative D-dimer and lactate 2.2. He was given ASA 325 and
Kayexalate. His K continued to rise (5.6->5.8->5.9) and his
second troponin was 0.04. EKG was notable for a prolonged PR
interval, low voltage and poor R wave progression, but was
otherwise unchanged from baseline and changes consistent with
hyperkalemia.
Bedside ultrasound was performed which was concerning for
pericardial effusion, without tamponade physiology noted. CXR
showed no acute process. D-dimer negative and VQ scan showed low
probability of PE. LENIs showed an OLD DVT present. Received 15
g of kayexalate and 325 mg of aspirin.
Pt did not feel shortness of breath when he arrived to the
floor. He denied any current complaints.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
All other 10-system review negative in detail.
Pain: The patient reported chest pain with exertion on
admission, which subsequently resolved with treatment for his
volume overload. He also reported abdominal pain as noted above,
on several occasions.
Past Medical History:
1) Gout - last flare ___ years ago in his feet
2) Hypertension
3) Diabetes
4) Hyperlipidemia
5) Chronic renal insufficiency (baseline 1.3-1.5)
6) Neuropathy
7) Anal fissures
8) Alcohol use
9) B12 deficiency
Social History:
___
Family History:
Mother with IDDM passed away in ___.
Father died of lung cancer at age ___.
Younger brother living with DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97 ___ RA BS 277
GEN - Alert, oriented, no acute distress, obese
HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear
NECK - supple, no JVD, no LAD
PULM - CTAB, no w/r/r
CV - RRR, S1/S2, no m/r/g
ABD - obese, distended but not tense, + BS, mildly tender RUQ
EXT - WWP, mild chronic venous stasis changes, 1+ edema
bilaterally ___, and non-pitting edema both hands
NEURO - CN II-XII intact, motor function grossly normal
SKIN - no ulcers or lesions
Discharge Exam
VS 97.9 115/62 66 18 97% RA, I/O ___
GEN - Alert, oriented, no acute distress, obese
HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear
NECK - supple, no JVD, no LAD
PULM - CTAB, no w/r/r
CV - RRR, S1/S2, no m/r/g
ABD - obese, distended but not tense, + BS, nontender
EXT - WWP, mild chronic venous stasis changes, 1+ edema
bilaterally ___, and non-pitting edema both hands
Pertinent Results:
Admission Labs
___ 09:40PM WBC-9.2 RBC-3.71* HGB-11.7* HCT-34.3* MCV-93
MCH-31.6 MCHC-34.1 RDW-14.5
___ 09:40PM NEUTS-67.4 ___ MONOS-4.1 EOS-2.5
BASOS-0.3
___ 09:40PM PLT COUNT-308
___ 09:40PM ___ PTT-33.8 ___
___ 09:40PM D-DIMER-167
___ 09:40PM proBNP-351*
___ 09:40PM cTropnT-0.03*
___ 09:40PM GLUCOSE-215* UREA N-27* CREAT-1.4* SODIUM-142
POTASSIUM-5.6* CHLORIDE-105 TOTAL CO2-29 ANION GAP-14
___ 09:49PM LACTATE-2.2*
___ 04:54AM LACTATE-1.7
___ 04:54AM cTropnT-0.04*
___ 04:54AM GLUCOSE-181* UREA N-29* CREAT-1.5* SODIUM-141
POTASSIUM-5.8* CHLORIDE-105 TOTAL CO2-28 ANION GAP-14
___ 01:20PM CK-MB-8
___ 01:20PM CK(CPK)-332*
Discharge Labs
___ 07:30AM BLOOD WBC-8.6 RBC-4.23* Hgb-12.9* Hct-38.4*
MCV-91 MCH-30.5 MCHC-33.7 RDW-14.7 Plt ___
___ 07:30AM BLOOD Glucose-202* UreaN-35* Creat-1.5* Na-139
K-4.7 Cl-101 HCO3-27 AnGap-16
___ 05:38PM BLOOD CK-MB-8 cTropnT-0.03*
___ 07:30AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.2
Reports
Cardiac Perfusion study
IMPRESSION:
Normal myocardial perfusion with mildly reduced LVEF and mildly
increased
LV size since prior study
Cardiac Stress Test
INTERPRETATION: This ___ year old type 2 IDDM man with CKD and
diastolic CHF was referred to the lab for evaluation of chest
discomfort
and shortness of breath. The patient exercised for 9 minutes of
a
modified Gervino protocol and stopped for fatigue. The estimated
peak
MET capacity was 3.5 which represents a poor functional capacity
for his
age. No arm, neck, back or chest discomfort was reported by the
patient
throughout the study. There were no significant ST segment
changes
during exercise or in recovery. The rhythm was sinus with rare
isolated
vpbs. Appropriate increase in systolic BP with a blunted HR on
beta
blocker therapy.
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Nuclear
report sent separately.
___
IMPRESSION:
Subacute to chronic nonocclusive thrombus within the proximal
aspect of one of the right superficial femoral veins, which are
duplicated. This finding is unchanged since ___.
V/Q Scan
IMPRESSION: Low likelihood ratio for recent pulmonary embolism.
CXR
IMPRESSION: No evidence of pneumonia
Brief Hospital Course:
___ year old man with acute on chronic diastolic HF,
Hypertension, DM, CKD who presents with shortness of breath,
weight gain, consistent with an acute exacerbation of diastolic
heart failure.
#Acute exacerbation of diastolic HF: Patient presented with
symptoms of left and right sided failure. There was high
suspicion in the ED that he had a PE given his chronic and
unchanged RLE DVT- however his DDimer was negative and VQ scan
unremarkable. He was admitted to the medicine service where
further history revealed a 23 lb gradual weight gain in the past
few months with high salt diet. He had evidence of volume
overload on exam. We diuresed him with 40 mg IV lasix
(increased from his home dose 40 mg PO). Patient was also ruled
out for ACS. Given the history of chest pain with DOE, we sent
the patient for a myocardial stress perfusion study which did
not reveal any focal ischemia. However, it did show a mildly
depressed EF, indicating systolic as well as previously
documented diastolic heart failure. His pioglitazone was held
during this time, although it was restarted on discharge. It
would be possible to consider alternative agents for his
diabetes given the concern regarding his EF, although given his
current deferring of insulin therapy, that discussion should
continue as an outpatient. His breathing notably improved during
his admission. We would recommend that the patient see a
cardiologist as an outpatient, although the patient deferred
this direct referral, and expressed the wish to speak with his
internist prior to this referral.
#Troponin leak, consistent with demand-mediated ischemia: The
patient was thought to have demand ischemia given no obvious EKG
changes concerning for ACS. Pt had Tr of 0.04 during past
admission but this was during ___. We cycled his troponins which
downtrended and monitored on tele. He underwent stress
perfusion study as above, which did not reveal reversible
ischemia at the exercise level achieved. He also noted that he
did not experience his symptoms of chest pain nor dyspnea he
experienced with exertion prior to admission.
#Hyperkalemia- appears long standing per notes, now improved.
Patient was recently on losartan which may have acutely worsened
his hyperkalemia. He received 15 g of kayexalate in the ED and
his losartan was held. We did not restart this medication, as
given his hyperkalemia in the past in the setting of CKD, an
___ seemed relatively contraindicated at this time.
#HTN- patient generally 120s-130s systolic as an outpatient. He
peaked at 160s systolic in the ED. Transfer vitals with SBP 202,
but improved initially with PO hydralazine q 6 hrs. We then
increased his labetolol from 100 to 200 mg BID. Losartan was
held for hyperkalemia.
#RLE DVT- per ___ it is old and stable. Patient states he was
treated with anticoagulation the past, which we were able to
confirm with his internist.
-PCP ___ follow up regarding if further treatment is warranted,
given it's persistence despite prior treatment. Will defer to
his internist, which we discussed both with the patient and his
internist.
Chronic Issues
#Gout- continued allopurinol ___ mg daily
#DM- Held oral meds while in house and continued patient on ___.
Transitional Issues
-Pt's old RLE DVT should be revisited with PCP to determine if
the full course he received previously was adequate, given
persistence of imaging findings notable for chronic clot.
-We recommend diabetes follow-up either with an endocrine or
___ provider, as well as renal and cardiology follow-up for
the end-organ related damage to his hypertension and diabetes.
The patient noted that he preferred to discuss follow-up plans
with his internist, and deferred having our team schedule these
directly at the time of discharge. We spoke directly with his
internist, given the patient's wishes, and he will work with the
patient to address these follow-up needs. In particular, we
suspect the patient may soon benefit from insulin therapy,
although he strongly deferred this treatment on discharge home.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. fenofibrate *NF* 54 mg Oral daily
3. Gabapentin 800 mg PO TID
4. Labetalol 100 mg PO BID
5. Losartan Potassium 50 mg PO DAILY
6. Pioglitazone 30 mg PO DAILY
7. Simvastatin 40 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO BID
11. MetFORMIN (Glucophage) 1500 mg PO QAM
12. MetFORMIN (Glucophage) 1000 mg PO QPM
13. Furosemide 40 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO BID
5. Gabapentin 800 mg PO TID
6. Labetalol 200 mg PO BID
7. Simvastatin 40 mg PO DAILY
8. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
9. fenofibrate *NF* 54 mg Oral daily
10. Simethicone 40-80 mg PO QID:PRN abdominal cramps
11. MetFORMIN (Glucophage) 1500 mg PO QAM
12. MetFORMIN (Glucophage) 1000 mg PO QPM
13. Pioglitazone 30 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Diastolic (minor part systolic) heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ for shortness of breath and chest
pain. Given your recent weight gain and your swelling, we
thought your symptoms were mainly due to heart failure. We
ruled out a heart attack by following your EKGs and cardiac
enzymes. You went for a perfusion stress test which did not
show that there were any areas of your heart which were low on
blood supply (indicating no heart attack).
Please follow up with your cardiologist and primary care
physician as below
___ continue to take lasix 40 mg daily
Please STOP taking the losartan- this caused your potassium to
be high
Followup Instructions:
___
|
19814315-DS-9
| 19,814,315 | 20,093,120 |
DS
| 9 |
2162-08-26 00:00:00
|
2162-08-26 15:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Wound Eval, Hyperkalemia, Anemia
Major Surgical or Invasive Procedure:
amputation of R ___ toe on ___
History of Present Illness:
___ PMH T2DM with nephropathy and neuropathy, CKD (recent
baseline ~1.7), h/o hyperkalemia, HTN, HLD, gout, p/w R ___ toe
infection. He initially presented ___ to ED with exam was
concerning for a serious infection of right fourth toe that
would require amputation. Lab work was concerning for a
significantly elevated potassium level (6.6). Patient has
previously been followed by Dr. ___ seen approximately
1 week ago with a healed ulceration sub hallux. Patient
originally presented to the ED on ___ where he was found
to have a necrotic Right toe,but refused admission because his
brother died and he had to attend his funeral and wake. He was
discharged on PO Clindamycin and Ciprofloxacin and ___ services
were set up so the patients dressing could be changed daily.
Patient re-presents to the ED on ___ with continued pain
of right foot. In the ED, initial vitals: Pain 7, 97.1 70
154/63 16 100% RA
K- 5.5 gave 1L NS in ER for ___.
Pt was given vanc and zosyn.
CRP: 172.1
Seen by podiatry in ER; plan for surgery for open ___ toe
amputation. Podiatry performed bedside excisional debridement to
the level of SubQ tissue with 15 blade and forceps. Upon
debridement, purulence was expressed.
- Vitals prior to transfer: Pain 7 98.4 63 133/67 16 100% RA
On arrival to the floor, pt has no complaints; R foot/toe do not
hurt currently; has no sensation there at baseline. Denies F/C,
CP, HA, abdom pain, N/V/D. Uses diabetic shoes at home. Cannot
recall any recent trauma/trigger to the current toe infection.
Had been seeing podiatrist recently for R hallux/medial foot
ulcer which had been healing well.
Past Medical History:
DM with nephropathy and neuropathy
HTN
HLD
Gout
Anemia
Chronic renal insufficiency (recent baseline ~1.7)
Anal fissures
Alcohol use
B12 deficiency
Social History:
___
Family History:
Mother with IDDM passed away in ___.
Father died of lung cancer at age ___.
Younger brother living with DM.
Physical Exam:
============================
ADMISSION PHYSICAL EXAM:
============================
Vitals- 98.5 174/65 71 20 98%RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes,crackles
CV- RRR, Nl S1, S2, No MRG
Abdomen- obese, soft, NT/ND bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 3+ edema RLE, 2+ LLE
Neuro- CNs2-12 intact, motor function grossly normal
Right ___ toe gangrenous, black discoloration; no purulent
drainage currently. Erythema surrounding affected toe and
extending up to the mid shin (erythema on shins is baseline).
Diminished DP pulse. No sensation around area of ulcer or
hallux.
==========================
DISCHARGE PHYSICAL EXAM
==========================
Vitals- 98, 164/79 (140-160s/60-70s), 59, 20, 98%RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple
Lungs- CTAB no wheezes, crackles
CV- RRR, Nl S1, S2, No MRG
Abdomen- obese, soft, NT/ND bowel sounds present, no rebound
tenderness or guarding
GU- no foley
Ext- warm, well perfused, 3+ edema RLE, 2+ LLE
Neuro- motor function grossly normal
Extremity: s/p right ___ toe amputation. wound closed. No
drainage.
Pertinent Results:
==================
ADMISSION LABS:
==================
___ 01:30PM BLOOD WBC-12.4* RBC-3.73* Hgb-10.7* Hct-34.4*
MCV-92 MCH-28.7 MCHC-31.1* RDW-14.0 RDWSD-47.5* Plt ___
___ 01:30PM BLOOD Neuts-76.0* Lymphs-11.5* Monos-8.1
Eos-3.3 Baso-0.3 Im ___ AbsNeut-9.43* AbsLymp-1.42
AbsMono-1.00* AbsEos-0.41 AbsBaso-0.04
___ 07:05AM BLOOD ___ PTT-32.4 ___
___ 01:30PM BLOOD Glucose-140* UreaN-47* Creat-2.0* Na-138
K-5.5* Cl-100 HCO3-24 AnGap-20
___ 07:05AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.2
___ 01:30PM BLOOD CRP-172.1*
==================
DISCHARGE LABS:
==================
___ 06:07AM BLOOD WBC-9.0 RBC-3.74* Hgb-10.9* Hct-34.3*
MCV-92 MCH-29.1 MCHC-31.8* RDW-13.8 RDWSD-46.3 Plt ___
___ 06:07AM BLOOD Glucose-161* UreaN-33* Creat-1.6* Na-139
K-5.5* Cl-101 HCO3-25 AnGap-19
___ 06:07AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.0
==============
IMAGING:
==============
___ R FOOT AP,LAT & OBL RIGHT
IMPRESSION:
No definite radiographic evidence of osteomyelitis. Findings are
similar to the radiograph from 2 days prior. If clinical concern
persists, consider bone scan or repeat radiograph in ___ days.
============
MICRO:
============
bone biopsy pending
Brief Hospital Course:
___ PMH T2DM with nephropathy and neuropathy, CKD, HTN, HLD,
gout, p/w R ___ toe infection.
# Right ___ gangrenous toe: likely in setting of DM and
neuropathy; unclear trigger for the wound. CRP: 172.1 on
admission. XRAY without obvious e/o osteomyelitis. Pt was seen
by podiatry in ER with debridement and purulence expressed; plan
for surgery for open ___ toe amputation. Wound culture misplaced
in ED, and no bacteria every identified. Podiatry performed
bedside debridement on ___ and ___. Patient went to OR for
amputation on ___, and with no evidence of osteomyelitis or
purulence. Initially left site open. Wound closed on ___ at
the bedside. He was initially on vanc/zosyn, and given
appearance of wound in OR, converted to ciprofloxacin 500mg BID
and clindamycin 300mg TID for a total of 2 week course (day 1
___, end date ___. Wound culture from OR pending at
time of discharge.
# ___ on CKD: baseline ~1.7 recently; initially he was Cr 2.1
but was back to baseline as of ___ after 500cc's IVF. On
___, patient kept NPO for procedure. Cr 2 on day after
procedure. Cr at discharge 1.6.
# Hyperkalemia: In ER, given kayexalate, insulin and glucose.
EKG stable. Patient without symptoms. Per OMR, this has been a
recurrent issue for the patient; by his current and prior PCP,
this was thought ___ pseudohyperkalemia. Current acute on
chronic kidney injury may be contributing. However, pt on Lasix
at home, which may have been helping keep K down, while losartan
may have increased K slightly. Losartan stopped giving recurrent
hyperkalemia. Labs were monitored, and pt did not want to take
kayexelate on the floor. Of note, K drawn out of peripheral
blood gas tube consistently lower than chem 7 tube.
Chronic Issues:
# HTN: continued lasix and labetolol
# DM: held metformin, ISS in-house.
# ?h/o dCHF: per OMR, notes from ___ mention heart failure
requiring Lasix; pt last saw cardiology in ___, however, and
CHF was not mentioned; his TTE in ___ showed normal regional
and systolic function without any significant valvular lesions.
Per pt, his heart has not had issues recently.
====================
TRANSITIONAL ISSUES:
====================
- should have repeat Cr done 1 week after discharge
- ___ underwent right ___ toe amputation
- will complete 2 week course of antibiotics, discharged on
clindamycin 300mg TID /cipro 500mg BID for total 2 week course
(day 1 ___, end date ___
- recommended ambulation with forefoot offloading shoe
- d/c with wound care for every other day dressing changes.
- losartan discontinued due to persistent hyperkalemia. Of note,
K lower when drawn through blood gas tube rather than tiger top.
- SBP 130s at discharge without losartan. However, could
consider starting amlodipine as outpatient. Would need to switch
simvastatin to atorvastatin to minimize drug-drug interactions.
- Cr at discharge 1.6
- full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 1000 mcg PO DAILY
2. Allopurinol ___ mg PO QAM
3. Allopurinol ___ mg PO QPM
4. Aspirin 81 mg PO DAILY
5. Fenofibrate 54 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Labetalol 100 mg PO BID
8. Losartan Potassium 50 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO TID
10. Simvastatin 40 mg PO QPM
11. Gabapentin 800 mg PO BID
12. Acetaminophen 650 mg PO Q6H:PRN pain
13. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN
pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO QAM
3. Allopurinol ___ mg PO QPM
4. Aspirin 81 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Fenofibrate 54 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. Gabapentin 800 mg PO BID
9. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
10. Labetalol 100 mg PO BID
11. Simvastatin 40 mg PO QPM
12. Ciprofloxacin HCl 500 mg PO Q12H
End date ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
(12 hours apart) Disp #*19 Tablet Refills:*0
13. Clindamycin 300 mg PO Q8H
End date ___
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every 8 hours
(three times a day) Disp #*28 Capsule Refills:*0
14. MetFORMIN (Glucophage) 500 mg PO TID
15. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Take this medication every 4 hours as needed in between normal
vidocin pills.
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*10
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
R ___ toe infection
Secondary:
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege to provide care for you here at the ___
___. You were admitted because you had an
infection on your Right fourth toe. You had it debrided by
podiatry, and underwent amputation of the toe. You were treated
with antibiotics as well. You will continue two antibiotics:
ciprofloxacin 500mg twice a day and clindamycin 300mg three
times a day. You will take these medications through ___.
You should wear the protective shoe while walking. Your
condition has improved and you can be discharged to home.
For your high potassium levels, we stopped your losartan. Please
talk to your PCP about ___ new blood pressure medication you can
take instead.
Please keep your follow-up appointments as scheduled below.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19814381-DS-8
| 19,814,381 | 23,181,088 |
DS
| 8 |
2171-02-20 00:00:00
|
2171-02-26 02:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zolpidem / Purinethol / mesalamine / enticort
Attending: ___.
Chief Complaint:
Abdominal Pain, Nausea, Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with PMH of Crohn's disease on Humira
presents with 2 days of diarrhea, vomiting and abdominal pain.
Pain states at 3am on morning of presentation. Patient reports
nausea, and vomiting which progressed to loose watery stools.
Patient does endorse dark colored stool x1 but otherwise denies
melena/hematochezia. Patient has abdominal pain in epigastric
region, which is unusual for prior Crohn's flares.
In the ED, initial vitals were: 97.2 91 149/90 16 100% RA
- Exam notable for: epigastric and LLQ tenderness
- Labs: normal CBC and chem 7, lactate 1.6, negative UA
- Imaging: CT abdomen pelvis showed no evidence of bowel wall
thickening, hyperenhancement or dilation to suggest acute
Crohn's flare.
- Patient was given Zofran 4mg IV x3, morphine 4mg IV x4, IV NS
GI c/s in the ED recommended testing for C diff, consider MRE in
AM.
VS on transfer: 98.3 82 103/54 16 98% RA
On the floor, the patient reports improvement in abdominal pain
and nausea. She does endorse eating a "suspicious" ___
sandwich on the day before the onset of her symptoms. Patient
notes recent history of psoriasis outbreak, thought to be
related to her humira, for which she was using topical steroid
creams. She denies fevers, chills.
Past Medical History:
1. Crohns - Diagnosed in ___ but symptomatic for many years,
she initially complained of diarrhea, later on developed
recurrent episodes of abdominal pain, rectal bleeding, nausea,
vomiting. She has been evaluated by a gastroenterologist ___
___, a colonoscopy was carried out at ___
and she was found to have ileocolitis, initial therapy consisted
of a daily Asacol, later on she was switched over to Pentasa and
as a result of an exacerbation of symptoms. Has had numerous
trials of prednisone.
2. Herpes Simplex of Eye
Social History:
___
Family History:
Father has ulcerative colitis, there are several relatives with
colon cancer (maternal aunt, paternal grandfather, and paternal
cousin).
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 98.6 115 / 72 72 18 96 ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, TTP in epigastric region, non-distended, bowel
sounds present
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
============================
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.2, BP 101 / 64, HR 54, RR 18, O2 sat 96 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, TTP in epigastric region, RLQ, non-distended,
bowel sounds present. No rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
Access: PIV
Pertinent Results:
ADMISSION LABS:
___ 10:37AM BLOOD WBC-8.1 RBC-4.75 Hgb-15.2 Hct-43.5 MCV-92
MCH-32.0 MCHC-34.9 RDW-11.7 RDWSD-39.1 Plt ___
___ 10:37AM BLOOD Neuts-84.9* Lymphs-8.3* Monos-5.3 Eos-1.0
Baso-0.1 Im ___ AbsNeut-6.87*# AbsLymp-0.67* AbsMono-0.43
AbsEos-0.08 AbsBaso-0.01
___ 10:37AM BLOOD ___ PTT-24.0* ___
___ 10:37AM BLOOD Glucose-88 UreaN-14 Creat-0.8 Na-137
K-4.0 Cl-101 HCO3-23 AnGap-17
___ 10:37AM BLOOD ALT-23 AST-32 AlkPhos-57 TotBili-0.8
___ 10:44AM BLOOD Lactate-1.6
=========================
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-4.0# RBC-3.76* Hgb-11.7# Hct-35.1
MCV-93 MCH-31.1 MCHC-33.3 RDW-11.9 RDWSD-40.3 Plt ___
___ 06:15AM BLOOD Glucose-84 UreaN-7 Creat-1.0 Na-138 K-3.9
Cl-105 HCO3-24 AnGap-13
___ 06:15AM BLOOD ALT-16 AST-21 AlkPhos-41 TotBili-0.5
___ 06:15AM BLOOD CRP-38.9*
==========================
IMAGING:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation
throughout.
Small hypodensity is noted in the right lobe of the liver, too
small to
characterize. There is no evidence of intrahepatic or
extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis.
There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The
colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
Small amount
of free fluid in the pelvis, likely physiologic.
REPRODUCTIVE ORGANS: Uterus and adnexae 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.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
No evidence of bowel wall thickening, hyperenhancement, or
surrounding
inflammation suggest acute Crohn's flare.
Brief Hospital Course:
___ yoF with PMH of Crohn disease on Humira presents with 2 days
of diarrhea, vomiting and abdominal pain. CRP was elevated at 38
from 2 in ___ ___bdomen and pelvis showed no signs
active inflammation. GI was consulted and felt there was no need
for urgent EGD, but recommended getting this in the next week as
an outpatient. It was likely that her presentation was a result
of viral gastroenteritis vs toxin-mediated gastroenteritis after
eating bad meat. Stool culture and norovirus PCR were pending at
discharge. Her diet was advanced and she tolerated PO without
difficulty. Patient was discharged home with close follow up
with GI. One day post-discharge, Norovirus test came back
positive. The patient was called at home and notified of the
result. She had not had any symptoms since leaving the hospital.
She was instructed to practice good hand hygiene, avoid sharing
food for 48 hours, and was educated on reasons to pursue medical
attention for her and any close contacts that should become ill.
============================
TRANSITIONAL ISSUES:
-New meds: Omeprazole
-Stopped meds: None
-Pending Labs: Blood culture, stool culture, norovirus PCR
-Abdominal Pain: Patient should have outpatient EGD to rule out
other upper GI pathology given epigastric pain and tenderness on
exam.
-Unclear why patient was taking cephalexin. Plan per outpatient
provider.
-CODE STATUS: FULL CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ___ FE ___ (28) (norethindrone-e.estradiol-iron) 1.5
mg-30 mcg (21)/75 mg (7) oral DAILY
2. Cephalexin 500 mg PO Q6H
3. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY
4. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY
5. famciclovir 125 mg oral TID:PRN
6. Humira (adalimumab) 40 mg/0.8 mL subcutaneous 1X:ASDIR
Discharge Medications:
1. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN Nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*20 Tablet Refills:*0
3. Cephalexin 500 mg PO Q6H
4. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY
5. famciclovir 125 mg oral TID:PRN
6. Humira (adalimumab) 40 mg/0.8 mL subcutaneous 1X:ASDIR
7. ___ FE ___ (28) (norethindrone-e.estradiol-iron) 1.5
mg-30 mcg (21)/75 mg (7) oral DAILY
8. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Epigastric Pain
Secondary Diagnoses:
Nausea
Crohn Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the hospital because you had nausea,
vomiting, and abdominal pain, which was concerning for a flare
of your Crohn's Disease. You were treated with pain and
anti-nausea medication. A CAT scan of your abdomen was normal.
Some other labs were sent off as well. The intestine doctors
came to ___ you and did not think this was a Crohn flare, but
most likely a viral infection of your intestine or food
poisoning. They did not feel that you need an urgent endoscopy
at this time. They are in the process of making you an
appointment with your outpatient gastroenterologist for a scope.
Over the next day, you improved and were able to eat and drink.
Therefore you were allowed to go home.
It was a pleasure participating in your care. We wish you the
best!
Your ___ Care Team
Followup Instructions:
___
|
19814407-DS-18
| 19,814,407 | 20,210,983 |
DS
| 18 |
2141-05-04 00:00:00
|
2141-05-04 17:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
visual changes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
visual field changes
Past Medical History:
Ms. ___ is a ___ year old right handed lady with history of
BPPV,
vestibular neuritis, sensineural hearing loss, essential tremor,
pre-DM, HLD who presents with acute onset visual changes 2 weeks
ago for which she went to ophthalmology today and was diagnosed
with right homonymous hemianopia and subsequently referred to
the
emergency department.
She was in her usual state of health and was reading the
newspaper on ___ when she suddenly had some difficulty
"tracking the lines". She didn't think she lost her vision or
had
missing vision. She was able to read the words but does think
there was an issue with comprehending the meaning. She has
trouble describing what she means by this. She attributed this
to
just perhaps the small print. She was doing much better reading
larger print on her phone. She denies that she ever couldn't
read
at all. She never had to spell the letters or say them out loud.
She has not been bumping into anything on her right and she has
been able to drive. She does not think she had any associated
weakness, tingling/numbness, memory issues, dizziness or
headache. She thinks she snores. She doesn't have palpitations.
She finally had optho appointment today at which time a dense
right homonymous hemianopia was noted WITHOUT macular sparing.
She was referred to ___.
She does report that about a year ago she had an episode of
isolated vertical diplopia lasting a minute. Per At___ records
by Dr. ___ occurred while walking down stairs. She had
had cataract surgery at some point that year. ESR and CRP were
normal. MRI brain with and without contrast, MRA brain/neck at
___ ___ showed no acute infarct, normal MRAs, tortuous
but otherwise normal vertebral arteries. TTE ___ showed LVEF
approximately 60%, trace-mild aortic regurgitation, mild mitral
regurgitation, no shunt by color Doppler. Holter monitor ___
showed sinus rhythm with sinus arrhythmia, occasional APBs, one
run of SVT. The transient diplopia was felt to be possible
migraine variant but given possibility of TIA, she was started
on
ASA. Patient reports she has had several more episodes of
vertical diplopia since that initial one. The longest was 10
minute episode about 1 week ago. She woke up at 3AM and noticed
it. Seemed the same regardless if she looked right or left;
perhaps worse with her head back. This went away and was not
associated with any other symptoms.
Social History:
___
Family History:
Her father had tremor and hearing loss. Father
had stroke in ___ but she thinks it was bleeding type. Her
mother
had ___ disease with onset in the late ___. There is no
family history of migraines. She wonders if her maternal
grandmother had a stroke.
Physical Exam:
Admission Physical Exam:
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects. Able to read
without difficulty and describe meaning of words. She can write
a
complex sentence. No dysarthria. Able to follow both midline and
appendicular commands. Able to register 3 objects and recall ___
at 5 minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk, post surgical,
narrow
palpebral fissure on left (chronic). EOMI with 5 beats end gaze
nystagmus bilaterally. Right homonymous hemianopia with finger
counting, perhaps more pronounced on right vs. left with pin.
Right eye hypotropic relative to left.
V: Facial sensation intact to light touch.
VII: Left NLFF but strong eye closure and lip closure, scar on
philtrum from prior surgery
VIII: Hearing "different" tones bl, possibly dec more on right
(chronic)
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. Slight cupping and
drift
on pronator testing on LEFT.
[Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA]
L 4+ 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, or
proprioception
of large toe. No extinction to DSS. Romberg
-Reflexes:
reflexes slightly more brisk on left
toe up on left, down on right
-Coordination: Intention tremor right>left. Finger taps slow on
left, no dysmetria on FnF.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing
but slight stoop to right. Quick turn. Steps to side with
tandem,
can heel and toe walk.
Discharge Physical Exam:
Neurologic:
-Mental Status: Alert, oriented x 3. Her speech is somewhat
hesitant, takes many pauses before speaking. She tends to repeat
herself, and perseverates. Attentive, able to name ___ backward
without difficulty. She has trouble with repetition, though this
may have been limited by hearing (says ___ is the one to help
today" instead of "I only know that ___ is the one to help
today", and "the cat hit under the couch" instead of "the cat
always hid under the couch when the dog was in the room".
Comprehension is impaired as well, also possibly limited by
hearing. For example, when asked to touch her finger to her nose
(finger specified by examiner) she says "which finger" and it
takes repetition of command several times for her to understand,
despite the fact she has been asked to do this every day for the
past 12 days. Her speech is halting, but normal prosody. There
were no paraphasic errors. Able to name both high and low
frequency objects. Able to read with difficulty very large text.
Trouble with drawing a cube and clock on MOCA testing. No
dysarthria. Able to register ___ objects and recall ___ at 5
minutes without cues. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk, post surgical,
narrow palpebral fissure on left (chronic). EOMI without
nystagmus. Eyes are orthotropic in primary position. Right
homonymous hemianopia with finger counting, cannot count fingers
until directly in her field of vision on the right, the left
upper quadrant also is restricted to finger count, less so than
the left lower quadrant.
V: Facial sensation intact to light touch.
VII: Left NLFF but strong eye closure and lip closure, scar on
philtrum from prior surgery
VIII: Decreased hearing bilaterally, which is chronic but
worsened over the past month. Hearing aids in place.
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronation or drift
bilaterally.
[Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA]
L 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS. Romberg
-Reflexes:
reflexes slightly more brisk on left, with suprapatellar on the
left but not on the right. Toes mute bilaterally.
-Coordination: No dysmetria on FNF. Slight intention tremor
bilaterally. Slowed finger tapping bilaterally.
-Gait: Good initiation. Ambulating independently around the
halls with narrow-based, normal stride and arm swing but slight
stoop to right. Turns very quickly and almost appears off
balance.
Pertinent Results:
___ 06:10AM BLOOD WBC-6.8 RBC-4.15 Hgb-12.2 Hct-37.9 MCV-91
MCH-29.4 MCHC-32.2 RDW-13.5 RDWSD-45.5 Plt ___
___ 06:10AM BLOOD Plt ___
___ 08:50AM BLOOD ___ PTT-31.8 ___
___ 06:10AM BLOOD Glucose-104* UreaN-25* Creat-1.0 Na-142
K-4.5 Cl-107 HCO3-23 AnGap-12
___ 06:10AM BLOOD ALT-38 AST-39 LD(LDH)-141 CK(CPK)-32
AlkPhos-61
___ 02:40PM BLOOD cTropnT-<0.01
___ 06:10AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.9 Mg-2.2
UricAcd-5.7
___ 02:54PM BLOOD %HbA1c-5.6 eAG-114
___ 02:40PM BLOOD Triglyc-111 HDL-64 CHOL/HD-3.0
LDLcalc-108
___ 02:40PM BLOOD TSH-0.82
___ 09:54AM BLOOD ___ CRP-6.5*
___ 02:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 09:43PM BLOOD Lactate-1.1
MRI Brain ___
IMPRESSION:
1. Redemonstration of diffusion-weighted hyperintense signal
involving the
left parietooccipital cortex, with associated decreased ASL
perfusion in the
left occipital lobe with similar distribution and extent.
Interval
development of subtle cortical thickening and FLAIR
hyperintensity involving
the median occipital lobe most likely represents manifestation
of the
perfusion abnormality.
2. No additional new intracranial abnormalities.
Brief Hospital Course:
Ms. ___ is a ___ year old right handed lady with history of
BPPV,
vestibular neuritis, sensineural hearing loss, essential tremor,
pre-DM, HLD who presents with acute onset visual changes 2 weeks
ago for which she went to ophthalmology on the day of admission
and was diagnosed
with right homonymous hemianopia and subsequently referred to
the
emergency department.
She was in her usual state of health and was reading the
newspaper on ___ when she suddenly had some difficulty
"tracking the lines". She didn't think she lost her vision or
had
missing vision. She was able to read the words but does think
there was an issue with comprehending the meaning. She has
trouble describing what she means by this. She attributed this
to
just perhaps the small print. She was doing much better reading
larger print on her phone. She denies that she ever couldn't
read
at all. She never had to spell the letters or say them out loud.
She has not been bumping into anything on her right and she has
been able to drive. She does not think she had any associated
weakness, tingling/numbness, memory issues, dizziness or
headache. She thinks she snores. She doesn't have palpitations.
She finally had optho appointment today at which time a dense
right homonymous hemianopia was noted WITHOUT macular sparing.
She was referred to ___.
She does report that about a year ago she had an episode of
isolated vertical diplopia lasting a minute. Per Atrius records
by Dr. ___ occurred while walking down stairs. She had
had cataract surgery at some point that year. ESR and CRP were
normal. MRI brain with and without contrast, MRA brain/neck at
___ ___ showed no acute infarct, normal MRAs, tortuous
but otherwise normal vertebral arteries. TTE ___ showed LVEF
approximately 60%, trace-mild aortic regurgitation, mild mitral
regurgitation, no shunt by color Doppler. Holter monitor ___
showed sinus rhythm with sinus arrhythmia, occasional APBs, one
run of SVT. The transient diplopia was felt to be possible
migraine variant but given possibility of TIA, she was started
on
ASA. Patient reports she has had several more episodes of
vertical diplopia since that initial one. The longest was 10
minute episode about 1 week ago. She woke up at 3AM and noticed
it. Seemed the same regardless if she looked right or left;
perhaps worse with her head back. This went away and was not
associated with any other symptoms.
Hospital Course:
She was initially admitted to the stroke service, with an
initial NIHSS 3 and last known well 2 weeks prior to admission.
Her exam was notable for right homonymous hemianopia, mild word
finding difficulties, and mild right facial droop. Her initial
MRI showed thin cortical diffusion-weighted hyperintense signal
along the left parietooccipital lobe and possible potential
milder signal along the right parieto-occipital lobe without
corresponding signal abnormality on FLAIR or T2. We felt this
was highly atypical for stroke given the lack of FLAIR correlate
and crossing PCA/MCA territories. We evaluated for whether she
could have an occipital seizure with an EEG. The EEG showed
frequent delta slowing over the left temporal region, at times
sharply contoured, with rare LRDAs. There was also asymmetric
PDR on the left side indicating occipital dysfunction, and GRDA
indicating mild encephalopathy, but no clear electrographic
seizures or epileptiform discharges. Therefore, seizure was felt
to be extremely unlikely. We also evaluated and ruled out
cortical venous thrombosis and PRES (no risk factors).
She was transferred to the general neurology service for further
workup as her presentation was not thought to be vascular in
nature. We then considered MELAS given her history of idiopathic
sensorineural hearing loss, and sent metabolic and genetic
testing. Her visual symptoms continued to progress during the
admission with denser right hemianopia, some left visual field
involvement, and increased word finding difficulties. Repeat MRI
showed evolving and slightly worsening findings:
"Redemonstration of diffusion-weighted hyperintense signal
involving the
left parietooccipital cortex, with associated decreased ASL
perfusion in the
left occipital lobe with similar distribution and extent.
Interval
development of subtle cortical thickening and FLAIR
hyperintensity involving
the median occipital lobe most likely represents manifestation
of the
perfusion abnormality." Ultimately, we felt that this would be
an atypical presentation of MELAS given the lack of resolution
of her symptoms, her age at presentation, and her normal lactate
(including post-prandial lactate), CK, and minimally elevated
pyruvate, with other labs pending at discharge.
Given her imaging findings and predominant visual symptoms, we
considered ___ variant CJD and sent ___ and RT-QuIC
from the CSF, with results pending at discharge. She was also
evaluated by Neuro-ophthalmology on ___, and her exam showed
Right homonymous hemianopia without significant neglect in the
setting of left parietal/occipital cortical diffusion
restriction sparing the white matter and in a non-vascular
distribution, simultanagnosia, and progressive cognitive
decline, as well as right hypertropia with full ductions, likely
decompensated phoria.
She was initially started on ASA and Plavix given our first
concern for stroke, and she was ultimately discharged on
aspirin. We also started coenzyme Q10 given our concern for a
possible mitochondrial disorder.
She was set up with home ___, OT, nursing and social work. She
will follow up with neuro-ophthalmology within the next ___
weeks. We have referred her to cognitive neurology and brain fit
club for cognitive rehab. We also contacted her outpatient
neurologist Dr. ___ to coordinate follow up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Pravastatin 10 mg PO QPM
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
4. Meclizine Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. coenzyme Q10 200 mg oral DAILY
2. Pravastatin 20 mg PO QPM
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
4. Aspirin 81 mg PO DAILY
5. HELD- Meclizine Dose is Unknown PO Frequency is Unknown
This medication was held. Do not restart Meclizine until you
follow up with your primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Progressive visual symptoms
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because of difficulties with
your vision as well as word-finding difficulties. You were
initially admitted to the Stroke service because we were
concerned for a stroke, but your symptoms and your MRI did not
fit that diagnosis. You were then transferred to the General
Neurology team. We did 2 brain MRIs, a spinal tap, an EEG, CTs,
an echocardiogram, and multiple lab tests. These tests evaluated
for stroke, seizure, infection, metabolic or genetic causes, and
dementia. We are still waiting for many of the results from our
lab testing. You were also evaluated by our Neuro-ophthalmology
colleagues.
At this time, we do not have a definitive diagnosis for your
symptoms, and we need more information from the lab tests that
are still pending. Once we have these test results back, we can
come up with a plan for further workup if needed.
We added co-enzyme Q10 to your medication list. This is a
naturally occurring antioxidant that can help many metabolic or
mitochondrial illnesses.
We will schedule a follow up appointment in Neurology and
Neuro-ophthalmology as below. You should not drive until your
vision improves and you are evaluated formally by Drive Wise.
It was a pleasure taking care of you!
Your ___ Neurology team
Followup Instructions:
___
|
19814580-DS-6
| 19,814,580 | 28,381,314 |
DS
| 6 |
2118-03-27 00:00:00
|
2118-03-28 13:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Motrin
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female brought in by EMS as a basic trauma in the
setting of a rollover MVC. Per EMS report, the patient was
driving a high rate of speed around a corner and struck a
parked car, pushing it ___ feet and causing her own car to
roll over. On EMS arrival, the patient was hanging upside
down talking on her telephone. She complained of chest pain
only and as found to have chest wall tenderness. Prolonged
extrication-25 minutes.
Past Medical History:
DM, HTN, anemia, unclear hx of renal problems related to
diabetes, Listed as Stage 3 Chronic Kidney disease at ___.
___
___: cholecystectomy
Social History:
___
Family History:
no fh of bleeding diathesis
Physical Exam:
On admission:
Constitutional: Boarded, collared, awake and conversant
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
No midline C-spine tenderness to palpation
Chest: Clear to auscultation, marked lower chest wall
tenderness both left and right ribs, no crepitus, no
deformity
Cardiovascular: Normal
Abdominal: Soft, tender to palpation with guarding in the
right lower quadrant
Extr/Back: pelvis stable x 3, mild ttp T1
Skin: Warm and dry
Neuro: motor ___ bilat ___
On discharge:
T 98.3 HR 69 BP 136/52 RR 18 95% RA
Gen: alert, pleasant, nontoxic, no apparent distress
HEENT: mmm, atraumatic normocephalic
CV: rrr, no m/r/g
Chest: ctab, nonlabored breathing, mild b/l anterior chest wall
tenderness
Abd: soft ntnd
Ext: no ___
___ Results:
___ 09:15AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM
___ 08:51AM HGB-11.7* calcHCT-35 O2 SAT-86 CARBOXYHB-3
MET HGB-0
___ 08:40AM LIPASE-68*
___ 08:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:40AM WBC-4.9 RBC-3.79* HGB-11.5* HCT-34.8* MCV-92
MCH-30.3 MCHC-33.0 RDW-14.6
CT head, c-spine, chest, abdomen, and pelvis:
1. No acute abnormalities in the chest, abdomen, and pelvis. 2.
7 mm
subpleural nodule in the anterior right middle lobe, ___ year
followup is recommended to ensure stability.****** [emphasis
added] 3.
Symmetrically enlarged thyroid gland can
be further evaluated with ultrasound if clinically indicated.
IMPRESSION: No fracture or malalignment of the cervical spine.
IMPRESSION: No acute intracranial abnormality.
Brief Hospital Course:
Ms ___ suffered a rollover MVC and was transported to
___ ED as a basic trauma. She was evaluated with a CT head,
c-spine, chest, abdomen, and pelvis and was not found to have an
acute injury. In the ED, she did not remember the crash, and
there was concern for syncope as the etiology of her car crash.
She was admitted for syncope workup, and admitted to the acute
care surgery service for observation with a medicine consult.
Medicine evaluated the patient in the morning. In the morning,
the patient now remembered feeling very tired and falling asleep
at the wheel. We performed an EKG which was normal. She was
also noted to have a grade ___ systolic murmur by the medicine
team for which they recommended an outpatient TTE to evaluate
for aortic stenosis. They did not believe this had to be done
on this admission and medically cleared her for discharge, and
signed off. She was feeling well and her pain was well
controlled. Her only pain was mild anterior chest wall
tenderness where her airbag deployed. She was tolerating a
regular diet. Incidentally, she was also on her initially
imaging found to have a lung nodule which needs to be followed
up in one year. She was told this information, and the medicine
team also send her PCP ___ letter explaining this. She will also
need to have an outpatient echo performed which she is aware of
and which was communicated to her PCP. She was informed to
return to the ED with any fainting or chest pain.
Medications on Admission:
Metropolol 25 mg Daily
Metropolol-Succinate ER 50 mg Daily (per Dr. ___ 100mg
Daily)
Felodipine 10 mg Daily
Furosemide 20 mg 2 tablets Daily
Micardis 80 mg Daily
Lasix 20 mg Daily (per Dr. ___
ASA 81 mg Daily
Crestor 20 mg Daily
Allopurinol ___ mg Daily
Loratadine 10 mg Daily
Rocaltrol 0.25 mcg Daily
Novalin 100U/ml BID
Novalog 100 U/ml Daily
Insulin syringe 0.3cc BID
Colace 100mg BID
Kayexalate 15g 4tsp one time weekly
Sarna 1 app TID
Tramadol 50 mg Q4H PRN
Vitamin D 50,000 Intl Units 2 times monthly
Vitamin D 50,000 Intl Units 1 time monthly
Discharge Medications:
Instructed to continue to take her home medications.
Discharge Disposition:
Home
Discharge Diagnosis:
Motor vehicle collision - observation.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after a car accident, and you were evaluated
by the medicine because initially we wondered if you fainted
prior to your car accident causing the crash. You were admitted
to the acute care surgery service to observe you overnight after
your accident. The medicine team has cleared you medically from
discharge. They heard a grade ___ systolic murmur, which can be
seen in aortic stenosis, and recommend to your PCP to have an
echocardiogram done to evaluate your heart. This does not have
to happen during this inpatient admission. Please follow up
with your primary care provider so that he/she may manage your
care.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Followup Instructions:
___
|
19814667-DS-6
| 19,814,667 | 20,546,295 |
DS
| 6 |
2159-07-10 00:00:00
|
2159-07-10 23:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal fullness and weight loss
Major Surgical or Invasive Procedure:
LN biopsy
History of Present Illness:
___ woman with COPD on home O2, HTN, DM2, chronic back
pain (chronic narcotics), and depression/anxiety who presented
to ___ with abdominal pain and was found to have
suspicious RP lymphadenopathy on CT A/P and so sent to ___ ED
for further evaluation.
She reports feeling in her usual state of health until she
developed constipation about one week ago. She tried multiple
bowel medications at home without relief with worsening
abdominal
pain yesterday, and so she presented to the ED at ___. Denies
nausea/vomiting, bloody stool, black stools, change in stool
caliber.
At ___ showed Cr 1.0 (baseline 0.5-0.7), LFT wnl, lipase
205, CBC stable anemia (Hct 31.3). CT A/P was done and showed RP
LAD concerning for malignancy, possible enlarged adrenal gland,
possible L hydronephrosis. Given need for malignancy workup she
was transferred to ___ ED.
On arrival to the floor she reports that her abdominal pain has
resolved, though she continues to feel constipated and has not
had a BM yet. She notes a 10 lb unintentional weight loss over
the past 6 months attributed to poor appetite. She denies
ongoing
fevers/chills/night sweats/palpable LAD. Her last colonoscopy
was
___ years ago and she is not sure where it was performed. Her
last mammogram was ___ years ago, again not sure where it was
done.
She is not sure about her last pap smear. Her father had colon
cancer around age ___.
Past Medical History:
HTN
Depression/anxiety
Chronic back pain
Hypothyroidism
COPD
Chronic respiratory failure on home O2
DM2
Social History:
___
Family History:
Father with colon cancer at age ___
Mother with cirrhosis
No family history of hematologic malignancies
Physical Exam:
DISCHARGE EXAM:
___.___
GEN: Elderly female in NAD
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate, no
palpable cervical adenopathy
CV: Heart regular, no murmur, no S3/S4. JVP 6cm
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, mildly distended, non-tender to palpation.
Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted on examined skin
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout
PSYCH: anxious and intermittently tearful. Perseverates.
Pertinent Results:
___ 05:04AM BLOOD WBC: 6.5 RBC: 3.21* Hgb: 9.6* Hct: 30.7*
MCV: 96 MCH: 29.9 MCHC: 31.3* RDW: 13.3 RDWSD: 46.9* Plt Ct: 268
___ 05:04AM BLOOD Glucose: 122* UreaN: 12 Creat: 0.8 Na:
141
K: 3.9 Cl: 100 HCO3: 29 AnGap: 12
___ 05:04AM BLOOD Calcium: 8.7 Phos: 3.8 Mg: 1.7 UricAcd:
5.2
___ 05:18AM BLOOD PEP: NO SPECIFIC ABNORMALITIES SEEN IgG:
654* IgA: 198 IgM: 24* IFE: NO MONOCLONAL IMMUNOGLOBULIN SEEN
___ 05:18AM BLOOD HIV Ab: NEG
___ 05:18AM BLOOD HCV Ab: NEG
Second opinion CT Torso (___) ___. Large retroperitoneal and mesenteric adenopathy with mild
adjacent inflammatory signs. Lymphoma seems very likely based
on
this appearance.
2. Right adrenal nodule of nonspecific attenuation. A dedicated
MRI can provide more details of this finding, if clinically
warranted.
3. Very mild right sided hydronephrosis to the ureteropelvic
junction. Irregular urothelial thickening, query sequela of
inflammation or tumor, including possibility of lymphoma or
transitional cell carcinoma.
4. Mild left sided hydronephrosis with possible hyperattenuating
filling defect, including possibility of small tumor, lymphoma
versus transitional cell carcinoma.
5. Coarse calcification in the left ovary, nonspecific.
6. Small bilateral pleural effusions.
TTE ___
Normal biventricular wall thicknesses, cavity sizes, and
regional/global systolic function. LVEF 60%. Indeterminate
diastolic function. No prior TTE available for comparison.
Lymph node, retroperitoneal, biopsy:
METASTATIC ADENOCARCINOMA, consistent with lower
gastrointestinal origin.
By immunohistochemistry, tumor cells show the following staining
profile:
___ Positive: CK20, CK7 (focal), CDX-2, TTF-1 (focal),
synaptophysin (focal), chromogranin (focal).
___ Negative: p40, GATA3, PAX-8.
The overall morphology and immunophenotype is consistent with
metastasis from a moderately to poorly differentiated colorectal
adenocarcinoma.
Brief Hospital Course:
___ with COPD, HTN, DM2, chronic back pain (on narcotics), and
depression/anxiety, who presented to ___ with abdominal pain
(likely just due to constipation) and was found to have bulky
adenopathy above and below the diaphragm. Paraaortic LN biopsy
was performed by ___ and pathology shows metastatic colorectal
cancer. She has remained in house to await biopsy results at
request of oncology consultants due to her baseline crippling
anxiety and inability to cope emotionally with a terminal cancer
diagnosis outside of an environment of maximal support.
#Stage IV colorectal cancer
The patient has diffuse lymph node metastases with biopsy
showing metastatic colorectal cancer. She is aware of the
diagnosis and had a family meeting with oncology prior to
discharge. She will be following up in ___ clinic with
Dr. ___ to plan ___ chemotherapy. Pt was
discharged on Allopurinol ___ daily with plan to titrate as
needed due to concern for ongoing low grade tumor lysis (LDH
~600).
- HIV, HBV, and HCV neg. TTE unremarkable.
#Abdominal Pain:
#Constipation: multifactorial with high dose chronic opiate use.
Pt may have a malignant stricture from a primary colorectal
cancer contributing to her significant constipation and slow
motility. Notably her stool is now quite soft and she is having
multiple soft BMs per day. Pt was discharged on an aggressive
bowel PO/PR regimen to continue at home.
#R Adrenal gland enlargement
Noted on ___ radiology report
- Consider dedicated MRI (adrenal mass protocol) if it would
change treatment for metastatic malignancy.
#L Hydronephrosis
___ (resolved): Pt was taking po well and BP was uptrending. Pt
was restarted on home HCTZ 25mg daily.
#COPD: stable, no acute exacerbations. Pt was continued on
overnight home o2 of 2L.
#DM2: BG were well controlled in house with rare insulin
coverage required. Pt was restarted on Metformin home regimen
at discharge.
CHRONIC ISSUES
#Anxiety/Depression: Pt does not feel her symptoms are well
controlled on these meds. She reports poor therapeutic alliance
with her psychiatrist but hasn't communicated that very
directly. She may benefit from a systematic overhaul of her
psych meds in the outpatient setting. There were no changes
made to her home regimen prior to discharge.
- DULoxetine 30 mg PO DAILY
- LamoTRIgine 200 mg PO BID
- ALPRAZolam 1 mg PO QHS:PRN
- Modafinil 200 mg PO DAILY
#Chronic pain: Pt has close follow up scheduled with her primary
pain team at ___ and has enough medications at home to bridge
until her appointment. There was no changes made and pt was
not provided prescriptions for opiates at discharge.
- DULoxetine 30 mg PO DAILY
- OxyCODONE SR (OxyconTIN) 10 mg PO Q8H
- OxyCODONE SR (OxyconTIN) 20 mg PO QHS
- OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN
#Hypothyroidism: cont Levothyroxine Sodium 75 mcg PO DAILY
#HLD: cont Simvastatin 40 mg PO QPM
Transition Issues:
Pt was diagnosed with metastatic colorectal carcinoma and is
still processing this information with her family. She has
close follow up with oncology here at ___ but will benefit
from additional psychosocial support given her baseline severe
anxiety. Pt was given a referral for home ___, ___ for
medication teaching and assessment for home health needs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 1 mg PO QHS:PRN anxiety, insomnia
2. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation BID
3. DULoxetine 30 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. LamoTRIgine 200 mg PO BID
6. Levothyroxine Sodium 75 mcg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Modafinil 200 mg PO DAILY
9. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain -
Moderate
10. OxyCODONE SR (OxyconTIN) 10 mg PO Q8H
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
12. Simvastatin 40 mg PO QPM
13. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
14. OxyCODONE SR (OxyconTIN) 20 mg PO QHS
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Bisacodyl 10 mg PR QHS:PRN Constipation - Third Line
RX *bisacodyl 10 mg one suppository(s) rectally daily as needed
Disp #*50 Suppository Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg one capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg one tablet(s) by mouth TID PRN Disp #*30
Tablet Refills:*0
5. Polyethylene Glycol 17 g PO TID
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
7. ALPRAZolam 1 mg PO QHS:PRN anxiety, insomnia
8. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation BID
9. DULoxetine 30 mg PO DAILY
10. Hydrochlorothiazide 25 mg PO DAILY
11. LamoTRIgine 200 mg PO BID
12. Levothyroxine Sodium 75 mcg PO DAILY
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Modafinil 200 mg PO DAILY
15. OxyCODONE SR (OxyconTIN) 10 mg PO Q8H
16. OxyCODONE SR (OxyconTIN) 20 mg PO QHS
17. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain
- Moderate
18. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Stage IV colorectal cancer
Constipation
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 because of abdominal fullness,
bloating and weight loss. We performed a CT scan of your abdomen
and chest which showed multiple enlarged lymph nodes. Biopsy
showed this was colon cancer that has spread to multiple areas
around the body.
The treatment for advanced colon cancer is chemotherapy.
Chemotherapy cannot cure cancer that has spread this far, but we
hope to keep you feeling pretty good for as long as possible, so
you can spend time with your wonderful, loving family.
The main problem the cancer is causing right now is bad
constipation. Please continue to take the intensive regimen of
stool softeners we started you on in the hospital.
You have follow up scheduled with Dr. ___ in Oncology and
your primary care as shown below.
Best wishes from your team at ___
Followup Instructions:
___
|
19814667-DS-7
| 19,814,667 | 27,007,782 |
DS
| 7 |
2159-08-13 00:00:00
|
2159-08-13 18:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Upper endoscopy and ERCP with biliary sphincterotomy and
placement of a 10 mm x 16 mm fully covered metal stent
History of Present Illness:
___ is a ___ year old woman with recent diagnosis
of
metastatic cancer to retroperitoneal nodes, biopsy c/w colon
cancer (although primary tumor not yet identified), who is
admitted from the ___ with elevated bilirubin.
Initial admission on ___ with abdominal pain and
retroperitoneal lymphadenopathy led to diagnosis of metastatic
cancer (presumably colon cancer based on retroperitoneal
biopsy).
Since then, she was hospitalized at ___ on ___ for
confusion. Ultimately found to have hydronephrosis, ___, and
UTI.
She underwent ureteral stenting. Apparently MCRP was done which
did not show biliary obstruction. Afterwards, she developed
recurrent dysuria and was prescribed nitrofurantoin on ___.
She was seen in ___ clinic on ___. She reported
persistent
dysuria with associated weakness. She was found to have
obstructive pattern liver dysfunction, and she was referred to
the ___ for further evaluation.
In retrospect, Ms. ___ reports that she has noticed
darkened urine for the last 4 days and paler "yellow" stools
since last week. She endorses 2 days of worsening nausea without
emesis. Her daughter mentioned that she appeared more yellow
over
the last day. She also thinks she has had worsening right sided
abdominal pain x 1 day. Her pain is currently "moderate" and
achy. Otherwise however, she denies fevers/chills/night sweats.
No cold symptoms, cough, chest pain, palpitations, SOB,
confusion, bleeding, rashes, focal numbness/tingling. She
endorses generalized weakness and poor appetite since diagnosis.
She has been taking nitrofurantoin for 4 days as prescribed.
In the ___, initial VS were pain 0, T 97.2, HR 87, BP 107/55, RR
14, O2 96%RA. Initial labs notable for Na 140, K 3.7, HCO3 29,
Cr
1.2, Ca 8.8, Mg 1.1, P 3.1, ALT 120, AST 126, ALP 1605, LDH
1129,
TBili 6.1, DBili 5.3, Alb 3.3, lipase 63, CEA 16.7, WBC 7.2, HCT
31.6, PLT 376. Liver US showed new 2.2 cm mass in right hepatic
lobe, along with new intrahepatic and extrahepatic biliary
dilation. CXR showed right pleural effusion. Patient was given
IV
NS and 2g IV Mg. VS prior to transfer were pain 0, HR 80, BP
113/61, RR 18, O2 98%RA.
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
The patient reports being at her baseline (relatively limited) a
month before this presentation. At that time she noticed that
she
was getting weak and she had a few episodes of falls (despite
using her walker). Upon further discussion she reported that she
lost 20lbs within the last 2 months due to poor appetite.
Recently (___), she went to ___ for abdominal pain.
She was found to have UTI. However, CT imaging done for
evaluation of pain showed extensive lymphadenopathy, Thus, she
was transferred to ___ for further evaluation.
On ___ she underwent biopsy of retroperitoneal LN that showed
metastatic adenocarcinoma. By immunohistochemistry, tumor cells
show the following staining profile: ___ Positive: CK20, CK7
(focal), CDX-2, TTF-1 (focal), synaptophysin (focal),
chromogranin (focal). ___ Negative: p40, GATA3, PAX-8. These
results were thought to be consistent with poorly differentiated
colorectal adenocarcinoma.
We met with the patient on ___. We discussed about our D/D and
our diagnostic algorithm in order to confirm the diagnosis. The
plan was to do a PET CT and upper/lower endoscopy. The patient
had the PET but did not have the endoscopies due to
hospitalization in OSH.
PAST MEDICAL HISTORY:
- Metastatic adenocarcinoma, presumably colonic origin (RP node
biopsy ___ - ___
- Hydronephrosis sp ureteral stenting ___ at ___
- Mood disorder
- Cognitive impairment
- DMT2
- Hypothyroidism
- COPD with nocturnal 2L O2
Social History:
___
Family History:
Father with colon cancer at age ___
Mother with cirrhosis
No family history of hematologic malignancies
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
___ 0123 Temp: 98.5 PO BP: 124/66 L Lying HR: 73 RR: 18 O2
sat: 95% O2 delivery: RA FSBG: 105
GENERAL: Pleasant, tired appearing, elderly Caucasian woman
resting in bed in no acute distress
EYES: +Scleral icterus
ENT: Oropharynx clear without lesion, +sublingual icterus.
CARDIOVASCULAR: Regular rate and rhythm, III/VI systolic murmur
best appreciated at RUSB. Radial pulses 2+
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation on the left. Decreased breath sounds up to the mid
lung field on the right with scant overlying crackles. Dull to
percussion halfway up the right lung field.
GASTROINTESTINAL: Bowel sounds present; nondistended; soft,
tender to palpation in the right upper/middle quadrants.
Negative
Murphys
MUSKULOSKELATAL: Warm, well perfused extremities, 1+ pitting
edema up to the knees bilaterally
NEURO: Alert, oriented ___ "The hospital"), CN
II-XII
intact, sensation intact to light touch throughout. No
asterixis.
DISCHARGE PHYSICAL EXAM
========================
VITALS:
24 HR Data (last updated ___ @ 818)
Temp: 98.1 (Tm 98.4), BP: 129/72 (118-134/63-72), HR: 81
(80-82), RR: 18, O2 sat: 98% (94-99), O2 delivery: 2L, Wt:
208.99
lb/94.8 kg
GENERAL: Pleasant, tired appearing, elderly Caucasian woman
resting in bed in no acute distress
ENT: Oropharynx clear without lesions
CARDIOVASCULAR: Regular rate and rhythm, III/VI systolic murmur
best appreciated at ___
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation on the left. Decreased breath sounds up to the mid
lung field on the right
GASTROINTESTINAL: Bowel sounds present; distended; soft,
tenderness on palpation of upper quadrants
MUSKULOSKELATAL: Warm, well perfused extremities, 1+ pitting
edema up to the knees bilaterally
NEURO: Alert, oriented, moving all extremities without
difficulty
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS
==============
___ 01:30PM BLOOD WBC-7.9 RBC-3.21* Hgb-9.5* Hct-31.2*
MCV-97 MCH-29.6 MCHC-30.4* RDW-15.4 RDWSD-55.0* Plt ___
___ 01:30PM BLOOD Neuts-80.0* Lymphs-9.7* Monos-6.1 Eos-3.1
Baso-0.3 Im ___ AbsNeut-6.30* AbsLymp-0.76* AbsMono-0.48
AbsEos-0.24 AbsBaso-0.02
___ 05:45PM BLOOD ___ PTT-25.1 ___
___ 01:30PM BLOOD UreaN-15 Creat-1.2* Na-140 K-3.7 Cl-96
HCO3-29 AnGap-15
___ 01:30PM BLOOD ALT-120* AST-126* LD(LDH)-1129*
AlkPhos-1605* TotBili-6.1* DirBili-5.3* IndBili-0.8
___ 01:30PM BLOOD Lipase-63*
___ 01:30PM BLOOD TotProt-6.4 Albumin-3.3* Globuln-3.1
Calcium-8.8 Phos-3.1 Mg-1.1*
___ 06:25AM BLOOD %HbA1c-5.8 eAG-120
___ 06:25AM BLOOD TSH-4.5*
___ 06:45PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG IgM HAV-NEG
___ 01:30PM BLOOD CEA-16.7*
___ 06:45PM BLOOD Acetmnp-NEG
___ 06:45PM BLOOD HCV VL-NOT DETECT
___ 05:57PM BLOOD Lactate-1.7
DISCHARGE LABS
=============
___ 06:24AM BLOOD WBC-5.6 RBC-2.81* Hgb-8.3* Hct-27.3*
MCV-97 MCH-29.5 MCHC-30.4* RDW-14.6 RDWSD-52.2* Plt ___
___ 06:24AM BLOOD ___ PTT-25.4 ___
___ 06:24AM BLOOD Glucose-113* UreaN-13 Creat-0.8 Na-138
K-4.1 Cl-94* HCO3-29 AnGap-15
___ 06:00AM BLOOD ALT-48* AST-30 LD(___)-1065* AlkPhos-967*
TotBili-1.5 DirBili-0.9* IndBili-0.6
___ 06:24AM BLOOD ALT-26 AST-21 LD(___)-977* AlkPhos-660*
TotBili-1.2
PATHOLOGY
==========
Duodenal mass biopsy: Mixed adenocarcinoma and neuroendocrine
carcinoma. The adenocarcinoma component is positive for CEA,
the neuroendocrine component is positive for chromogranin and
synaptophysin, while both components are positive for CDX-2. The
site of origin include gastrointestinal and pancreatico-biliary.
MICRO
=====
___ urine culture: contamination only
___ blood culture: no growth
RADIOLOGY
==========
___
LIVER ULTRASOUND
1. A 2.2 cm mass in the right hepatic lobe is not seen on recent
prior CT
abdomen pelvis and concerning for metastasis given history of GI
cancer.
2. New intrahepatic and extrahepatic biliary dilation, suspected
to be likely
secondary to extrinsic compression of the distal common bile
duct by enlarged
periportal lymph nodes, though the source of obstruction is not
visualized on
the current ultrasound exam.
3. Patent portal vasculature with appropriate direction of flow.
4. Incidentally noted right pleural effusion.
___ CXR
Unchanged moderate right pleural effusion with associated mild
right basilar compressive atelectasis. Known mediastinal
lymphadenopathy is better assessed on the prior PET CT.
___ ERCP
Duodenal ulcerated mass
Long tight malignant appearing CBD stricture s/p biliary stent
placement across CBD stricture
___ CXR PICC
In comparison with the study of ___, there has been
placement of a
right subclavian PICC line that extends to the lower SVC or
cavoatrial
junction region The opacification at the right base seen
previously is substantially reduced. Otherwise, little change.
Brief Hospital Course:
SUMMARY:
========
___ year old woman with recent diagnosis of metastatic cancer to
retroperitoneal nodes with duodenal pathology showing mixed
adenocarcinoma and neuroendocrine carcinoma who is admitted
after found to have obstructive jaundice now improving following
placement of a fully covered metal stent in the bile duct.
ACTIVE ISSUES:
==============
# Metastatic mixed adenocarcinoma/neuroendocrine carcinoma:
PET on ___ was unrevealing for primary tumor. She underwent
endoscopy on ___, which revealed a cratered duodenal bulb
ulcer which was biopsied and found to be consistent with mixed
adenocarcinoma/neuroendocrine carcinoma. Her nausea was
controlled with Compazine and Zofran. Her home allopurinol was
continued. Her home pain regimen was continued, including 10 mg
oxycontin TID + 20 mg qHS with oxycodone PRN breakthrough, as
well as Tylenol as needed (<2g/day). She will undergo
chemotherapy initiation following discharge.
# Malignant biliary obstruction
Her Tbili was noted to be 6.1 on admission (direct bili 5.3),
likely due to malignant obstruction. RUQ US with intra and
extrahepatic biliary dilation thought to be secondary to
extrinsic compression of the distal common bile duct by enlarged
periportal lymph nodes. There was no evidence of cholangitis or
other infection. She underwent upper endoscopy and ERCP on ___
Cholangiogram showed a severe stricture in the lower third of
the bile duct. Biliary sphincterotomy was performed. A 10 mm x
16 mm fully covered metal stent was placed. Following this, Bili
and AST/ALT normalized.
# Coagulopathy
INR was noted to be 1.4 on admission, likely due to hepatic
dysfunction resulting from malignancy. However coagulopathy may
also be related to nutritional deficiency caused by poor PO
intake. Coags were trended and improved during the admission
without direct intervention.
# Moderate Malnutrition in Context of Acute Illness
Decreased appetite in the setting of metastatic cancer.
Electrolytes were monitored and repleted as needed. Nutrition
was consulted. Her diet was advanced to diabetic/consistent
carb. Daily standing scale weights were obtained. The option of
tube feeds were recommended by the Nutritionist, which should be
discussed with the patient in the future if her oral intake
remains poor.
# Deconditioning-
The patient was noted to be deconditioned in the setting of
metastatic cancer, poor oral intake and prolonged
hospitalization. Physical Therapy evaluated the patient and
worked with her during this admission. Following discharge from
the hospital, the patient should continue home physical therapy.
CHRONIC CONDITIONS:
===================
# UTI - The patient has a history of MDR E coli. Started
nitrofurantoin prior to admission. UCx on this admission showed
contamination only. She completed a 7 day course of Macrobid on
___.
# ___ edema- venous insufficiency- reports edema has started with
prolonged hospitalization recently. TTE ___ with EF 60%;
indeterminate diastolic function. Her legs were elevated while
in bed and her home HCTZ was continued.
# Moderate right pleural effusion
Noted on ___ CXR. She denied any dyspnea or right sided
chest discomfort. Moderate effusion was noted to be low level
FDG avid on PET. Further workup was not performed as she had no
respiratory or infectious symptoms during this admission.
# Elevated Creatinine
# Malignant ureteral obstruction s/p stenting
Her Cr was noted to be 1.2 on admission, elevated from her
baseline ~1. Her Cr was monitored daily and normalized during
the admission following IVF.
# Hypothyroidism - her home levothyroxine was continued. Her TSH
was checked given her malaise on admission, and noted to be 4.5
on ___. Levothyroxine titration was deferred to the
outpatient setting given her acute illness currently.
#COPD on nocturnal 2L - Her home Breo ellipta was held and
fluticasone-salmeterol was given while in the hospital instead,
in addition to albuterol PRN. She received 2L O2 by NC at night.
# Mood disorder- Continued home duloxetine, alprazolam,
lamotrigine and modafinil.
# DMT2- Held home metformin. Low dose sliding scale insulin was
given. A1c was noted to be 5.8 this admission.
# HTN- Continued home HCTZ.
# GERD- Continued home omeprazole.
# Chronic pain- Continued home oxycodone.
TRANSITIONAL ISSUES:
====================
[] The outpatient oncology team should consider whether it will
be possible for the patient to undergo chemotherapy at a
location closer to her home, which was requested by both the
patient and her family during this admission.
[] ___ was checked on admission given her malaise, and was
notified to be 4.5 on ___. Levothyroxine titration was
deferred to the outpatient setting, when she is no longer
acutely ill.
[] Port should be placed prior to initiation of chemotherapy.
She last received antibiotics on ___. This has not been
ordered at the time of discharge. (Two weeks following
antibiotics will be ___
[] Chemotherapy will be initiated as an outpatient.
[] If PO intake is inadequate, the patient and her outpatient
providers should discuss the appropriateness of tube feeds going
forward. Tube feeds were recommended as a potential option by
the Nutritionist team during this admission.
EMERGENCY CONTACT HCP: ___ (___) ___
CODE: DNR/DNI okay escalation
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. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. ALPRAZolam 1 mg PO QHS:PRN anxiety, insomnia
3. DULoxetine 30 mg PO DAILY
4. LamoTRIgine 200 mg PO BID
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Modafinil 200 mg PO DAILY
7. OxyCODONE SR (OxyconTIN) 10 mg PO TID
8. OxyCODONE SR (OxyconTIN) 20 mg PO QHS
9. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain -
Moderate
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation BID
12. Allopurinol ___ mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Bisacodyl 10 mg PR QHS:PRN Constipation - Third Line
15. Polyethylene Glycol 17 g PO TID
16. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
17. Hydrochlorothiazide 25 mg PO DAILY
18. Dexamethasone 4 mg PO TWICE A DAY FOR DAY ___ AFTER
CHEMOTHERAPY
19. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
Discharge Medications:
1. ondansetron HCl 8 mg oral Q8H:PRN
RX *ondansetron HCl 8 mg 1 tablet(s) by mouth Every 8 hours Disp
#*30 Tablet Refills:*0
2. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
4. Allopurinol ___ mg PO DAILY
5. ALPRAZolam 1 mg PO QHS:PRN anxiety, insomnia
6. Bisacodyl 10 mg PR QHS:PRN Constipation - Third Line
7. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation BID
8. Dexamethasone 4 mg PO TWICE A DAY FOR DAY ___ AFTER
CHEMOTHERAPY
9. Docusate Sodium 100 mg PO BID
10. DULoxetine 30 mg PO DAILY
11. Hydrochlorothiazide 25 mg PO DAILY
12. LamoTRIgine 200 mg PO BID
13. Levothyroxine Sodium 75 mcg PO DAILY
14. MetFORMIN (Glucophage) 500 mg PO BID
15. Modafinil 200 mg PO DAILY
16. OxyCODONE SR (OxyconTIN) 10 mg PO TID
17. OxyCODONE SR (OxyconTIN) 20 mg PO QHS
18. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain
- Moderate
19. Polyethylene Glycol 17 g PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Metastatic mixed adenocarcinoma/neuroendocrine carcinoma
Malignant biliary obstruction
Secondary diagnoses:
Moderate Malnutrition in Context of Acute Illness
Urinary tract infection
Coagulopathy
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?
- One of your liver enzymes (bilirubin) was very high, which
made us concerned that one of the ducts in your liver was
blocked.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You underwent a procedure called ERCP, and a stent was placed
in one of your liver ducts to keep it open and allow bile to
drain normally.
- You were evaluated by our Physical Therapy team, who helped
you rebuild some of your strength while you were in the
hospital.
- You completed treatment for a urinary tract infection (UTI).
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19815165-DS-10
| 19,815,165 | 25,397,666 |
DS
| 10 |
2204-10-04 00:00:00
|
2204-10-05 10:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Chest nodule biopsy
History of Present Illness:
___ yo F with PMH HTN, HLD, osteoarthritis, GERD, 2 recent
hospital evaluations for abdominal pain / chest pain at ___
___, now p/w persistent abdominal pain, found on CT
Abd/Pelvis to have colitis.
.
Pt was initially admitted at ___ from ___ for chest
pain and abdominal pain. ruled out for ACS, was seen by
Cardiology, noted to be bradycardic, so atenolol was ___ and
lisinopril increased from 10 to 40mg daily to maintain BP
control. Cardiology had recommended outpt stress test. Was
also seen by Psychiatry and diagnosed with depression, started
on Remeron 7.5mg qhs. For abdominal pain, no imaging obtained,
was clinically diagnosed with GERD, so started on PPI.
.
Symptoms never resolved completely, so returned to ___ on
___, was observed in ___ and ruled out for ACS and discharged to
home.
.
Over the weekend, she has continued to feel worse, and now also
notes diarrhea with her abdominal pain. Called PCP office and
was directed to ___. Pt reports that she has epigastric pain,
cannot describe quality well, but endorses "strong pain," ___
at its worst, no N/V, no association with food intake, although
she describes general loss of appetite. She has associated
diarrhea, non-bloody. Reports 10 pound weight loss over last 4
weeks. Denies oral ulcers. Denies fevers, chills. Denies
recent travel or sick contacts. no recent antibiotics. She
also continues to have chest pain, which is mid-sternal,
radiates to left-side, non-exertional, non-pleuritic. No N/V or
diaphoresis. Denies SOB, palps or LH. Denies orthopnea, PND,
or ___ edema.
.
In the ___, initial VS 98.1, 118/58, 108, 16, 98% on RA.
Received GI cocktail and donnatol with some improvement.
Underwent CT Abd/Pelvis that shows non-specific colitis of cecum
and ascending colon. Troponin was negative. Mild lipase
elevation of 94. EKG with sinus tach at 105, but otherwise no
e/o ischemia or infarct, stable vs previous EKG.
.
Currently, on arrival to floor, she feels comfortable, still has
mild abdominal pain, ___ in severity. Otherwise denies chest
pain at this time.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath. Denies palpitations. Denies nausea, vomiting,
constipation. No recent change bladder habits. No dysuria.
Denies arthralgias or myalgias. Ten point review of systems is
otherwise negative.
Past Medical History:
Hypertension, benign
Hyperlipidemia
Seasonal allergies
Osteoarthritis
Migraine
GERD
heart murmur (has mitral regurgitation on TTE in ___
h/o facial cellulitis in ___ with admission
.
Colonoscopy with single hyperplastic polyp (___)
EGD with H. Pylori (___), s/p treatment
Social History:
___
Family History:
Father died at ___ yo from CAD
Mother ___ yo, alive and healthy.
1 sister with pancreatic or stomach cancer.
1 sister with uterine cancer.
1 uncle died of CAD
5 children, all healthy
Physical Exam:
ADMISSION EXAM
--------------
VS 98.1, 124/85, 60, 16, 100% on RA
Pain: ___
Gen: NAD, pleasant, appears comfortable
HEENT: dry MM, anicteric, OP clear
CV: RRR, ___ systolic murmur
Lungs: CTAB/L
Abd: soft, non-distended, NABS, no CVA tenderness, + epigastric
TTP on deep palpation, no rebound or guarding
Ext: WWP, no edema
Skin: no rashes or lesions
Neuro: AAOx3
Rectal: GUAIC NEGATIVE ___ eval)
.
DISCHARGE EXAM
--------------
VS: Tc 98.0 BP 170/60 (132-170/58-63) P 49 R 18 Sat 98%RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric, o/p
clear, MM dry.
Neck: Supple, no JVD.
Lymph nodes: No cervical, supraclavicular, axillary LAD.
Chest: prominent area noted over mid-to-right sternum, slightly
erythematous, slightly tender to palpation, unchanged from
yesterday.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-distended, no tenderness, no rebound tenderness
or guarding, + bowel sounds, no organomegaly noted.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: non-focal
Pertinent Results:
ADMISSION LABS
--------------
Bloodwork:
___ 03:40PM BLOOD WBC-9.1 RBC-4.37 Hgb-12.9 Hct-37.8 MCV-86
MCH-29.6 MCHC-34.3 RDW-13.5 Plt ___
___ 03:40PM BLOOD Glucose-89 UreaN-21* Creat-1.7* Na-138
K-3.9 Cl-100 HCO3-27 AnGap-15
___ 03:40PM BLOOD ALT-20 AST-31 LD(LDH)-316* AlkPhos-86
TotBili-0.4
___ 03:40PM BLOOD Lipase-94*
___ 03:40PM BLOOD cTropnT-<0.01
___ 09:35PM BLOOD cTropnT-<0.01
___ 03:40PM BLOOD Albumin-4.1 Calcium-10.1 Phos-3.3 Mg-2.2
___ 05:39PM BLOOD Lactate-2.4*
___ 06:28PM BLOOD Lactate-1.5
Urine:
-----
___ 06:55PM URINE Color-Yellow Appear-Hazy Sp ___
___ 06:55PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-SM Urobiln-NEG pH-5.5 Leuks-TR
___ 06:55PM URINE RBC-2 WBC-8* Bacteri-FEW Yeast-NONE Epi-1
___ 06:55PM URINE CastHy-82*
DISCHARGE LABS
--------------
___ 10:45AM BLOOD WBC-5.3 RBC-3.46* Hgb-10.4* Hct-29.3*
MCV-85 MCH-30.2 MCHC-35.6* RDW-13.5 Plt ___
___ 10:45AM BLOOD ___ PTT-28.6 ___
___ 10:45AM BLOOD Glucose-70 UreaN-7 Creat-0.9 Na-142 K-3.5
Cl-104 HCO3-30 AnGap-12
___ 10:45AM BLOOD Calcium-9.0 Phos-2.5* Mg-1.5*
UricAcd-6.2*
Imaging:
-------
CT Abd/Pelvis (___)
FINDINGS:
There is minimal ground-glass opacification at the left greater
than right lung base, which could represent atelectasis, but is
incompletely imaged. No pleural or pericardial effusion is
seen. Mitral anulus calcifications are partially imaged. Small
hiatal hernia is noted.
Abdomen: The absence of intravenous contrast limits evaluation
of the
intra-abdominal organs. Within this limitation, no acute
abnormalities are detected in the liver, gallbladder, spleen,
atrophic pancreas, adrenal glands, right kidney, stomach, or
small bowel. There is mild wall thickening of the cecum and
ascending colon with prominent vasa recta and mild adjacent
stranding. There is no free intraperitoneal air or ascites. The
appendix is normal. Peripelvic cysts are seen in the left
kidney. Dense arterial atherosclerotic calcification is seen
along the abdominal aorta, which is normal in caliber, and along
the branch vessels.
Pelvis: Few diverticula are noted within the sigmoid colon
without evidence of diverticulitis. There is trace free fluid
in the pelvis. The urinary bladder, rectum, and uterus are
unremarkable. No adnexal abnormalities are detected within the
limitations of CT.
No acute bony abnormality is detected.
.
IMPRESSION:
Mild cecal and ascending colitis. Differential diagnosis
includes infectious, inflammatory and ischemic etiologies.
.
EGD (___)
Impression: Medium size hiatal hernia
Normal mucosa in the esophagus (biopsy)
Normal mucosa in the stomach (biopsy)
Otherwise normal EGD to third part of the duodenum
.
Colonoscopy (___)
Polyp in the mid-transverse colon (polypectomy).
Grade 1 internal hemorrhoids.
Otherwise normal colonoscopy to cecum.
.
MICROBIOLOGY
------------
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Final ___:
Reported to and read back by ___. ___ ___
10:15AM.
CAMPYLOBACTER JEJUNI.
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.
.
MODERATE POLYMORPHONUCLEAR LEUKOCYTES.
___ 11:39 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).
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.
.
MODERATE POLYMORPHONUCLEAR LEUKOCYTES.
___ 8:20 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
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.
PATHOLOGY
---------
Chest nodule: pending
Brief Hospital Course:
___ year old female with hypertension, hyperlipidemia,
osteoarthritis, GERD, hiatal hernia, presents with persisent
chest pain, abdominal pain, and diarrhea.
# Abdominal pain: evidence of colitis on CT scan, with
differential diagnosis including infectious vs inflammatory vs
ischemic. Stool culture revealed Campylobacter infection, and
patient was placed on a 3-day course of azithromycin. IBD was
considered less likely, although can have bi-modal age
distribution. Though she has hyperlipidemia, hypertension, but
no post-prandial abdominal pain, ischemic colitis was considered
unlikely as well. Patient was guaiac negative in ___. ESR and
CRP were elevated. Ova and parasite testing was negative x 2.
Patient was provided IV fluids, and her diet was slowly
advanced. GI was consulted and recommended infectious work-up,
and they will pursue colonoscopy as an outpatient. She will
follow up with GI as an outpatient, and colonoscopy will be
scheduled at this follow-up.
.
# Chest pain: patient has ruled out for ACS multiple times in
past month. On admission, she had a stable EKG and negative
troponin. It is likely that her pain is gastrointestinal in
etiology, differential includes her known hiatal hernia vs
gastritis vs persistent H. Pylori vs pancreatitis (given mild
lipase elevation). Lipase elevation was mild and can be seen
with nausea/vomiting. She was treated for H. Pylori in ___,
stool antigen was negative on this admission. She was continued
on a PPI and H2 blocker, and sucralfate was added to her
regimen. It's also possible that the nodule in her chest was
contributing her pain, though the patient denied this.
# Chest nodule: on examination, it was noted that had a
protuberant area over her right middle chest. Chest X-ray was
unremarkable. CT chest showed a small nodule on the right chest
wall. LDH on admission was elevated. Uric acid was also
elevated on admission. The patient was placed on allopurinol.
General Surgery was consulted and performed biopsy on the chest
nodule, with pathology results pending currently. She will
follow up with Oncology as an outpatient to follow up Pathology
results. If negative, might consider reactive arthritis (given
Campylobacter infection) as cause of sternal pain.
# Acute kidney injury: suspect volume depletion in setting of
poor PO intake, diarrhea, and recent increase in ACEi dose.
Baseline creatinine 1.3, creatinine 1.7 on admission. Her
creatinine improved to 0.9 with hydration, suggesting prerenal
state. Her ACEi and diuretic were held on admission, and her
ACEi was restarted upon resolution of creatinine. Her diuretic
should be restarted upon discharge
.
# Hypertension, benign: patient was hypertensive off her home
antihypertensive regimen. ACEi was restarted upon improvement
in her creatinine, and blood pressure slightly improved. Her
blood pressure should be followed up by her PCP
.
# Hyperlipidemia: patient was continued on home simvastatin.
.
# Depression: patient was continued on her home mirtazapine.
Mood was stable during her admission.
# Osteoarthritis: patient was continued on her home celecoxib.
.
TRANSITIONS OF CARE
-------------------
# Follow-up: patient will follow up with her PCP. She will
follow up with Oncology to go over her chest nodule biopsy
results. She will follow up with Gastroenterology to arrange
colonoscopy and to follow up her gastrointestinal infection.
Her blood pressure should be followed up by her PCP. There is a
pending chest nodule biopsy at discharge, to be followed up by
Oncology.
# Code status: Full code, confirmed
# Contact: Daughter, ___ (Unit Coordinator on ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO BID
2. Simvastatin 20 mg PO DAILY
3. celecoxib *NF* 200 mg Oral daily
4. Mirtazapine 7.5 mg PO HS
5. Fexofenadine 180 mg PO DAILY allergy
6. Omeprazole 40 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. celecoxib 200 mg Oral daily
2. Lisinopril 40 mg PO DAILY
3. Mirtazapine 7.5 mg PO HS
4. Omeprazole 40 mg PO DAILY
5. Ranitidine 150 mg PO BID
6. Simvastatin 20 mg PO DAILY
7. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
8. Fexofenadine 180 mg PO DAILY allergy
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Acetaminophen 1000 mg PO Q8H:PRN pain
11. Azithromycin 500 mg PO Q24H Duration: 3 Days
RX *azithromycin 500 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
12. Sucralfate 1 gm PO QID
RX *sucralfate [Carafate] 1 gram 1 tablet(s) by mouth four times
a day Disp #*28 Tablet Refills:*0
13. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*14 Capsule Refills:*0
14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Do not drive, drink alcohol or operate heavy machinery while on
this medication
RX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Campylobacter small bowel infection
Chest nodule
Acute kidney injury
Hypertension
Secondary diagnosis:
Depression
Osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at the ___. You came for
further evaluation of chest and abdominal pain. Further
evaluation showed that you had Campylobacter infection of your
gastrointestinal tract, which has likely been the cause of your
diarrhea, and possibly your weight loss. You will take an
antibiotic for a few days for this infection. Colonoscopy will
be performed as an outpatient when you follow up with
Gastroenterology.
While here, it was noted that you had a possibly abnormal area
on your chest. CT scan was obtained of the area and a biopsy
was performed. The results of this biopsy are currently
pending. You will follow up with Dr. ___ oncologist,
to follow up these results.
Please do not shower or soak the area of the chest until your
___ removes the dressing.
It is important that you continue to take your medications as
listed and follow up with all appointments listed below.
Thank you and good luck.
Followup Instructions:
___
|
19815230-DS-4
| 19,815,230 | 22,179,750 |
DS
| 4 |
2169-11-25 00:00:00
|
2169-11-27 14:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine / hydrocodone / propoxyphene / iodine / Haldol / vicodan
Attending: ___
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with ESRD ___ HTN nephrosclerosis on
HD, multiple clotted AV fistulas, on warfarin, PVD, COPD, HTN,
HLD, CAD s/p CABG, atrial fibrillation, anxiety & depression who
presents as a transfer from ___ w/ GIB.
The patient went to hemodialysis ___ and 30 minutes prior to
finishing became hypotensive and was sent to the ___.
He was found to have positive FOBT w/ hypotension & was
transfused 1U pRBCs. He admitted to having a few days of dark
stools. He was then transferred to ___ for further management
given his complex medical history.
Of note, the patient has a poor vascular substrate w/ fistulas
in all extremities & can only have BP obtained in his RLE.
Multiple attempts at IV access were made in the ___ CVL
placement failed due to inability to thread wire. A-line
placement also failed. 1 peripheral IV (20) able to be placed.
His outpatient nephrologist was contacted, who confirmed that
his anticoagulation is for afib rather than history of vascular
surgeries. Given low Hgb and elevated INR, decision was made to
reverse with FFP.
-Initial VS:
T 97.1 HR 76 BP 69/42 RR 18 O2 sat 98% 4L NC
-Labs significant for:
Hgb 6.5 from 8.0 in ___, plt 90, INR 3.3, K 5.3, lactate 1.4.
-Patient was given: 1U pRBC, 1U FFP for INR reversal.
On arrival to the MICU, he reports normal mentation, no CP, SOB,
abdominal pain. He does endorse low back pain and some dyspnea
which is unchanged from his baseline. Also endorses nausea, but
denies vomiting. Reports being confused by people saying he is
"hemorrhaging", and on this evaluation reports only occasional
blood seen on toilet paper.
Past Medical History:
ESRD ___ HD
hypertension
hyperlipidemia
hypothyroidism
anxiety disorder
depression
secondary hyperparathyroidism
CAD is status post coronary artery bypass graft
SVC syndrome
severe valvular heart disease
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM:
================
VITALS: Reviewed in metavision
GENERAL: Appears chronically ill, alert and responsive, not in
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. Dialysis port in right upper chest.
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
DISCHARGE EXAM:
================
General: AOx3, NAD, cachectic, DOWB+
HEENT: Sclerae anicteric, MMM, oropharynx clear, no teeth
Neck: supple, JVP not elevated
Lungs: CTAB, no increased WOB
CV: RRR distant heart sounds
Abdomen: soft, mildly tender suprapubic region, nondistended
Ext: no peripheral edema, bandaged ulcer on L malleolus
Neuro: CN2-12 grossly intact
Skin: No rashes or lesions noted aside from bandaged ulcer on L
malleolus
Pertinent Results:
ADMISSION:
===========
___ 08:40PM BLOOD WBC-7.0 RBC-1.84* Hgb-6.5* Hct-21.8*
MCV-119*# MCH-35.3* MCHC-29.8* RDW-18.6* RDWSD-78.7* Plt Ct-90*
___ 08:40PM BLOOD Neuts-75.5* Lymphs-16.4* Monos-5.0
Eos-1.9 Baso-0.3 Im ___ AbsNeut-5.31 AbsLymp-1.15*
AbsMono-0.35 AbsEos-0.13 AbsBaso-0.02
___ 08:40PM BLOOD ___ PTT-47.3* ___
___ 04:07AM BLOOD Glucose-83 UreaN-39* Creat-4.0*# Na-142
K-5.0 Cl-103 HCO3-23 AnGap-16
___ 04:07AM BLOOD ALT-17 AST-22 LD(LDH)-184 AlkPhos-76
TotBili-0.4
___ 04:07AM BLOOD Calcium-7.8* Phos-2.7 Mg-1.8
___ 02:00AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS* IgM
HBc-NEG
___ 09:07PM BLOOD Lactate-1.4 K-4.5
___ 09:07PM BLOOD Hgb-7.6* calcHCT-23
IMAGING:
========
CXR:
R
i
g
h
t
s
u
b
c
l
avian catheter terminates in the low SVC. Surgical clips in the
left axilla. Patient is status post sternotomy and CABG.
Heart size is normal and mediastinal silhouette is unremarkable.
T
r
a
c
h
e
al tube terminates in good position 5 cm from carina, asymmetric
o
p
a
c
i
f
i
c
a
t
ion over right hemithorax is concerning for asymmetric pulmonary
e
d
e
m
a
.
Costophrenic angles were not imaged and there is no evidence of
pleural effusion.
P
o
t
e
n
t
i
a
l
l
y
vascular stents in the chest wall, for clinical correlation and
lateral chest radiograph.
Scrotal US:
1. No evidence of testicular torsion.
2. Small hydrocele, and left varicocele.
3
.
M
i
c
r
o
l
i
t
h
i
asis of the left testis. The presence of microlithiasis alonein
t
h
e
a
b
s
e
n
c
e of other risk factors is not an indication for regular scrotal
u
l
t
r
a
s
o
u
n
d
,
f
u
rther ultrasound screening or biopsy. Ultrasound is recommended
i
n
t
h
e follow-up of patient is at risk, where risk factors other than
microlithiasis are present.
MICROBIOLOGY:
==============
Blood Culture: NEGATIVE.
DISCHARGE:
==========
___ 06:20AM BLOOD WBC-8.3 RBC-2.90* Hgb-9.5* Hct-30.3*
MCV-105* MCH-32.8* MCHC-31.4* RDW-19.7* RDWSD-74.2* Plt ___
___ 06:20AM BLOOD ___ PTT-38.6* ___
___ 06:20AM BLOOD Glucose-90 UreaN-28* Creat-5.5*# Na-140
K-4.1 Cl-93* HCO3-28 AnGap-19*
___ 06:20AM BLOOD Calcium-7.2* Phos-4.7* Mg-1.9
Brief Hospital Course:
Mr. ___ is a ___ with ESRD ___ HTN nephrosclerosis on
HD, PVD, COPD, HTN, HLD, CAD s/p CABG, anxiety & depression who
presents as a transfer from ___ w/ GIB found to have
esophageal varices on EGD.
ACUTE ISSUES:
# Esophageal Varices/GIB: EGD ___ demonstrate grade III varices
(3 cords) in upper esophagus, non-bleeding, as well as mosaic
appearance of stomach mucosa with 2 spots of spontaneous
bleeding. Clip placed and thermal therapy applied with
hemostasis. Likely the source of melena/anemia. Hgb stable since
___. Continued on PPI BID. Per GI, upper esophageal varices
are at risk for bleeding, but not as high of a risk as more
distal varices given location. No indication for nadolol from
variceal standpoint at this time. No recommended interval to
repeat EGD and no indication for banding given location. Varices
should not prevent anticoagulation if other indications. No need
to repeat CTA unless other indication. Source of varices likely
increased pressures from significant history of catheters and
lines placed causing SVC syndrome and vascular congestion.
#Hypotension: Suspect false hypotension given preserved MS,
normal lactate, no tachycardia. Known vasculopathy as seen on
___ CTA. Anuric at baseline so cannot use UOP to gauge
perfusion. ___ records patient persistently in with
SBPs in the ___ there. Started on midodrine in ICU, tapered down
and discontinued given lack of improvement in BPs.
#Afib: In sinus and rate controlled on admission; afib history
is reportedly from prior hospitalization in ___. Chads-Vasc =
2. Per his PCP, no history of blood clots. His SVC syndrome is
___ vascular scarring from numerous lines and procedures in his
vasculature causing stenosis. This is likely the source of his
varices as well. Anticoagulation held iso recent GIB, risks may
outweigh benefits of anticoagulation, and patient in agreement
with discontinuing warfarin. Can continue to discuss risks and
benefits of anticoagulation with patient in the future.
#Pain Management
#Anxiety Management
Patient on high doses of narcotics and anxiolytics at home,
confirmed with PCP that these are chronic doses of these meds
and patient maintained on this regimen for numerous years.
#Depression/Homicidal ideation: Patient reported he had a bad
year and his wife died in ___. he believes the nursing home she
was in "smothered her with a pillow." He expressed at one point
that he wanted to kill these employees, evaluated by psychiatry
who felt this was frustration rather than actual HI. Felt low
safety risk to others given his lack of access to weapons,
physical limitations, general debilitation. Patient denied HI at
time of discharge and was able to admit that this was just said
out of anger.
# Scrotal pain:
Patient reported scrotal pain ___. We obtained scrotal US which
showed no evidence of testicular torsion, but did show small
hydrocele, left varicocele, & microlithiasis of the left testis.
Per urology, no need for intervention or further imaging for
microlithiasis or other findings on U/S. Will set up for
urologic outpatient follow up for further management/evaluation
should symptoms persist.
CHRONIC ISSUES:
===============
#ESRD on HD:
Nephrology consulted, inpatient HD. Normally ___ HD via right
tunneled catheter. S/P multiple failed fistulas and numerous
failed grafts.
#Hypothyroidism:
Continued levothyroxine PO 150 mcg QD
#PVD sp R SFA stent
ASA held iso GIB, then restarted. Discussed statin with patient
who agreed with starting. Started atorvastatin 40 mg qpm.
#Chronic diastolic HF
#MR ___ TR
___ managed through HD.
TRANSITIONAL ISSUES:
==========================
[ ] BID PPI should be continued for 4 weeks then transitioned to
daily dosing afterwards for minimum of 4 weeks (___). Can
reassess need for PPI at all at that time.
[ ] Patient's O2 saturations have been in mid to high ___ during
hospitalizations and may not require home O2
[ ] Started Tiotropium maintenance inhaler once daily, please
continue to evaluate his COPD management and titrate as needed
[ ] HBV core Ab positive, Surface Ab negative, may require HBV
vaccine
[ ] SW filed report with elder services regarding the death of
the patient's wife in nursing home to decide if they would like
to investigate; please follow up with the investigation
[ ] Discharge weight: 57.9 kg (127.65 lb)
[ ] Last HD session: ___
[ ] U/S findings as below. If persistent scrotal pain, patient
may benefit from urologic follow up. Appointment scheduled at
discharge, can cancel if symptoms resolve.
Small hydrocele, and left varicocele.
Microlithiasis of the left testis. The presence of
microlithiasis alonein the absence of other risk factors is not
an indication for regular scrotal ultrasound, further ultrasound
screening or biopsy. Ultrasound is recommended in the follow-up
of patient is at risk, where risk factors other than
microlithiasis are present.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ALPRAZolam 2 mg PO QID:PRN anxiety
2. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
dyspnea
3. Gabapentin 300 mg PO BID
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Warfarin Dose is Unknown PO DAILY16
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Pantoprazole 40 mg PO Q12H
3. Polyethylene Glycol 17 g PO DAILY
4. Senna 17.2 mg PO BID
5. Tiotropium Bromide 1 CAP IH DAILY
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
7. ALPRAZolam 2 mg PO QID:PRN anxiety
RX *alprazolam 2 mg 1 tablet(s) by mouth four times a day Disp
#*24 Tablet Refills:*0
8. Aspirin 81 mg PO DAILY
9. Calcium Acetate 667 mg PO TID W/MEALS
10. Diazepam 10 mg PO QHS
RX *diazepam 10 mg 1 tab by mouth at bedtime Disp #*3 Tablet
Refills:*0
11. Diazepam 10 mg PO 3X/WEEK (___)
RX *diazepam 10 mg 1 tablet by mouth 3x/week Disp #*3 Tablet
Refills:*0
12. Gabapentin 300 mg PO DAILY
13. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
dyspnea
14. Levothyroxine Sodium 150 mcg PO DAILY
15. Nicotine Patch 14 mg TD DAILY
16. oxyCODONE-acetaminophen ___ mg oral Q4H:PRN pain
2 tablets every 4 hours as needed
RX *oxycodone-acetaminophen 10 mg-325 mg 2 tablet(s) by mouth
every four (4) hours Disp #*36 Tablet Refills:*0
17. Vitamin B Complex w/C 1 TAB PO DAILY
18. HELD- Warfarin 4 mg PO EVERY OTHER DAY This medication was
held. Do not restart Warfarin until discussing with PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
GI Bleed
Secondary Diagnoses
Peripheral vascular disease
atrial fibrillation
esophageal varices
end stage renal disease
chronic pain
anxiety
Hypothyroidism
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 during your stay at ___.
WHY WAS I HERE?
- You were bleeding from your stomach
WHAT WAS DONE WHILE I WAS HERE?
- A camera was used to look at your stomach and throat. You were
bleeding in your stomach
- You were given blood
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- You should talk to your doctor about warfarin in the future
- Continue to talk your other medications as prescribed and
attend your follow up appointments.
Be well!
Your ___ Care Team
Followup Instructions:
___
|
19815230-DS-5
| 19,815,230 | 23,339,111 |
DS
| 5 |
2170-12-01 00:00:00
|
2170-12-02 15:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine / hydrocodone / propoxyphene / iodine / Haldol / vicodan
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Implant leadless pacemaker, ___ guided ___
History of Present Illness:
___ with a history of CAD, ESRD (HD ___ who was
transferred from ___ for subdural hematoma.
Patient is very frail at baseline. He had a fall at rehab ___
and hit his face on the ground. Endorses some shortness of
breath
prior to falling, does not remember exactly what happened
however. Currently endorses whole body pain, shortness of
breath,
denies belly pain/nausea vomiting/diarrhea/dysuria. OSH CT max
face head neck w/only SDH (right tentorial SDH measuring up to
4.5mm thickness. There is also trace posterior falx subdural
blood measuring up to 2.5mm thickness), no ocular entrapment or
c-spine abnormality. Per EMS RSV+ recently. Tetanus status
unknown. At OSH, received 2L IVF.
Of note, he was admitted ___, for GI bleed, found to
have esophageal varices, felt to be due in part vascular
scarring
from numerous lines and procedures in his vasculature causing
stenosis. He was also noted to have SVC syndrome. During that
hospitalization he was noted to have blood pressures in 70-90s
without elevated lactate. He was started on midodrine which was
quickly tapered down.
In the ED, initial vitals were:
96.0 100 96/64 18 98% 3L NC
- Exam notable for:
Con: A+Ox3 however slightly confused, very frail
HEENT: Large L forehead hematoma and periorbital edema and
ecchymosis, L forehead lac 2 cm linear, bilat chemosis but
w/intact EOMI, intraocular pressures <25 bilat, dry MM
Resp: Diffuse rhonchi and rales, productive cough
CV: Tachycardic and irregular, normal ___ and ___ heart sounds
Abd: Soft, mildly tender, Nondistended
GU: No costovertebral angle tenderness
MSK: c-spine w/o TTP, t and l spine ttp
Skin: No rash, Warm and dry
Neuro: Cranial nerves grossly intact, strength and sensation
grossly intact all ext
Psych: Normal mood/mentation
- Labs notable for:
hgb 9.9, plt 106, MCV 105
___ 17742
ALT 11, AST 20, ALP 128, lipase 12, albumin 3.3
CK 37 MB 5
Na 138, K 4.9, bicarb 24, BUN 37, Cr 4.8
trop T of 0.03
VBG: 7.22/64/38, lactate 1.0
fluA/B negative
serum tox negative
- Imaging was notable for:
Moderate pulmonary edema with bilateral small pleural effusions.
No focal consolidation.
- Patient was given:
IHIpratropium-Albuterol Neb 1 NEB
IVPiperacillin-Tazobactam 4.5 g
IHIpratropium-Albuterol Neb 1 NEB
IMTetanus-DiphTox-Acellular Pertuss (Tdap)
IVVancomycin 1000 mg
IV DRIPNORepinephrine (0.03-0.25 mcg/kg/min ordered)
On arrival to the floor Mr. ___ reports episodes of "attacks"
for the last two days that occurred up to three times daily. He
describes these episodes as a "warmth" rising in this chest
while
he is laying flat that is accompanied by a sensation his heart
is
beating rapidly in his neck. His vision then goes "yellow" but
he
can see clearly. He has preceding anxiety which also occurs
throughout the duration of the "attack." He denies chest pain or
pressure during these episodes. Episodes do not occur during
exertion.
An "attack" preceded his fall ___. He remembers falling out of
bed and sliding to the floor; he does not remember hitting his
head however nursing note from rehab referral state he bumped
his
head on the headboard. He did not loose bowel or bladder
function. He otherwise feels well, denies cough, rhinorrhea,
sore
throat, nausea, vomiting, diarrhea, constipation, lower
extremity
edema, fevers, weight loss.
ROS positive for chills but no rigors
ROS negative for fevers
Past Medical History:
-ESRD on HD ___
-Hypertension
-Hyperlipidemia
-Hypothyroidism
-Anxiety disorder
-Depression
-Secondary hyperparathyroidism
-CAD is status post coronary artery bypass graft
-SVC syndrome
-Severe valvular heart disease
-Atrial fibrillation
Social History:
___
Family History:
Noncontributory to presenting complaint
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Reviewed in MetaVision.
GENERAL: frail appearing
HEENT: 8cmx4cm hematoma to R forehead. L eye with ecchymoses and
swelling. EOMI, PERRLA.
CARDIAC: distant heart sounds, irregular rhythm, tachycardic
PULMONARY: Diffuse wheezes, decreased breath sounds at bases.
ABDOMEN: soft, diffusely tender to palpation but not replicable,
no rebound or guarding
EXTREMITIES: warm, well perfused
SKIN: no lesions
NEURO: alert and oriented x3, intermittent jerks of arms
ACCESS: R tunneled line with no surrounding erythema or
tenderness
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 1135)
Temp: 97.4 (Tm 98.1), BP: 95/65 (78-102/48-79), HR: 126
(110-137), RR: 18 (___), O2 sat: 98% (94-100), O2 delivery: 2
L
(2L-3 L), Wt: 131.17 lb/59.5 kg
GENERAL: Thin, ill appearing man in no acute distress.
NEURO: AAOx3. Moving all four extremities with purpose.
HEENT: Bilateral orbital hematomas with extensive facial
bruising.
CARDIAC: tachycardic, irregular rhythm, distant heart sounds, no
murmurs appreciated
CHEST: Right subclavian tunneled line in place with clean
overlying dressing.
PULMONARY: Bilateral course ronchi. No increased work of
breathing.
ABDOMEN: Soft, mild diffuse ttp.
EXTREMITIES: No edema
SKIN: Warm and well perfused, dry skin
Pertinent Results:
ADMISSION LABS:
===============
___ 05:10AM BLOOD WBC-9.4 RBC-3.11* Hgb-9.9* Hct-32.5*
MCV-105* MCH-31.8 MCHC-30.5* RDW-18.2* RDWSD-69.8* Plt ___
___ 05:10AM BLOOD Neuts-82.7* Lymphs-7.3* Monos-8.2
Eos-0.7* Baso-0.2 Im ___ AbsNeut-7.78* AbsLymp-0.69*
AbsMono-0.77 AbsEos-0.07 AbsBaso-0.02
___ 05:10AM BLOOD Glucose-120* UreaN-37* Creat-4.8* Na-138
K-4.9 Cl-99 HCO3-24 AnGap-15
___ 05:10AM BLOOD Albumin-3.3* Calcium-7.7* Phos-3.7 Mg-1.6
___ 05:15AM BLOOD ___ pO2-38* pCO2-64* pH-7.22*
calTCO2-28 Base XS--2
DISCHARGE LABS:
===============
___ 08:00AM BLOOD WBC-6.7 RBC-2.66* Hgb-8.6* Hct-27.9*
MCV-105* MCH-32.3* MCHC-30.8* RDW-19.7* RDWSD-74.6* Plt Ct-56*
___ 08:00AM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-1+*
Macrocy-1+* Ovalocy-1+* RBC Mor-SLIDE REVI
___ 08:00AM BLOOD Glucose-103* UreaN-14 Creat-2.1* Na-135
K-3.5 Cl-94* HCO3-26 AnGap-15
___ 08:00AM BLOOD Calcium-7.9* Phos-1.2* Mg-2.1
MICROBIOLOGY:
=============
___ 5:10 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:29 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:38 am SPUTUM Site: EXPECTORATED
Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS
AND
CHAINS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
GRAM NEGATIVE ROD(S). RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 3:51 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
ENTEROBACTER CLOACAE COMPLEX. MODERATE GROWTH.
Piperacillin/Tazobactam AND cefepime test result
performed by
___.
STAPH AUREUS COAG +. SPARSE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
| STAPH AUREUS COAG +
| |
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S <=0.5 S
LEVOFLOXACIN---------- 0.25 S
MEROPENEM-------------<=0.25 S
OXACILLIN------------- 0.5 S
PIPERACILLIN/TAZO----- S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S
___ 11:45 am BLOOD CULTURE Source: Line-R IJ HD line 1
OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:23 pm BLOOD CULTURE Source: Venipuncture 2 OF
2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING AND REPORTS:
====================
___ CT Torso
1. No fracture.
2. No definite organ injury, although trace hemorrhage is noted
in the right
pericolic gutter, the only specific sign of injury on this
study.
3. Findings of fluid overload including mild pulmonary edema,
pleural
effusions, ascites, anasarca.
4. 6 mm right upper lobe nodular opacity surrounding
ground-glass opacity
could be inflammatory or infectious. Followup CT could be
considered in one
year if there are risk factors such as smoking, strong family
history of
pulmonary malignancy or occupational exposure.
5. Pericardial thickening without effusion, probably chronic.
There may be
some mass effect on the right heart chambers associated with
this although not
likely to represent an acute process. This may be due to
sequela of renal
disease.
___ ECHO
The left atrial volume index is SEVERELY increased. The right
atrium is mildly enlarged. 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.
Quantitative biplane left ventricular ejection fraction is 72 %.
There is no resting left ventricular
outflow tract gradient. Dilated right ventricular cavity with
normal free wall motion. Intrinsic right
ventricular systolic function is likely lower due to the
severity of tricuspid regurgitation. There is
abnormal interventricular septal motion c/w right ventricular
pressure and volume overload. The aortic
sinus diameter is normal for gender with mildly dilated
ascending aorta. The aortic arch diameter is
normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. There is no
aortic regurgitation. The mitral valve leaflets are mildly
thickened. There is severe mitral annular
calcification. No valvular systolic anterior motion (___) is
present. There is no mitral valve stenosis.
There is SEVERE [4+] mitral regurgitation. Due to acoustic
shadowing, the severity of mitral
regurgitation could be UNDERestimated. The tricuspid valve
leaflets are mildly thickened. There is
SEVERE [4+] tricuspid regurgitation. There is mild pulmonary
artery systolic hypertension. In the
setting of at least moderate to severe tricuspid regurgitation,
the pulmonary artery systolic pressure may
be UNDERestimated. There is no pericardial effusion.
CHEST (PORTABLE AP) ___
Moderate pulmonary edema with bilateral small pleural effusions.
No focal
consolidation.
Transthoracic Echo Report ___
FOCUSED STUDY- There is no evidence for an atrial septal defect
by 2D/color Doppler. The estimated
right atrial pressure is ___ mmHg. There is normal regional and
global left ventricular systolic function.
No ventricular septal defect is seen. Diastolic function could
not be assessed. The right ventricle has
uninterpretable free wall motion assessment. The aortic valve
leaflets (?#) are mildly thickened. The
mitral valve leaflets are moderately thickened. There is
moderate mitral annular calcification. There is
SEVERE [4+] mitral regurgitation. Due to the Coanda effect, the
severity of mitral regurgitation could
be UNDERestimated. The tricuspid valve leaflets are mildly
thickened. There is moderate to severe [3+]
tricuspid regurgitation. There is mild pulmonary artery systolic
hypertension. In the setting of at least
moderate to severe tricuspid regurgitation, the pulmonary artery
systolic pressure may be
UNDERestimated. There is a trivial pericardial effusion.
IMPRESSION: Severe mitral regurgitation with moderate MAC.
Moderate to severe tricuspid
regurgitation. Overall normal global left ventricular systolic
function. At least mild pulmonary
artery systolic hypertension.
Compared with the prior TTE (images reviewed) of ___, the
findings are similar.
___ DUP EXTEXT BIL (MAP/DVT) PORT ___
Thrombosed arteriovenous graft in the proximal left thigh.
Left common femoral vein has no color flow concerning for
thrombus.
The right common femoral vein appears diminutive with minimal to
no color
flow. The visualized femoral arteries bilaterally are patent
EP BRIEF PROCEDURE REPORT ___
Procedure aborted after anesthesia.
___ with severe peripheral arterial and venous vascular disease
with multiple prior AV fistulae and
symptomatic slow AF referred for leadless pacemaker implant.
After anesthesia, detailed ultrasound of bilateral groin
vasculature did not identify any suitable venous
conduit for the delivery sheath. Case aborted with plans to
consult vascular surgery for further
procedural planning.
EGD ___
Varices at the upper esophagus (15cm to 25cm). Erosions in the
antrum
Mosaic appearance in the fundus and body (endoclip, thermal
therapy)
Hiatal hernia
Otherwise normal EGD to third part of the duodenum
CTA ABD & PELVIS ___
1. Extensive venous collaterals along the left lateral abdominal
wall are
likely related to central venous occlusion.
2. The external iliac veins are not seen bilaterally, possibly
due to chronic
thrombosis.
3. Dislodged vascular stent in the left anterior thigh.
CT CHEST W/CONTRAST ___
1. Chronic occlusion of central veins in the upper chest with
extensive
venous collaterals in the mediastinum and left chest wall.
2. Right IJ hemodialysis catheter with tip in the distal SVC.
3. Moderate upper lobe predominant paraseptal and centrilobular
emphysema.
4. Moderate bilateral pleural effusions with associated
compressive
atelectasis.
5. Ascending aorta top-normal in size, measuring up to 4 cm.
CT HEAD W/O CONTRAST ___
1. Limited exam due to motion.
2. Right tentorial subdural hematoma. The overall size is
stable from prior.
3. Interval decrease in size of a right frontal scalp hematoma.
4. Paranasal sinus inflammatory disease and partial mastoid air
cell
opacification.
CHEST (PORTABLE AP) ___
Compared to chest radiographs ___ through ___.
Moderate to severe pulmonary edema has worsened since ___.
There may be better aeration at the lung bases but substantial
lower lobe atelectasis and large pleural effusions persist.
Heart size is normal. Cannula projects over the right heart.
Dual channel central venous catheter ends in the low SVC.
CHEST (PORTABLE AP) ___
No significant change in appearance of the chest compared to the
most recent
prior study. Of note, while there is no new focal
consolidation, superimposed
infection cannot be excluded.
CHEST (PORTABLE AP) ___
The patient has been intubated since prior with the tip of the
endotracheal tube projecting over the midthoracic trachea. The
tip of an enteric tube projects over the left upper quadrant.
The tip of a right tunneled central venous catheter projects
over the cavoatrial junction. Vascular stents are unchanged.
There are layering bilateral pleural effusions and moderate to
severe pulmonary edema, unchanged. Bibasilar atelectasis is also
noted. The size and appearance of the cardiomediastinal
silhouette is unchanged.
CHEST (PORTABLE AP) ___
The tip of the enteric tube projects over the stomach.
Unchanged
cardiopulmonary findings when compared to the radiograph
performed 2 hours
prior.
EP PROCEDURE REPORT ___
Successful implantation of a ___ Micra ventricular
pacemaker. There were no complications
CHEST (PA & LAT) ___
Moderate to severe pulmonary edema as well as pleural effusions
bilaterally. A new leadless pacing device projects over the
lower mediastinum at midline.
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[] Patient has persistently low BPs iso peripheral vascular
disease, so BPs may be unreliable. He mentated well with normal
lactate with BPs in ___. His goal MAP is 55 mmHg.
[] Please consider referral to Psychiatry for management of
anxiety and depression.
[] Varices seen in the upper esophagus w/o evidence of liver
disease on imaging and unremarkable labs. Consider fibroscan or
further workup as an outpatient.
MICU Course
===========
Presented after a fall. Evaluated by neurosurgery on arrival who
did not recommend surgical intervention. He was initially
admitted to the MICU for labs concerning for hypercarbic
respiratory failure. He was also hypotensive requiring levo fed
briefly. The Levophed was quickly weaned off. He was never
intubated or put on BiPAP for his respiratory failure. His blood
pressures were persistently in the ___ systolic. He was
mentating appropriately, with a normal lactate. This is assumed
to be his baseline. He is s/p prednisone burst for presumed COPD
exacerbation ___ s/p azithromycin 500mg x 3 days
(___)
While in the MICU, he was found to have tachy-brady syndrome.
Electrophysiology, cardiac surgery, and interventional radiology
were all consulted. There was an attempted pacemaker placement
for his tachy-brady syndrome on ___ via an attempted
R-femoral venous access. However, the pacemaker was not
successfully placed due to difficult vascular access. The
patient was then transferred to the cardiology floor while
awaiting multidisciplinary discussion between electrophysiology,
cardiac surgery, vascular surgery, interventional radiology with
a approach as to how best to implant the pacemaker.
FLOOR COURSE
============
On the floor, there were continued discussion regarding how best
to place a pacemaker. Consulting teams requested the operative
reports of his prior surgeries so as to better understand his
anatomy, however these unfortunately could not be obtained as it
was unknown where he had had these surgeries. Consulting teams
continued to discuss best approach for providing patient a
pacemaker, with a tentative plan for access through his tunneled
line or possible epicardial leads. He continued to be
tachycardic to the 110s, as well as hypotensive to SBPs ___.
He triggered on the floor multiple times for unstable vitals,
however continued to mentate well, and had normal lactate on
each check. His respiratory status remained stable on his ___
baseline NC requirement. Nephrology attempted perform HD while
on the floor, however patient could only tolerate 1 hr of
dialysis due to significant hypotension. They stated they would
not pursue further dialysis on the floor given his hypotension.
On ___, patient began to have episodes of very symptomatic
bradycardia lasting ___ minutes. He would temporarily lose
consciousness, have HRs in the ___, and then spontaneously
return to his baseline tachycardia and mental status. He had
multiple episodes of this on the floor over the night, with the
last episode requiring a few seconds of transcutaneous pacing.
This prompted his transfer to the CCU. Patient's floor course
was also complicated by significant pain requiring breakthrough
oxycodone, as well as significant anxiety, which seemed to
worsen his symptoms.
CCU COURSE
==========
In the CCU, patient was monitored while awaiting pacemaker
placement and continued to have several episodes of slow atrial
fibrillation associated with episodes of presyncope. Through
combined efforts by ___ and EP, patient underwent ___ procedure on
___ to establish venous access through the R groin into the IVC
with plan to undergo Micra pacemaker placement on ___. During
this procedure, ___ performed angioplasty of the R external iliac
which was found to be occluded ___ scarring from prior access of
this vein. A dialysis catheter was placed as a placeholder to
maintain vascular access for pacemaker placement. During this
procedure, patient require both levophed and vasopressin to
maintain adequate BPs in setting of anesthesia. The patient
remained intubated after this procedure and was maintained on
two pressors while sedated. On ___, he had a permanent
pacemaker placed and remained intubated since his procedure
occurred late. He was successfully extubated in the AM of ___.
He was weaned off vasopressin and levophed before transfer to
the floor. He was followed by Nephrology for HD. Of note,
patient continued to have significant anxiety that was acutely
exacerbated by his bradycardic episodes in which patient feels
he's about to die. Palliative care was consulted to help assist
with management of patient's pain and anxiety. He was deemed
clinically stable for floor transfer.
___ COURSE
============
Patient was transferred to the Cardiology service for further
management after CCU course. He was started on rate control with
metoprolol for his atrial fibrillation. BPs and respiratory
status remained stable and volume was managed with HD as he was
transitioned back to ___ HD.
SUMMARY:
========
___ man with history of CAD s/p CABG, SVC syndrome and
PAD s/p right SFA stent, ESRD (___ HD), atrial fibrillation,
chronic hypotension, esophageal varices, COPD on baseline ___
O2, HTN, and HLD who initially presented as transfer from
___ for fall at rehab c/b subdural hematoma and
respiratory failure. Hospital course later complicated by
frequent episodes of symptomatic bradycardia, now s/p leadless
PPM. Called out to ___ for further management where he was
started on metoprolol for rate control.
# CORONARIES: s/p CABG
# PUMP: normal systolic function
# RHYTHM: atrial fibrillation
# TACHY-BRADY SYNDROME S/P PPM
# ATRIAL FIBRILLATION
Bradycardia resolved now s/p leadless PPM on ___ in conjunction
with ___ due to severe peripheral arterial disease with complex
vascular anatomy. Was persistently tachycardic but asymptomatic
in this regard.
Started metoprolol for rate control. He was not anti-coagulated
due to recent subdural and known esophageal varices.
# HYPOTENSION
Persistently low BPs 80-90s systolic. Asymptomatic, no signs of
inadequate perfusion.
Mentating well, lactate repeatedly normal. Suspect due to stiff
vasculature and possibly exacerbated by tachycardia. Off
pressors
since ___ and tolerating well. MAP goal ~55. Midodrine prior to
HD sessions.
# SUBDURAL HEMATOMA
Presented after a fall. Evaluated by neurosurgery on arrival who
did not recommend surgical intervention. OK for prophylactic
heparin and aspirin. No need for repeat imaging unless exam
change. No need for neurosurgical follow up or seizure
prophylaxis. Outpatient follow up in ___ clinic.
# ESRD
MWF HD via right subclavian tunneled line.
# THROMBOCYTOPENIA
Platelet count drifted down to ___, now stable. Unclear cause,
may be medication induced. No e/o infection. No signs of
bleeding. 4T score 4, but has been receiving heparin sq this
admission and heparin in dialysis.
Platelets stable in ___, seems unlikely to be HIT. Platelet
smear pending. Should be followed up as an outpatient.
# HYPOXIC/HYPERCARBIC RESPIRATORY FAILURE
# SOB
Initially due to volume overload and COPD exacerbation, now
resolved. Sputum with MDR enterobacter / ESBL but was more
likely
colonization. Did not require BiPAP or mechanical ventilation in
the MICU, though was subsequently intubated for PPM insertion.
Extubated ___, currently stable from respiratory standpoint,
but
endorsing SOB likely ___ volume overload managed w/ HD.
# ANXIETY DISORDER
# DEPRESSION
Complex situation with underlying psychiatric issues exacerbated
by inpatient stay. Palliative care following. ___ also benefit
from psychiatry.
- psychiatry consult if ongoing issues
- BusPIRone 10 mg PO TID
- Escitalopram Oxalate 5 mg PO/NG DAILY
- ALPRAZolam 0.5 mg PO/NG TID anxiety
- LORazepam 0.5 mg IV Q4H:PRN anxiety
- appreciate palliative care recs
- social work following
# GOALS OF CARE
With discussion on ___ patient expressed desire for
escalation of care as needed. His goal is to get back to
___. He has been consistent with his wishes.
CHRONIC / STABLE ISSUES
=================================
# CAD s/p CABG
Continued ASA as above, and atorvastatin.
# SYNCOPE / FALL
Presumed due to symptomatic bradycardia, now resolved. ___
evaluated and recommended rehab.
# SEVERE MITRAL/TRICUSPID REGURGITATION
Noted on TTE with 4+ MR and 3+ TR. Not currently appropriate for
intervention given above issues.
# PERIPHERAL VASCULAR DISEASE S/P SFA STENT
ASA, statin as above.
# ESOPHAGEAL VARICES
EGD ___ with grade III varices in upper esophagus. Switched
to Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY.
# HYPOTHYROIDISM
Continued Levothyroxine Sodium 150 mcg PO/NG DAILY.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 150 mcg PO DAILY
2. ALPRAZolam 0.5 mg PO TID anxiety
3. Aspirin 81 mg PO DAILY
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
5. Calcium Acetate 667 mg PO TID W/MEALS
6. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
dyspnea
7. oxyCODONE-acetaminophen ___ mg oral Q4H:PRN pain
8. Vitamin B Complex w/C 1 TAB PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Senna 17.2 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY
12. Pantoprazole 40 mg PO Q12H
13. Atorvastatin 40 mg PO QPM
14. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
15. RisperiDONE 0.25 mg PO QHS
16. Escitalopram Oxalate 5 mg PO DAILY
17. BusPIRone 10 mg PO TID
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H
2. Calcitriol 0.5 mcg PO 3X/WEEK (___)
3. GuaiFENesin ___ mL PO Q6H cough
4. LORazepam 0.5 mg IV Q4H:PRN anxiety
5. LORazepam 0.5 mg PO Q6H:PRN anxiety
6. Metoprolol Succinate XL 50 mg PO DAILY
7. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: d/cing liquid form
8. OxycoDONE Liquid 1.25-2.5 mg PO Q4H:PRN Pain - Moderate
9. TraZODone 25 mg PO QHS:PRN insomnia
10. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Wheezing,
shortness of breath
11. Senna 8.6 mg PO BID:PRN Constipation
12. ALPRAZolam 0.5 mg PO TID anxiety
13. Aspirin 81 mg PO DAILY
14. Atorvastatin 40 mg PO QPM
15. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
16. BusPIRone 10 mg PO TID
17. Escitalopram Oxalate 5 mg PO DAILY
18. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
dyspnea
19. Levothyroxine Sodium 150 mcg PO DAILY
20. Pantoprazole 40 mg PO Q12H
21. Polyethylene Glycol 17 g PO DAILY
22. Tiotropium Bromide 1 CAP IH DAILY
23. Vitamin B Complex w/C 1 TAB PO DAILY
24. HELD- Calcium Acetate 667 mg PO TID W/MEALS This medication
was held. Do not restart Calcium Acetate until you follow up
with your Nephrologist.
25. HELD- RisperiDONE 0.25 mg PO QHS This medication was held.
Do not restart RisperiDONE until you follow up with your PCP or
___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subdural hematoma
Hypoxic/hypercarbic respiratory failure
COPD exacerbation
End stage renal disease
Tachy-brady syndrome
Atrial fibrillation
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 at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital for a brain bleed after a
fall.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were evaluated by Neurosurgery who did not recommend
surgery for your brain bleed.
- You were treated in the ICU for extra fluid in your lungs.
Your breathing improved with dialysis (removed the fluid).
- You had low blood pressures, and you were started on a
medication to take before dialysis to support your blood
pressure.
- You were found to have unstable heart rates that were low and
high. You had a pacemaker placed to help control your heart
rate. You were also started on a medication to help control your
heart rate.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19815269-DS-17
| 19,815,269 | 25,452,637 |
DS
| 17 |
2160-05-27 00:00:00
|
2160-05-27 11:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
iodine
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
LAMINECTOMY LUMBAR L3-L5 on ___ with Dr. ___
___ of Present Illness:
Patient is a ___ male with history of HIV presenting for
back pain and numbness in his feet. Patient states he has had a
few weeks of lower back pain. States that he had an episode of
fecal incontinence last week and another episode yesterday.
Patient states that he has not had any bowel movements in the
interim which is abnormal for him. Patient also states that he
is having trouble initiating urination. States that his foot
feels numb bilaterally with the left worse than the right.
Patient denies any trauma. Patient had an outpatient MRI of the
L-spine yesterday. Report came back today with concern for
cauda equina so was referred to the emergency room.
Past Medical History:
ANXIETY
DAUNOXOME
DIARRHEA
GIARDIA
HEALTH MAINTENANCE
HEMOCHROMATOSIS
HIP PAIN
HIV INFECTION
HYPERCHOLESTEROLEMIA
HYPERTENSION
KAPOSI'S SARCOMA, CUTANEOUS
MYCOBACTERIUM
PENILE LESION
SYPHILIS
THERAPEUTIC PHLEBOTOMY
BACK PAIN
SKIN CHECK
OSTEOARTHRITIS
H/O RADIATION
Social History:
Tobacco use: Never smoker
Physical Exam:
PE:
Vitals: Temperature 97.1, heart rate 73, BP 140/99, respiratory
rate 18, O2 saturation 97% on room air
General:
Mental Status: Alert and oriented x4
Cranial nerves II-XII grossly intact.
Vascular
Radial Ulnar Fem Pop DP ___
R 2 2 2 2 2 2
L 2 2 2 2 2 2
Sensory:
UE
C5 C6 C7 C8 T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
R intact intact intact intact intact
L intact intact intact intact intact
T2-L1 (Trunk) intact
___ L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R intact intact intact diminished intact intact
L intact intact intact diminished intact intact
Motor:
UE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8)FinAbd(T1)
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
Reflexes
Bic(C4-5) BR(C5-6) Tri(C6-7) Pat(L3-4) Ach(L5-S1)
R 2 2 2 3 2
L 2 2 2 2 2
___: negative
Babinski: Equivocal
Clonus: None
Perianal sensation: Normal
Rectal tone: Intact
Estimated Level of Cooperation: Good
Estimated Reliability of Exam: Good
AVSS
Well appearing, NAD, comfortable
All fingers WWP, brisk capillary refill, 2+ distal pulses
BLE: SILT L1-S1 dermatomal distributions
BLE: ___ ___
BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle
All toes WWP, brisk capillary refill, 2+ distal pulses
Pertinent Results:
___ 09:50PM BLOOD WBC-8.4 RBC-4.00* Hgb-13.9 Hct-40.1
MCV-100* MCH-34.8* MCHC-34.7 RDW-12.8 RDWSD-47.5* Plt ___
___ 07:29PM BLOOD WBC-6.9 RBC-4.03* Hgb-13.9 Hct-39.4*
MCV-98 MCH-34.5* MCHC-35.3 RDW-12.6 RDWSD-45.5 Plt ___
___ 09:50PM BLOOD Neuts-80.5* Lymphs-12.4* Monos-5.0
Eos-1.1 Baso-0.4 Im ___ AbsNeut-6.76*# AbsLymp-1.04*
AbsMono-0.42 AbsEos-0.09 AbsBaso-0.03
___ 07:29PM BLOOD Neuts-57.5 ___ Monos-10.2 Eos-3.5
Baso-0.4 Im ___ AbsNeut-3.93 AbsLymp-1.92 AbsMono-0.70
AbsEos-0.24 AbsBaso-0.03
___ 09:50PM BLOOD Plt ___
___ 07:29PM BLOOD Plt ___
___ 07:29PM BLOOD ___ PTT-33.1 ___
___ 09:50PM BLOOD Glucose-135* UreaN-13 Creat-0.8 Na-140
K-3.4 Cl-103 HCO3-21* AnGap-19
___ 07:29PM BLOOD Calcium-8.9 Phos-3.1 Mg-2.1
___ 09:50PM BLOOD HCV Ab-Negative
___ 09:50PM BLOOD HBsAg-Negative
MRI L-spine ___
1.Interval progression of severe lumbar spondylosis compared to
the prior exam from ___, now with severe spinal canal stenosis
at L3-L4, and moderate spinal canal stenosis at L2-L3 and L4-L5.
There is buckling and crowding of the nerve roots in the area
of severe canal stenosis at L3-L4. Given the patient's symptoms
and imaging findings, the possibility of cauda equina syndrome
cannot be completely excluded, and correlation in the
appropriate clinical setting is advised.
2.Moderate to severe bilateral neural foraminal narrowing is
seen spanning from L2-L3 through L5-S1 secondary to facet joint
osteophytes, as described above.
3.No terminal cord signal abnormalities identified.
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:
Medications - Prescription
ACYCLOVIR - acyclovir 200 mg capsule. one Capsule(s) by mouth
five times a day as needed Take for 5 days
AMLODIPINE - amlodipine 5 mg tablet. One tablet(s) by mouth once
daily for control of hypertension
CYCLOBENZAPRINE - cyclobenzaprine 5 mg tablet. One to two
tablet(s) by mouth every 6 hours as needed for back pain.
DICLOFENAC SODIUM - diclofenac sodium 75 mg tablet,delayed
release. One tablet(s) by mouth once daily.
DOXYCYCLINE HYCLATE - doxycycline hyclate 20 mg tablet. one
Tablet(s) by mouth twice daily
EFAVIRENZ-EMTRICITABIN-TENOFOV [ATRIPLA] - Atripla 600 mg-200
mg-300 mg tablet. one Tablet(s) by mouth one tablet at night on
empty stomach
FLUOROURACIL - fluorouracil 5 % topical cream. apply to nose
twice daily x 3 weeks
HYDROCHLOROTHIAZIDE - hydrochlorothiazide 12.5 mg tablet. 1
tablet(s) by mouth once a day
HYDROMORPHONE - hydromorphone 4 mg tablet. One tablet(s) by
mouth every 3 hours as needed for back pain not alleviated with
ibuprofen.
LORAZEPAM - lorazepam 1 mg tablet. One tablet(s) by mouth hs as
needed for sleep. - Entered by MA/Other Staff
POTASSIUM CHLORIDE - potassium chloride ER 10 mEq
tablet,extended release. One tablet(s) by mouth twice daily.
SIMVASTATIN - simvastatin 20 mg tablet. 1 tablet(s) by mouth
once a day
TADALAFIL [CIALIS] - Cialis 20 mg tablet. one Tablet(s) by mouth
use one hour prior to act
ZOLPIDEM - zolpidem 10 mg tablet. One Tablet(s) by mouth hs as
needed for sleep. - Entered by MA/Other Staff
Medications - OTC
ASPIRIN - aspirin 81 mg tablet,delayed release. one tablet(s) by
mouth once a day last dose ___
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Diazepam 5 mg PO Q6H:PRN pain/spasm
3. Docusate Sodium 100 mg PO BID
please take while taking narcotics
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
5. Emtricitabine 200 mg PO Q24H
6. Efavirenz 600 mg PO DAILY
7. Tenofovir Disoproxil (Viread) 300 mg PO DAILY retroviral
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
1. Lumbar spinal stenosis.
2. Radiculopathy.
3. Episodic fecal incontinence.
4. Difficulty initiating urination.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Lumbar Decompression Without Fusion
You have undergone the following operation: Lumbar 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: Remove the dressing in 2 days.If
the incision is draining cover it with a new sterile dressing.If
it is dry then you can leave the incision open to the air.Once
the incision is completely dry (usually ___ days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery,do not get the incision wet.Cover it with a sterile
dressing and call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___.We are not allowed to call in or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your incision,
take baseline X-rays and answer any questions.We may at that
time start physical therapy.
We will then see you at 6 weeks from the day of
the operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Followup Instructions:
___
|
19815283-DS-10
| 19,815,283 | 21,908,090 |
DS
| 10 |
2131-08-07 00:00:00
|
2131-08-07 12:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / atenolol
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
___: Closure of open globe injury, anterior chamber
wash-out, lid laceration repair, right eye
History of Present Illness:
___ female past medical history CKD, HTN, c diff
infection s/p treatment, presenting as a transfer from outside
hospital after mechanical
fall with head strike suffering a right eye injury as well as a
C2 fracture. Reports that she is unable to visualize any light
out of the right eye. Denies any weakness or numbness in the
arms of the legs. Denies chest pain, abdominal pain, nausea,
vomiting. Unclear why she fell. There is no reported loss of
consciousness. When she fell she may have struck her right eye
against the arm of the chair. CT shows extensive vitreous
hemorrhage. Question of a right globe rupture on CT scan.
Past Medical History:
PMH/PSH:
CKD
Left THR
HTN
History of c diff infection s/p treatment
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
General: In no acute distress. Right eye s/p lateral canthotomy
with significant edema and ecchymosis.
Vitals: 97.2F, HR 88, BP 190/80, RR 18, 96% on RA
HEENT: Right eye with traumatic hyphema, hemorrhagic chemosis,
significant edema and ecchymosis of the lids, decreased visual
acuity, does not see light shined in the eye, 2 cm laceration
above the right eye.
Respiratory: No Resp Distress and Chest non-tender
Cardio-Vascular: RRR
Abdomen: Non-tender and Soft
___: No Midline Tenderness; Severe kyphosis
Extremity: No edema
Neurological: Alert, moving extremities equally, strength and
sensation grossly intact
Skin: Right eye ecchymoses, right forehead laceration
Psychological: Mood/Affect Normal
Spine exam: Tenderness with palpation up upper cervical spine,
no
other midline bony spinal tenderness
Discharge Physical Exam:
Vitals: T 98.8, BP 145/97, HR 90, RR 20, SpO2 93%Ra
Gen: Elderly female in NAD
HEENT: R eye with swollen-appearing eyelid, decreased visual
acuity. Cervical spinal collar in place. Healing R forehead
laceration
CV: RRR
Resp: No respiratory distress
Abd: Soft, NTND
Ext: No ___: No thoracic or lumbar spinal tenderness
Psychological: Mood/Affect Normal
Pertinent Results:
___ 04:52AM BLOOD WBC-7.1 RBC-3.37* Hgb-9.6* Hct-29.8*
MCV-88 MCH-28.5 MCHC-32.2 RDW-14.9 RDWSD-47.9* Plt ___
___ 01:31AM BLOOD WBC-9.0 RBC-3.41* Hgb-9.9* Hct-31.1*
MCV-91 MCH-29.0 MCHC-31.8* RDW-15.0 RDWSD-49.9* Plt ___
___ 01:59AM BLOOD WBC-7.5 RBC-3.29* Hgb-9.5* Hct-29.6*
MCV-90 MCH-28.9 MCHC-32.1 RDW-14.6 RDWSD-47.7* Plt ___
___ 01:15AM BLOOD WBC-8.5 RBC-3.05* Hgb-8.8* Hct-27.2*
MCV-89 MCH-28.9 MCHC-32.4 RDW-14.4 RDWSD-46.8* Plt ___
___ 02:45PM BLOOD WBC-15.2* RBC-3.67* Hgb-10.6* Hct-32.6*
MCV-89 MCH-28.9 MCHC-32.5 RDW-14.4 RDWSD-46.5* Plt ___
___ 04:52AM BLOOD Glucose-76 UreaN-56* Creat-2.5* Na-143
K-3.6 Cl-102 HCO3-18* AnGap-23*
___ 01:31AM BLOOD Glucose-120* UreaN-44* Creat-2.5* Na-139
K-4.5 Cl-102 HCO3-19* AnGap-18
___ 01:59AM BLOOD Glucose-89 UreaN-44* Creat-2.6* Na-142
K-4.3 Cl-103 HCO3-21* AnGap-18
___ 01:15AM BLOOD Glucose-112* UreaN-48* Creat-2.5* Na-139
K-4.1 Cl-103 HCO3-19* AnGap-17
___ 04:52AM BLOOD Calcium-8.4 Phos-4.6* Mg-2.2
___ 01:31AM BLOOD Calcium-8.9 Phos-5.8* Mg-2.2
___ 01:59AM BLOOD Calcium-8.6 Phos-5.1* Mg-2.4
___ 01:15AM BLOOD Calcium-8.4 Phos-4.5 Mg-1.8
CT Torso:
1. No evidence of acute traumatic intrathoracic or
intraabdominal injury
within the limitation of an unenhanced scan.
2. Small bilateral nonhemorrhagic pleural effusions with
subjacent
atelectasis.
3. 16 mm left adrenal adenoma and thickening of the right
adrenal gland,
likely reflecting adenomatous hyperplasia.
4. The right greater than left renal cortical atrophy.
5. Large hiatus hernia containing most of the stomach.
6. Right inguinal hernia containing a nonobstructed loop of
bowel.
7. Multilevel thoracic vertebral body height loss appears
chronic.
Brief Hospital Course:
Patient presented to the ED as a trauma activation after a
mechanical fall with C2 fracture and right eye injury. Ct scan
showed concern for vitreous hemorrhage and right globe rupture.
Ophthalmology evaluated the patient was took her to the OR for
repair (please refer to Operative report for details). Patient
was transferred to the ___ post op after closure of open globe
injury, anterior chamber wash-out, and lid laceration repair of
the right eye. Patient remained intubated for respiratory
concerns with difficult intubation in setting of c-spine
fracture. She was extubated on ___ and continue to progress
well, she was tolerating a regular diet. On ___ she was
transferred to the surgical ward.
Ortho Spine was recommending non-operative management of the C2
fracture with a ___ collar. Opthalmology recommended post-op
eye drops and fox-shield to be worn at all times and then
subsequently to be worn at night and during physical therapy,
and no straining or valsalva maneuvers. Pain was well
controlled. 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.
Physical Therapy and Occupational Therapy evaluated the patient
and recommended rehab once medically clear. At the time of
discharge on ___, the patient was doing well, afebrile with
stable vital signs. The patient was tolerating a regular diet,
out of bed to chair, voiding without assistance, and pain was
well controlled. The patient was discharged to rehab. The
patient and her daughter 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. amLODIPine 2.5 mg PO DAILY
2. Florastor (Saccharomyces boulardii) 250 mg oral DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN nasal
congestion
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE BID
3. Docusate Sodium 100 mg PO BID
4. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE QHS *AST
Approval Required*
5. moxifloxacin 0.5 % ophthalmic (eye) QID to right eye
6. Polyethylene Glycol 17 g PO DAILY
7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID
8. amLODIPine 2.5 mg PO DAILY
9. Florastor (Saccharomyces boulardii) 250 mg oral DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN nasal
congestion
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Type II dens fracture
Zone II and III open globe injury with prolapse of intraocular
contents.
Eight-ball hyphema.
Right upper eyelid laceration
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ after a fall. You were found to have
a C2 type II fracture and right eye globe rupture. The Spine
team was consulted and they recommended hard cervical collar for
3 months and outpatient follow-up for repeat imaging. The
Opthalmologists were consulted and you were taken to the
operating room to undergo closure of the eye injury. You
tolerated this well. You have worked with ___ and OT and they are
recommending you be discharged to rehab to continue your
recovery. Your kidney function has also been monitored while you
were in the hospital and your labs are ___ to their baseline
values and you are making a healthy amount of urine.
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
___.
*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 wear the ___ eye patch over the right eye at night
and whenever you are moving around or any other time when the
eye could potentially be touched or injured. If your family or
the rehab staff feels you are experiencing agitation it is ok to
take off the eye patch.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
|
19815419-DS-10
| 19,815,419 | 28,492,166 |
DS
| 10 |
2135-05-20 00:00:00
|
2135-05-21 10:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headache, confusion, N/V; IPH with IVH.
Major Surgical or Invasive Procedure:
Intubation ___ Extuabtion ___
EVD placement ___
Flexible bronchoscopy ___
History of Present Illness:
___ is a ___ yo ___ speaking man who was
brought in to OSH for AMS and found to L BG hemorrhage with IVH.
Per report patient's brother reports he was acting strange
starting last night but they thought it was related to alcohol
intoxication. This morning he was more altered, complained
headache, was nauseated and vomiting. He was taken to OSH where
BP was 230/110 and CT showed IPH with IVH. He was intubated for
airway protection and transferred to ___ for further
management. No family present to obtain further history at the
time of this note.
There is no family at bedside. Per OSH records, ___ is
the emergency contact at ___, but no answer was
available (and the voicemail was for a different person). Was
told by neurosurgery that ___ who is patient's brother-in-law
can be reached at ___, but that he would not be able to
be in the hospital today.
Past Medical History:
EtOH abuse
Suspected hypertension, though not on any medicines
Social History:
___
Family History:
Unknown
Physical Exam:
ON ADMISSION
============
General: intubated male
HEENT: ETT, OGT in place
Neck: supple
CV: RRR, normal S1, S2
Lungs: CTA
Abdomen: soft, NT, ND
GU: foley in place
Ext: warm, well perfused
Skin:
Neuro:
MS- Intubated. No commands but may be language barrier. open
eyes to sternal rub.
CN- Pupils 2-1mm and sluggish. + Corneal bilaterally. Difficult
to assess facial movement symmetry ___ ETT. VOR Absent. + Cough
and + Gag, both weakly.
Sensory/Motor- moves RUE spont and localizes to pain. LUE
antigravity at elbow to noxious and withdraws. Withdraws with
bilat ___.
Coordination- unable to assess
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
ON DISCHARGE
============
Vitals: T 98.1 145/106 66 16 100 RA
General: reclined in bed, awake, alert
HEENT: NCAT, no scleral icterus
Pulmonary: breathing comfortably, no tachypnea or increased WOB
Cardiac: skin warm, well-perfused
Abdomen: soft, ND
Extremities: symmetric, no edema
Neurologic:
-Mental Status: Awake, alert. Oriented to self, "BI", and date.
Follows axial and appendicular commands, intermittently
non-cooperative with exam.
-Cranial Nerves: PERRL. EOMI. L NLFF Slower activation on R
side.
Hearing intact to conversation.
-Sensorimotor:
RUE: Delt 5, Tri 5, Biceps 5
LUE: Delt 4+, Tri 4, Biceps 5, WE 4, FE 4+, FF 5
RLE: IP 5, Ham 5, TA 5, Gastroc 5
LLE: IP 5, Ham 4+, TA 4+, Gastroc 5
-DTRs: ___.
-Coordination: Dysmetria on FNF on the left.
Gait: Deferred
Pertinent Results:
ADMISSION LABS
==============
___ 02:21PM BLOOD WBC-8.9 RBC-4.93 Hgb-15.8 Hct-46.0 MCV-93
MCH-32.0 MCHC-34.3 RDW-13.5 RDWSD-45.7 Plt ___
___ 02:21PM BLOOD Neuts-85.2* Lymphs-5.8* Monos-8.7
Eos-0.0* Baso-0.1 Im ___ AbsNeut-7.60* AbsLymp-0.52*
AbsMono-0.78 AbsEos-0.00* AbsBaso-0.01
___ 02:21PM BLOOD ___ PTT-26.1 ___
___ 02:21PM BLOOD Glucose-116* UreaN-19 Creat-1.8* Na-140
K-4.3 Cl-94* HCO3-25 AnGap-21*
___ 02:21PM BLOOD ALT-40 AST-34 AlkPhos-59 TotBili-1.2
___ 02:21PM BLOOD Lipase-21
___ 02:21PM BLOOD cTropnT-<0.01
___ 02:21PM BLOOD Albumin-5.0 Calcium-9.2 Phos-3.6 Mg-2.1
___ 02:21PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:44PM BLOOD ___ pO2-37* pCO2-56* pH-7.34*
calTCO2-32* Base XS-2
___ 02:10PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:10PM URINE Blood-MOD* Nitrite-NEG Protein-300*
Glucose-1000* Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.0
Leuks-NEG
___ 02:10PM URINE RBC-3* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
PERTINENT LABS
==============
___ 12:09AM BLOOD %HbA1c-4.7 eAG-88
___ 12:09AM BLOOD Triglyc-176* HDL-69 CHOL/HD-4.1
LDLcalc-179*
___ 12:09AM BLOOD TSH-9.0*
___ 04:55PM BLOOD Lupus-NEG
Test Result Reference
Range/Units
CARDIOLIPIN AB (IGG) <14 GPL
Value Interpretation
----- --------------
< or = 14 Negative
15 - 20 Indeterminate
21 - 80 Low to Medium Positive
>80 High Positive
Test Result Reference
Range/Units
CARDIOLIPIN AB (IGM) <12 MPL
Value Interpretation
----- --------------
< or = 12 Negative
13 - 20 Indeterminate
21 - 80 Low to Medium Positive
>80 High Positive
Test Result Reference
Range/Units
B2 GLYCOPROTEIN I (IGG)AB <9 <=20 SGU
IMAGING
=======
CT Head: L BG IPH with IVE extending into ___ ventricle
___ CTA Head
NECT: Right frontal ventriculostomy catheter terminates near
right foramina ___. Small pneumocephalus is noted.
Intraventricular hematoma appears similar in overall size
compared to 6 hours ago, with interval redistribution of the
hematoma in the ventricles. Enlarged right ventricle is slightly
smaller compared to before. Otherwise the remaining enlarged
ventricles appear similar to before.
CTA: Major intracranial and cervical arteries are patent without
occlusion, dissection, or aneurysm.
TTE ___
The left atrial volume index is normal. A left-to-right shunt
across the interatrial septum is seen at rest c/w a small
secundum atrial septal defect. Right to left flow of agitated
saline at rest is also seen. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Small secundum type atrial septal defect with
left-to-right flow at rest on color Doppler and right-to-left
flow of agitated saline at rest. Mild symmetric left
ventrricular hypertrophy with preserved regional and low normal
global left ventricular systolic function.
RENAL ARTERY U/S ___. Slightly limited study, with no evidence of renal artery
stenosis.
2. Normal appearance of the renal parenchyma, without stones,
masses, or
hydronephrosis.
B/L LOWER EXT U/S ___:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
CTV PELVIS ___:
No evidence of pelvic venous thrombosis.
MR head w/ contrast ___:
Left basal ganglia hemorrhage with intraventricular extension
appear similar compared to most recent prior CT done, but
appears
improved compared to initial CT as described above. No
underlying mass or vascular malformation. Imaging follow-up
after complete resolution is advised to exclude an underlying
mass or vascular malformation with certainty.
The ventricular profile is stable and improved compared to
initial CT. Right frontal approach external ventricular drain
in
situ.
There are multiple most subacute infarcts in the right basal
ganglia and thalamus as well as bilateral occipital and to a
lesser degree the posterior parietal and left frontal cortical
gray matter as described above. Infarcts in various vascular
territories suggest an embolic etiology.
Suspected chronic lacunar infarcts also noted in the midbrain
bilateral. Hemorrhagic transformation of a left basal ganglia
infarct and subsequent hemorrhage should be considered as a
possible explanation of all of the above findings.
DISCHARGE LABS
==============
___ 05:35AM BLOOD WBC-4.9 RBC-4.53* Hgb-14.3 Hct-41.9
MCV-93 MCH-31.6 MCHC-34.1 RDW-12.7 RDWSD-43.2 Plt ___
___ 05:35AM BLOOD ___ PTT-30.9 ___
___ 05:35AM BLOOD Glucose-92 UreaN-18 Creat-1.2 Na-139
K-4.4 Cl-97 HCO___ AnGap-15
___ 05:35AM BLOOD Calcium-9.9 Phos-3.7 Mg-1.9
Brief Hospital Course:
Mr. ___ is a ___ man with history notable for
presumed alcohol use disorder transferred from OSH for
left-sided basal ganglia IPH c/b IVE s/p EVD placement.
Agitation, akathisia improved after removal of EVD and
discontinuation of
Dobhoff tube. Given absence of further nausea, vomiting, or
somnolence, VPS shunting was been deferred by neurosurgery.
He was initially admitted to neuro ICU from ER intubated and
sedated. EVD placed in ER. Post EVD CT done and showed stable
hemorrhage. Nicardipine gtt started to maintain SBP < 140.
A-line placed. He received intermittent fluid boluses due to low
urine output and ___, with creatinine as high as 2.4.
On ___, he was noted to have an episode of right gaze
preference, LUE stiffness, lasting minutes. A STAT head CT was
obtained and showed stable bleed with decreasing ventricle size.
Due to concern for seizure, Keppra was started and EEG leads
were placed. He was monitored on EEG for 24 hours without any
seizures or epileptiform discharges seen. EEG and Keppra were
therefore discontinued.
He was extubated successfully on ___. He remained stable from a
respiratory standpoint. After extubation, he was noted to have a
right facial droop as well as significant weakness of his left
side.
Periodic elevations were noted in his ICPs, corresponding
largely to periods of agitation or systemic hypertension. He was
started on PO Labetalol as well as Clonidine for blood pressure
control, and was able to transition off the Nicardipine drip.
Clonidine was chosen as he was also frequently agitated after
extubation. He received haloperidol IV intermittently as needed,
though developed akathisia with this regimen and was
subsequently transitioned to quetiapine without adverse effects.
His agitation improved on this regimen, with improvement in his
ICPs, with subsequent discontinuation of his EVD on ___. His
mental status improved markedly following discontinuation of EVD
and NGT.
Regarding the etiology of his hemorrhage, it was felt to most
likely be due to hypertension, given reports of BPs as high as
230 systolic at the outside hospital. His serum and urine tox
screens were negative. CTA of the head showed no aneurysm. Of
note, during hospital course, he was noted to have left sided
weakness that was unexplained by L basal ganglia hemorrhage.
Repeat noncontrast head CT on ___ revealed subacute right
thalamocapsular infarct. MRI confirmed this infarct, and also
showed a right occipital and left fronto-parietal infarct.
Etiology for these infarcts is also likely cardioembolic (given
broad distribution). Stroke workup included hemoglobin A1c 4.7
and LDL 179, for which he was started on Atorvastatin 40mg
daily. TTE revealed small ASD, mild symmetric LVH with low
normal global LV dysfunction (EF 50-55%). Given his ASD, he
underwent b/l lower extremity dopplers and CT venogram of the
pelvis to evaluate for DVT, which were negative. He also had
antiphospholipid antibodies checked to evaluate for arterial
hypercoagulability which were negative. A TEE was ordered to
definitively rule out a vegetation. However, he was unable to
consent for this, and we were not able to contact any family
members at the time to consent for him. This was therefore
deferred to the outpatient setting.
#Alcohol withdrawal: Patient developed clinical signs/symptoms
of alcohol withdrawal with diaphoresis, hallucinations,
tachycardia, HTN and agitation, in setting of heavy alcohol use
prior to admission and prior admissions to ___ for
alcohol withdrawal. He was started on phenobarbital protocol on
___. He was placed on Precedex drip for agitation (weaned prior
to transfer), as well as clonidine 0.3mg q8h, thiamine, folate
and multivitamin.
#HTN with poor medication adherence: Blood pressures were
maintained SBP<150 for several days, and liberalized to SBP<160
on ___. He was placed on cardene drip, clonidine 0.3mg q8h
(uptitrated to this dose) and labetalol. Workup to evaluate for
secondary HTN included renal ultrasound which was negative, TTE
revealing ASD, mild L ventricular hypertrophy, and 24 hour urine
for catacholamines/metanephrines which was overall unremarkable.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
AHA/ASA Core Measures for Ischemic Stroke and Transient
Ischemic Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? () Yes - (x) No - due to presence of hemorrhage
4. LDL documented? (x) Yes (LDL = 179) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - Aspirin () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
TRANSITIONAL ISSUES:
-Needs TEE as an outpatient to help determine if there are other
potential causes for his ischemic strokes other than PFO. No
vegetation/thrombus seen on TTE.
-Labs pending at time of discharge: Protein C, Protein S, and
Antithrombin assays
-Goal systolic BP <160
-Recommend Lorazepam 0.5-1mg IV if needed for agitation
-Has history of prolonged QTc - monitor if changing meds
-Limited ___, needs ___ interpretor for ___
Creole
-Complete hypercoaguable w/u. Needs Factor V Leiden, Prothrombin
gene mutation tested
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain or temp > ___
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. CloNIDine 0.3 mg PO Q8H
5. Docusate Sodium 100 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Heparin 5000 UNIT SC BID
8. Multivitamins 1 TAB PO DAILY
9. QUEtiapine Fumarate 100 mg PO Q8H
10. Senna 8.6 mg PO BID:PRN constipation
11. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute left basal ganglia intraparenchymal hemorrhage
Acute ischemic stroke
Hypertension
Alcohol withdrawal
Patent foramen Ovale/Atrial Septal Aneurysm
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at ___
___.
You were hospitalized after you were found to have bleeding in
your brain. In the hospital, we also found evidence of stroke
(lack of blood supply to the brain) in other parts of your
brain.
We believe your bleeding was most likely due to high blood
pressure. We started you on medication to help control your
blood pressure.
When you leave the hospital, it will be very important for you
to continue to see your doctor and take your medicines as
prescribed.
Best wishes,
Your ___ Neurology team
Followup Instructions:
___
|
19815454-DS-14
| 19,815,454 | 20,851,877 |
DS
| 14 |
2205-02-25 00:00:00
|
2205-02-25 20:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Gadolinium-Containing Agents
Attending: ___.
Chief Complaint:
cough and confusion
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with hx of HL, AS, DMII, mild "short term memory problems"
per son who presents with cough and confusion. Per the patient
he has had a nonproductive cough for about the last week, but
has worsened over the last 2 days, without chest pain or
difficulty breathing. Today he was noted to be confused by his
son and did not know what month he was in (he typically would
know this). He has had no fevers or chills. He has had no sick
contacts, not recently hospitalized, and no recent travel. He
has not had his flu shot yet this season.
In the ED intial vitals were: 100.2 90 144/69 16 96% though T
reached a max of 103. Exam showed an erythematous throat,
diminished breath sounds on right, with no meningimus and no
focal neurologic findings. Labs were significant for HCT 35.5,
lactate 2.4, and troponin 0.01. CXR showed no acute findings.
EKG demonstrated 1-2mm STD in I, II, v2-v6 and TWI in III, which
is similar to prior but just more pronounced. Patient was given:
1g acetaminophen, 325mg aspirin, and 750mg levofloxacin. Vitals
on transfer: 99.0 83 113/48 16 96% RA.
Upon arrival to the floor, he has no complaints and is
alert-oriented x3.
Review of Systems:
(+) per HPI
(-) fever, chills, sore throat, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Anemia - documented by PCP, though pt denies
Abnormal EKG - Nonspecific ST-T wave abnormalities increasing
over years likely secondary to LVH ___.. RBBB ___
Dermatitis
DM II
HL
GERD
Hx syncope
B/l knee arthroscopies 1980s by history
Hx Bilateral achilles tendonitis
Hx L rotator cuff tear s/p surgery by Dr ___ at ___
___
Social History:
___
Family History:
Per OMR: Father died in his ___ of CVA. Paternal grandmother
with DM. Mother died at ___. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
ADMISSION EXAM:
Vitals-97.7 112/47 70 20 97 RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear and not
particularly erythematous. tonsils not enlarged.
Neck- supple
Lungs- Clear to auscultation bilaterally with minimal rhonchi at
the RLL, no wheezes, rales
CV- Regular rate and rhythm, with SEM at the LUSB, normal S1 +
S2
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: 97.9, 56, 123/56, 18, 100 on RA
GENERAL: asleep, comfortable, pleasant when aroused
HEENT: NC/AT, no head/neck lymphadenopathy, sclerae anicteric,
no conjunctival injection or pallor; oropharynx clear without
erythema or exudate; MMM
LUNGS: Clear to auscultation except minor crackles at b/l bases,
otherwise no w/r/r
HEART: RRR; III/VI SEM
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP
NEURO: awake, A&Ox3
Pertinent Results:
=============
ADMISSION LABS:
=============
___ 06:00PM BLOOD WBC-8.1 RBC-3.97* Hgb-12.4* Hct-35.5*
MCV-90 MCH-31.3 MCHC-35.0 RDW-12.8 Plt ___
___ 06:00PM BLOOD Neuts-82.4* Lymphs-8.8* Monos-6.4 Eos-1.9
Baso-0.7
___ 06:00PM BLOOD Glucose-120* UreaN-13 Creat-1.1 Na-139
K-3.7 Cl-102 HCO3-26 AnGap-15
___ 06:00PM BLOOD CK(CPK)-123
___ 06:00PM BLOOD CK-MB-2
___ 06:00PM BLOOD cTropnT-0.01
___ 06:00PM BLOOD Calcium-9.0 Phos-2.3* Mg-1.8
___ 06:22PM BLOOD Lactate-2.4*
=============
DISCHARGE LABS:
=============
___ 07:05AM BLOOD WBC-6.4 RBC-3.69* Hgb-11.4* Hct-33.7*
MCV-92 MCH-31.0 MCHC-33.9 RDW-13.5 Plt ___
___ 07:05AM BLOOD WBC-6.4 RBC-3.69* Hgb-11.4* Hct-33.7*
MCV-92 MCH-31.0 MCHC-33.9 RDW-13.5 Plt ___
___ 07:05AM BLOOD Glucose-88 UreaN-14 Creat-1.1 Na-139
K-4.4 Cl-103 HCO3-28 AnGap-12
___ 07:05AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.9
=============
OTHER RESULTS:
=============
___ 07:20AM BLOOD CK(CPK)-352*
___ 07:20AM BLOOD CK-MB-3 cTropnT-<0.01
___ 08:43AM BLOOD Lactate-1.6
___ 08:15PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 08:15PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 1:15 am Influenza A/B by ___
Source: Nasopharyngeal swab.
**FINAL REPORT ___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
`
Brief Hospital Course:
___ year old gentleman with type 2 diabetes not on insulin who
presents with worsening nonproductive cough and confusion found
to be febrile to 103 in the emergency department.
# Presumed community-acquired pneumonia:
Fever and increased neutrophils on differential suggest
bacterial source of symptoms. Non-productive cough and clear
chest xray are more suggestive of viral URI. Influenza swab
negative. Blood cultures negative. UA benign. Patient was
started on levofloxacin for presumed community-acquired
pneumonia. His confusion resolved and he remained afebrile. His
cough remained unchanged. He was discharged the following day
to complete a five-day course of antibiotics. He declined home
___ services. He will follow-up with his PCP in two days.
# EKG changes:
On admission, EKG demonstarted more pronounced ST segment
depression in leads I, II, v2-v6 when compared with prior EKG in
___. There was unchanged right bundle branch block and t
wave inversion in lead III. Patient denied any chest pain or
dyspnea. He had two negative troponins, ad EKG changes resolved
in the morning without intervention.
# Diabetes mellitus, type 2:
Patient's glyburide was held on admission. Overnight he had an
episode of hypoglycemia that resolved with administration of
juice. In discussion with the PCP, it was decided to
discontinue the glyburide permanently.
# HL:
Patient continued on home statin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. GlyBURIDE 7.5 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
2. Levofloxacin 750 mg PO Q48H
End date ___.
RX *levofloxacin 750 mg 1 tablet(s) by mouth every other day
Disp #*2 Tablet Refills:*0
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
RX *albuterol sulfate 90 mcg ___ puffs every 4 hours Disp #*1
Inhaler Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Presumed community acquired pneumonia
Secondary diagnosis:
Diabetes mellitus, type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ were to ___ due to worsening cough and some confusion. We
started ___ on levofloaxacin to cover a presumed
community-acquired pneumonia given your cough and fever. Your
chest xray and urinalysis were both normal and did not indicate
a source of infection. Your EKG was unchanged and your cardiac
enzymes were negative. We felt this was likely a viral URI or
mild pneumonia and that this was most likely cause of your
confusion. ___ were discharged on levofloxacin to complete a 5
day course (END DATE ___. Please follow-up with your
primary care provider this week.
It was a pleasure taking care of ___. We wish ___ all the best.
Sincerely,
The medicine team at ___
Followup Instructions:
___
|
19815454-DS-15
| 19,815,454 | 20,990,758 |
DS
| 15 |
2205-09-05 00:00:00
|
2205-09-07 12:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Gadolinium-Containing Agents
Attending: ___.
Chief Complaint:
weakness, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is an ___ y.o male with h.o Dm2, HL, who presented to the ED
with reports of weakness and confusion over the past several
days. Per report, pt was noted to have difficulty getting up out
of bed to use the commode. Reportedly with nonproductive cough
but no fevers. Pt's wife and son report increased memory lapses
at home. Pt currently denies any pain and states that he feels
well without any concerns.
Pt otherwise denies fever, chills, headache, dizziness,
weakness, ST, URI, cp, sob, palpitations, abdominal pain,
nausea, vomiting, diarrhea, constipation, melena, brbpr,
dysuria, rash, paresthesias, weight loss or gain.
In ED, pt reportedly had distractibility, failed clock drawing
test, and was only able to recall ___ objects. VSS in the ED, CT
unrevealing.
Other 10 pt ROS reviewed and otherwise negative.
Past Medical History:
per OMR, pt states he has no medical history
Anemia - documented by PCP, though pt denies
Abnormal EKG - Nonspecific ST-T wave abnormalities increasing
over years likely secondary to LVH ___.. RBBB ___
Dermatitis
DM II
HL
GERD
Hx syncope
B/l knee arthroscopies 1980s by history
Hx Bilateral achilles tendonitis
Hx L rotator cuff tear s/p surgery by Dr ___ at ___
___
Social History:
___
Family History:
Per OMR: Father died in his ___ of CVA. Paternal grandmother
with DM. Mother died at ___. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
GEN: well appearing, comfortable, cooperative, intermittent
coughing
vitals: T 98.1 BP 140/64 HR 62 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: AAOx3, CN2-12 intact, motor ___ x4, no tremor
psych: calm, cooperative
skin: no apparent rash
Negative Romberg
Able to recite MOS of year backwards, only omitting one month.
Able to spell "WORLD" forward and backwards
Able to perform serial sevens.
However, when RN asked patient if he had gone for a walk with
the doctor, he could not recall us having done so.
He has detailed recollection of past events.
Pertinent Results:
___ 11:30PM URINE HOURS-RANDOM
___ 11:30PM URINE HOURS-RANDOM
___ 11:30PM URINE UHOLD-HOLD
___ 11:30PM URINE GR HOLD-HOLD
___ 11:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 11:30PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 11:30PM URINE MUCOUS-RARE
___ 08:42PM LACTATE-1.3
___ 08:20PM GLUCOSE-160* UREA N-16 CREAT-1.1 SODIUM-137
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-14
___ 08:20PM estGFR-Using this
___ 08:20PM ALT(SGPT)-9 AST(SGOT)-15 ALK PHOS-84 TOT
BILI-0.5
___ 08:20PM ALBUMIN-3.7
___ 08:20PM WBC-6.4 RBC-3.59* HGB-11.3* HCT-34.4* MCV-96
MCH-31.6 MCHC-33.0 RDW-13.1
___ 08:20PM NEUTS-68.8 LYMPHS-17.0* MONOS-10.7 EOS-2.1
BASOS-1.2
___ 08:20PM PLT COUNT-178
.
Head CT:
IMPRESSION:
No evidence of acute intracranial process.
.
CXR:
IMPRESSION: No acute cardiopulmonary process
.
EKG-unchanged from prior RBBB
___ 08:20PM BLOOD VitB12-206* Folate-6.1
___ 08:20PM BLOOD TSH-1.1
Brief Hospital Course:
Pt is an ___ y.o male admitted with an acute episode of weakness
(difficulty getting up from a chair. His strength was normal
and he had no focal deficits on exam during his hospitalization.
Discussion with his wife reveals a progressive decline over the
past few years, with him becoming less active and more
forgetful. Our w/u negative with the exception of B12
deficiency.
.
#.Weakness: Non focal exam during this hospitalization.
Patient's wife requested home physical therapy and this was
arranged during this hospitalization.
# B12 deficiency: Started on high dose vitamin B12 replacement,
and this may be contributing to some of his symptoms.
# Progressive decline - Patient will need outpatient evaluation
for more formal neurocognitive testing. His worsening
functional status likely secondary to
aging and underlying cognitive impairment. Needs to also be
screened for depression. Patient has not had primary care f/u
for one year.
#hyperlipidemia-continued statin
.
#History of Diabetes: Sugars well controlled and patient had
stopped taking DM meds on his own
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
2. Atorvastatin 20 mg PO DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*90 Tablet Refills:*2
2. Atorvastatin 20 mg PO DAILY
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Vitamin B12 deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after evaluation for weakness
at home. The CT scan of your head is normal so it does not
appear that you had a stroke. Our testing found that you have a
low vitamin B12 level. We are prescribing vitamin B12 for that.
Followup Instructions:
___
|
19815454-DS-16
| 19,815,454 | 29,524,378 |
DS
| 16 |
2206-05-24 00:00:00
|
2206-05-25 21:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Gadolinium-Containing Agents
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with history falls, possible prior syncopal
events with no clear explanation on workup, progressive
dementia, DMII diet controlled, who presents with fall. The
details of the event are per the ___ as the patient does not
remember the event itself. Reportedly, he was walking in the
kitchen and was found on the floor in the kitchen yesterday
night by his wife, presumed from fall. His wife was unable to
help him up and so she gave him a pillow and a heat pack for his
painful back and the pt slept on the floor the entire night.
This morning, the wife called the ___, who came to the
home, helped his father up and called ___. The pt states he has
no memory of the event and how he felt before the incident, but
states that he does not remember feeling lightheaded, dizzy,
diaphoretic. On waking, the pt states not feeling confused at
all. He denied any bowel or bladder incontinence. He said he did
have a painful back which resulted from his last fall a few
weeks ago.
Notably, he was evaluated in the ED post fall on ___ with
negative head CT and Lumbosacral spine xray showing possible
minimal L1 compression deformity.
In the ED, pt initially bradycardic in ___ and hypertensive to
170s systolic. Received trauma workup with CT chest, abdomen,
pelvis, c-spine, remarkable for minimal compression deformity of
L1 which is new. ECG demonstrated sinus bradycardia to 50 with
likely ___, RBBB, and lateral ST depressions from likely LVH
with subendocardial ischemia. Trops x1 negative, no gross
electrolyte abnl, UA negative.
On the floor, pt states feeling very well except for back pain
across his lumbar area. At rest he says the pain is ___, with
movement it increases to ___. He has been using tylenol for the
pain with mild relief. I spoke with ___, one of the ___ who is
very worried about his father's ___ to care for himself with
his wife. There has been progressive cognitive decline in the
patient and ___ states that without his wife he would be unable
to do many things and is essentially dependent on her. He states
that everytime he watches him walk, he feels that he is close to
falling, remarking that he has a shuffling, unsteady gait. The
___ also notes that he rarely brushes his teeth, hasn't showered
in weeks, and doesn't change his clothes regularly. The pt
states he is very active and goes out routinely and has no
difficulty with walking.
The pt currently denies any pain, shortness of breath,
palpitations, dizziness, lightheadedness. He only endorses lower
back pain with movement. Denies any loss of bowel or bladder.
Does drink 2oz bourbon per night.
Past Medical History:
per OMR, pt states he has no medical history
Anemia - documented by PCP, though pt denies
Abnormal EKG - Nonspecific ST-T wave abnormalities increasing
over years likely secondary to LVH ___.. RBBB ___
Dermatitis
DM II
HL
GERD
Hx syncope
B/l knee arthroscopies 1980s by history
Hx Bilateral achilles tendonitis
Hx L rotator cuff tear s/p surgery by Dr ___ at ___
___
Social History:
___
Family History:
Per OMR: Father died in his ___ of CVA. Paternal grandmother
with DM. Mother died at ___. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
VS 98.1 141/68 P 55 RR 18 98% RA
General: Well appearing man in NAD
HEENT: Atrauamatic, EOMI, anicteric
CV: RRR, ___ crescendo systolic murmur heard throughout with
radiation to carotids, normal S1 and S2
Lungs: CTA b/l
Abd: Soft, non tender, +BS, no organomegaly
Ext: Warm and well perfused with no edema
Neuro: CN II-XII intact. Strength in upper extremities difficult
to assess as patient had prior Left rotator cuff tear and
reports a difficult surgery with residual weakness, also while
testing strength in arms, he complains of back pain.
Lower extremities are ___ bilaterally with hip flexion,
abduction and adduction, knee flexion and extension, plantar
flexion and extension. Patellar Reflexes 2+ and symmetric. No
pain on straigh leg raise testing, Good sensation in perineal
area
Back: No pain on palpation through thoracic, lumbosacral area.
Psych: A and O x3, linear, appropriate, ___ minutes recall,
names ___ backwards without problem
Pertinent Results:
___ 10:15AM WBC-7.7 RBC-4.47* HGB-14.0 HCT-41.4 MCV-93
MCH-31.3 MCHC-33.7 RDW-13.2
___ 10:15AM NEUTS-68.0 ___ MONOS-7.5 EOS-4.6*
BASOS-0.5
___ 10:15AM PLT COUNT-267
___ 10:15AM ___ PTT-25.5 ___
___ 10:15AM GLUCOSE-79 UREA N-21* CREAT-1.2 SODIUM-138
POTASSIUM-5.4* CHLORIDE-102 TOTAL CO2-21* ANION GAP-20
___ 10:15AM CK(CPK)-102
___ 10:15AM cTropnT-<0.01
___ 10:15AM CALCIUM-9.4 PHOSPHATE-3.5 MAGNESIUM-2.3
___ 12:47PM BLOOD Lactate-1.4
___ 10:58AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
Discharge Labs:
___ 06:00AM BLOOD Glucose-84 UreaN-20 Creat-1.1 Na-138
K-4.3 Cl-103 HCO3-26 AnGap-13
___ 06:00AM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.5 Mg-2.1
___ 06:00AM BLOOD VitB___
Imaging:
___, CT head:
No evidence of acute intracranial process.
CT chest/abd/pelvis:
1. No evidence of acute thoracic, abdominal, or pelvic process.
2. Minimal compression deformity of L1 is new from ___.
3. Substantial calcified atherosclerotic plaque at the origin of
the celiac trunk with high grade stenoses but immediate
reconstitution of flow after the origin of the vessel.
Atherosclerotic plaque at the origin of the SMA is also present
with moderate stenosis.
4. Chronic conditions include: Small hiatal hernia; severe
atherosclerotic calcifications within the mitral and aortic
valve, coronary arteries, and abdominal aorta; long-term stable
focal dissection of the ectatic distal aorta, bladder
diverticulae; colonic diverticulosis.
Brief Hospital Course:
___ y.o man admitted for fall and syncope workup in the setting
of a recent fall 2 weeks ago and mild cognitive decline over the
past few years.
# Fall: The fall was most likely mechanical. Pt had two other
falls which were witnessed by wife and occurred when pt tried to
get out of bed. This fall was unwitnessed and occurred at night
with patient walking in the kitchen. When the wife found the
pt, he was completely alert and oriented but could not get up
due to back pain. The pt was monitored on telemetry without any
arrythmia. His ECGs were unconcerning. He was evaluated by ___
who recommended home with services. The patient and his wife
were agreeable to this. The sons were concerned about the fall
as the wife is unable to help the pt if he falls since she is
quite elderly and frail. He will have a home safety evaluation.
# Minimal compression deformity of L1: Pt initially had pain but
this resolved by discharge. He was seen by ortho who said that
he could use a brace for comfort but the patient did not feel a
need for this.
# Marked vascular disease seen on CT: Continue statin. Will
defer CV risk reduction with aspirin to outpt physician given
___ age.
# B12 deficiency: Reports not taking supplementation. Level is
borderline low. Restarted supplementation
#History of Diabetes: Sugars well controlled and patient had
stopped taking DM meds on his own
Code status: DNR/DNI confirmed
Contact:
Name of health care proxy: ___
Relationship: wife
Phone number: ___
Alternate: ___, ___.
___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Cyanocobalamin 1000 mcg PO DAILY
3. Acetaminophen 325 mg PO PRN pain
4. Ibuprofen 200 mg PO PRN back pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN back pain
2. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
3. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*0
4. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Fall
L1 compression 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:
You were admitted for a fall. This was most likely mechanical.
You were found to have an L1 compression fracture which may have
been from your previous fall. You were seen by physical therapy
who felt that you would benefit from greater supervision at
home. You were seen by orthopedics who felt that your fracture
did not require any intervention.
Followup Instructions:
___
|
19815499-DS-7
| 19,815,499 | 28,481,991 |
DS
| 7 |
2125-08-27 00:00:00
|
2125-08-27 19:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Shellfish / Taxol / olanzapine
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
___ is a ___ year old man with metastatic GEJ
adenocarcinoma cb biliary obstruction with PTBD placement and
currently on FOLFOX + Nivolumab who is admitted from the ED with
pain and imaging concerning for worsening biliary obstruction.
Patient had admission from ___ to ___ for fevers shortly
after a trip to ___. Extensive workup at the time was
negative
and fevers resolved. He underwent C6D1 FOLFOX/Nivolmab on
___
and received Neulasta support on ___.
He reports return of his fevers about 3 days prior to admission.
T up to 102 at home with associated chills. He also notes he has
intermittent abdominal discomfort in the RUQ since about
___, but was worse a few days ago. He otherwise has no new
focal complaints. He does get headaches with his fevers and has
chronic loose stool. No odynophagia. No CP, SOB, or cough. No
URTI symptoms. Has some mild nausea after chemo, and feels a bit
bloated. No dysuria. No new rash. No leg pain or swelling. No
known sick contacts.
In the ED, initial VS were pain 0, T 100.8, HR 126, BP 112/65,
RR
16, O2 99%RA. Initial labs notable for Na 137, K 3.4, HCO3 23,
Cr
0.7, ALT 141, AST 124, ALP 402, TBili 1.0, WBC 19.8 (70%N), HCT
28.6, PLT 180, lactate 1.6, rapid flu swab negative. UA
negative.
RUQ US showed patent portal veing with hepatopetal flow and no
asacites; known biliary dilation was not well seen. Patient was
given LR and IV vancomycin. VS prior to transfer were T 99.4, HR
95, BP 104/66, RR 16, O2 97%RA.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
early ___, when he developed mild dysphagia. His
dysphagia got worse and he had an EGD performed by Dr. ___ at
___ which showed a polypoid/vascular lesion at the
gastroesophageal junction. On ___ Dr. ___
EGD/EUS which showed a 2.5 cm esophageal pedunculated polyp at
the gastroesophageal junction prolapsing into the stomach from
the esophageal side. There was a 4 cm ulcerated mass in the
gastric cardia. The duodenum appeared normal. EUS showed a few
areas suspicious for tumor extension beyond the muscularis
propria compatible with a T3 lesion. There was a 1.3 x 0.7 cm
lymph node in the perigastric region at 45 cm which was very
suspicious but could not be sampled. There was a
1.0 x 0.5 cm lymph node at 30 cm which was sampled. Pathology
from the gastroesophageal junction polyp showed adenocarcinoma,
moderately differentiated seen underlying reactive squamous
epithelium. The gastric cardia ulcer was positive for
adenocarcinoma, moderately to poorly differentiated; the lymph
node at 30 cm on FNA was positive for malignant cells compatible
with metastatic adenocarcinoma and there was evidence of
lymphocytes compatible with lymph node sampling. PET/CT on
___ showed focal thickening and FDG avidity (SUV 10.5) of
the
distal esophagus/GE junction with prominent perigastric lymph
nodes along the gastric antrum measuring up to approximately 7
mm
with increased FDG avidity and a max SUV of 3.8. There was no
evidence of distant metastatic disease. ___ started neoadjuvant
chemoradiation according to the CROSS regimen with radiation
therapy to a dose of 41.4 Gy and weekly carboplatin 2AUC and
paclitaxel 50mg/m2. He had a taxol reaction with first infusion
and sent to ED for chest pain but ekg and troponins negative. Pt
had "chest discomfort" with C1D8, EKG normal, pt seen by Dr.
___ in cardiology. He completed chemoradiation on ___.
Social History:
___
Family History:
Paternal grandfather: laryngeal cancer in his ___
Paternal great aunt: breast cancer in her ___
Maternal grandfather: diabetes ___ grandmother: CVA
Physical ___:
Vitals reviewed and found to be stable
GENERAL: Very pleasant and generally well, but thin, appearing
young man in no distress.
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Decreased bulk
NEURO: Alert, oriented, CN III-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
Pertinent Results:
___ 09:20PM BLOOD WBC-19.4* RBC-3.75* Hgb-8.9* Hct-28.6*
MCV-76* MCH-23.7* MCHC-31.1* RDW-25.4* RDWSD-67.5* Plt ___
___ 05:09AM BLOOD WBC-15.8* RBC-3.84* Hgb-9.0* Hct-29.3*
MCV-76* MCH-23.4* MCHC-30.7* RDW-25.5* RDWSD-67.4* Plt ___
___ 04:33AM BLOOD WBC-18.2* RBC-3.90* Hgb-9.3* Hct-30.1*
MCV-77* MCH-23.8* MCHC-30.9* RDW-25.8* RDWSD-69.7* Plt ___
___ 09:20PM BLOOD Glucose-105* UreaN-6 Creat-0.7 Na-137
K-3.4* Cl-104 HCO3-23 AnGap-10
___ 05:09AM BLOOD Glucose-85 UreaN-5* Creat-0.6 Na-142
K-3.8 Cl-104 HCO3-24 AnGap-14
___ 04:33AM BLOOD Glucose-111* UreaN-7 Creat-0.7 Na-141
K-3.8 Cl-105 HCO3-25 AnGap-11
___ 09:20PM BLOOD ALT-141* AST-124* AlkPhos-402*
TotBili-1.0
___ 05:09AM BLOOD ALT-135* AST-116* LD(LDH)-175
AlkPhos-386* TotBili-1.1
___ 04:33AM BLOOD ALT-111* AST-85* AlkPhos-355* TotBili-0.7
___ Imaging LIVER OR GALLBLADDER US
1. Patent portal vein with hepatopetal flow. No ascites.
2. Left-sided pneumobilia as seen on the same day CT. Known
biliary ductal dilatation is not well seen.
___HEST W/CONTRAST
- No evidence of obstruction or tumor recurrence involving neo
esophagus.
- Improved left lower lobe atelectasis, attributable to chronic
elevation of the postoperative left hemidiaphragm.
___BD & PELVIS WITH CO
1. Unchanged soft tissue nodules inferior to the liver and
within
the right rectus abdominus muscle, compatible with metastatic
lesions. No evidence new metastatic lesions in the abdomen and
pelvis.
2. Interval development of mild right intrahepatic biliary
ductal
dilatation, new from prior study dated ___. Metallic
biliary stents are in stable position with no definite evidence
of obstruction.
3. Please refer to separate report of CT chest performed on the
same day for description of the thoracic findings.
___ Imaging MRCP (MR ABD ___
1. The liver demonstrates heterogeneous signal in predominantly
the right anterior segments, suggestive of ongoing inflammation
with fibrosis. Biliary stents are in situ with mild increased
___ enhancement; however, no evidence of biliary
obstruction.
2. Interval decrease in the size of a previously described
subcentimeter enhancing nodule inferior to the liver. The other
previously described soft tissue nodules from ___ are
not
visualized/included on today's scan.
3. Post resection of gastroesophageal junction cancer with
gastric pull through.
Brief Hospital Course:
___ is a ___ year old man with metastatic GEJ
adenocarcinoma cb biliary obstruction with PTBD placement and
currently on FOLFOX + Nivolumab who is admitted from the ED with
pain and imaging concerning for worsening biliary obstruction.
Although his bilirubin is not grossly elevated, his presentation
was concerning for cholangitis. Should note that his bili did
double (0.5 -> 1.0) and ALP has been slowly trending up.
Fortunately he appears hemodynamically stable.
# Sepsis
# Fever
# Leukocytosis
# Biliary dilatation
Pt underwent ERCP on ___ with successful balloon sweep with
removal of copious amount of sludge. He was treated with Zosyn,
___, pt was given Cipro/Flagyl at discharge for another 5
days. BLood cultures negative at the time of discharge.
WBCs went up to 18k from 15k on the day of discharge, although
no fever and LFTs improved, unclear if this was reactive or
related to patient getting neulasta the previous week. ___ D/w Dr.
___ will get repeat labs in 5 days during his
appointment with her and will be monitored. Pt requested to go
home today.
# Hypokalemia
- Repleted
# Anemia in malignancy
- Stable,no transfusion needed.
# Metastatic GEJ adneomcarcinoma
- Supportive care with ondansetron and lorazepam (note he
received palonsetron with chemotherapy, and thus does not use
ondansetron at home after chemo)
- Further plans per Dr. ___, has an appointment on ___.
#Cold sores: Lesions with some discomfort noted on the day of
discharge. Acyclovir PO prescribed.
Transitional issues:
=====================
-Leukocytosis needs to be followed up
-Biliary ERCP biopsies need to be followed up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 1000 mg PO DAILY
2. Omeprazole 20 mg PO BID
3. Vitamin D 1000 UNIT PO DAILY
4. Vitamin B Complex 1 CAP PO DAILY
5. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
6. LORazepam 0.5 mg PO Q4H:PRN nausea/anxiety
7. Pegfilgrastim 6 mg SC ASDIR
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Medications:
1. Acyclovir 400 mg PO Q8H Duration: 7 Days
RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*21 Tablet Refills:*0
2. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*10 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H Duration: 5 Days
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*15 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. Calcium Carbonate 1000 mg PO DAILY
6. LORazepam 0.5 mg PO Q4H:PRN nausea/anxiety
7. Omeprazole 20 mg PO BID
8. Pegfilgrastim 6 mg SC ASDIR
9. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
10. Vitamin B Complex 1 CAP PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute cholangitis and biliary duct obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WAS I ADMITTED:
You presented to our ER with fevers and abdominal pain.
WHAT WAS DONE FOR ME?
You underwent imaging with CT abdomen which showed dilatation
in your biliary tract, worrisome for biliary obstruction. You
underwent a procedure called ERCP during which they performed
"balloon sweeps" which released large amount of sludge. Biopsies
were taken which will be followed up by your oncologist. Your
lab abnormalities improved following this.
WHAT SHOULD I DO NEXT?
Continue to follow up with your Oncologist and keep up your
appointments on ___ (see below). If you develop
worrisome symptoms like worsening abdominal pain, fever or
jaundice, please return to the ER.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19815913-DS-18
| 19,815,913 | 23,147,444 |
DS
| 18 |
2122-02-15 00:00:00
|
2122-02-15 15:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Penicillins
Attending: ___.
Chief Complaint:
Jaundice, Biliary Mass
Major Surgical or Invasive Procedure:
liver biopsy
History of Present Illness:
___ year old Male presents with a week of painless jaundice. The
patient had a recent fall with a resultant C2 fracture for which
he was placed in a soft-collar and noted 1 week prior to
admission that he was becoming yellow. He lives at a SNF, and
they obtained LFTs which were noted to be elevated.
Initial vitals in the ___ ED were 98.3, 65, 117/62, 18, 96% In
the ED he underwent an ultrasound which was notable for a
patient portal vein, but a large mass around the biliary duct
causing intrahepatic ductal dilatation bilaterally. In addition
he was markedly hyperkalemic and received calcium, insulin to
lower his K, although his BMP is marked as hemolyzed.
Past Medical History:
___ Disease
Recent C2 fracture due to fall
hypertension
GERD,
benign prostatic hyperplasia
Bradycardia
dysphagia
history of femur fracture
history of falls
colon cancer
anemia
hyperlipidemia
depression
right knee surgery
right hip replacement
Social History:
___
Family History:
noncontributory
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomiting, - Diarrhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash, + Jaundice
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: RR 17
GEN: NAD
Pain: ___
HEENT: EOMI, icteric sclera, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, + Cogwheeling
DERM: Markedly Jaundiced
Pertinent Results:
___ 09:56PM BLOOD WBC-12.2* RBC-4.07* Hgb-11.7* Hct-34.0*
MCV-84 MCH-28.7 MCHC-34.4 RDW-19.5* RDWSD-57.4* Plt ___
___ 09:56PM BLOOD Neuts-83.0* Lymphs-7.1* Monos-7.7
Eos-0.8* Baso-0.2 Im ___ AbsNeut-10.11* AbsLymp-0.87*
AbsMono-0.94* AbsEos-0.10 AbsBaso-0.03
___ 09:56PM BLOOD Glucose-96 UreaN-25* Creat-1.0 Na-130*
K-7.4* Cl-95* HCO3-21* AnGap-14
___ 09:56PM BLOOD ALT-18 AST-98* AlkPhos-753* TotBili-17.9*
DirBili-11.8* IndBili-6.1
___ 09:56PM BLOOD Albumin-3.3* Calcium-8.7 Phos-4.1 Mg-2.2
___ 02:49AM BLOOD K-4.4
___ 10:00PM BLOOD Lactate-1.6 K-6.2*
___ 10:08PM URINE Color-DkAmb* Appear-Cloudy* Sp ___
___ 10:08PM URINE Blood-MOD* Nitrite-POS* Protein-30*
Glucose-NEG Ketone-NEG Bilirub-LG* Urobiln-4* pH-6.0 Leuks-LG*
___ 10:08PM URINE RBC-17* WBC->182* Bacteri-MOD* Yeast-NONE
Epi-0
___ 10:08PM URINE CastHy-3*
___ 10:08PM URINE WBC Clm-FEW* Mucous-MANY*
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
10:54 ___
IMPRESSION:
1. Much of the right and left hepatic parenchyma is encompassed
by
heterogeneous mixed echogenicity ill-defined mass resulting in
bilateral
peripheral intrahepatic biliary dilatation. Non-emergent
cross-sectional
imaging such as multiphasic liver CT is recommended for further
evaluation.
2. Main portal vein is patent without evidence of thrombosis.
Brief Hospital Course:
#Biopsy proven HCC: s/p ERCP ___ with stents though brushing
inconclusive, with liver bx showing HCC
Pt tolerated ERCP well with mild epigastric pain that resolved
within a few days and gradual improvement in liver labs.
Plan for repeat ERCP in 4 weeks (approx ___ for plastic stent
removal and
replacement of metal stent however given biopsy showing HCC
decision was made to transition to comfort care.
#Epigastric Pain: Improved with repositioning. EKG non ischemic.
Suspect post ERCP pain vs HCC. Improved with IV morphine.
#GOC: Previously documented as DNR/DNI but asking for all
measures on arrival. A family meeting with pts son was
___ with decision to pursue CMO and hospice
___ Disease: Sinemet continued however pt largely
unable to reliably take them. Dc/ed when made CMO
#Dysphagia: Cleared by s/s or his diet at NH (puree and thin
liquids).
#BPH with ?chronic indwelling foley. Pt underwent voiding trial
on ___. Continued on FInasteride, Flomax
# Positive UA: Unclear why this was evaluated in the ED, but
will
hold on therapy for now in the absence of symptoms.
- CTM clinically for now
#C2 fracture, T2 compression fracture : Per spine surgery note
___ pt was continued on ___ J collar during the day and when
he is upright/ -
Soft collar to wear to sleep. Plan for 2 month f/u with Dr.
___ repeat new cervical spine x-rays
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Finasteride 5 mg PO QHS
2. Senna 8.6 mg PO BID:PRN Constipation - Second Line
3. Carbidopa-Levodopa (___) 1 TAB PO TID
4. Famotidine 20 mg PO DAILY
5. Tamsulosin 0.4 mg PO QHS
6. Sertraline 100 mg PO DAILY
7. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN Pain
RX *acetaminophen 325 mg 2 tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
2. Albuterol ___ PUFF IH Q6H:PRN Bronchospasm
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 2.5 mg IN every 4
hours Disp #*1 Vial Refills:*0
3. LORazepam 0.5 mg PO Q4H:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth every 4 hours
Disp #*30 Tablet Refills:*0
4. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Second Line
RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 mL by
mouth every 6 hours Refills:*0
5. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q6H:PRN
Pain - Severe
RX *morphine 10 mg/5 mL 10 mg by mouth every 6 hours Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth every day Disp #*3 Packet Refills:*0
7. Senna 17.2 mg PO QHS
RX *sennosides [senna] 8.8 mg/5 mL 17.2 mg by mouth every day
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hepatocellular carcinoma
Discharge Condition:
Mental status: clear and coherent, sometimes confused and
agitated
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with jaundice and found to have a mass in your
gallbladder concerning for cancer. Your pathology report of your
liver biopsy showed evidence of liver cancer. A decision was
made to focus on your comfort rather than continue to treat your
cancer. You will be discharged to a ___ facility with
medicines for discomfort.
Followup Instructions:
___
|
19816309-DS-5
| 19,816,309 | 23,309,368 |
DS
| 5 |
2138-04-03 00:00:00
|
2138-04-03 12:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
milk / egg
Attending: ___.
Chief Complaint:
Malaise, fatigue, dry cough, RLE swelling
Major Surgical or Invasive Procedure:
Inguinal Lymph Node Biopsy - ___
History of Present Illness:
Ms. ___ is a ___ female with HTN who presented to her
PCP with fatigue, dry cough, and RLE edema, was send to
___ for CTA after D-dimer returned at >3000, was found to
have a large uterine mass with pelvic adenopathy and possible
liver/lung mets, and was transferred to ___ for evaluation by
GYN and ___.
For the past month, she has had a non-productive cough, malaise,
fatigue, fevers, and night sweats. She has lost about 7 lbs in
the past year despite a stable appetite. She has some dyspnea on
exertion as well. She a skin lesion on her abdomen which has
been present for about ___ years but she developed a new one in
the
last few months. No vaginal bleeding, hematuria, hemoptysis, or
melena/hematochezia. No vaginal discharge or vaginal lesions.
She noticed swelling in her RLE for the past few weeks. No calf
tenderness. She had ___ which was negative for
DVT. No chest pain or palpitations. No focal weakness or loss of
sensation.
Overall, she just feels profoundly fatigued.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
HTN
Bilateral knee replacement (___)
Gastric sleeve (___)
C-sections ___ and ___
Social History:
___
Family History:
Stroke - maternal grandmother
___ - father and mother
___ cancer - father
___ dementia - father
Physical ___:
VITALS: T 98.6, HR 109, BP 152/77, RR 20 SpO2 95% on RA
GENERAL: Alert, NAD, breathing room air comfortably
EYES: Anicteric, PERRL
ENT: OP clear, mucous membranes slightly tacky
CV: Tachycardic, RR, no m/r/g
RESP: CTAB, no wheezes, crackles or rhonchi
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, ___ pitting edema in
RLE, no edema in the LLE
SKIN: Violet/red spherical skin lesions in the suprapubic region
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
Mild leukocytosis (10.9)
Microcytic anemia (7.___.4)
Normal platelets
INR 1.5
HCO3 21
BUN 21, Cr 1.3
LFTs wnl
___ Labs (___):
WBC 13.2
H/H 8.2/27.1
Plt 360
Na 139, K 4.3, Chl 106, HCO3 23, BUN 28, Cr 1.7
IMAGING:
CT Read from ___:
1. Heterogeneous uterus with focal region of hypoattenuation
along the posterior fundus is concerning for malignancy.
Differential considerations include endometrial and
leiomyosarcoma.
2. Multiple ill-defined hypodense liver lesions and extensive
retroperitoneal, predominantly right pelvic, and bilateral
iinguinal lymphadenopathy are concerning for metastasis.
3. Additionally, a lobulated, exophytic cystic and solid lesion
along the anterior abdominal wall may also represent a cutaneous
metastasis.
4. Multiple pulmonary nodules, measuring up to 5 mm bilaterally.
5. Cholelithiasis.
Duplex US RLE:
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. Suspicious, prominently enlarged right inguinal lymph node
measuring 6.5 x 3.5 x 3.3 cm. Correlate with malignancy
history. FNA is recommended.
CXR Pa/Lat: IMPRESSION: No acute cardiopulmonary abnormality.
Brief Hospital Course:
Ms. ___ is a ___ female with HTN who presented to her
PCP with fatigue, dry cough, and RLE edema, was send to
___ for CTA after D-dimer returned at >3000, was found to
have a large uterine mass with pelvic adenopathy and possible
liver/lung mets, and was transferred to ___ for evaluation by
GYN and ___.
ACUTE/ACTIVE PROBLEMS:
# Suspected pelvic malignancy with metastases - imaging
concerning for endometrial carcinoma vs. leiomyosarcoma with
extensive lymphadenopathy (involving the pelvic, inguinal, and
retroperitoneal chains) and possible metastases to the lung and
liver. No evidence of pelvic malignancy on gynecologic / rectal
exam done by gyn team. Oncology recommended targeting the left
inguinal lymph node for biopsy due to its accessibility and also
for diagnostic yield.
- ___ consulted for LN biopsy; discussed with ___ patient
underwent LN biopsy by ___ on ___. Oncology (Dr. ___
___ follow up results outpatient and coordinate
appropriate care.
- Uric acid level elevated and per Oncology recommendations she
was started on allopurinol.
# Acute Kidney Injury
-Baseline Creatinine unknown, but creatinine at ___ was 1.7
improved to 1.0 with IV fluids. No clear cause of volume
depletion.
# Iron deficiency microcytic anemia - acute on chronic /
subacute iron deficiency anemia for which patient is already
taking iron pills at home. Hemolysis workup here reassuring
though with mild elevation in uric acid level for which she was
started on allopurinol. She was transfused 1U PRBC on ___ given
concern for symptomatic anemia as patient c/o ongoing fatigue
and mild dyspnea on exertion. Her Hgb improved from 7.8 to 8.9
after 1 unit of packed red blood cells which is also reassuring
and no concern for active bleeding at this time. She will resume
home dose of daily iron pills after discharge and follow up with
her PCP for ongoing management of her chronic iron deficiency
anemia. Could consider IV iron infusions down the line depending
on iron stores.
#SIRS
-Fever and tachycardia without localizing signs or symptoms of
active infection, with negative culture results from urine and
blood testing. Fever likely inflammatory/noninfectious in
setting of malignancy and as long as continues without
localizing symptoms of shortness of breath / cough, diarrhea or
dysuria, can manage supportively with anti-pyretics.
# Skin lesions
Violaceous cystic lesions in suprapubic region, one of which has
been present for ___ years and the other just a few months.
Unclear if this is related to her suspected malignancy. Advised
to follow up with PCP and consider outpatient dermatology
referral.
CHRONIC/STABLE PROBLEMS:
# HTN - continued home amlodipine 10 mg daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 0.5 (One half) tablet(s) by mouth Daily
Disp #*30 Tablet Refills:*0
2. amLODIPine 10 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Uterine Mass, Suspected pelvic malignancy with metastases
Microcytic, Iron Deficiency Anemia
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to participate in your care.
WHY WAS I ADMITTED TO THE HOSPITAL?
You came in to the hospital because you were having swelling in
your leg. We did an ultrasound which did not show signs of a
clot in the leg, but we did see an enlarged lymph node in the
groin area which is probably causing swelling because of a
blockage in the lymphatic drainage system from the enlarged
lymph node. We did also find a tumor in your uterus and this
looks concerning for cancer (metastatic gynecologic malignancy,
likely leiomyosarcoma v. uterine carcinoma), but we won't know
exactly or what the definitive origin is until the results from
the biopsy come back. You had a biopsy done of this lymph node
on ___. The Oncology Fellow who saw you here (Dr. ___
___ be following up on the biopsy results and schedule
follow up for you with the appropriate doctors.
Given your iron deficiency anemia and complaints of fatigue and
low energy, we gave you a blood transfusion which you tolerated
well with an appropriate rise in your blood counts. You should
resume your home dose of iron pills after discharge and follow
up with your PCP for ongoing management. They can check your
iron levels and assess your response to the oral iron pills.
Sometimes iron levels are low enough to warrant iron infusion
rather than pills, so this could be considered in the outpatient
setting.
You did have fevers while you were with us, but no high grade
fevers since yesterday. Our tests including blood, urine and
scans did not show any signs of an active infection, so we
suspect this is likely from inflammation. This can happen in the
setting of cancer even in the absence of infection because of
high cell turnover and involvement of your lymph nodes. This can
be treated with Tylenol or Naprosyn for management of symptoms.
If you develop new cough or burning on urination, or diarrhea,
you should see your PCP or return to the ED because these could
be signs of a new infection. Otherwise, if you continue to have
isolated fevers without any new symptoms as mentioned, you can
take Tylenol or Naprosyn as needed for fevers.
Uric acid which can be tested for in the blood is released by
cells that are rapidly multiplying which happens in the setting
of cancer. Your level was elevated enough to warrant starting a
medication called allopurinol which is frequently used in the
chronic management of gout to help reduce gout attacks. It acts
the same way in this setting to reduce your uric acid level in
the blood to prevent gout-like attacks and reduce risk of kidney
failure from this.
We have included her contact information below to use in the
meantime if you have questions. You should also ask your PCP to
help coordinate the referral as well.
We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19816432-DS-3
| 19,816,432 | 24,479,243 |
DS
| 3 |
2150-02-28 00:00:00
|
2150-02-28 14:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left ankle pain
Major Surgical or Invasive Procedure:
I & D and ORIF L ANKLE (___)
History of Present Illness:
Mr. ___ is a ___ y/o male who presents s/p slip and fall on
ice while intoxicated at 12:30 AM. Denies head strike, LOC, or
pain to other anatomic areas. Presented to ___ and
___
to have isolated left open ankle fracture that was splinted and
transferred to ___ ED for further eval.
Past Medical History:
Hernia repair
Left foot bunion surgery
Left hip closed reduction as child
Social History:
___
Family History:
NC
Physical Exam:
Vital Signs: 97.8 80 150/80 16 95%
Gen: NAD, A&O x 3, Calm and comfortable
Upper Extremities:
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearm compartments soft
No pain with passive motion
SILT in the Axillary, Radial, Median, Ulnar nerve distributions
motor intact for EPL FPL EIP EDC FDP FDI
2+ radial pulses
Lower Extremities:
Left ankle with large medial laceration over medial malleolus
with extrusion of the medial malleolus
Gross ankle deformity with lateral dislocation of the talus
No other tenderness, deformity, erythema, edema, induration or
ecchymosis
Thighs and leg compartments soft
No pain with passive motion of toes
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
___ FHS ___ TA Peroneals Fire
2+ DP pulse
Pertinent Results:
___ 05:30AM GLUCOSE-102* UREA N-6 CREAT-0.8 SODIUM-140
POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-20* ANION GAP-18
___:30AM estGFR-Using this
___ 05:30AM WBC-10.4 RBC-4.76 HGB-15.6 HCT-47.4 MCV-100*
MCH-32.8* MCHC-33.0 RDW-13.1
___ 05:30AM NEUTS-82.1* LYMPHS-12.9* MONOS-3.9 EOS-0.4
BASOS-0.8
___ 05:30AM PLT COUNT-190
___ 05:30AM ___ PTT-31.7 ___
___ 05:30AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:40AM GLUCOSE-112* UREA N-7 CREAT-0.7 SODIUM-137
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-21* ANION GAP-16
___ 03:40AM estGFR-Using this
___ 03:15AM WBC-10.1 RBC-4.82 HGB-15.9 HCT-48.1 MCV-100*
MCH-33.0* MCHC-33.2 RDW-13.1
___ 03:15AM NEUTS-81.3* LYMPHS-14.6* MONOS-3.1 EOS-0.5
BASOS-0.5
___ 03:15AM PLT COUNT-190
___ 03:15AM ___ PTT-32.5 ___
___ 03:15AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an open left trimalleolar ankel fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for I&D and ORIF L ankle,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor.
Musculoskeletal: Prior to operation, patient was NWB LLE.
After procedure, patient's weight-bearing status was
transitioned to TDWB LLE in ___. Throughout the
hospitalization, patient worked with physical therapy.
Neuro: post-operatively, patient's pain was controlled by
dilaudid PCA and was subsequently transitioned to oxycodone with
good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was not transfused blood.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #3, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aluminum-Magnesium Hydrox.-Simethicone ___ ml PO Q6H:PRN
Dyspepsia
3. Docusate Sodium 100 mg PO BID
4. Multivitamins 1 CAP PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
7. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe SC QPM Disp #*14 Syringe
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left open trimalleolar ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Cast must be left on until follow up appointment unless
otherwise instructed
- Do NOT get cast wet
ACTIVITY AND WEIGHT BEARING:
- TDWB LLE in short leg cast
Physical Therapy:
- TDWB LLE in short leg cast
Treatments Frequency:
- Cast must be left on until follow up appointment unless
otherwise instructed
- Do NOT get cast wet
Followup Instructions:
___
|
19816690-DS-16
| 19,816,690 | 29,290,624 |
DS
| 16 |
2129-07-23 00:00:00
|
2129-07-23 14:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
motorcycle crash
Major Surgical or Invasive Procedure:
___: Intramedullary nailing reconstruction nail of
right femoral shaft fracture, and irrigation debridement down
to and inclusive of bone of an 8-cm tibial laceration.
___: 1. Closed reduction and percutaneous pinning of right
___,
___ carpometacarpal fracture-dislocations.
2. Closed reduction and percutaneous pinning of right
metacarpal shaft fracture.
3. Application of uniplanar external spanning fixator.
4. Irrigation and debridement of dorsal hand wound.
History of Present Illness:
___ M with no pertinent PMHx presenting from OSH with concern
for R femur fx with possible vascular injury, multiple R
metacarpal fx, R PNX post pigtail, grade 1 liver lac. Onset:
immed prior to presenting to OSH. Precede: practicing riding on
motorcycle hills, struck pole head on. Charac: Helmeted, no LOC,
no amnesia, no seizure activity, unknown speed (approx
___. Known injuries per below. Denies f/c, n/v/d,
HA/change in vision/neck pain, CP/SOB/cough, abd pain, lower
back pain, GI incont/GU retention, focal n/t/w of R hand distal
to injuries and distal to R femur fx.
Pt arrived to ED with exam notable for a R femoral artery thrill
and no palpable distal pulses whilst in traction. 15 minutes
post removal of Buck's Traction, pulses returned. ABI of 0.4 was
concerning for aterial injury. CTA demonstrated R CFA
dissection.
Past Medical History:
PMH: Denies
PSH: Appendectomy
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Exam -
Vitals: BP 104/50 HR 88
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses. Large abrasion on
the RLQ
Ext: Large right thigh hematoma with deformity consistent with
right femur fracture. Large deep laceration anterior to the
tibia.
Pulses:
Initially
Fem Pop DP ___
Left 2+ 1+ 1+ 1+
Right 2+ - - -
On traction of RLE
Fem Pop DP ___
Left 2+ 1+ 1+ 1+
Right 2+ 1+ 1+ 1+
On discharge:
VS: 98.3 76 129/69 16 !00% RA
GEN: A&O, NAD
PULM: CTAB
ABD: Soft, nontender, nondistended. No palpable masses. Large
abrasion on
the RLQ healing well.
EXTR: RUE with orthoplast spint and external fixator. Pin sites
with minimal errythema and no drainage. Minimal swelling with
good distal pulses. RLE with moderate edema, soft compartments,
strong DP and TP pulses. RLE warm and pink.
Pertinent Results:
Labs on admission:
Lactate:2.2
140 105 16
-------------< 135
3.8 23 0.9
24.3 > 45.8 < 294
N:90 Band:0 ___ M:3 E:0 ___ Metas: 1
___: 11.9 PTT: 25.0 INR: 1.1
ABIs (off traction): 0.49 (right) - 0.9 (left)
___ 03:50PM URINE COLOR-Orange APPEAR-Cloudy SP ___
___ 03:50PM URINE RBC->182* WBC-25* BACTERIA-NONE
YEAST-OCC EPI-0
___ 03:50PM URINE RBC->182* WBC-25* BACTERIA-NONE
YEAST-OCC EPI-0
___ 03:50PM URINE MUCOUS-RARE
___. Minimally displaced ulnar styloid fracture.
2. Fracture of the proximal pole of the pisiform bone.
3. Comminuted fracture of the trapezoid bone.
4. Fracture of the base of the hook of hamate.
5. Fracture of the base of the index finger metacarpal.
6. Comminuted fracture of the proximal shaft of the middle
finger metacarpal.
7. Comminuted fracture of the mid shaft of the ring finger
metacarpal.
8. Intra-articular comminuted fracture at the base of the small
finger
metacarpal.
9. Intra-articular fracture of the base of the middle phalanx,
ring finger.
10. Subcutaneous edema and soft tissue swelling consistent with
recent
trauma.
___: CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS
1. Stable appearance of segment VI liver laceration and liver
contusion.
2. Hemorrhagic fluid within the right paracolic gutter.
3. Stable enlargement of the right psoas muscle with multiple
foci of air
suspicious for right psoas hematoma.
4. Completely displaced fracture of the right mid femur.
5. Thrombus and small dissection within the right common femoral
artery. The remainder of the visualized vessels are patent.
6. Hematoma surrounding the right common femoral artery, right
SFA and right and left popliteal arteries.
___ CT RLE:
Right Mid Shaft Femur Fracture
___ Chest x-ray:
No evidence of chest tube or pneumothorax. Opacification at the
right base medially persists. Remainder of the lungs is
essentially clear.
Labs at discharge:
___ 04:46AM BLOOD WBC-9.9 RBC-3.51*# Hgb-10.6*# Hct-32.1*#
MCV-92 MCH-30.1 MCHC-32.9 RDW-17.2* Plt ___
___ 04:54AM BLOOD Glucose-100 UreaN-13 Creat-0.6 Na-140
K-3.5 Cl-102 HCO3-29 AnGap-13
___ 04:54AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1
Brief Hospital Course:
Mr ___ was admitted to the trauma ICU given the complexity of
his injuries and need for frequent vascular checks of his right
lower extremity. In brief during his ICU stay, he went to the OR
HD 2 for fixation of his right hand and thigh, then was
transferred to the floor HD 3. His hospital course is summarized
below by system.
Neurologic:
He remained alert and oriented. Pain control was achieved with a
dilaudid PCA initially, and he was transitioned to an oral
regimen with adequate pain control by discharge.
Cardiovascular:
Imaging at presentation was consistent with a right CFA filling
defect, most consistent with an intimal flap. A vascular surgery
consult was obtained. Pulse checks were done Q1 hour which
consistently showed a bounding ___ pulse (pulse had returned
after reducing fracture). An ABI done intra-op ___ was 0.68,
improved from 0.45 the day prior. He was started on a heparin
drip (goal PTT 50-70) following fixation of his fractures on
___. On ___ he was transitioned to a lovenox bridge to
coumadin. By ___ his INR was therapeutic and lovenox was
discontinued. At discharge his INR is 2.8. Plan is for ___ to
draw ___ on ___ and anticoagulation to be monitored by pt's
PCP who has been notified.
His vital signs were routinely monitored throughout his
hospitalization and he remained hemodynamically stable. His
hematocrit was checked serially initially given his liver
laceration for the first 48 hours, and remained stable. However,
he continued to be orthostatic and dizzy when getting out of bed
and ambulating with physical therapy. On ___ he was transfused
2 units of pRBC's and his hematocrit went from 24.6 to 32.1. He
was no longer orthostatic or dizzy when ambulating after the
transfusion.
Pulmonary:
On presentation he had a small right pneumothorax with no
evidence of rib fracture or pulmonary contusion/hematoma. A
small ___ pigtail catheter was placed in the ED with good
evacuation of the pleural air. The catheter was kept on -20cm
H20 suction for 48 hours then removed. His OSH CT scan showed
bilateral pulmonary lesions, initally read as contusions, but
did not appear consistent with this diagnosis, instead seeming
more likely to be infectious in nature. His supplemental oxygen
was weaned and his oxygenation remained excellent on room air.
Pulmonary toileting was encouraged. He remained without cough,
shortness of breath or any further evidence of pneumothorax or
an infectious process.
Gastrointestinal / Abdomen:
He presented with a Grade 1 liver laceration for which no
intervention was indicated. Hematocrits were stable further
reassuring that his liver had no clinically significant bleed.
His diet was advanced to regular on POD#1 which he tolerated
without abdominal pain. He was also started on a bowel regimen
given the administration of narcotics. He was passing flatus and
having bowel movements at discharge.
Renal:
He presented with hematuria, presumed to be from a blunt renal
injury not visually apparent on CT scan. His urine continued to
clear and his foley was removed once the hematuria resolved. At
discharge he had no further evidence of hematuria and was
voiding without difficulty.
Musculoskeletal:
His right metacarpal fractures were placed in an external
fixator. Follow up was scheduled with hand surgery prior to
discharge. His right femur fracture was fixed with an
intramedullary nail. He remained weightbearing as tolerated on
his RLE and weightbearing through a platform crutch on his RUE.
Physical therapy and occupational therapy were consulted and
work with the patient to progress his mobility status. On ___
he was cleared for discharge home with home ___ and OT at home.
ID:
His WBC count normalized within 24 hours from 24.3 on admission
to 9.7. At discharge he is afebrile without any signs of
infection. He was placed perioperatively on prophylactic IV
cefazolin, which was discontinued on POD#4. He had recently
started on a course of doxycycline as an outpatient per pt
history for treatment of chlamydia. The course was continued
when tolerating PO's and he was discharged with a prescription
for 2 more days to complete a 7 day course.
On ___ he remains afebrile without any evidence of infection
and stable vital signs. He is ambulatory with assistance and his
pain is well controlled on an oral regimen. He is tolerating a
regular diet and voiding without difficulty. His INR is
therapeutic on coumadin and he continues to have good peripheral
pulses, sensation and color in his RLE. He is being discharged
home with scheduled follow up with his PCP, ___, ortho, and
vascular.
Medications on Admission:
none
Discharge Medications:
1. Outpatient Lab Work
Please draw ___ on ___ and as needed per patient's PCP
___. Fax results to: ___, Location: ___
___ MEDICAL Address: ___., NO. ___
Phone: ___ Fax: ___
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. warfarin 5 mg Tablet Sig: 0.5 Tablet PO once a day: Take 2.5
mg on ___. Dose to be adjusted for goal INR ___. Dr. ___
office to adjust dosing as needed.
Disp:*30 Tablet(s)* Refills:*1*
5. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Dosing to be adjusted by Dr. ___ goal INR ___.
Disp:*30 Tablet(s)* Refills:*1*
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 2 days.
Disp:*4 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
s/p motorcycle crash
Inujuries:
1. Right midshaft femur fracture, closed
2. Right common femoral artery dissection
3. Right pneumothorax
4. Grade I liver laceration
5. Minimally displaced ulnar styloid fracture
6. Right ___ carpometacarpal fracture-
dislocations.
7. Right ___ metacarpal shaft fracture.
8. Trapezoid fracture.
9. Hook of hamate fracture.
10. Fracture of the proximal pole of the pisiform bone
11. Acute Blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after motorcycle accident. You
sustained multiple injuries including multiple broken bones in
your right hand and wrist, right femur fracture, dissection of
your right femoral artery, a collapse in your right lung and a
small laceration to your liver.
You were taken to the operating room with the hand surgeons and
orthopedic surgeons to fix your fractures. You had a chest tube
placed to pull your lung back up and you have no evidence on
x-ray of remaining collapse. You also have no evidence of
bleeding from your liver injury.
Because of the dissection in your artery, the vascular surgeons
recommend that you be on a blood thinning medication called
coumadin (warfarin) for 3 months. You will need to have your
blood work checked frequently in the first couple of weeks while
taking coumadin. You should take this medication at the same
time every day. Your primary care provider ___ has been
notified of this. The ___ will draw you lab work tomorrow and
send the results to Dr. ___, who will contact you
and adjust the dosing of the coumadin as needed. It is important
that you keep your follow up appointments as scheduled below and
that you see your PCP next week.
You are being discharged on narcotic pain medication. Narcotic
medications can cause constipation. 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.
Narcotic medications also cause sedation so you should not drink
alcohol or drive while taking narcotics.
Followup Instructions:
___
|
19816881-DS-10
| 19,816,881 | 21,402,550 |
DS
| 10 |
2161-09-04 00:00:00
|
2161-09-06 15:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Compazine / Reglan
Attending: ___.
Chief Complaint:
Trauma: pedestrian struck
Major Surgical or Invasive Procedure:
staples to head laceration
History of Present Illness:
___ year old female crossing street stuck at approximately 20mph,
thrown 10
ft, doesn't remember event, lumbar back pain. Spidered
window of car. Up and over. Last meal at 6 am. Pain in the
midline lumbar back which radiates down the bilateral legs.
Denies chest pain, abdominal pain. Denies headache,
vomiting. Up to date on tetanus.
Past Medical History:
cluster headaches
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION: ___:
HR: 102 BP: 130/90 Resp: 24 O(2)Sat: 100 Normal
Constitutional: Patient in obvious discomfort , GCS 15
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact, R posterior occiput laceration
In C-collar, no midline C spine tenderness
Chest: Clear to auscultation, no chest wall tenderness
Cardiovascular: Normal first and second heart sounds,
Regular Rate and Rhythm
Abdominal: Soft, Nontender, Nondistended
Extr/Back: no midline spinal tenderenss or step offs,
abrasion to L elbow, bruise to medial R knee, 2+ radial and
DP pulses bilaterally
Skin: abrasion to L elbow, R posterior occiput
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Pertinent Results:
___ 04:50AM BLOOD WBC-8.6# RBC-3.04* Hgb-9.8* Hct-29.6*
MCV-97 MCH-32.2* MCHC-33.1 RDW-13.2 RDWSD-47.2* Plt ___
___ 10:25AM BLOOD WBC-19.5* RBC-3.80* Hgb-12.1 Hct-36.9
MCV-97 MCH-31.8 MCHC-32.8 RDW-13.2 RDWSD-47.4* Plt ___
___ 10:25AM BLOOD Neuts-86.7* Lymphs-6.3* Monos-5.0
Eos-0.1* Baso-0.2 Im ___ AbsNeut-16.93* AbsLymp-1.24
AbsMono-0.98* AbsEos-0.01* AbsBaso-0.04
___ 04:50AM BLOOD Plt ___
___ 04:50AM BLOOD Glucose-99 UreaN-7 Creat-0.6 Na-137 K-3.6
Cl-104 HCO3-24 AnGap-13
___ 04:50AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7
___: chest x-ray:
. Chest radiograph is not optimal to assess the chest cage
after trauma.
Within this limitation, no focal consolidation, pleural
effusion, or
pneumothorax.
2. Scoliosis of the thoracic spine without obvious compression
fracture
deformity. Further evaluation by the ordered CT chest is
recommended and will be performed
___: cat scan of the head:
1. No evidence of intracranial hemorrhage or fracture.
2. Right parietal subgaleal hematoma.
___: bilateral knee x-rays:
. Comminuted fracture of the right fibular head. No
dislocation.
2. No acute fracture or dislocation in the left knee.
___: bil. hips:
Re- demonstration of left superior pubic ramus and left S1
fractures. No
dislocation or additional fractures identified.
___: bil. tib/fib x-ray:
1. Comminuted fracture of the right fibular head, not changed in
the interval.
2. No acute fracture within the left tibia or fibula.
Brief Hospital Course:
Patient presented to the ER after being struck crossing street
at approximately 20mph, thrown 10 ft., doesn't remember event,
lumbar back pain. Trauma basic alarmed was activated and patient
was assess in the ER. Patient was pan scanned in the ER and was
found to have a L5/S1 superior facet fracture, hip fracture and
a right fibula Fracture. Patient was admitted to ___ service
subsequently. Orthopedic service was consulted and recommended
the pelvic fracture and fibular fracture were non operative,
placed knees in bilateral unlocked ___, X Ray of all
remaining ___ bones with special attention to R ankle, weight
bearing as tolerated, elevation b/l lower extremities to
decrease swelling and Lovenox at 8pm 40mg SQ. Physical therapy
evaluated patient and recommended that the patient be OOB to
chair for all meals with ACs and stand-pivot, and ambulating
short distances with RW/ACs TID to bathroom with standby assist
with ___ locked in extension. Subsequently patient was changed
from IV pain medication to PO pain medication. Patient diet was
progress and upon discharge patient was tolerating regular diet.
Patient was instructed to follow up in the ___ clinic for
removal of the staples in the scalp on her follow up
appointment. Patient should follow on orthopedic trauma clinic
for further work up.
Medications on Admission:
motrin prn
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Cyclobenzaprine 10 mg PO TID
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
7. Ibuprofen 600 mg PO Q6H pain
8. Lidocaine 5% Patch 1 PTCH TD QAM pain
9. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Trauma: pedestrian struck:
L5/S1 sup. facet fracture
right fibular fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) ( with crutches), Blesdoe brace right leg, locked in
extension, no brace left leg
Discharge Instructions:
You were admitted to the hospital after you were struck by a
vehicle. You sustained a right fibula fracture and a fracture
to the ___ area in your back. You did not require any
surgery. You had a brace placed on the right leg and you will
follow-up with the Orthopedic service. Your vital signs have
been stable and you are being discharged with the following
instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Please wear the Blesdoe brace on right leg in locked position.,
left leg no brace
Please report the following:
*numbness/tingling toes
*increased swelling and pain right leg
*chest pain
You will need an MRI knees. This can be arranged when you
follow-up with Ortho.
Orthopaedic Surgery Discharge Instructions
You were evaluated in the hospital by orthopaedic surgery and
were found to have a right pelvis fracture and a right sided
fibular head fracture. The orthopaedic team plans to manage your
injuries nonoperatively. You may weight bear as you are able to
tolerate but avoid any activities that are overly strenuous
including heaving lifting or running. Until otherwise instructed
by your surgeon. You should keep the hinged knee brace in the
locked position on the right side until your follow up with the
orthopaedic surgery team in clinic in 2 weeks on ___.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
Followup Instructions:
___
|
19817441-DS-11
| 19,817,441 | 27,669,615 |
DS
| 11 |
2155-07-06 00:00:00
|
2155-07-06 13:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
animals
Attending: ___
Chief Complaint:
chills, jaundice
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy ___
History of Present Illness:
Mr. ___ is an ___ yo male with medical history notable for afib
and tachybrady syndrome s/p PPM on metoprolol and Xarelto, HTN,
aortic stenosis s/p AVR, CAD, nonhodgkin lymphoma on
surveillance
who presents w/x1 week of decreased appetite and po intake,
fatigue, generalized weakness, and chills.
Per patient, around 230AM he woke up with severe shaking chills.
He reports getting up to use the bathroom and losing his balance
due to the chills; he hit his left knee, denied head strike,
LOC.
He also reports x2 episodes of NB/NB vomiting. He checked his
blood pressure and noted it was 98/58 which is low compared to
baseline of BO 120-130/60-70. In addition, per one family member
patient was confused. He denies fever, headache,
lightheadedness/dizziness, CP/palp, SOB, dysuria, changes in BM,
rash. He denies new medications. He denies recent travel. He
endorses dark/orange urine.
In the ED, initial VS were: 97 75 115/60 95% RA.
On arrival to the floor patient is feeling nearly back to normal
save for continuing to have dark brownish urine. He denies
fevers, chills, confusion, abdominal pain, orthopnea, PND, leg
swelling.
ED labs imaging notable for:
13.4>13.4/39.0<156
Na 133 K 4.6 Cl 95 BUN 24 Cr 1.0 Gluc 139
ALT: 428 AST: 370 AP: 480 Tbili: 5.2 Alb: 4.3 Lip: 50
Flu negative
U/A few bacteria
Imaging showed:
-CXR: IMPRESSION: Mild cardiomegaly, hilar congestion.
-CT A/P:
IMPRESSION:
1. The gallbladder is not significantly distended, however the
wall is edematous and enhancing. Early acute cholecystitis
cannot
be excluded. Recommend further evaluation with gallbladder
ultrasound.
2. Retroperitoneal and pelvic sidewall lymphadenopathy,
unchanged
since ___ compatible with history of lymphoma.
3. Borderline splenomegaly.
RECOMMENDATION(S): US of the gallbladder
-RUQ U/S:
IMPRESSION:
Biliary sludge with mild gallbladder wall edema without
sonographic ___ sign. No definite sonographic evidence of
cholecystitis
Past Medical History:
-Atrial fibrillation with tachy brady syndrome
-S/p dual chamber SJM Accent RF on ___ on
rivaroxaban
-AS s/p AVR in ___ complicated by abdominal incisional
hernia.
-Minimal CAD
-Non-Hodgkin Lymphoma - Currently monitoring
Social History:
___
Family History:
Family history reviewed and found to be
noncontributory to this illness
Physical Exam:
DISCHARGE PHYSICAL EXAM:
VS: Afebrile and vital signs stable (reviewed in POE)
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, no JVD
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, ___ systolic murmur RUSB
Gastrointestinal: nd, +b/s, soft, nt, -___ sign
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.
fluent speech.
Psychiatric: pleasant, appropriate affect
GU: no catheter in place
Pertinent Results:
ADMISSION LABS:
___ 02:10PM BLOOD WBC-13.4*# RBC-4.47* Hgb-13.4* Hct-39.0*
MCV-87 MCH-30.0 MCHC-34.4 RDW-13.3 RDWSD-42.7 Plt ___
___ 02:10PM BLOOD Neuts-85.5* Lymphs-6.6* Monos-7.1
Eos-0.0* Baso-0.2 Im ___ AbsNeut-11.48*# AbsLymp-0.89*
AbsMono-0.95* AbsEos-0.00* AbsBaso-0.03
___ 02:10PM BLOOD Glucose-139* UreaN-24* Creat-1.0 Na-133*
K-4.6 Cl-95* HCO3-24 AnGap-14
___ 02:10PM BLOOD ALT-428* AST-370* AlkPhos-480*
TotBili-5.2*
___ 05:11AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.2
___ 02:10PM BLOOD Albumin-4.3
___ 02:10PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 05:11AM BLOOD Acetmnp-NEG
DISCHARGE LABS:
___ 05:07AM BLOOD WBC-6.3 RBC-3.92* Hgb-11.5* Hct-34.9*
MCV-89 MCH-29.3 MCHC-33.0 RDW-13.2 RDWSD-42.9 Plt ___
___ 05:07AM BLOOD Glucose-74 UreaN-11 Creat-0.9 Na-142
K-4.9 Cl-102 HCO3-28 AnGap-12
___ 05:07AM BLOOD ALT-134* AST-40 AlkPhos-285* TotBili-2.8*
___ 05:07AM BLOOD Albumin-3.7 Calcium-9.0 Mg-2.2
IMAGING:
CT A/P ___:
IMPRESSION:
1. Gallbladder wall thickening with mucosal hyperenhancement
with moderate gallbladder distension. No intra or extrahepatic
biliary ductal dilation. Findings may reflect early acute
cholecystitis. Further evaluation with gallbladder ultrasound is
advised.
2. Prominent lymph nodes and borderline splenomegaly likely
reflect known history of lymphoma.
CXR ___: Mild cardiomegaly, hilar congestion.
RUQ US ___: No evidence of acute cholecystitis. No biliary
dilation.
ERCP ___
Impression: The scout film was normal.
The bile duct was successfully cannulated using a Rx
sphincterotome preloaded with 0.035in guidewire.
Contrast was injected and there was brisk flow through the
ducts.
Contrast extended to the entire biliary tree.
Contrast injection revealed multiple filling defects in the CBD
consistent with stones.
A biliary sphincterotomy was successfully performed with the
sphincterotome.
There was no post-sphincterotomy bleeding.
A biliary sphincteroplasty was successfully performed using a
6-8mm CRE balloon upto 8mm.
The biliary tree was swept with a 9-12mm balloon starting at
the bifurcation.
Multiple stones and sludge were successfully removed.
The CBD and CHD were swept repeatedly until no further stones
were seen.
The final occlusion cholangiogram showed no evidence of filling
defects in the CBD.
Excellent bile and contrast drainage was seen endoscopically
and fluoroscopically.
I supervised the acquisition and interpretation of the
fluoroscopic images.
The quality of the fluoroscopic images was good.
Otherwise normal ercp to third part of the duodenum
Recommendations:
NPO overnight with aggressive IV hydration with LR at 200 cc/hr
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
Recommend surgical evaluation for possible cholecystectomy.
If any abdominal pain, fever, jaundice, gastrointestinal
bleeding please call Advanced Endoscopy Fellow on call
___
Brief Hospital Course:
___ male with medical history notable for afib and tachybrady
syndrome s/p PPM, HTN, aortic stenosis s/p AVR, CAD, non-hodgkin
lymphoma on surveillance who presents w/x1 week of decreased
appetite and po intake, fatigue, generalized weakness, and
chills found to have choledocholithiasis.
#Choledocholithiasis vs. cholangitis
Pt presented with chills, leukocytosis, and found to have
elevated LFT's, bili. CT a/p showed biliary sludge with mild
gallbladder wall edema. He was started on IV
zosyn->cipro/flagyl x7 day course for presumed cholangitis. He
underwent ERCP on ___ which showed multiple stones and
sludge in the CBD, removed and sphincterotomy performed. Pt
tolerated the procedure well with no post-procedural pain or
nausea. He was counseled to hold his xarelto for 1 week
post-procedure or unless otherwise directed by his Cardiologist.
He ___ also d/w his PCP and ___ prior to deciding on
ccy.
#Afib
#Tachybrady syndrome s/p pacer placement
Xarelto held for procedure and pt got 1x dose of 5mg IV vitamin
K and FFP for elevated INR: 2.9 prior to ERCP. Xarelto also
held for 1 week post-procedure unless otherwise directed by pt's
Cardiologist. Pt's HR controlled with Metoprolol.
#Hyponatremia: Mild. Likely in the setting of poor po intake,
hypovolemia, vomiting. S/p IVF in ED. Now resolved.
#CAD: Continued simvastatin
#HTN: hold valsartan
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. Metoprolol Succinate XL 50 mg PO BID
2. Rivaroxaban 20 mg PO DAILY
3. Simvastatin 10 mg PO 3X/WEEK (___)
4. Valsartan 80 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*10 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8
hours Disp #*15 Tablet Refills:*0
3. Ferrous Sulfate 325 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO BID
5. Simvastatin 10 mg PO 3X/WEEK (___)
6. Valsartan 80 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. HELD- Rivaroxaban 20 mg PO DAILY This medication was held.
Do not restart Rivaroxaban until ___ or as directed otherwise
by your Cardiologist
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Afib
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came in with chills and jaundice. We found that you had
some gallstones blocking your bile ducts. We did a procedure
called an ERCP with sphincterotomy to relieve this blockage and
you tolerated this procedure well.
Please discuss with your PCP and your ___ regarding
timing of a cholecystectomy or a surgery to remove your
gallbladder.
Please return if you have worsening abdominal pain,
nausea/vomiting, jaundice, fevers/chills, or if you have any
other concerns.
It was a pleasure taking care of you at ___
___.
Followup Instructions:
___
|
19817448-DS-10
| 19,817,448 | 25,943,393 |
DS
| 10 |
2187-11-20 00:00:00
|
2187-11-20 18:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right leg weakness
Major Surgical or Invasive Procedure:
- OPERATIONS:
1. Fusion T2-T8.
2. Extra cavitary decompression T5.
3. Laminectomies T4, t6
4. Instrumentation T2-8.
5. Cage placement at T5.
6. Autograft.
History of Present Illness:
This is a ___ year old male with a history of metastatic renal
cell carcinoma with metastasis to multiple ribs and lungs with
associated pleural effusions s/p Genentech study drug who
presents with right leg weakness, urinary retention, and
constipation over the past several days. Ordinarily, Mr
___ is able to ambulate with a walker without difficulty at
home - he prepares meals for himself at his home he shares with
his wife. Over the past few days, due to increasing weakness in
his right leg, he has had difficulty with walking. He has also
been constipated over this same time period, his last bowel
movement 5 days ago. His PO intake has been diminished over the
last several months, although he takes considerable fluids. He
has also described urinary retention over the past three months.
Otherwise, he denies any other extremity weakness, with no
numbness or tingling. Back pain is minimal at rest, although
coughing does make it worse. He recently had a pleurex catheter
in place for pleural effusion during last admission.
An MRI was performed on day of admission which reveals multiple
spinal mets with significant collapse of the T5 vertebral body
with epidural extension and marked canal narrowing with cord
impingement at this level. The other areas of metastases are
not associated with cord compression. For the MRI, the patient
was intubated for claustrophobia and anxiety treatment - he was
immediately extubated thereafter without need for supplemental
O2.
Neurosurgery saw the patient and plan on taking the patient to
the OR assuming that this plan is acceptable per the Oncology
team, based on their overall treatment plan.
At time of transfer to floor, the patient was comfortable with
no pain, but continued symptoms as described above.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-- On ___, MRI revealed a 3.2 cm solid exophytic lesion
arising from the lower pole of left kidney suspicious for clear
cell renal cell carcinoma and a 1.6 cm solid lesion in the
anterior left pole of the left kidney and a 2.4 cm lesion in the
mid pole of the right kidney, both of which concerning for tumor
cell carcinoma, papillary type. He was referred to Dr. ___
on
___. Given its small size, he was recommended to have
followup imaging ___ MRI at ___ compared to CT without
contrast from ___.
-- On ___, he underwent repeat MRI, which showed no
significant change and bilaterally no masses.
-- On ___, he underwent repeat MRI, which revealed
significant interval increase in the lower pole of the left
kidney obstructing mass, now measuring 4.9 x 3 cm from 3.1 x 2.7
cm and development of nodules in the perinephric fat, consistent
with extrarenal spread suspicious for clear cell renal cell
carcinoma, and there were also two other lesions that were
minimally increased in size. On ___, he underwent
laparoscopic left radical nephrectomy, which revealed a 4.6 cm
clear cell carcinoma and a 2.8 cm papillary renal cell
carcinoma,
grade 3 tumors with tumor extension into the perinephric tissue
(T3a N0), ___. Of note, the clear cell renal cell carcinoma
shows no areas of signaling, no definitive sarcomatoid
differentiation.
Renal cell carcinoma is diffusely positive CA9, negative for CK7
and patchy positivity for P504s. The papillary renal cell
carcinoma is again diffusely positive for CK7 and P504s and
focally positive for CA9. Packs two shows focal weak staining
for both tumors with no after lymphovascular invasion as
identified on CT31 staining.
-- on ___ Splenectomy showed vascular congestion with
subcapsular hematoma.
-- On ___, the lesion in the pole of the right kidney most
consistent with papillary renal cell carcinoma is unchanged, and
fluid collection consistent with pseudocyst of one of the
pancreas is noted.
-- On ___, he underwent partial right nephrectomy of the
2.6 cm papillary renal cell carcinoma, grade 2 (T1a Nx) with the
size of the tumor measured as a solid part 2.6 cm, adjacent cyst
continued minimal tumor. Specimen one in the belt of the cyst
adjacent to the tumor, right margin with papillary carcinoma
cauterized.
--On ___, post-nephrectomy period complicated by fever and
treated for pneumonia. He was noted to have a low O2 and
underwent a chest x-ray, which noted a 5 cm elliptical opacity
in
the left upper hemi collapse with apparent adjacent local
destruction, new since ___.
--On ___, CT abdomen and pelvis revealed a 5.1 x 2.2 soft
tissue density lesion with destruction of the third posterior
lateral rib, fluid collection in the right partial nephrectomy
bed with a seroma. Coronary and aortic valve calcifications,
enlarged pulmonary artery, right lower lobe consolidation
concerning for pneumonia. A 7-mm right lung nodule, nonspecific
left upper lobe ground-glass opacity.
--On ___ admitted for pleural effusion which was tapped by
IP. Interval need of supplemental O2. He was stopped on his
experimental therapy.
Past Medical History:
PMH: HTN, bilateral renal masses, HLD
PSH: splenectomy ___, lap left radical nephrectomy ___, R CEA
(___) ___, hernia repair x 2
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM ON DISCHARGE:
Vitals - T: 97.6 BP: 118/52 HR: 65 RR: 18 02 sat: 96% 2L NC
GENERAL: NAD, tired appearing
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
BACK: Dressing c/d/i with drain in place
ABDOMEN: nondistended, dec BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ biceps and triceps
bilaterally, left hip flexors, plantar and dorsiflexion; 4- R
dorsiflexion, 4+ R hip flexors
Pertinent Results:
MR ___ ___: There are multiple vertebral body metastases
demonstrated. These are identified at T1, T2, T4, T5, and
sacrum. The largest of these lesions is at T5 where there is
collapse of the vertebral body, to a considerably greater extent
than present on the ___ CT scan. There is extensive
soft tissue extending from the posterior vertebral body into the
spinal canal producing severe spinal cord compression at T5.
Tumor extends into the canal from the T2 body and just touches
the left anterior surface of the spinal cord. Tumor also
extends into the canal from the T4 body, again touching the
anterior surface of the cord. There is no evidence of cord or
cauda equina compromise at the other metastatic levels.
At the level of most severe spinal compression, there is
hyperintensity in the spinal cord on the long TR images,
presumably edema related to severe compression.
The metastases enhance after contrast administration. No
intradural tumor is identified.
Again noted are multiple other metastases in the chest wall,
incompletely
evaluated on this examination. Also again seen are bilateral
pleural
effusions, greater on the left than right.
CONCLUSION: Multiple spinal vertebral metastases with collapse
of the T5 vertebral body and a soft tissue extending into the
canal at this level producing severe spinal cord compression.
Soft tissue extends into the canal at T2 and T4 contacting the
spinal cord but not producing cord compression.
Brief Hospital Course:
Mr. ___ is a ___ with metastatic renal cell carcinoma with
known malignant right sided pleural effusion s/p recent drainage
who presented with several days of right sided leg weakness,
urinary retention for several weeks/months and constipation,
with radiographic evidence of cord compression at the level of
T5 as above.
1) Cord compression - Upon admission, Mr. ___ exhibited
clinical signs of cord compression, including right leg
paralysis and radiographic evidence of T8 cord invasion. He
underwent operative intervention on ___ with decompression
at the level of the T5 lesion, fusion T2-T8, laminectomies at T4
and T6, instrumentation T2-8, cage placement at T5, and
autografting. Please see the operative report for complete
details. Following this procedure, his strength improved. He was
placed on a post-operative steroid taper, starting at
dexamethasone 6mg IV q6hrs to be tapered down by 1mg q6hrs every
other day. This regimen was converted to PO on the day of
discharge. He was discharged taking 4mg PO q6hrs. His next
adjustment was to be a decrease to 3mg PO q6hrs, to be initiated
48 hours after discharge.
2) Pleural Effusion - Patient was recently discharged after
drainage of a recurrent malignant right pleural effusion and
placement of Pleurx catheter. Admission CXR demonstrated a
stable/slightly decreased effusion. He was saturating well on
room air at time of discharge. This collection was drained every
other day per his regular scheduled.
3) Hyponatremia - Stable sodium at 132 upon admission.
Previously attributed to ___. Stable throughout this
hospitalization; sodium equal to 133 on day of discharge.
4) Hypercalcemia - Calcium at admission 10.4. Previous
admissions with suspicion of etiology secondary to combination
of bony metastases and paraneoplastic hypercalcemia, though no
definitive work-up for PTHrP performed. Managed well via
intravenous fluids. Corrected calcium equal to 9.1 on day of
discharge.
4) Leukocytosis - Patient with persistent leukocytosis of
several years - attributed on previous admissions to be
secondary to his renal cell carcinoma. Relatively stable
througout admission, though did exhibit increase in WBC count
status-post initiation of dexamethasone therapy. WBC count equal
to 21.4 on day of discharge, comparable to previous values.
Expected to trend downwards with tapering of steroids as above.
5) Thrombocytosis - Patient's thrombocytosis attributed to
previous splenectomy/hyposplenism.
6) Metastatic renal cell carcinoma - Had been receiving Genetech
study drug, but discontinued on recent admission secondary to
dyspnea and progressive disease. Mr. ___ is to ___ as
an outpatient for re-evaluation and initiation of chemotherapy.
CHRONIC ISSUES:
7) Hyperlipidemia - continued simvastatin.
8) Hypertension - continued metoprolol.
==========================================
TRANSITIONAL ISSUES:
- Mr. ___ remained full code throughout his
hospitalization.
- His HCP is ___ (girlfriend of many years):
___, Cell phone: ___
- He will require outpatient ___ with ___,
NP ___ after discharge.
- He has an appointment with Dr. ___ on
___ at 9:30 AM
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Metoprolol Tartrate 25 mg PO BID
4. Senna 1 TAB PO BID:PRN constipation
5. Simvastatin 10 mg PO DAILY
6. Tamsulosin 0.4 mg PO BID
7. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
Breakthrough pain. Hold for RR < 12.
8. Bisacodyl 10 mg PO DAILY
9. Morphine SR (MS ___ 30 mg PO Q8H
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Polyethylene Glycol 17 g PO DAILY constipation
3. Tamsulosin 0.4 mg PO BID
4. Simvastatin 10 mg PO DAILY
5. Dexamethasone 4 mg PO Q6H Duration: 48 Hours
6. Ondansetron 4 mg IV Q8H:PRN nausea
7. Pantoprazole 40 mg PO Q24H
8. Metoprolol Tartrate 25 mg PO BID
9. Morphine SR (MS ___ 30 mg PO Q8H
RX *morphine 30 mg 1 tablet(s) by mouth q8hrs Disp #*52 Tablet
Refills:*0
10. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
Breakthrough pain. Hold for RR < 12.
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth q4hrs
Disp #*80 Tablet Refills:*0
11. Senna 1 TAB PO BID:PRN constipation
12. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
- metastatic renal cell carcinoma
SECONDARY:
- T5 cord compression
- hypercalcemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
Thank you for choosing ___ for your medical care. You were
admitted to the hospital for compression of your spinal cord
caused by a metastatic lesion from your renal cancer. You
underwent surgery to relieve this compression. You did well.
Upon discharge, please keep all of your scheduled appointments
with your doctors. ___ take all medications as prescribed.
Refrain from driving while taking pain medication.
Please return to the hospital or call Dr. ___ office at
___ if you experience any of the following: fever,
chills, night sweats, loss of conciousness, chest pain, trouble
breathing, opening of your incision, foul smelling or pus-like
discharge from your wound, worsening back pain, increasing
weakness, or any other symptoms that concern you.
___ Surgery recommendations per Dr. ___:
Do not smoke.
Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
Dressing may be removed on Day 2 after surgery.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
Do not take any medications such as Aspirin unless directed by
your doctor.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 101° F.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
___
|
19817865-DS-17
| 19,817,865 | 20,999,086 |
DS
| 17 |
2113-06-20 00:00:00
|
2113-06-20 09:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Prednisone / Sulfa (Sulfonamide Antibiotics) / Gluten
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Patient is a ___ ___ transferred from
___ after falling down 4 steps. He reports that he
was wearing new socks tonight when he slipped at home and fell
down a
flight of stairs of 4 steps around 7:30 pm. He reports to have
landed on his back and there was no loss of consciousness. He
may have hit his head but he tried to protect his head using his
hands.
He reports that he was not able to get up due to severe back
pain
that radiated anteriorly and up the chest. He was talking to his
brother at the time hence he was able to call for EMS. He was
initially taken to ___ where CT of T-spine showed
T11/12 fracture hence he was transferred here for further care.
He reportedly had a good rectal tone and he did urinate x1 since
the fall. He reports severe back pain and abdominal pain. The
pain is worse on the left than right. He also reports tingling
sensation in all toes. He has trouble moving especially his legs
due to back pain.
Review of systems negative otherwise.
Past Medical History:
1. Post-concussive syndrome - multiple concussions and most
recently ___ years ago. He is on disability due to the
post-concussive syndrome resulting in constant dizziness and
frequent fainting spells.
2. Chronic low back pain
3. s/p R rotator cuff repair - planned for L rotator cuff repair
this week
4. Anxiety
Social History:
___
Family History:
non-contributory
Physical Exam:
On admission:
O: T: 97.4 BP: 124/80 HR:90 R: 16 O2Sats: 98% RA
Gen: Supine and with a hard-cervical collar
Lungs: clear anteriorly
Cardiac: RRR.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Attention: Able to ___ backwards.
Motor:
D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 * * * 5 5 5
L 5 5 5 5 5 * * * 5 5 5
* Deferred due to patient reporting severe pain and inability to
move his legs.
Sensation: Intact to light touch, JPS, pinprick and vibration
bilaterally. No sensory level found on torso anteriorly.
Reflexes: B T Br Pa Ac
Right ___ 3 2
Left ___ 3 2
Toes downgoing bilaterally
On Discharge:
Full strength, no sensory deficit, ambulatory with ___, TLSO
brace well fitting, pt exhibited knowledge of donning
Pertinent Results:
CT C-spine: no fracture
CT Head: No intracranial hemorrhage or fractures. Chronic
involutional
changes.
CT Torso: Acute compression deformities of T11 and T12, with
minimal loss of anterior height, and no retropulsion into the
spinal canal. Please refer to subsequent thoracic spine MR for
further detail.
MRI T/L spine: Mild superior endplate compression fractures of
T11 and T12
without retropulsion, spinal stenosis, or cord compression. No
evidence of
intra- or paraspinal hematoma.
L-Spine x-rays
T11 and T12 compression fractures better shown on MRI. Loss of
height is
minimal. Normal alignment with brace in place. Normal bowel gas
pattern.
Brief Hospital Course:
On ___ Pt was admitted to neurosurgery service. MRI was
obtained that showed mild compression fractures of T11 and T12
without cord compression. The patient had an encouraging
neurologic exam, and surgical intervention was not indicated. He
was measured for a TLSO brace. He initially had some difficulty
voiding, and required a straight catheterization. Following this
the patient was able to void appropriately once given a condom
catheter. On ___ he was started on aspirin 325mg for DVT
prophylaxis due to his history of possible heparin/lovenox
allergy. On ___ his brace was placed and standing films showed
good alignment. He was out of bed and worked with physical and
occupational therapy. On ___ he was deemed fit for discharge
home with outpatient ___ and ___. He was given isntructions for
follow-up and discharged.
Medications on Admission:
1. Prilosec 40mg daily
2. Metoprolol 25mg daily
3. Klonopin 0.5mg TID
Discharge Medications:
1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for T>100.4 or pain.
4. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day).
5. methocarbamol 500 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*80 Tablet(s)* Refills:*0*
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
T11 & T12 endplate fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Do not smoke.
Take your pain medication, including Tylenol, as instructed;
you may find it best if taken in the morning when you wake-up
for morning stiffness, and before bed for sleeping discomfort.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
You must wear your TLSO brace for support for 8 weeks,
until follow-up.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 101° F.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
___
|
19818094-DS-7
| 19,818,094 | 20,692,793 |
DS
| 7 |
2173-01-14 00:00:00
|
2173-01-14 09:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Suicidal ideation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ with a PMH of polysubstance abuse,
depression, ___ Tooth syndrome, discharged from the ED
earlier yesterday for EtOH intoxication and head laceration who
re-presents to the ED with weakness and suicidal ideation.
Per EMS he was out in the hot sun with minimal hydration after
his discharge. He also reports he has not eaten for 4 days.
During the interview, he admitted to SI but did not express a
plan or intent. Per the ED, his interview is limited as patient
is distraught and mildly agitated.
In the ED, initial VS were 96.9 77 144/108 22 97% RA.
He was noted to be covered in blood from a head laceration.
Labs were notable for leukocytosis to 14.4, H/H of 15.7/46.0,
Plt
285. BMP initially hemolyzed but electrolytes largely WNL. His
urine toxicology was positive for barbituates and otherwise
negative.
He was initially evaluated by psychiatry and found to meet
___ criteria.
His ED course subsequently was notable for new atrial
fibrillation with RVR. He received multiple doses of IV dilt (10
mg x 2, then 20 mg x 1, then 30 mg PO dilt). He subsequently was
given amiodarone 150mg bolus IV. He also received several doses
of Ativan and 2 doses of diazepam for treatment of withdrawal.
HR
was well controlled at 67 after the amiodarone.
Upon arrival to the floor, the patient tells the story as
follows. He states that he has had suicidal ideation for the
past
month, worse in the past week. It improves w/ neurotin and
worsens with drinking. It has also been worse in the past week
as
the anniversary with his prior girlfriend was yesterday. It is
constant.
In addition, he came in yesterday b/c of feeling weak and having
palpitations for several hours prior to coming in. This was
constant, not associated w/ CP, SOB. It is now resolved.
ROS otherwise also positive for constipation (last BM 4 days
ago), and occasional difficulty with urinary stream.
Past Medical History:
- Hepatitis C
- Charcot ___ Disease
- Myofacial Pain Syndrome
- Manic depression
- Alcohol use disorder
- C7 compression fracture
Past Psychiatric History:
- Diagnoses: reported diagnosis of bipolar disorder, depression,
schizophrenia in the past
- SA/SIB: Of note, per OMR, patient has denied history of SA on
prior examinations. However, patient states he has had numerous
suicide attempts including cutting his wrists at age ___ years of
age; denied seeking medical attention at the time. States he has
also overdosed on Seroquel in ___.
- Hospitalizations: patient reports first hospitalization was at
___ in the ___ last known hospitalization
was at ___ in ___. Per OMR, numerous
admissions for detox from alcohol
- Medication Trials: Unknown, but patient currently on Seroquel,
Wellbutrin
- Psychiatrist: none
- Therapist: none
Social History:
Per review of prior documentation:
- Alcohol: patient with history of alcohol use, at peak drank
___ pints per day. States he has been drinking intermittently,
sometimes 1 pint per day. Denies history of withdrawal seizures
- Illicits: Patient with history of opiate use disorder, on
suboxone. Denies current opiate use. Last cocaine use one week
prior to admission. Admits using cannabis daily. Denies other
illicits
- Tobacco: smokes 1 pack per day
Social History: Patient born in ___ and grew up in
___. Father worked as a ___ for a ___
___ and mother was a house___. Patient is the oldest of 4
children and has 2 brothers and 1 sister. Reported childhood as
"good," describing his father as "reserved but not abusive."
Biological mother died when the patient was ___ years old and
father remarried soon after. Mr. ___ described his
stepmother as "a bitch," and stated she was verbally abusive.
Patient graduated high school and attended ___ school,
studying ___, graduating in
___. Has worked in the past in ___. Was married for ___
years in the ___ and has a ___ year old daughter who is "doing
awesome." Stated his marriage ended after he became increasingly
paranoid the government was responsible for a "chem trail,"
believing they were spraying metals and chemicals on US citizens
while smoking significant amounts of cannabis. Patient stated
his paranoia placed a significant stress on his marriage, which
eventually "dissolved because I got involved in conspiracy
theories." Patient reported he "had a nervous breakdown"
following the separation with subsequent admission to ___
___. Following this admission, he started a
relationship with a fellow patient, who became pregnant with his
child. Stated the woman's family pressured her to have an
abortion and she later killed herself. Reported he feels very
guilty regarding this event. Currently he is homeless and
receives SSDI, approximately $1000/month.
Family History:
Significant for multiple sclerosis in his
father; mother just died in ___ of emphysema
Physical Exam:
ADMISSION EXAM:
VITALS: Afebrile and vital signs stable
GENERAL: Sleeping but easily arousable disheveled man
EYES: Anicteric, pupils equally round, no obvious nystagmus
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
Mucous membranes dry; teeth absent
CV: Heart regular w/ ?PVCs, not tachycardic, no obvious murmus
RESP: Lungs clear to auscultation with good air movement
bilaterally
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs; + arch deformities in
feet b/l
SKIN: skin laceration on R forehead, crusted over
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, normal F-t-N b/l
PSYCH: depressed mood
The patient was examined on day of discharge.
Pertinent Results:
ADMISSION RESULTS:
___ 09:35AM BLOOD WBC-14.4* RBC-5.09 Hgb-15.7 Hct-46.0
MCV-90 MCH-30.8 MCHC-34.1 RDW-13.8 RDWSD-46.1 Plt ___
___ 09:35AM BLOOD Glucose-104* UreaN-13 Creat-0.6 Na-143
K-4.1 Cl-103 HCO3-22 AnGap-18
___ 04:07PM BLOOD ALT-60* AST-102* AlkPhos-122 TotBili-0.4
___ 04:07PM BLOOD Albumin-4.6 Calcium-9.8 Phos-3.4 Mg-2.0
___ 04:07PM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
OTHER RELEVANT RESULTS:
___ 04:07PM BLOOD TSH-0.09*
___ 10:10AM BLOOD T3-105 Free T4-1.2
___ MRCP:
IMPRESSION:
Mild dilation of the pancreatic duct and common bile duct which
tapers at the
ampulla, with no pancreatic head or periampullary mass seen.
Findings may
represent sphincter of Oddi dysfunction or ampullary stenosis;
ampullary
region could be directly evaluated with ERCP if there are
laboratory findings
to suggest ductal obstruction.
IMAGING/OTHER STUDIES:
======================
TEE without vegetation
CT CSPINE ___
1. Study is moderately degraded by motion artifact; in the
context of these limitations;
2. No evidence of traumatic malalignment.
3. Evaluation of the lower cervical spine is extremely limited
due to motion, however there appears to be a smooth rounded
density extruding posteriorly from C5-C6. There are also
calcifications extending posteriorly from C6-C7, which could
represent a disc osteophyte complex. Extremely limited
evaluation for fracture given motion, there does appear to be
irregularity along the posterior margin of the C6 vertebral
body. If there is continued clinical
concern for acute fracture, MRI cervical spine may be obtained.
CT HEAD ___
1. No evidence of acute intracranial process.
2. Soft tissue swelling over the right frontal bone without
evidence of underlying fracture.
3. Findings consistent with sinus disease.
MRCP ___
Mild dilation of the pancreatic duct and common bile duct which
tapers at the ampulla, with no pancreatic head or periampullary
mass seen. Findings may represent sphincter of Oddi dysfunction
or ampullary stenosis; ampullary region could be directly
evaluated with ERCP if there are laboratory findings to suggest
ductal obstruction.
TTE ___
Poor image quality. Normal overall LV systolic function. There
is an echobright mobile mass associated with the mitral valve.
Differential includes thickened calcified chord, less likely a
vegetation, with trace mitral regurgitation. Rhythmn appears to
be sinus.
TEE ___:
IMPRESSION: No discrete vegetation or abscess seen. No
spontaneous echo contrast or thrombus in the left atrium/left
atrial appendage/right atrium/right atrial appendage. Normal
global left ventricular systolic function. Calcified chord in
the posterior mitral valve apparatus.
Brief Hospital Course:
___ with a PMH of polysubstance abuse, depression, ___
Tooth syndrome, admitted with SI and for treatment of EtOH
withdrawal. Noted to have newly diagnosed AFib on arrival as
well with RVR managed with nodal agents, ultimately converted
back to sinus prior to discharge. EtOH withdrawal was managed
with valium for ~24 hours without complication. He was noted to
have He endorsed persistent suicidality, and was maintained on
1:1 supervision and ___. He was seen by psychiatry and
social work, and ultimately discharged to an inpatient
psychiatric facility per psychiatry recommendation.
TRANSITIONAL ISSUES:
====================
-New atrial fibrillation, CHADSVASC 0 so did not initiate
anticoagulation. Spontaneously converted to sinus rhythm
-TSH 0.09 with normal T3/T4. Repeat as outpatient
-Hepatology referral as able for HCV treatment
-PFTs for evaluation for ?COPD
-Patient with significant distress from tardive dyskinesia;
endorses significant response to klonopin. Did not start during
this medical hospitalization and defer to inpatient psychiatry
team.
-Patient with housing insecurity; given medical comorbidities,
may be a candidate for SNF placement after discharge from
inpatient psychiatry facility.
ACUTE/ACTIVE PROBLEMS:
# Paroxysmal AFib: New diagnosis, initially in RVR in ED
requiring nodal agents, then spontaneously converted to sinus
rhythm. TSH low although T3/free T4 normal. TTE obtained and
showed ##. Discontinued metoprolol on discharge, particularly
given risks of hypotension (BPs ~100s while inpatient) if
ongoing EtOH use.
CHADS2VASC: 0, so did not initiate anticoagulation.
# Anxiety
# Suicidal ideation: Expressed persistent suicidal ideation
throughout hospitalization. Maintained on ___. Anxiety
managed with seroquel 12.5mg prn, and discharged to inpatient
psychiatric facility per psychiatry recommendations.
# Alcohol use disorder: Uncomplicated. Required ~24 hours of
valium for CIWA >10.
# Likely hemangioma
# Dilatation of the main pancreatic duct:
Both noted incidentally on RUQUS obtained for transaminitis.
MRCP showed no mass, did confirm dilation of pancreatic duct
(mild) which could be due to sphincter of oddi dysfunction or
ampullary stenosis. Given no evidence of cholestasis on LFTs,
will not pursue ERCP at this time.
# Lack of housing: Pt reports as significant barrier to staying
sober. Social work consulted.
CHRONIC/STABLE PROBLEMS:
#Charcot ___: Significant bilateral hand contractions,
impairing function.
Continued Neurontin 800mg TID. Discussed possibility of
transitioning to SNF.
#HCV: Transaminases in 100s on admission, RUQUS with normal
liver architecture and no evidence of cirrhosis on labs/exam.
HCV viral load ~5. Would benefit from hepatology referral and
anti-viral therapy if socially feasible.
#Tobacco use d/o
#?COPD: Patient with productive cough, intermittent wheeze. Did
not use nicotine replacement while admitted. Would benefit from
PFTs and possible COPD-directed therapy if confirmed.
> 30 mins spent on coordination of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL DAILY
2. ClonazePAM 1 mg PO TID
3. Gabapentin 800 mg PO TID
4. Amphetamine-Dextroamphetamine 20 mg PO BID
Discharge Medications:
1. Cyclobenzaprine 10 mg PO TID:PRN facial spasm
2. Multivitamins 1 TAB PO DAILY
3. Nicotine Patch 14 mg/day TD DAILY
4. QUEtiapine Fumarate 12.5 mg PO Q6H:PRN anxiety
5. Thiamine 100 mg PO DAILY
6. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL DAILY
7. Gabapentin 800 mg PO TID
8. HELD- Amphetamine-Dextroamphetamine 20 mg PO BID This
medication was held. Do not restart
Amphetamine-Dextroamphetamine until instructed by your
psychiatrists
9. HELD- ClonazePAM 1 mg PO TID This medication was held. Do
not restart ClonazePAM until instructed by your psychiatrists
10.Rollator
Rollator
ICD-10: G60.0
___: 13 months
Prognosis: Good
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Suicidal ideation
Alcohol withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for monitoring for alcohol
withdrawal. You were seen by our psychiatrists who recommended
that you continue receiving psychiatric care at an ___
facility. We wish you all the best in your path toward recovery.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19818127-DS-20
| 19,818,127 | 22,219,600 |
DS
| 20 |
2150-07-05 00:00:00
|
2150-07-05 17:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old woman with HFpEF (LVEF 50%
___, CAD s/p CABG, ESRD (HD MF via RIJ tunneled cath), AFib
(on Coumadin), history of MRSA endocarditis and pacemaker lead
infection in ___ s/p mitral valve annuloplasty (on
suppressive doxycycline) who presented ___ with vague
complaint of several days of dyspnea, decreased PO intake, and
possible loose stools. She had mild non-productive cough for
several days without fevers, chills, or night sweats. She denied
chest pain. She had no leg swelling or orthopnea.
In the ER, she was found to have BPs in the ___ and was
afebrile. Her WBC ct was 14.9 and a CXR showed possible right
mid-lung opacity, so she was given levofloxacin and 250mL IVF.
Her BPs improved to the 110s upon arrival to the floor and she
was on 2L/min oxygen by nasal canula.
Past Medical History:
MEDICAL HISTORY
#Coronary artery disease s/p CABG (unknown anatomy)
#Heart failure with preserved EF, chronic
#Atrial fibrillation (CHADS = 3)
#Hypothyroidism
#End stage renal disease (Right IJ tunneled catheter)
#History of MRSA pacemaker lead infection and endocarditis
___ treated with 6 weeks of vancomycin and rifampin, now on
doxycycline suppressive therapy
#Severe tricuspid regurgitation
#Pulmonary hypertension
SURGICAL HISTORY
-s/p mitral valve annuloplasty ___
-s/p dual chamber pacemaker placement ___
-s/p R knee hemiarthroplasty due to fracture
-s/p hysterectomy
-s/p appendectomy
-s/p L AV fistula placement ___
-s/p R IJ tunneled catheter placement ___
Social History:
___
Family History:
No history of renal or heart disease
Physical Exam:
Admission exam:
VS - T 98.2 BP 99/52 HR 71 RR 22 98% 2L NC
GENERAL: Elderly frail female in NAD, lying in hospital bed,
AAOx3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
dry MM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: mechanical valve, normal S1, S2, SEM heard best at ___,
no rubs
RESP: Bilateral rhonchi to mid lung field bilaterally, no rales,
no wheeze.
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
Access: R tunneled IJ
Discharge exam:
VS - T 97.6 BP 104/63 HR 70 RR 18 100% RA weight 40.7 <- 40.8
<- 41.2 <- 41.6(?dry weight)
GENERAL: Elderly frail female, uncomfortable appearing, sitting
up in hospital bed eating breakfast
HEENT: AT/NC, anicteric sclera, pink conjunctiva, dry MM
NECK: nontender supple neck
CARDIAC: normal S1, S2, ___ SEM heard best at ___, no rubs
RESP: Bilateral rhonchi to mid lung field bilaterally, no rales,
no wheeze. Tachypnic, crackles on R anterolaterally.
ABDOMEN: nondistended, 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: Grossly normal
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission and notable labs:
___ 03:45PM WBC-14.9*# RBC-4.04# HGB-11.6# HCT-39.7#
MCV-98 MCH-28.7 MCHC-29.2* RDW-17.2* RDWSD-61.4*
___ 03:45PM NEUTS-81.0* LYMPHS-8.2* MONOS-9.6 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-12.07* AbsLymp-1.23 AbsMono-1.43*
AbsEos-0.00* AbsBaso-0.02
___ 03:45PM ALBUMIN-2.8* CALCIUM-8.4 PHOSPHATE-4.2#
MAGNESIUM-1.8
___ 03:45PM LACTATE-1.4
___ 03:45PM CK-MB-1 cTropnT-0.05* ___
___ 03:45PM LIPASE-10
___ 03:45PM ALT(SGPT)-19 AST(SGOT)-19 ALK PHOS-150* TOT
BILI-0.6
___ 03:45PM GLUCOSE-75 UREA N-30* CREAT-3.0* SODIUM-137
POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-32 ANION GAP-13
___ 04:28PM BLOOD ___ pO2-69* pCO2-42 pH-7.45
calTCO2-30 Base XS-4 Intubat-NOT INTUBA
___ 07:10AM BLOOD calTIBC-85* Ferritn-1806* TRF-65*
___ 08:15AM BLOOD TSH-0.082*
___ 08:15AM BLOOD CK-MB-1 cTropnT-0.05*
___ 05:50AM BLOOD WBC-14.6* RBC-3.75* Hgb-10.7* Hct-37.0
MCV-99* MCH-28.5 MCHC-28.9* RDW-17.3* RDWSD-62.3* Plt ___
Discharge labs:
___ 05:50AM BLOOD ___
___ 05:50AM BLOOD Glucose-106* UreaN-71* Creat-4.0*# Na-139
K-3.6 Cl-99 HCO3-26 AnGap-18
___ 05:50AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.3
MICROBIOLOGY:
Sputum culture:
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
Blood culture ___: negative
MRSA screen: negative
___ 5:29 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
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..
Imaging:
TTE ___ The left atrial volume index is severely increased.
The right atrium is moderately dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with mild hypokinesis of
the inferior/inferolateral walls. The remaining segments
contract normally (LVEF = 40%). There is no left ventricular
outflow obstruction at rest or with Valsalva. The right
ventricular cavity is moderately dilated with mild global free
wall hypokinesis. The ascending aorta is mildly dilated. The
aortic arch is mildly dilated. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. Moderate to severe [3+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. [In the setting of at least moderate to
severe tricuspid regurgitation, the estimated pulmonary artery
systolic pressure may be underestimated due to a very high right
atrial pressure.] There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Dilated right ventricle with mild RV systolic
dysfunction. Calcific aortic valve disease with mild stenosis
and mild regurgitation. Mild mitral regurgitation. Moderate to
severe tricuspid regurgitation. At least mild pulmonary
hypertension.
CTA Chest ___
There is aneurysmal dilatation of the ascending aorta measuring
up to 4.3 cm. Moderate atherosclerotic calcification is noted.
There is calcification of the aortic valve leaflets as well as
moderate coronary artery calcification. An AICD/ pacemaker is
seen with the leads in the right heart. A right internal
jugular approach dialysis catheter is seen terminating in the
upper right atrium. The heart is enlarged and contrast refluxes
into the IVC and hepatic veins in keeping with congestive heart
failure. There is no pericardial effusion.
The pulmonary arteries are well opacified to the segmental
level, with no evidence of filling defect within the main,
right, left, lobar or segmental pulmonary arteries. Evaluation
of the subsegmental pulmonary arteries is somewhat limited by
respiratory motion. The main pulmonary artery is enlarged
measuring 3.5 cm with dilatation of the right and left pulmonary
arteries.
There is no supraclavicular, axillary, mediastinal, or hilar
lymphadenopathy.
The thyroid gland appears unremarkable.
There are trace bilateral pleural effusions greater on the left
than the right with associated atelectasis.
Along the right major fissure there is a 1.2 x 2.6 cm tubular
lesion which is partially fat density on partially soft tissue
density that may reflect mucous impaction. There is biapical
pleural scarring with calcification and bronchiectasis. In the
right lower lobe there is a 0.6 x 0.8 cm nodule (02:55) which
also measures fat density. Scattered ground-glass opacities are
seen in the bilateral lower lobes likely reflecting aspiration
or infection. Calcified granulomas are noted in the lingula
(02:36) and right lower lobe
(02:43). Limited images of the upper abdomen are notable for a
partially imaged heterogeneous mass which appears to arise from
the upper pole of the left kidney measuring at least 6.1 x 8.4
cm and displacing the spleen anteriorly. Multiple
calcifications or nonobstructing stones are seen in the atrophic
right kidney.
No lytic or blastic osseous lesion suspicious for malignancy is
identified. Severe compression deformity of T8 is unchanged
from the chest radiograph of ___ but new from more
remote chest radiographs. There is a 2.1 x 3 cm soft tissue
density mass in the right breast with a calcification within it.
IMPRESSION: 1. No evidence of pulmonary embolism to the
segmental level. Evaluation of subsegmental pulmonary arteries
is limited by respiratory motion. 2. Large heterogeneous mass
partially imaged which appears to be arising from the left
kidney suspicious for malignancy. 3. 3 cm mass in the right
breast. 4. Cardiomegaly with reflux of contrast into the IVC and
hepatic veins consistent with congestive heart failure. 5.
Ascending aortic aneurysm measuring 4.3 cm. 6. Dilatation of the
pulmonary artery as seen in pulmonary artery
hypertension. 7. T8 compression deformity, unchanged from ___ but new from more remote studies of uncertain
chronicity.
8. Multiple pulmonary opacities in the right middle lobe and
lower lobe which appear somewhat tubular and could reflect mucus
plugging or ABPA, less likely metastatic disease. Follow-up
would depend on the outcome of the abdominal imaging and breast
and renal mass evaluation.
RECOMMENDATION(S):
1. Recommend imaging of the abdomen and pelvis with contrast to
further evaluate the left renal mass.
2. Correlation with mammography for the right breast mass.
CXR ___
FINDINGS: New compared to prior older exam is hazy right
midlung opacity seen on the frontal view. Increased opacity
projecting over the hilar region on the lateral view is also new
and may correspond a finding on the frontal view. Biapical
scarring is grossly unchanged. The cardiac silhouette is
enlarged but similar compared to prior. Markedly tortuous
thoracic aorta is noted. Left chest wall dual lead pacing
device is again noted. Right-sided dual lumen central venous
catheter seen with tip projecting over the proximal right
atrium. There is no pleural effusion. Compression deformity in
the mid thoracic spine is new since ___ but is age
indeterminate. IMPRESSION: Hazy right midlung opacity which
could represent infection in the proper clinical setting. Severe
mid thoracic compression deformity new since ___ but age
indeterminate, to be correlated clinically.
Brief Hospital Course:
Ms. ___ is an ___ year old woman with a history of AF (on
Coumadin and s/p dual chamber pacemaker), history of
endocarditis (?MRSA) and pacemaker infection in ___ requiring
mitral valve annuloplasty, ESRD (on HD MF), CAD, sCHF, who
presented ___ with dyspnea and possible diarrhea for past
several days.
#HCAP: Patient presented with dyspnea on admission and was found
to have leukocytosis, hypoxemia, and possible opacity on CXR
initially concerning for HCAP. She was started on cefepime and
levofloxacin as empiric coverage. There was also a concern for
volume overload and pulmonary edema causing SOB, as she had
elevated NT-pro-BNP (>40000) on admission. She had a TTE that
showed pulmonary hypertension, dilated right ventricle, and 3+
TR, which were also felt to be contributing to her SOB. She had
a CTA chest, which showed pulmonary opacities in the right
middle lobe and lower lobe which were consistent with mucus
plugging or ABPA. As there was no evidence of pneumonia, her
antibiotics were discontinued. There was no evidence of PE on
CTA. Ultimately, it was felt that her SOB for which she
presented was multifactorial, related to her 3+ TR, pulmonary
hypertension, and mucous plugging. She remained tachypneic to
the ___ throughout hospital course but maintained O2 sats >92%
without supplemental O2.
#?Renal, breast malignancy: CTA chest was highly concerning for
malignancy, specifically a 6.1 x 8.4 cm mass in the left kidney
and a 3 cm mass in the right breast. An extensive discussion was
had with the patient regarding further work up. Patient declined
biopsy and treatment, whether that be palliative or curative in
the future. Per goals of care discussion, patient wanted to
transition to hospice rather than seek diagnosis or treatment
for these masses.
#ESRD on HD: Patient has a long history of HTN, which is the
presumed etiology of her ESRD, not her malignancy. She was
continued on HD during admission. Her dry weight was reportedly
44kg prior to admission, but was suspected to be lower and so 1L
was taken off with each HD session. Goals of care discussion was
had at length with patient, who wanted to transition to hospice.
With specific regard to her dialysis, she does prefer to
continue HD after discharge for a limited time. She understood
that discontinuation of HD would be life-limiting on the order
of days to weeks rather than the months she may have otherwise.
Given this, she preferred to continue with HD for the time
being.
#Leukocytosis: Patient noted to have leukocytosis throughout
admission, which was most likely secondary to malignancy rather
than infection. CT chest negative for PNA, unable to give urine
for UCx since anuric, blood cultures negative. Patient remained
afebrile and did not meet SIRS criteria to require antibiotics
over course of admission.
#systolic CHF: per records, last EF seen was 50% (___). EF of
40% this admission concerning for worsening HF. BNP was
elevated, although no baseline was provided in records. She did
have fluid removed in HD, with a discharge weight of 40.7 kg.
#H/o MRSA endocarditis and pacemaker lead infection in ___
s/p mitral valve annuloplasty (on suppressive doxycycline).
Given MRSA swab negative and transition to hospice care, her
doxycycline prophylaxis was discontinued. Her pacemaker was
interrogated prior to discharge, and was found to be pacemaker
dependent. Her ERI is 2 months.
#H/o Afib: CHADS 3. Her home amiodarone was discontinued prior
to discharge as with other home meds, scaling back per GOC.
Coumadin was restarted after initially supratherapeutic INR
since admission, and will continue on discharge for a goal INR
of ___.
#CAD s/p CABG: discontinued home aspirin 81, simvastatin 20 mg
qHS per GOC by the time of discharge.
#Hypothyroidism: continued home levothyroxine. TSH this
admission was 0.082 and so decreased levothyroxine approx. 15%
to 50 mcg daily from 50 mcg 5x/week, 75 mcg 2x/week
#Anemia: Fe studies consistent with ACD.
TRANSITIONAL ISSUES:
- Patient completed MOLST form to indicate DNR/DNI status, does
want BiPAP, does want HD, does want fluids if necessary but not
supplemental nutrition. She would be amenable to antibiotics if
po only. She would be amenable to transport to hospital for
comfort only. Please see MOLST form for details.
- Patient's levothyroxine was decreased given low TSH; she will
continue on levothyroxine at home.
- Patient's medications were scaled back, including aspirin,
statin, amiodarone, given hospice goals. She was continued on
warfarin at discharge.
- Patient's biotronic pacemaker was interrogated during hospital
course; she is ___ pacemaker dependent. Her ERI is 2 months.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO 4X/WEEK (___)
4. Levothyroxine Sodium 75 mcg PO 3X/WEEK (___)
5. Midodrine 7.5 mg PO 2X/WEEK (MO,FR)
6. Mirtazapine 15 mg PO QHS
7. Senna 8.6 mg PO DAILY
8. Simvastatin 20 mg PO QPM
9. Warfarin ___ mg PO DAILY16
10. Polyethylene Glycol 17 g PO DAILY
11. Doxycycline Hyclate 100 mg PO EVERY ___ DAY
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Midodrine 5 mg PO TID
3. Senna 17.2 mg PO QHS:PRN constipation
4. Warfarin 2 mg PO DAILY16
5. Calcium Acetate 667 mg PO TID W/MEALS
RX *calcium acetate 667 mg 1 capsule(s) by mouth TID with meals
Disp #*90 Capsule Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
#Hypoxemic respiratory distress
#End stage renal disease
#Likely left renal cancer
SECONDARY DIAGNOSES
#Chronic systolic heart failure
#Hypothyroidism
#Pulmonary Hypertension
#Severe Tricuspid regurgitation
#Atrial fibrillation
PRIMARY DIAGNOSES:
#Hypoxemic respiratory distress
#End stage renal disease
#Likely left renal cancer
SECONDARY DIAGNOSES
#Chronic systolic heart failure
#Hypothyroidism
#Pulmonary Hypertension
#Severe Tricuspid regurgitation
#Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ due to
shortness of breath, cough, and decreased eating and drinking.
You had a CT scan of your lungs which showed extensive lung
scarring and some areas where there may have been plugs of
mucous. Your shortness of breath is most likely due to these as
well as your heart disease. Some of the valves in your heart are
leaky, and this may affect your shortness of breath.
In addition, on your CT scan, there were concerning findings for
cancer. Specifically, there is a large mass in your left kidney
as well as a mass in your right breast. This mass in your kidney
is especially concerning for cancer. We discussed your options
for diagnosis and treatment at length, and you felt it would be
best for you to not pursue biopsy for diagnosis or treatment at
this time.
Given this, we arranged hospice services for you. This is a
treatment team that specializes in care at the end of life.
Per our discussion, you opted to continue with dialysis for now
after you go home. If you choose to stop dialysis in the future,
you can communicate this to your providers, including those who
take care of you through hospice.
For now, please take all medications as prescribed and please
follow up with the appointments we arrange.
It was a pleasure taking care of you at ___.
Sincerely, your ___ care team.
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / Cleocin
Attending: ___
Chief Complaint:
left and arm weakness and trembling.
Major Surgical or Invasive Procedure:
___ Right Burr holes x2 for evacuation of subdural
hematoma.
History of Present Illness:
Mr. ___ is a ___ y/o M who presents with 2 days of left and
arm weakness
and trembling. Pt reports syncopal fall around ___ at which
time head CT was negative at ___. After that
hospitalization patient has been doing well until 2 days ago
when he began to feel unsteady standing and walking. He
developed some "trembling" in his left leg. Yesterday he noted
weakness in his left arm with "trembling" of the left arm.
Today
he had worsening gait and so he brought himself to the ED where
Head CT showed large right sided SDH at ___. He was
started on Keppra for sz prophylaxis and transferred to ___
for
definitive treatment. Mild HA. Denies N/V, dizziness, blurred
vision or double vision, numbness or tingling.
Past Medical History:
PMHx: HTN, High Cholesterol, s/p prostate resection for cancer
Medications: Aspirin, Cardizem CD, Centrum Silver,
Glucosamine-Chondroitin, Hydrochlorothiazide, Simvastatin,
Toprol
XL, Vitamin C, Vitamin E, lisinopril
All: Cleocin, Penicillins
Social History:
___
Family History:
Family Hx: NC
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
O: T: 97.9 BP: 173/71 HR: 76 R: 18 O2Sats: 96% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Normocephalic, atraumatic
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3 to
2mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
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 in Left UE is 4+/5 in all muscle groups
Otherwise strength is full ___ in Left ___, Right UE and Right
___.
Positive Left Drift.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Handedness Right.
PHYSICAL EXAMINATION ON DISCHARGE:
Alert and oriented x3. PERRL bilaterally, 3-2mm. EOMs intact
with nystagmus noted with lateral gaze. Face symmetric, tongue
midline. Sensation intact throughout face. Speech fluent and
clear. Comprehension intact.
No pronator drift.
Motor examination reveals ___ strength throughout all four
extremities with the exception of gastroc which is 5- on the
right.
Incision: Staples in place. Clean, dry and intact. No edema,
erythema or discharge.
Pertinent Results:
Head CT without Contrast: ___
1. Interval right burr hole and subdural drain placement.
Decrease in
subdural hematoma with decrease in leftward shift of midline
structures from 10 mm to 5 mm. No new areas of hemorrhage.
2. Small left subdural fluid collection along superior parietal
convexity
again noted.
Brief Hospital Course:
Mr. ___ was admited to the intensive care unit for
observation and taken to the operating room on ___ for
evacuation of the subdural hematoma with placement of subdural
drain. The patient tolerated the procedure well and was
extubated in the OR electively and transferred to the ICU for
recovery. The patient had a post operative NCHCT that was
consistent with expected post operative changes. On exam, the
patient was very alert and neurologically intact. The patient's
diet was advanced and a consult for physical therapy was placed.
On ___ patient is doing well. His JP drain was removed and a
staple was placed. Patient was transfered to the floor. He was
re-started on ___ and a urinalysis was sent for retention.
Results were negative.
On ___ he was re-assessed by ___ who recommended Mr. ___ be
discharged to home with a prescription for outpatient physical
therapy. It was determined he would be discharged to home later
today.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Cardizem CD 180 mg oral QD
3. Multivitamins 1 TAB PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. Vitamin E 400 UNIT PO DAILY
9. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Vitamin E 400 UNIT PO DAILY
8. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*2
9. Acetaminophen 650 mg PO Q8H:PRN Pain
10. 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
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*40
Tablet Refills:*0
12. Cardizem CD 180 mg ORAL QD
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Outpatient Physical Therapy
ICD9 Code: ___.2
Discharge Disposition:
Home
Discharge Diagnosis:
Right Subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Burr holes for Evacuation of Subdural Hematoma:
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Your wound was closed with staples. Keep your wound clean and
dry until seen in follow-up for staple removal.
You may shower before this time using a shower cap to cover
your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
***You have been discharged to home with a prescription for
outpatient physical therapy. You are not permitted to drive
until cleared by Dr. ___. You will need to arrange for
a friend/family member to take you to outpatient physical
therapy.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101.5° F.
Followup Instructions:
___
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2143-11-20 22:43:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zantac / lisinopril
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p CABG ___ prior, stent & AVR in ___ discharged 1
week ago that presents with CP. Started suddenly this morning
after returning to his bed from the restroom. In his left chest
and arm. Associated with dyspnea. Pain then resolved
spontaneously. Occurred ___ time again after activity. Currently
having mild chest discomfort. Denies diaphoresis, cough, fevers,
back pain, abd pain. Patient states he took a ASA 324 today.
In the ED intial vitals were: 97.7 70 112/50 18 99% RA. Patient
was noted to have troponin 0.02 which is decreased compared to
earlier in ___. EKG was aflutter consistent with prior. His
cardiologist was contacted who wanted patient admitted. Further
work up was negative.
Vitals on transfer: 97.9 87 119/67 21 98% Nasal Cannula
On the floor patient states he has slightly different chest
discomfort located where his pacer placement was.
ROS: On review of systems, s/he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. S/he denies recent
fevers, chills or rigors. S/he denies exertional buttock or calf
pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
CAD s/p CABG, PCI, and MI
Chronic systolic CHF (EF ___ w/ dilated cardiomyopathy,
severe global hypokinesis
Severe aortic stenosis s/p ___ TAVR ___
Hypertension
Hyperlipidemia
Type 2 diabetes c/b retinopathy, CKD
Non-Hodgkin's Lymphoma, s/p chemo and radiation in ___,
recurrence in ___ with additional chemotherapy.
Hypothyroidism
Anemia
Pancytopenia
Benign Thyroid nodule
Vitamin B 12 deficiency
Vitamin D deficiency
Hearing loss (bilateral hearing aids)
Lumbosacral radiculopathy
Constipation
Difficulty swallowing food and water- attempt at esophageal
dilation several years ago ineffective
Social History:
___
Family History:
There is a family history of an early myocardial infarction. His
mother died at age ___ of uterine cancer. His father died at ___
of a myocardial infarction.
Physical Exam:
VS: 98 135/51 80 18 100RA
General: elderly male, in NAD
HEENT: oropharynx clear, no LAD
Neck: JVD @ level of clavicle
CV: irreg, not tachy, ___ systolic ejection murmur @ LUSB,
bruising over L chest, ttp in left chest at lateral border of
pectoralis major
Lungs: CTA ___
Abdomen: soft, nt, nd
GU: no foley
Ext: no CCE
Neuro: moves all 4 extremities purposefully and without
incident, no facial droop
Pertinent Results:
___ 06:58PM BLOOD WBC-7.8 RBC-3.19* Hgb-9.7* Hct-29.0*
MCV-91 MCH-30.5 MCHC-33.5 RDW-14.7 Plt ___
___ 06:58PM BLOOD Neuts-50 Bands-0 ___ Monos-24*
Eos-0 Baso-0 Atyps-1* ___ Myelos-0
___ 01:42AM BLOOD WBC-7.8 RBC-3.32* Hgb-9.8* Hct-30.2*
MCV-91 MCH-29.5 MCHC-32.4 RDW-14.9 Plt ___
___ 06:10AM BLOOD WBC-7.3 RBC-3.18* Hgb-9.4* Hct-29.3*
MCV-92 MCH-29.4 MCHC-31.9 RDW-14.9 Plt ___
___ 01:42AM BLOOD ___ PTT-41.9* ___
___ 05:00PM BLOOD ___ PTT-42.1* ___
___ 05:46AM BLOOD ___ PTT-42.2* ___
___ 06:58PM BLOOD Glucose-103* UreaN-22* Creat-1.3* Na-134
K-4.2 Cl-100 HCO3-23 AnGap-15
___ 01:42AM BLOOD Glucose-122* UreaN-22* Creat-1.3* Na-136
K-4.2 Cl-100 HCO3-27 AnGap-13
___ 06:10AM BLOOD Glucose-105* UreaN-24* Creat-1.3* Na-140
K-4.4 Cl-101 HCO3-28 AnGap-15
___ 05:46AM BLOOD Glucose-116* UreaN-24* Creat-1.1 Na-137
K-3.9 Cl-100 HCO3-27 AnGap-14
___ 06:58PM BLOOD cTropnT-0.02*
___ 01:42AM BLOOD CK-MB-3 cTropnT-0.02*
___ 12:06AM BLOOD cTropnT-0.01
___ 05:46AM BLOOD proBNP-4518*
___ 01:42AM BLOOD Calcium-9.2 Phos-4.2 Mg-1.9
___ 06:10AM BLOOD Calcium-9.3 Phos-4.6* Mg-1.8
___ 05:46AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.1
ECG: ___
Atrial flutter/coarse atrial fibrillation with variable block.
Left bundle-branch block. No major change from previous tracing.
ECG ___
Sinus rhythm. Prolonged A-V conduction. Intraventricular
conduction delay.
Diminished voltage in the limb leads with preserved precordial
voltage
consistent with cardiomyopathy. Compared to the previous tracing
of ___
sinus rhythm has replaced atrial flutter.
CXR:
FINDINGS: Frontal and lateral views of the chest were obtained.
There is
blunting of the posterior costophrenic angle suggesting small
pleural
effusions. No overt pulmonary edema is seen. There is no focal
consolidation. The patient is status post median sternotomy and
CABG and
aortic valve replacement. Dual-lead left-sided pacemaker is
again seen,
unchanged in position, with leads extending to the expected
positions of the
right atrium and right ventricle. The cardiac and mediastinal
silhouettes are
stable.
IMPRESSION: Small bilateral pleural effusions.
ECHO: ___
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated with moderate to severe global hypokinesis
(LVEF = 30 %). Suboptimal image quality precludes regional
assessment. Right ventricular cavity size is top normal. An
aortic ___ prosthesis is present. The prosthesis is well
seated with normal gradient. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is trivial
mitral stenosis. Mild to moderate (___) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
estimated. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Well seated aortic
___ bioprosthesis with normal gradient and trace aortic
regurgitation. Left ventricular cavity dilation with global
hypokinesis c/w diffuse process. Mild-moderate mitral
regurgitation. Trivial mitral stenosis.
Compared with the prior study (images reviewed) of ___
the gradient across the aortic valve ___ and the severity
of aortic regurgitation are both slightly lower.
Nuclear Stress12/23
Uninterpretable ECG with no anginal type symptoms to vasodilator
stress. Appropriate hemodynamic response to Persantine Nuclear
report sent separately.
1. No evidence of reversible ischemia. Decreased radiotracer
uptake in the inferolateral wall, likely secondary to soft
tissue attenuation.
2. Global hypokinesis with markedly reduced ejection fraction
of 21%.
3. Enlarged Left ventricular cavity with end diastolic volume
of 220 ml.
Brief Hospital Course:
Mr. ___ is an ___ w/ symptomatic severe AS s/p ___
TAVR, dilated cardiomyopathy, T2DM, HTN, prior nonhodgkins
lymphoma s/p chemo and XRT with recurrence s/p chemo who
presents with chest pain.
#Chest Pain: ECG without ischemic changes. Troponins negative
x3. Chest pain resolved spontaneously. Possible MSK component
given bruising over chest wall and tenderness to palpation.
However, given risk factors, could not exclude cardiac etiology.
He had a nuclear pharm stress which showed no evidence of
reversible ischemia making cardiac etiology less likely. He
remained chest pain free. He was continued on ASA, plavix, beta
blocker, statin.
# Atrial Flutter: The patient developed paroxysmal A-fib,
A-flutter with variable block, and ___ periodic 2nd degree AV
block with Wenkebach conduction after his recent core valve
placement. He was started on anticoagulation. He was noted to
have pre-syncopal episodes with prolonged sinus pauses and
therefore underwent pacemaker placement. Pacemaker was
interrogated during admission. He was continued on warfarin. INR
was supratherapeutic on day of discharge and dose was held on
___. He was instructed to take 2 mg on ___ and to have his
INR drawn on ___ and adjust his dose as directed by his MD.
# Severe aortic stenosis s/p Core Valve TAVR: Pt. with hx. of
severe aortic stenosis with recent clinical
decompensation, NYHA class III symptoms. The post-operative
course was complicated by new paroxysmal atrial fibrillation,
new ___ degree AV conduction delay w/ Wenkebach, and hematoma
formation
at the femoral access site. A repeat echo during admission
showed EF of 30% and ___ bioprosthesis with normal
gradient and trace aortic regurgitation. He was continued on his
current medication regimen.
# Coronary artery disease: Pt. with hx. of silent MI and CAD
s/p CABG in ___. Cath in ___ revealed three patent grafts
but 70% stenosis in the SVG to the PDA, now s/p DES. The
patient to be continued on Aspirin and Plavix during this
hospitalization. He was also continued on Metoprolol Succinate
25mg, simvastatin and Losartan
# Type 2 diabetes: held home oral medications and treated with
HISS
# Chronic dysphagia: soft diet during this admission
# Hypothyroidism: continued home levothyroxine
# B12 deficiency: continuted B12 supplementation
transitional issues:
- INR was supratherapeutic on day of discharge. patient will
need to have his INR closely followed and warfarin dose may need
further adjustment
- patient appeared euvolemic at time of discharge. monitor
cardiopulmonary exams and daily weights. lasix dose may need
adjustment
# CODE: full (confirmed)
# CONTACT: Patient, ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Vitamin D 1000 UNIT PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
2. Nitroglycerin SL 0.4 mg SL PRN Chest Pain *Research Pharmacy
Approval Required* Research protocol ___
3. Multivitamins 1 TAB PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
4. Aspirin 81 mg PO DAILY *Research Pharmacy Approval Required*
Research protocol ___
5. Clopidogrel 75 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
6. Cyanocobalamin 100 mcg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
7. Docusate Sodium 100 mg PO DAILY
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Losartan Potassium 25 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Senna 2 TAB PO DAILY:PRN Constipation
13. Simvastatin 10 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
14. Acetaminophen 1000 mg PO Q8H:PRN pain *Research Pharmacy
Approval Required* Research protocol ___
15. Bisacodyl 10 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
16. Furosemide 20 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
17. Miconazole Powder 2% 1 Appl TP TID intertriginous rash
*Research Pharmacy Approval Required*
18. glimepiride 2 mg ORAL DAILY *Research Pharmacy Approval
Required*
19. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain *Research Pharmacy
Approval Required*
20. ___ MD to order daily dose PO DAILY16 Atria
Fibrillation / Cardioverion *Research Pharmacy Approval
Required*
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain *Research Pharmacy
Approval Required* Research protocol ___
2. Aspirin 81 mg PO DAILY *Research Pharmacy Approval Required*
Research protocol ___
3. Bisacodyl 10 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
4. Clopidogrel 75 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
5. Cyanocobalamin 100 mcg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
6. Docusate Sodium 100 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
RX *docusate sodium 100 mg 1 capsule(s) by mouth BID:PRN Disp
#*60 Capsule Refills:*0
7. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Losartan Potassium 25 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Miconazole Powder 2% 1 Appl TP TID intertriginous rash
12. Multivitamins 1 TAB PO DAILY
13. Pantoprazole 40 mg PO Q24H *Research Pharmacy Approval
Required* Research protocol ___
14. Senna 2 TAB PO DAILY:PRN Constipation *Research Pharmacy
Approval Required* Research protocol ___
15. Simvastatin 10 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
16. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain *Research Pharmacy
Approval Required* Research protocol ___
17. Vitamin D 1000 UNIT PO DAILY *Research Pharmacy Approval
Required*
18. glimepiride 2 mg ORAL DAILY
19. Nitroglycerin SL 0.4 mg SL PRN Chest Pain
20. ___ MD to order daily dose PO DAILY16 Atria
Fibrillation / Cardioverion
hold warfarin on ___.
take 2 mg on ___.
have INR drawn on ___ and take as directed by MD
RX *warfarin 1 mg ___ tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnosis: coronary artery disease, aortic stenosis s/p
Core Valve
secondary diagnosis: chronic systolic CHF, type 2 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you while you were admitted to
___. You were admitted because you were having chest pain.
Your heart was monitored and your electrocardiogram and blood
tests were reassuring. You had an echocardiogram and a stress
test which were also reassuring.
Your INR was slightly high and therefore you warfarin dose was
held on ___. You should resume taking 2 mg daily tomorrow. You
should have your INR checked on ___.
You should continue to 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:
___
|
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2143-12-30 17:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zantac / lisinopril
Attending: ___.
Chief Complaint:
Weakness, nausea, lethargy
Major Surgical or Invasive Procedure:
CVL placement
Endotracheal intubation
History of Present Illness:
Mr. ___ is an ___ gentleman s/p ___ ___,
dilated cardiomyopathy (EF 30%), CABG ___, T2DM, HTN,
non-hodgkins lymphoma with ___ course complicated by
atrial fibrillation and second degree AV block, s/p permanent
pacer placement ___ who presents with dyspnea and lethargy.
The history is obtained from chart review and from the patient's
daughter, as the patient is intubated and sedated on arrival.
Mr. ___ was recently discharged from ___ on ___
after admission for CHF exacerbation in the setting of atrial
fibrillation with RVR. The etiology of his Afib was thought to
be secondary to TAVR complication. He underwent cardioversion on
the day of admission, though a week later went back into atrial
flutter. He then underwent successful ablation and was in sinus
(paced) for the remainder of his admission. For his CHF
exacerbation he was diuresed with lasix drip with the aid of
dopamine. He was diuresed from admission weight of 91 kg to a
discharge weight of 87.5.kg. He was discharged on 10 mg PO lasix
daily. He was discharged to rehab on ___. On ___ he
reported worsening shortness of breath, nausea, and was becoming
increasingly lethargic. He worked with ___ at rehab and per
daughter report was noted to be hypoxemic with ambulation. CXR
at rehab reportedly notable for LLL pneumonia and he was started
on Cefipime, Vancomycin, and Azithromycin. On admission to the
ED he denied chest pain, cough, fevers, or chills.
Patient noted to have 02 saturation in the low ___ on room air
on initial presentation to the ED, though triage vitals note 02
sat of 100% 2L NC. He was noted to be obtunded and given concern
for airway patency he was intubated and sedated.
In the ED, initial vitals were: 97 69 103/44 16 100% 2L NC
Labs and imaging significant for: WBC 9.6, Na 131, K 5.3, Phos
7.3, BNP 28420, Troponin 0.09, INR 2.8, unremarkable UA.
CXR notable for evidence of mild pulmonary edema and layering
bilateral moderate size pleural effusions.
In the ED patient received Azithromycin, Cefipime, Vancomycin.
He received Midazolam/Fentanyl in the setting of intubation and
started on dobutamine and norepinephrine.
Vitals prior to transfer were 98 70 96/40 20 100% on CMV 450x18
100% PEEP 5
ABG 7.31/55/353
Setting changed to 500x20 40% +5 PEEP
Upon arrival to the floor, the patient is intubated and sedated.
He opens his eyes to voice and is responsive to simple commands.
REVIEW OF SYSTEMS:
Unable to obtain as the patient is intubated.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes II c/b retinopathy and CKD,
Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CAD s/p CABG, PCI, and MI
-- right coronary end-arterectomy, LIMA to the LAD, SVG to the
diagonal, OM and RCA. Had a saphenous vein harvesting from both
legs.
-- Xience DES to SVG to PDA in ___
-Chronic systolic CHF (EF ___ w/ dilated cardiomyopathy,
-Severe aortic stenosis s/p ___ TAVR ___ course
complicated by heart block, Afib/flutter
--Direct-current electrical cardioversion: ___
-PACING/ICD: DDD pacemaker implantation (___
___ RF):
___
3. OTHER PAST MEDICAL HISTORY:
-Non-Hodgkin's Lymphoma, s/p chemo and radiation in ___,
recurrence in ___ with additional chemotherapy.
-Hypothyroidism
-Anemia
-Pancytopenia
-Benign Thyroid nodule
-Vitamin B 12 deficiency
-Vitamin D deficiency
-Hearing loss (bilateral hearing aids)
-Lumbosacral radiculopathy
-Constipation
-Difficulty swallowing food and water- attempt at esophageal
dilation several years ago ineffective
-Bilateral hip replacements
Social History:
___
Family History:
There is a family history of an early myocardial infarction. His
mother died at age ___ of uterine cancer. His father died at ___
of a myocardial infarction
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: T= 98.6 BP= 112/43 HR=70 RR= 14 O2 sat= 100% CMV TV 500 RR
20 PEEP 5 Fi02 50%
General: Elderly gentleman appearing stated age, lying in bed,
intubated and sedated
HEENT: ETT in place
Neck: JVP to the level of the neck
CV: Regular rate and normal rhythm, no appreciable m/r/g
Lungs: Ventilator sounds anteriorly and bibasilarly posteriorly,
no appreciable crackles
Abdomen: Soft, nontender, non-distended
GU: Foley
Ext: Warm, 2+ pitting edema to the level of the upper shins
Neuro: Sedated but responsive to voice and simple commands
Skin: Warm, non-diaphoretic
PULSES: Dopplerable
DISCHARGE PHYSICAL EXAM
=======================
VS: 97.6 111/57 (106-113/48-61) 70 (69-71) 18 97% RA
I: 660/650
Tele: no alarms
General: Elderly gentleman appearing stated age, sitting up in a
chair, in NAD
HEENT: MMM, EOMI intact, PERRL
Neck: Dressing on right neck without oozing
CV: Regular rate and normal rhythm, no appreciable m/r/g
Lungs: Clear to auscultation
Abdomen: Soft, nontender, non-distended
GU: Foley
Ext: Warm, 2+ pitting edema to the level of the ankle
Neuro: Ax0 x3
Skin: Warm, non-diaphoretic
Pertinent Results:
ADMISSION LABS
==============
___ 12:45PM BLOOD WBC-9.6# RBC-3.97* Hgb-11.5* Hct-37.1*
MCV-93 MCH-29.0 MCHC-31.1 RDW-15.3 Plt ___
___ 12:45PM BLOOD Neuts-57 Bands-0 ___ Monos-20*
Eos-1 Baso-0 ___ Myelos-3*
___ 12:45PM BLOOD ___ PTT-39.8* ___
___ 12:45PM BLOOD Glucose-90 UreaN-37* Creat-2.3*# Na-131*
K-5.3* Cl-94* HCO3-27 AnGap-15
___ 04:00PM BLOOD CK(CPK)-39*
___ 12:45PM BLOOD cTropnT-0.09* ___
___ 04:00PM BLOOD CK-MB-6 cTropnT-0.14*
___ 12:45PM BLOOD Calcium-9.1 Phos-7.3*# Mg-2.1
___ 02:10PM BLOOD Type-ART pO2-353* pCO2-55* pH-7.31*
calTCO2-29 Base XS-0
___ 12:55PM BLOOD Glucose-86 Lactate-1.4 Na-132* K-5.2*
Cl-93* calHCO3-25
___ 08:14PM BLOOD Hgb-9.3* calcHCT-28
ANTICOAGULATION
===============
___ 12:45PM BLOOD ___ PTT-39.8* ___
___ 06:00PM BLOOD ___ PTT-35.7 ___
___ 03:07AM BLOOD ___
___ 06:09AM BLOOD ___ PTT-43.5* ___
___ 05:14AM BLOOD ___ PTT-43.8* ___
___ 08:26AM BLOOD ___ PTT-40.2* ___
___ 06:55AM BLOOD ___
DISCHARGE LABS
==============
___ 06:55AM BLOOD WBC-8.2 RBC-3.45* Hgb-9.8* Hct-31.3*
MCV-91 MCH-28.5 MCHC-31.4 RDW-15.2 Plt ___
___ 06:55AM BLOOD ___
___ 06:55AM BLOOD Glucose-139* UreaN-27* Creat-1.2 Na-139
K-4.3 Cl-97 HCO3-35* AnGap-11
___ 06:55AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9
REPORTS
=======
___ CHEST X-RAY
NG tube tip is in the stomach, but the side port is at the GE
junction and
should be advanced at least 6 cm for a more standard position.
Cardiac size is top normal. Engorgement of the mediastinal
vessels has improved. Moderate pulmonary edema has improved.
Large right effusion and probably moderate left effusion have
minimally improved. There are associated bibasilar atelectasis,
right greater than left. There is no pneumothorax. ET tube is
in standard position. Right IJ catheter is in the mid SVC.
Pacemaker leads are in standard position. Aortic stent is in
place. Patient is status post CABG. Sternal wires are aligned.
___ CHEST X-RAY
Mild pulmonary vascular congestion and small to moderate size
bilateral
pleural effusions. Bibasilar airspace opacities likely
reflecting atelectasis, though infection cannot be excluded.
___ CT HEAD W/O CONTRAST
There is no evidence of hemorrhage, edema, mass effect, or acute
vascular
territorial infarction. Prominent ventricles and sulci suggest
age related global atrophy. Periventricular white matter
hypodensities are non-specific, but likely sequelae from chronic
small vessel ischemic disease. The basal cisterns appear patent
and there is preservation of gray-white matter differentiation.
No fracture is identified. The visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The
globes are unremarkable. IMPRESSION: No evidence of acute
intracranial process.
Brief Hospital Course:
___ year-old man with a history of aortic stenosis s/p Core valve
___, dilated cardiomyopathy (EF 30%), CAD s/p CABG ___,
Type 2 Diabetes, HTN, non-hodgkins lymphoma, s/p permanent pacer
placement ___ who presents with dyspnea, found to be
obtunded in the ED, intubated, and admitted to the CCU for
further management, clinically improved and transferred to the
floor on ___.
# Respiratory failure: The patient presented to ___ ED
lethargic and was intubated for airway protection. Etiology of
his presentation was likely due to underlying CHF with
superimposed altered mental status causing a decreased
respiratory drive. Lethargy and CHF managed as below. Patient
had an infectious work-up that was negative. At the time
discharge, the patient is breathing comfortably on room air.
# Acute on chronic congestive heart failure: Prior to admission,
patient's most recent ECHO in ___ showed EF 25%. On
admission, patient had evidence of volume overload on exam,
laboratory findings notable for BNP doubled from prior, and
chest X-ray with pulmonary edema. The etiology of his CHF
exacerbation was thought likely secondary to underdiuresis. He
was diuresed successfully with IV furosemide, after which he was
switched to oral lasix. He is being discarged on furosemide
20mg PO daily. His home metoprolol was increased from 50mg to
75mg daily.
# Hypoglycemia: Patient presented with fasting hypoglycemia to
glucose 40-50s requiring dextrose boluses. The Endocrinology
team was consulted and confirmed that hypoglycemia was secondary
due to decreased excretion of home glimeperide in the setting of
worsening renal function. As the patient was extubated and
started eaint, patient's hypoglycemia resolved. At the time of
discharge, blood glucose ranged from 100-150s off insulin/home
diabetes medications. He is being discharged home off
glimeperide and other antihyperglycemic agents. Per ___
consultant recommendations, the patient can consider sitagliptin
or Trajenta as an outpatient as needed.
# Altered mental status: The patient presented with Likely
secondary to hypoglycemia and now resolved with resolution of
hypoglycemia. Infectious workup negative.
# Acute kidney injury: Patient was found to have an elevated
creatinine to 2.3 on admission from a baseline of 1.3. This was
likely secondary to cardio-renal syndrome/poor forward flow.
After diuresis, patient's creatinine improved and was 1.2 on the
day of discharge.
# Hypotension: On admission, the patient was hypotensive in the
setting of hypoglycemia and sedation briefly required
vasopressor support. This resolved after cessation of sedating
medications and normalization of blood sugars.
# Atrial fibrillation s/p ablation: The patient remained
predominantly A-paced throughout this admission. He had an
episode of atrial fibrillation ___ overnight with
overlying pacemaker firing that resolved spontaneously. The
patient was continued on home amiodarone, metoprolol was
increased to 75mg daily. Warfarin was held in the setting of
supratherapeutic INR and restarted at the time of discharge.
# Critical Aortic Stenosis s/p Transaortic valve replacement:
Stable. Patient was continued on his home aspirin and
clopidogrel.
# Coronary Artery Disease status post PCI & CABG: Stable. The
patient was continued on his home ontinue aspirin and
clopidogrel.
# Type 2 Diabetes Mellitus: In the setting of fasting
hypoglycemia (see above), patient's home antihyperglycemics were
held. Per above, the patient was not discharged on any agents.
# Hypothyroidism: Stable. Patient was continued on his home
levothyroxine.
=====================
TRANSITIONAL ISSUES
=====================
- Glimepiride discontinued on discharge
- Can consider starting sitagliptin
- Lasix increased to 20mg daily on discharge
- Metoprolol increased to 75 daily
- Will need INR check and chemistries on ___
- Also needs EP eval for pacer management as outpatient given
intermittent tachyarrhythmias while in house
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN pain *Research Pharmacy
Approval Required* Research protocol ___
2. Aspirin 81 mg PO DAILY *Research Pharmacy Approval Required*
Research protocol ___
3. Bisacodyl 10 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
4. Clopidogrel 75 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
5. Cyanocobalamin 100 mcg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
6. Docusate Sodium 100 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Senna 2 TAB PO DAILY:PRN Constipation
10. Vitamin D 1000 UNIT PO DAILY
11. Amiodarone 200 mg PO DAILY
12. Atorvastatin 40 mg PO DAILY
13. Miconazole Powder 2% 1 Appl TP TID intertriginous rash
*Research Pharmacy Approval Required* Research protocol
___
14. Multivitamins 1 TAB PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
15. Nitroglycerin SL 0.4 mg SL PRN Chest Pain *Research
Pharmacy Approval Required* Research protocol ___
16. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain *Research Pharmacy
Approval Required* Research protocol ___
17. Furosemide 10 mg PO DAILY *Research Pharmacy Approval
Required*
18. glimepiride 2 mg ORAL DAILY *Research Pharmacy Approval
Required*
19. Metoprolol Succinate XL 50 mg PO DAILY *Research Pharmacy
Approval Required*
20. Warfarin 2 mg PO DAILY16 *Research Pharmacy Approval
Required*
21. Losartan Potassium 25 mg PO DAILY *Research Pharmacy
Approval Required*
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain *Research Pharmacy
Approval Required* Research protocol ___
2. Amiodarone 200 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
3. Aspirin 81 mg PO DAILY *Research Pharmacy Approval Required*
Research protocol ___
4. Bisacodyl 10 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
5. Clopidogrel 75 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
6. Cyanocobalamin 100 mcg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
7. Docusate Sodium 100 mg PO DAILY
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Losartan Potassium 25 mg PO DAILY
10. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 25 mg 3 tablet extended release 24
hr(s) by mouth daily Disp #*90 Tablet Refills:*0
11. Miconazole Powder 2% 1 Appl TP TID intertriginous rash
12. Multivitamins 1 TAB PO DAILY
13. Senna 2 TAB PO DAILY:PRN Constipation *Research Pharmacy
Approval Required* Research protocol ___
14. Vitamin D 1000 UNIT PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
15. Warfarin 2 mg PO DAILY16 *Research Pharmacy Approval
Required* Research protocol ___
16. Atorvastatin 40 mg PO DAILY
17. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
18. Nitroglycerin SL 0.4 mg SL PRN Chest Pain
19. Pantoprazole 40 mg PO Q24H
20. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
21. Outpatient Lab Work
Dx: atrial fibrillation, CHF
please obtain INR and chemistry panel
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: acute chronic heart failure exacerbation
Secondary diagnosis: hypoglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your stay at ___
___. You were admitted for shortness of
breath and was found to have an exacerbation of your heart
failure. You required a breathing machine to help you breathe
initially. We gave you medicines to remove fluid from your
lungs and supported your blood pressures with medicines. You
improved over time and we were able to remove the breathing
tube. You were also found to have low blood sugars, so we
discontinued your glimepiride. You should not take this
medication at home until you discuss it further with your
endocrinologist. Additionally, we have increased your lasix
dose to 20mg daily and your metoprolol dose to 75.
You will need to have your INR and chemistry panel checked on
___ at your primary care provider's office.
Followup Instructions:
___
|
19818243-DS-18
| 19,818,243 | 28,738,864 |
DS
| 18 |
2144-02-04 00:00:00
|
2144-02-04 19:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zantac / lisinopril
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
EGD with clipping of AVM ___
History of Present Illness:
___ w/ complex cardiac hx notable for ___ (___) for
aortic stenosis, sCHF (EF ___ and AFib (CHADS2 of 3) on ASA,
clopidogrel and warfarin p/w melena, pre-syncope and Hct drop
from 28->21.2 (baseline 30) noted at ___ (___) today. Pt
was recently admitted to ___ for CHF exacerbation. Pt first
noted black tarry stool on ___ evening but may have
had intermittent dark stools for 1 week prior. He also noted
dark black/brown stool on the day of admission after pt
self-disimpacted himself. Pt reports we was feeling weak and
fatigued this AM after passing stool. After BM, he began to feel
weak, fatigued and lightheaded w/ darkening vision. Daughter
assisted pt off the toilet and to a supine position and sxs
resolved. Pt brought to ___ where noted to have Hct drop
to 21. Started on 1u PRBC and transferred to ___. He denies
any N/V, palpitations, SOB or hematemesis with these episodes of
black stool. He denies prior hx bloody or black stools,
abdominal pain, diarrhea, nausea, vomiting/hematemesis. His last
EDG was ___ and showed gastritis. Last colonoscopy was ___
which showed diverticuli.
In the ED, initial vs were: 99.0, 70, 94/41, 19, 100% 2L. Exam
was notable for dark brown/black guaiac positive stool without
abdominal tenderness. NGT was placed and no blood was suctioned
on lavage. He was started on IV PPI BID, made NPO and given 1
unit PRBCs. GI was consulted and will likely do EGD on ___ with
anesthesia. He was also given 10mg IV vitamin K for an INR of
1.9. Warfarin, ASA and Plavix were held. Vitals prior to
transfer were 98.9, 70, 99/54, 14, 100% RA.
On the floor, patient reports that he feels well and ___ no
complaints.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes II c/b retinopathy and CKD,
Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CAD s/p CABG, PCI, and MI
-- right coronary end-arterectomy, LIMA to the LAD, SVG to the
diagonal, OM and RCA. Had a saphenous vein harvesting from both
legs.
-- Xience DES to SVG to PDA in ___
-Chronic systolic CHF (EF ___ w/ dilated cardiomyopathy,
-Severe aortic stenosis s/p ___ TAVR ___ course
complicated by heart block, Afib/flutter
--Direct-current electrical cardioversion: ___
-PACING/ICD: DDD pacemaker implantation (___ Accent
___ ___):
___
3. OTHER PAST MEDICAL HISTORY:
-Non-Hodgkin's Lymphoma, s/p chemo and radiation in ___,
recurrence in ___ with additional chemotherapy.
-Hypothyroidism
-Anemia
-Pancytopenia
-Benign Thyroid nodule
-Vitamin B 12 deficiency
-Vitamin D deficiency
-Hearing loss (bilateral hearing aids)
-Lumbosacral radiculopathy
-Constipation
-Difficulty swallowing food and water- attempt at esophageal
dilation several years ago ineffective
-Bilateral hip replacements
Social History:
___
Family History:
There is a family history of an early myocardial infarction. His
mother died at age ___ of uterine cancer. His father died at ___
of a myocardial infarction
Physical Exam:
ADMISSION EXAM:
Vitals: 97.8, 112/52, 70, 14, 97% RA
General: Alert, oriented x3, no acute distress
HEENT: Normocephalic. Sclera anicteric, MM dry, oropharynx
clear. Poor dentition. NGT in right nostril without evidence of
bloody material in tubing.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2. ___ systolic murmur
heard best at the RUSB. No rubs or gallops.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
Vitals: T98.6 112/51 70 18 98%RA
Discharge weight 81.2 kg (179 lbs).
General: Lying in bed, awake, NAD
HEENT: EOMI, oropharynx clear
Neck: JVP not elevated
Lungs: CTAB
Heart: Regular rate and rhythm. ___ systolic murmur at RUSB.
Abd: ND, normoactive BS, NTTP, soft.
Ext: tr ___ edema.
Pertinent Results:
ADMISSION LABS:
___ 02:25PM BLOOD WBC-16.0*# RBC-2.82* Hgb-8.3* Hct-25.3*
MCV-90 MCH-29.6 MCHC-32.9 RDW-17.7* Plt ___
___ 02:25PM BLOOD Neuts-57.1 Lymphs-16.8* Monos-24.8*
Eos-1.2 Baso-0.2
___ 02:25PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-OCCASIONAL
Target-OCCASIONAL Tear Dr-OCCASIONAL
___ 12:35PM BLOOD ___ PTT-30.9 ___
___ 12:35PM BLOOD Glucose-122* UreaN-68* Creat-1.9* Na-139
K-3.9 Cl-92* HCO3-29 AnGap-22*
___ 01:08PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:08PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 01:08PM URINE CastHy-11*
DISCHARGE LABS:
___ 06:10AM BLOOD WBC-8.1 RBC-3.47* Hgb-9.8* Hct-31.7*
MCV-91 MCH-28.4 MCHC-31.1 RDW-16.0* Plt ___
___ 06:10AM BLOOD ___ PTT-58.7* ___
___ 06:10AM BLOOD Glucose-134* UreaN-37* Creat-1.4* Na-139
K-4.1 Cl-94* HCO3-32 AnGap-17
___ 06:10AM BLOOD Calcium-9.0 Phos-3.5# Mg-2.1
UA
___ 01:08PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:08PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 01:08PM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-<1
___ 10:29AM URINE Color-Yellow Appear-Clear Sp ___
___ 10:29AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:29AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
MICRO:
___ URINE CULTURE - NEGATIVE
___ Urine culture prelim negative, pending final.
IMAGING:
___ EGD
Findings: Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Flat Lesions A single angioectasia was seen in the
second part of the duodenum. It was gently washed and started
bleeding. One endoclip was successfully applied for the purpose
of hemostasis.
Impression: Angioectasia in the second part of the duodenum
(endoclip)
Otherwise normal EGD to second part of the duodenum
Recommendations: Possible but no definitive source identified.
Would discuss risks and benefits of anticoagulation with patient
and family.
Trend hematocrit.
Brief Hospital Course:
___ M with aortic stenosis s/p ___ (___), sCHF (EF
___ and AFib on ASA, clopidogrel and warfarin p/w melena,
pre-syncope and found to have bleeding duodenal AVM.
#GI bleed. Patient presented with melena and pre-syncope. He
presented to OSH with Hct to 21 (previously 30), and was given 1
unit pRBC prior to transfer to ___ where he was given two
additional units pRBC with Hct to 29. His coumadin was stopped
and he was given 10mg vitamin K and taken to ___ where a
bleeding duodenal AVM was visualized and clipped. As he had
melena and his bleed was though upper GI in origin, other
concurrent sources of bleeding via colonoscopy was not pursued.
Post-EGD, he had no recurrent GI bleed and his Hct remained
stable at 29. He was initially continued on asa and plavix and
coumadin was held but restarted with heparin bridge on ___ after
discussion with patient and family regarding risk of stroke with
afib and CHF despite potential for bleeding.
#Aortic Stenosis s/p ___ replacement in ___. Patient
at high risk given prothetic valve material. Continued
plavix/asa and coumadin held then restarted with heparin bridge
on ___ as above.
#CHF with reduced EF (___). Admission weight was 85.2 kg and
discharge weight 82.4 kg. ___ DDD pacemaker/ICD,
A-paced at a rate of 70. Last device interrogation was ___.
Last echo was ___ and showed an EF of ___ down from
previous which was ___ on ___. Patient was euvolemic and
continued on home torsemide. Coumadin per above.
Discharge weight 81.2 kg (179 lbs).
#CAD s/p CABG and recent PCI DES placed in ___. Patient is
at high risk for stent closure/ thrombosis given how recently
stent was placed. After discussion with patient and family,
continued plavix as above.
#AFib S/p ablation and A-paced at a rate of ___ DDD
pacemaker/ICD. On ASA, and Coumadin held then restarted per
above with heparin bridge with lower goal INR range of 2.0-2.5.
He was continued on amiodarone and metoprolol.
#Acute on chronic kidney disease. Patient presented with Cr 1.9
from baseline of 1.3 which was likely related to acute volume
loss due to GI bleed. Creatinine on discharge was 1.4.
#DM type 2. Home glimepiride held and on SSI during hospital
course. Continued on insulin sliding scale on discharge.
#Hypothyroidism. ___ h/o benign thyroid nodule. Takes synthroid
50mcg at home. We continued synthroid at home dose.
#HLD: We continued home atorvastatin 40mg daily
TRANSITIONAL ISSUES:
-Decision to restart coumadin and continue plavix after
discussion of risks and benefits with patient and family. Goal
INR on coumadin 2.0-2.5, being discharged on coumadin 1.5mg
daily with INR 2.6 at discharge. Please monitor closely for
recurrent GI bleed.
-No MRI for 6 weeks from date of AVM clip placement (___).
-Pending final cultures from prelim negative blood culture
___ and urine culture ___.
-Patient should be seen by Dr. ___ to have his PPM evaluated
within ___ weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY *Research Pharmacy
Approval Required* Research protocol ___
2. Clopidogrel 75 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
3. Levothyroxine Sodium 50 mcg PO DAILY *Research Pharmacy
Approval Required* Research protocol ___
4. Pantoprazole 40 mg PO Q24H *Research Pharmacy Approval
Required* Research protocol ___
5. glimepiride 2 mg oral daily *Research Pharmacy Approval
Required* Research protocol ___
6. Torsemide 20 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
7. Docusate Sodium 100 mg PO DAILY
8. Warfarin 2 mg PO DAILY16
9. Amiodarone 200 mg PO DAILY
10. Atorvastatin 40 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Cyanocobalamin 1000 mcg PO DAILY *Research Pharmacy
Approval Required* Research protocol ___
14. Senna 17.2 mg PO BID *Research Pharmacy Approval Required*
Research protocol ___
15. Aspirin 81 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
Discharge Medications:
1. Amiodarone 200 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
2. Aspirin 81 mg PO DAILY *Research Pharmacy Approval Required*
Research protocol ___
3. Atorvastatin 40 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
4. Clopidogrel 75 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
5. Docusate Sodium 100 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
6. Levothyroxine Sodium 50 mcg PO DAILY *Research Pharmacy
Approval Required* Research protocol ___
7. Multivitamins 1 TAB PO DAILY
8. Senna 17.2 mg PO BID
9. Torsemide 20 mg PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Vitamin D 1000 UNIT PO DAILY
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Warfarin 1.5 mg PO DAILY16
RX *warfarin [Coumadin] 2 mg 1.5 tablet(s) by mouth daily Disp
#*60 Tablet Refills:*1
15. glimepiride 2 mg ORAL DAILY
16. Outpatient Lab Work
Please check INR on ___ and fax to Dr. ___
office @ Tel: ___, Fax: ___.
17. Equipment
Air mattress, dispense #1. ICD-9: 70___.03 Pressure ulcer, lower
back.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Gastrointestinal bleed
Duodenal Arteriovenular malformation
Secondary diagnosis:
congestive heart failure
atrial fibrillation
aortic stenosis
type II diabetes mellitus
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) and nursing assist.
Discharge Instructions:
Dear Mr. ___,
You were admitted due to gastrointestinal bleeding and found to
have a bleeding AVM (arteriovenous malformation) which was
clipped. The bleeding stopped and after discussion about the
risk of re-bleeding and risk of stroke your coumadin was
restarted.
Please monitor for any signs of bleeding while on your
medications.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19818258-DS-16
| 19,818,258 | 29,756,580 |
DS
| 16 |
2161-08-15 00:00:00
|
2161-08-20 14:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Children's Tylenol Plus / Motrin / Optiray 350 / Alcohol,
Rubbing
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: EGD/ERCP
___: EGD
History of Present Illness:
As per HPI in H&P written by Dr. ___ on ___:
"Mr. ___ is a ___ year old man with schizophrenia, history of
polysubstance abuse on suboxone, hep C s/p successful
eradication, seizure disorder, history of duodenal ulcer, and
numerous ED and clinic visits in recent months for abdominal
pain of uncertain etiology, who presented to the ED with
abdominal pain. The history was obtained in part from the
patient and in part from the medical record. The patient is a
somewhat poor historian. He has been experiencing abdominal pain
for several months now, which has prompted evaluation in several
EDs, GI clinic at ___, and in his primary care clinic. His
work-up has been mostly unrevealing to date. When seen in GI
clinic several weeks ago it was felt the pain might be related
to constipation. The patient reports no recent bowel movements
or flatus, despite being on multiple bowel meds. He reports he
had a recent enema without improvement. He states that his
abdominal pain is primarily R sided, from the mid-to-upper R
abdomen. He is unable to identify alleviating or aggravating
factors although notes that it does fluctuate somewhat. The
character has remained the same over recent months, although the
severity has gradually worsened. He states that he has had
minimal PO intake recently and has lost ___ lbs in recent
months. He states that he has been having nausea and vomiting of
clear liquid. It sounds as though he went to an outpatient
appointment today and was noted to have multiple episodes of
vomiting while there, as well as tachycardia and worsened pain,
and so was referred to the ED. He states that he does not want
to leave the hospital until the cause of his pain is determined.
Of note, the patient is uncertain of his medications and certain
details of his medical history. He lives in a group home, where
his meds are administered. He states that his sister ___
___ (?___) is the primary contact. He also notes that
___ from his group home ___ - ___ is a
good source of his medical information, although notes that they
are not reachable overnight. Regarding his history of
polysubstance abuse, he reports no drugs or alcohol for at least
2 months. He continues to smoke 1 ppd.
In the ED he was afebrile, with HRs ___, BPs
140s-160s/70s-100s, satting 98-100% on room air. Labs were
notable for K 8.1 , which was hemolyzed, and was 5.4 on repeat,
with lactate 1.6, Na 132, ALT 88, AST 190, Alk Phos 225, TB, TB
1.0, WBC 10.6, hgb 11.5. He received suboxone ___ x2, Zofran,
normal saline, Compazine, and reglan."
Past Medical History:
Chronic hep C genotype ___ s/p eradication with harvoni ___
Polysubstance abuse
Abdominal pain/Constipation
Schizophrenia
Seizure disorder
HTN
Duodenal ulcer
HL
esophageal candidiasis
nephrolithiasis
pulmonary and adrenal nodules
SIADH due to valproic acid
Social History:
___
Family History:
Reports his father had alcoholic cirrhosis
Physical Exam:
VS: T 97.6, HR 82, BP 120/75, RR 18, SpO2 100% on RA
Gen: thin, lying in bed in no apparent distress, awake and alert
HEENT: PERRL, EOMI, MMM
CV: NR/RR, no M/R/G
Pulm: CTAB, no wheezes, rhonchi, or crackles
GI: soft, no tenderness to palpation, ND, normoactive bowel
sounds
MSK: No edema
Skin: No rashes or ulcerations evident
Neuro: A+O x4, speech fluent, face symmetric, moving all
extremities
Psych: calm mood, appropriate affect
Pertinent Results:
ADMISSION LABS:
========================
___ 01:40PM BLOOD WBC-10.6* RBC-3.64* Hgb-11.5* Hct-33.0*
MCV-91 MCH-31.6 MCHC-34.8 RDW-13.0 RDWSD-43.3 Plt ___
___ 01:40PM BLOOD Neuts-85.4* Lymphs-9.3* Monos-4.6*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-9.06*# AbsLymp-0.99*
AbsMono-0.49 AbsEos-0.00* AbsBaso-0.02
___ 01:40PM BLOOD Glucose-111* UreaN-15 Creat-0.8 Na-132*
K-8.1* Cl-90* HCO3-26 AnGap-16
___ 01:40PM BLOOD ALT-88* AST-190* AlkPhos-225* TotBili-1.0
___ 01:40PM BLOOD Albumin-3.9 Calcium-9.7 Phos-3.7 Mg-2.2
___ 01:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
RUQ in ED:
1. Dilated central CBD tp 10 mm with distal CBD not well imaged.
No intrahepatic biliary ductal dilation. Correlate with LFTs and
consider MRCP non-emergently to further evaluate as clinically
indicated.
2. Pancreas not well imaged.
3. Trace ascites.
MRCP:
IMPRESSION:
1. Moderate intrahepatic and extrahepatic biliary duct dilation
with abrupt tapering at the proximal common bile duct likely due
to obstructing stone or sludge although small intraductal mass
cannot be excluded.
2. Likely acute hepatitis given heterogeneous hepatic
parenchymal enhancement and periportal edema. No focal mass.
3. Mild esophagitis with adjacent reactive lymph nodes.
4. Trace ascites.
EGD/ERCP (___):
Impression:
The Z line was seen at 38 cm from the incisors. 4 non confluent
long mucosal breaks were seen extending from the Z line up to 34
cm, consistent with ___ grade B esophagitis. A 5 cm
hiatal hernia was seen as well.
Normal mucosa in the stomach
Given difficulties in passing the duodenoscope through D1, an
upper endoscope was used. A large non bleeding ulcer was found
in the duodenal bulb ___ III). Two cold forceps biopsies
were taken for histology (differentials include peptic vs
neoplasia).
The scope was not advanced into D2. This finding could account
for the MRCP findings (external compression of the CBD by
distorted D1-2).
DISCHARGE LABS:
___ 10:00AM BLOOD WBC-5.8 RBC-2.90* Hgb-9.0* Hct-27.3*
MCV-94 MCH-31.0 MCHC-33.0 RDW-13.2 RDWSD-45.6 Plt ___
___ 05:53AM BLOOD ALT-34 AST-21 AlkPhos-137* TotBili-0.3
___ 05:53AM BLOOD Glucose-97 UreaN-12 Creat-0.7 Na-138
K-4.4 Cl-98 HCO3-25 AnGap-15
___ 05:53AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.9
Hepatitis A IgM negative
Hep B serologies consistent with prior vaccination
HCV VL not detected
EBV serologies: IgG positive; IgM negative
CMV IgG postitive; CMV IgM negative
MICRO:
BCx (___): pending
UCx - no growth
PATHOLOGY:
Duodenal ulcer, mucosal biopsies: Chronic active duodenitis with
ulceration.
Brief Hospital Course:
Mr. ___ is a ___ year old man with schizophrenia, history of
polysubstance abuse on suboxone, hep C s/p successful
eradication, seizure disorder, history of duodenal ulcer, and
numerous ED and clinic visits in recent months for abdominal
pain of uncertain etiology, who presented to the ED with
worsening abdominal pain, nausea, and vomiting, imaging
concerning for possible choledocholithiasis +/- acute hepatitis
on imaging.
# Large duodenal ulcer causing biliary obstruction
# Melena
The patient has had a ___ month h/o unexplained abdominal pain,
nausea, and vomiting. In the ED, he had imaging (RUQ US and
MRCP) that were concerning for possible choledocholithiasis +/-
acute hepatitis. On ERCP (___), he was found to have
esophagitis, a hiatal hernia, and a large duodenal ulcer s/p
biopsies (ddx includes peptic vs. neoplasm). Because this large
ulcer could cause the MRCP findings (external compression of the
CBD by distorted D1-2), the endoscope was not advanced further
to complete ERCP. After ERCP, he was treated with high dose PPI
(initially IV, later transitioned to omeprazole 40 mg PO BID.
His diet was slowly advanced until he was tolerating a regular
diet. He developed melena so GI was consulted. However his Hgb
was stable and he started having brown stools again, so he did
not have a repeat EGD.
The biopsies of the duodenal ulcer show "chronic active
duodenitis with ulceration."
# Obstructive pattern LFTs
# Concern for hepatitis
The initial imaging was concerning for hepatitis, so hepatitis
labs were sent including viral hepatitis, EBV, and CMV
serologies. Hepatitis A IgM was negative,Hep B serologies were
consistent with prior vaccination, HCV VL not detected, EBV
serologies consistent with prior exposure, and CMV serologies
consistent with prior exposure. After the ERCP, his LFTs
improved until they normalized. Most likely these were due to
biliary obstruction from the distortion of the duodenum by the
large ulcer, as above.
# Severe malnutrition
He had poor PO intake in the setting of chronic abdominal pain.
Nutrition was consulted and recommended meal supplementation
with Prosource Gelatein QID.
# Hypovolemic hyponatremia - resolved with IV hydration
# History of polysubstance abuse (in remission) - continued
suboxone ___ TID
# Schizophrenia
# Seizure disorder
- continued Haldol 5 qam/10 qpm, Cogentin 0.5 BID
- continued lamictal 100 qam / 200 qpm
- continued keppra 500 BID
- continued Seroquel 600 HS
Mr. ___ is clinically stable for discharge today. The total
time spent today on discharge planning, counseling and
coordination of care was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea or wheezing
2. Benztropine Mesylate 0.5 mg PO BID
3. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL TID
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Haloperidol 5 mg PO QAM
6. LamoTRIgine 100 mg PO QAM
7. LevETIRAcetam 500 mg PO BID
8. Pantoprazole 20 mg PO Q24H
9. QUEtiapine extended-release 600 mg PO QHS
10. Docusate Sodium 100 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Senna 8.6 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. DICYCLOMine 10 mg PO TID:PRN abdominal pain
15. Haloperidol 10 mg PO QHS
16. LamoTRIgine 200 mg PO QHS
17. Nicotine Patch 21 mg TD DAILY
18. Desonide 0.05% Cream 1 Appl TP BID
19. Milk of Magnesia 30 mL PO DAILY:PRN constipation
20. Magnesium Citrate 300 mL PO BID:PRN constipation
21. Ondansetron 4 mg PO DAILY
Discharge Medications:
1. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp
#*180 Capsule Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea or wheezing
3. Benztropine Mesylate 0.5 mg PO BID
4. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL TID
5. Desonide 0.05% Cream 1 Appl TP BID
6. DICYCLOMine 10 mg PO TID:PRN abdominal pain
7. Docusate Sodium 100 mg PO BID
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Haloperidol 5 mg PO QAM
10. Haloperidol 10 mg PO QHS
11. LamoTRIgine 200 mg PO QHS
12. LamoTRIgine 100 mg PO QAM
13. LevETIRAcetam 500 mg PO BID
14. Magnesium Citrate 300 mL PO BID:PRN constipation
15. Milk of Magnesia 30 mL PO DAILY:PRN constipation
16. Multivitamins 1 TAB PO DAILY
17. Nicotine Patch 21 mg TD DAILY
18. Ondansetron 4 mg PO DAILY
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. QUEtiapine extended-release 600 mg PO QHS
21. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Duodenal ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for worsening abdominal pain,
nausea and vomiting. You had imaging that was concerning for
gallstones obstructing the biliary tree. For this, you had an
ERCP. On the ERCP they found a large ulcer in the duodenum that
was likely causing your symptoms so the procedure was not
continued. They took biopsies of the ulcer, which are still
pending.
Please follow up with pathology reports from the biopsies.
Please call Dr. ___ ___ in 10 days for
the pathology results.
Your liver tests improved after the procedure and you tolerated
a regular diet.
Best of luck with your continued healing!
Take care,
Your ___ Care Team
Followup Instructions:
___
|
19818362-DS-16
| 19,818,362 | 23,933,989 |
DS
| 16 |
2154-06-19 00:00:00
|
2154-06-19 18:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
TIA
Major Surgical or Invasive Procedure:
Left carotid artery stent
History of Present Illness:
___ year old right handed man with hx of HTN, HLD, CAD s/p
stents, DM, known carotid stenosis presents with an episode of
language difficulty suggestive of left frontal (MCA territory)
ischemia. CT scan without evidence of acute or subacute
ischemia. CTA reveals a high-grade stenosis of the left proximal
ICA. Tandem lesion intracranially in the petrous portion. MRI
brain without
acute or subacute infarction.
Past Medical History:
PMH: HTN, HLD, DMII, CAD s/p PCI ___, CKD baseline Cr,
homocystinuria, GERD
PSH:
Laparoscopic right inguinal hernia repair ,Excision of skin
cancer, PEG in ___.
Physical Exam:
Alert and oriented x 3. Neurologically intact.
VS:BP 97/61 HR 46 RR 18
Resp: Lungs clear
Abd: Soft, non tender
Groin puncture site: Dressing clean dry and intact. Soft, no
hematoma or ecchymosis.
Pertinent Results:
___ 05:04AM BLOOD WBC-6.0 RBC-2.89* Hgb-9.8* Hct-27.6*
MCV-96 MCH-33.9* MCHC-35.5 RDW-13.7 RDWSD-47.0* Plt ___
___ 05:04AM BLOOD Plt ___
___ 05:04AM BLOOD Glucose-163* UreaN-16 Creat-1.1 Na-137
K-4.0 Cl-105 HCO3-23 AnGap-13
___ 05:04AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.1
MR ___
No evidence of infarction.
Brief Hospital Course:
___ hx of DM, HTN, CAD s/p PCI, and tongue SCC s/p surgery x 2
and radiation to the neck presents to outside ER after TIA
consisting of aphasia, dysarthria,
confusion and left-sided facial droop. He has known 80% left ICA
stenosis and is scheduled for stenting in ___. He was
started on a heparin infusion then transferred to ___.
Intervention was planned for this admission. Prior to the
stenting, he did have another TIA consisting of expressive angio
which quickly resolved without treatment.
He was underwent left carotid stent as well as an intracranial
internal carotid stent by neurosurgery on ___. Post op
course was significant for bradycardia an a prolonged course of
neo through much of POD 1 secondary to low SBP.
By POD 2 he was off pressors and asymptomatic and neurologically
intact. By discharge he was ambulatory ad lib, tolerating a
regular diet and voiding qs. We changed the metoprolol to short
acting and held his enalapril secondary to relative hypotension.
We have arranged ___ for BP monitoring and follow up with his
PCP for next week. He will follow up with Dr. ___ in
one month.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Simvastatin 20 mg PO QPM
4. MetFORMIN (Glucophage) 100 mg PO BID
5. Atenolol 25 mg PO BID
6. Allopurinol ___ mg PO DAILY
7. Enalapril Maleate 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Enalapril Maleate 20 mg PO DAILY
HOLD this medication until BP check by ___ or PCP.
5. MetFORMIN (Glucophage) 100 mg PO BID
6. Simvastatin 20 mg PO QPM
7. Metoprolol Tartrate 12.5 mg PO BID
this is a short acting medication that is dosed twice daily.
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice daily Disp #*30 Tablet Refills:*0
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Symptomatic left carotid artery stenosis
Transischemic attack
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital after
placement of a stent in your carotid artery. The stent will
help keep the artery open so that blood can flow to the brain.
To perform the procedure, a small puncture was made in an artery
in your groin, the puncture site heals on its own. There are no
stiches to remove.
Division of Vascular and Endovascular Surgery
Carotid Artery Stent Discharge Information
Preventing a Blood Clot in the Stent
After getting a stent, you need to take aspirin and
clopidogrel (Plavix) medicines that work to prevent blood clots
from forming on the carotid stent.
Important: Do not stop taking aspirin and clopidogrel (Plavix)
without discussing it with the doctor who did your carotid stent
procedure.
Puncture Site Care
For one week:
Do not take a tub bath, go swimming or use a Jacuzzi or hot
tub.
Use only mild soap and water to gently clean the area around
the puncture site.
Gently pat the puncture site dry after showering.
Do not use powders, lotions, or ointments in the area of the
puncture site.
You may remove the bandage and shower the day after the
procedure. You may leave the bandage off.
You may have a small bruise around the puncture site. This is
normal and will go away one-two weeks.
Activity
For the first 48 hours:
Do not drive for 48 hours after the procedure
For the first week:
Do not lift, push , pull or carry anything heavier than 10
pounds
Do not do any exercises or activity that causes you to hold
your breath or bear down with abdominal muscles. Take care not
to put strain on your abdominal muscles when coughing, sneezing,
or moving your bowels.
After one week:
You may go back to all your regular activities, including
sexual activity. We suggest you begin your exercise program at
half of your usual routine for the first few days. You may
then gradually work back to your full routine.
Followup Instructions:
___
|
19818362-DS-17
| 19,818,362 | 27,702,494 |
DS
| 17 |
2154-07-09 00:00:00
|
2154-07-11 18:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo man with recent L ICA tandem stenting on
___ after presenting with TIA, who presents as a transfer
from ___ after telestroke for transient aphasia. NIHSS 1
for wrong month during telestroke, and no tPA was given. SBP
initially 200, down to 180 without intervention. TLSN 1530.
The patient noticed that he wasn't able to speak properly for 1
minute and had numbness in his right arm for ___ minutes.
There
was mildly slurred speech. He also felt lightheaded and unsteady
on his feet. This started at 3:30 pm. The patient was saying
words, but was having a hard time getting them out and when he
did get them out, they didn't make sense. Although the symptoms
resolved, they came and went even in OSH ED. He currently feels
back to his baseline.
He had an episode approx. 1 week ago with elevated blood
pressure, seen at ___ and amlodipine was added to his
medications.
He was recently admitted to ___ from ___ for transient
aphasia, dysarthria, confusion and left-sided facial droop,
thought due to symptomatic L carotid stenosis. He was treated
with heparin gtt and then tandem L ICA stents on ___.
Past Medical History:
PMH: HTN, HLD, DMII, CAD s/p PCI ___, CKD baseline Cr,
homocystinuria, GERD
PSH:
Laparoscopic right inguinal hernia repair ,Excision of skin
cancer, PEG in ___.
Social History:
___
Family History:
1. Mother: died of an MI
2. Brother: DM type ___
Physical Exam:
ADMISSION EXAM:
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Neck: Supple
Pulmonary: CTABL
Cardiac: RRR
Abdomen: soft, nontender, nondistended
Extremities: no edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to name, ___, year but not
month or date. Able to relate history. Language is fluent with
intact repetition and comprehension. Normal prosody. There
were
no paraphasic errors. Able to describe picture on stroke card.
Pt. was able to name both high and low frequency objects. Able
to read with mild difficulty because he was not wearing his
glasses. Speech was not dysarthric. Able to follow both
midline
and appendicular commands. Inattentive, makes 2 mistakes on ___
backwards, after starting the task twice because he thought he
was doing it wrong and wanted to self correct. Pt. was able to
register 3 objects and recall ___ at 5 minutes (remembers other
words, likely from prior testing today). There was no evidence
of
neglect.
-Cranial Nerves:
I: Olfaction not tested.
___: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, mildly increased tone in BLE. No
adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS.
-Coordination: Mild intention tremor L>R. No dysmetria on FNF or
HKS bilaterally.
-Gait: not tested.
DISCHARGE EXAM:
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Neck: Supple
Pulmonary: CTABL
Cardiac: RRR
Abdomen: soft, nontender, nondistended
Extremities: no edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to name, ___, date. Able to
relate history. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors. Able to describe picture on stroke card.
Pt was able to name both high and low frequency objects. Able
to read. Speech was not dysarthric. Able to follow both
midline and appendicular commands. There was no evidence of
neglect.
-Cranial Nerves:
I: Olfaction not tested.
___: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, mildly increased tone in BLE. No
adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
- Plantar response was flexor bilaterally.
- Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS.
- Coordination: Mild intention tremor L>R. No dysmetria on FNF
or
HKS bilaterally.
-Gait: not tested.
Pertinent Results:
======================
LABS:
___ 07:27PM WBC-9.7# RBC-3.81*# HGB-13.0*# HCT-36.3*#
MCV-95 MCH-34.1* MCHC-35.8 RDW-13.6 RDWSD-47.2*
___ 07:27PM PLT COUNT-186
___ 07:27PM ___ PTT-30.8 ___
___ 07:27PM GLUCOSE-222* UREA N-23* CREAT-1.1 SODIUM-135
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-26 ANION GAP-18
___ 07:27PM CALCIUM-9.6 PHOSPHATE-2.8 MAGNESIUM-1.0*
___ 05:25AM BLOOD %HbA1c-7.0* eAG-154*
======================
IMAGING:
CTA Head/Neck ___:
1. Stent in the left common carotid artery extending into the
left internal carotid artery as well as a stent in the petrous
segment of the left internal carotid artery with contrast
opacification of the lumen suggesting luminal patency.
2. Otherwise, unremarkable CTA of the head and neck noting mild
atherosclerosis.
3. No acute intracranial abnormality.
MRI Brain ___:
New foci of restricted diffusion involving the splenium of the
corpus callosum, and left parietal lobe, which are new compared
to the prior examination, and represent acute/subacute infarcts.
CTA Head/neck ___:
IMPRESSION:
1. Short segment severe stenosis at the left P4 segment
posterior cerebral
artery with filling of the distal parieto-occipital artery
either across a
stenosis or via collaterals. There is associated geographic
area of increased mean transit time within the parieto-occipital
cortex consistent with slow flow to the cortex supplied by the
parieto-occipital artery. No definitive underlying core infarct
on cerebral blood flow or blood volume. No associated
hemorrhage.
2. Unchanged focal hypodensity at the left splenium corpus
callosum consistent with site of subacute infarction.
3. Patent left P2 segment internal carotid artery stent.
4. Small focal filling defects within the common to bulb carotid
stent which may represent intimal thickening versus thrombus.
The upper filling defect appears mildly enlarged in comparison
to prior study.
5. Unchanged ulceration at the proximal left external carotid
artery.
6. Comminuted right medial clavicle fragment with adjacent
stranding which is unchanged comparison to ___
which may represent a subacute to chronic fracture possibly
secondary to osteonecrosis given history of
radiation. 7. Radiation changes within the neck including fatty
atrophy of the salivary glands, atrophic thyroid, and stranding
throughout the subcutaneous soft tissues.
MRI brain ___:
IMPRESSION:
1. Study is mildly degraded by motion.
2. Stable left splenium of corpus callosum subacute infarct .
3. Stable punctate left parietal occipital subcortical white
matter subacute infarct.
CT head noncontrast ___:
IMPRESSION:
Unchanged small hypodensity within the left aspect of the
splenium corpus
callosum corresponding to the known subacute infarction. No
acute hemorrhage. No CT evidence for an acute major vascular
territorial infarct.
======================
EEG REPORTS:
___:
IMPRESSION: This is mildly abnormal recording due to the
presence of a
somewhat slower than average waking background, although the
lack of
significant daytime recording makes this finding more tenuous.
No asymmetries of background were seen and no epileptiform
activity was captured. Note is made of an irregular cardiac
rhythm.
___:
IMPRESSION: This is a normal EEG telemetry recording. No
asymmetries of
background were seen and no epileptiform activity was captured.
Note is made of an irregular cardiac rhythm.
Brief Hospital Course:
Mr. ___ is a ___ yo male who was recently admitted to ___ from
___ for transient aphasia, dysarthria, confusion and
left-sided facial droop, thought due to symptomatic L carotid
stenosis. At that time he was treated with heparin gtt and had
tandem L ICA stents placed on ___, prior to discharge. He was
discharged home on Plavix and ASA. He was admitted to the ___
Stroke Service on ___ after being evaluation at an OSH for an
episode of transient aphasia.
Upon transfer to ___, neuro exam was only remarkable for mild
inattention and some difficulty with complex tasks. CTA
Head/Neck demonstrated stent in the left common carotid artery
extending into the left internal carotid artery as well as a
stent in the petrous segment of the left internal carotid artery
with contrast opacification of the lumen suggesting luminal
patency. MRI showed new foci of restricted diffusion involving
the splenium of the corpus callosum and left parietal lobe,
likely acute/subacute infarcts which were not felt to explain
his symptoms. Transcranial Doppler US was negative. Extended
routine EEG was also performed and was negative for epileptiform
activity. CTA showed patent carotid stent but possible luminal
irregularity which could be microthrombus vs artifact.
On ___ he had another event which lasted for 5 minutes, and
he was taken to CT for a perfusion scan which showed focally
decreased perfusion in the left parieto-occipital area. He had
another event on ___ which also resolved and was in the
setting of positive orthostatic vital sign changes. The etiology
of his events was not entirely clear but suspected to be a
combination of microemboli from plaques near the carotid stent
as well as hypoperfusion possibly in setting of atherosclerosis
or stenosis not well visualized on imaging.
He was started on Coumadin with heparin gtt bridge. He was
continued on aspirin and Plavix for the stent per
Vascular/Neurosurgery protocol. Once his INR increased to 1.8
the heparin was discontinued and he was discharged home.
------
Transitional issues:
[ ] Please continue Coumadin indefinitely for stroke prevention.
[ ] Please continue aspirin and Plavix as per protocol for
carotid stent.
[ ] Patient's INR on day of discharge was 1.8. He was instructed
to decrease dose of coumadin to 5mg daily. Please draw INR on
___ and determine dosage.
[ ] Stroke and Vascular Surgery followup arranged as below.
[ ] Patient's home antihypertensives were all resumed with
exception of metoprolol which was halved to 6.25mg BID. Please
continue to monitor and titrate for a long term goal of
normotension though with the caveat that he may have
perfusion-related neurologic symptoms not related to carotid
stenosis.
[ ] Continue atorvastatin for lipid-lowering therapy and obtain
repeat LDL in ___ months. Monitor LFTs.
------
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes -SC Heparin () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? (X) Yes (LDL = 55) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - Atrovastatin
80() No [if LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - Atorvastatin 80() No
[if LDL >100, reason not given: ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - ASA/Plavix (X) Anticoagulation] - coumadin () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (X) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Enalapril Maleate 20 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Simvastatin 20 mg PO QPM
7. Metoprolol Tartrate 12.5 mg PO BID
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Amlodipine 5 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Enalapril Maleate 20 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth every evening Disp
#*30 Tablet Refills:*5
9. Amlodipine 5 mg PO DAILY
10. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 2.5 mg 2 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
11. Metoprolol Tartrate 6.25 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Transient Aphasia/dysarthria, suspected secondary to
microemboli/intracranial atherosclerosis
Diabetes mellitus
Hypercholesterolemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for recurrent episodes of difficulty with
speech and slurring. We found that your carotid stent was open
and functioning well, but you may have small clot around the
stent that could be causing mini-strokes to a particular area of
your brain, which is particularly sensitive to changes in blood
flow. We started you on anticoagulation with Coumadin, which you
should continue to take as directed by your physician. Please be
sure to have your blood checked tomorrow ___ and follow
his/her instructions for changing dosage.
For your blood pressure, we initially held your blood pressure
medications and gradually restarted them. You should continue
your home medications with the exception of your metoprolol,
which you should take at a reduced dose of 6.25mg twice daily.
Your PCP can resume this back to normal dosing when you see
him/her. You should monitor your blood pressure and be careful
when switching positions, and maintain good hydration all the
time.
Please take all your other medications as prescribed and go to
your appointments as scheduled. If you have any of the symptoms
listed below, please seek medical attention immediately.
It was a pleasure taking care of you. We wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19818362-DS-18
| 19,818,362 | 26,152,254 |
DS
| 18 |
2154-07-18 00:00:00
|
2154-07-18 18:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
expressive aphasia
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
The patient is a ___ year old gentleman, pmh of HTN, HLD,
DMII, CAD, and multiple recent hospital admissions for TIA with
aphasia and L spenium infarct s/p L ICA tandem stenting with
?microthrombus vs artifact on CTA ___, presents from an OSH
for an episode of expressive aphasia. Per chart review: He was
admitted from ___ for transient aphasia, dysarthria,
confusion and leftsided facial droop, that was thought to be ___
symptomatic L carotid stenosis. He got a tandem L ICA stent on
___ and discharged home on ASA/Plavix. He was admitted again to
___ on ___ after presentation to OSH for transient
aphasia
(NIHSS1), but on presentation, exam was only notable for
inattention. His CTA was notable for patent stent, but with
possible irregularity, which could be microthrombus vs.
artifact.
His MRI was notable for new subacute infarcts in splenium of
corpus callosum and left parietal lobe, which were not the cause
of his symptoms. TCD and EEG were negative. He had two events
(unclear what the events were), that were felt to be due to
combination of microemboli near stents, atherosclerosis, and
hypoperfusion. He was started on a heparin bridge and
transitioned to Coumadin. He was discharged on ___ with goal of
normotension and continuation of asa/Plavix/Coumadin. His neuro
exam on discharge was overall normal, and only notable for:
intact language, naming, comprehension as well as mild L>R
intention tremor.
For this admission, he presented to ___ after an
episode of difficultly speaking. At 4:30 pm, he was sitting on
the couch, watching tv, when his speech changed. He had trouble
making words, but he is not sure if it was slurred or if the
words were nonsensical. He knows his wife (who is not present in
ED) had trouble understanding him. He also feels that he had
difficultly understanding. This was also associated with room
spinning dizziness. They called the Fire department who brought
them to ___. He felt his symptoms resolved within an
1.5 hrs, but he does not feel that his speech has returned ot
baseline. He mentions he had a similar event on either ___
or ___, but he does not remember the circumstances of the
event or the duration.
At ___, his NIHSS was 2 for expressive aphasia. His
INR was 1.7 so tpa was not given. He was transferred for
emergent
CTA/CTP/NCHCT
Past Medical History:
PMH: HTN, HLD, DMII, CAD s/p PCI ___, CKD baseline Cr,
homocystinuria, GERD, remote throat cancer
PSH:
Laparoscopic right inguinal hernia repair ,Excision of skin
cancer, PEG in ___.
Social History:
___
Family History:
1. Mother: died of an MI
2. Brother: DM type ___
Physical Exam:
ADMISSION EXAMINATION
Vitals: T 98.0 HR 92 BP 145/71 RR 18 98% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, dry mm and cracked lips,
neck supple
___: RRR, no MGR
Pulmonary: upper airway transmitted breath sounds (per pt
baseline breathing)
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 2 (Date ___, corrects to ___. Mildly inattention to examiner easily
maintained. Recalls a coherent history. Some difficulty when
reciting months of year backwards (omitted ___. Speech is
fluent with full sentences, intact repetition, and intact verbal
comprehension. Naming intact. No paraphasias. Normal prosody.
no lingual/labial/guttural difficulties. ?deep/hoarse speech.
Verbal registration ___. No apraxia. No evidence of hemineglect.
No left-right confusion.
- Cranial Nerves - PERRL 3->2 brisk. VF full to number counting.
EOMI, end-gaze nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. Right pronation, no drift. No
tremor or asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___- 5 5 5 5 5 5
R 5 ___ ___- 5 5 5 5 5 5
- Sensory - No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R * 1 1 1 1
Plantar response flexor bilaterally.
*not tested due to line placement.
- Coordination - L>R intention tremor bilaterally. No dysmetria
on finger following b/l. Good speed and intact cadence with
rapid
alternating movements.
- Gait - Deferred
DISCHARGE EXAMINATION:
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no MGR
Pulmonary: upper airway transmitted breath sounds
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily
maintained. Recalls a coherent history. Speech is fluent with
full sentences, intact repetition, and intact verbal
comprehension. Naming intact. No paraphasias. Normal prosody.
No lingual/labial/guttural difficulties. No dysarthria. Verbal
registration ___. No apraxia. No evidence of hemineglect.
No left-right confusion.
- Cranial Nerves - PERRL 3->2 brisk. VF full to number counting.
EOMI, end-gaze nystagmus. V1-V3 without deficits to light touch
bilaterally. Minimal right NLFF but symmetric activation and
strength of facial muscles. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. Right pronation, no drift. No
tremor or asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___- 5 5 5 5 5 5
R 5 ___ ___- 5 5 5 5 5 5
- Sensory - No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
Plantar response flexor bilaterally.
- Coordination - L>R intention tremor bilaterally. No dysmetria
on finger following b/l. Good speed and intact cadence with
rapid
alternating movements.
- Gait - Deferred
Pertinent Results:
LABS
___ 11:30PM BLOOD WBC-7.5# RBC-3.73* Hgb-12.6* Hct-34.9*
MCV-94 MCH-33.8* MCHC-36.1 RDW-13.2 RDWSD-44.9 Plt ___
___ 11:30PM BLOOD Neuts-77.6* Lymphs-12.9* Monos-8.2
Eos-0.5* Baso-0.4 Im ___ AbsNeut-5.80 AbsLymp-0.96*
AbsMono-0.61 AbsEos-0.04 AbsBaso-0.03
___ 11:30PM BLOOD ___ PTT-38.2* ___
___ 11:30PM BLOOD Glucose-227* UreaN-17 Creat-1.0 Na-131*
K-4.4 Cl-95* HCO3-24 AnGap-16
___ 11:30PM BLOOD ALT-26 AST-21 AlkPhos-83 TotBili-0.5
___ 11:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:55AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 10:55AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 10:55AM URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
*****************
IMAGING
CTA head/neck ___:
IMPRESSION:
1. Evolving subacute infarction in the left splenium of the
corpus callosum. No intracranial hemorrhage.
2. Stable appearance of the left proximal internal carotid
artery and left
petrous internal carotid artery stents with stable non calcified
plaque versus intimal hyperplasia along the dependent aspect of
the internal carotid artery stent.
3. Stable ulceration of the proximal left external carotid
artery.
4. Normal CT perfusion.
5. Post radiation changes to the neck, as described above.
6. Dental disease. Dental consultation is recommended.
MRI head ___:
IMPRESSION:
1. Evolving subacute infarcts in the splenium of the corpus
callosum and
parietal lobe.
2. Punctate focus of questionable restricted diffusion in the
superior medial left thalamus, which may represent an acute
infarction versus artifact. Otherwise, no new large acute
infarct or mass effect.
Carotid ultrasounds ___:
IMPRESSION:
1. Patent left ICA stent. Mild homogeneous plaque in the left
ICA results in less than 40% stenosis.
2. No right-sided carotid vasculature atherosclerotic disease.
Brief Hospital Course:
Please see previous discharge summary for details.
In summary, Mr. ___ returned for another recurrent episode of
aphasia/dysarthria. An MRI showed a left thalamic infarct which
was new in the interim since prior admission, in addition to the
known left splenium infarct. This was also not felt to be
explaining his symptoms and felt to be an indication of ongoing
thrombogenic physiology. Etiology of these recurrent
TIAs/strokes remained unknown. Coumadin was stopped as it was
felt to not be of additional utility. Platelet function and
clopidogrel test was sent and suggested some degree of
clopidogrel resistance. Per agreement with Vascular surgery and
Vascular medicine, decision was made to stop the clopidogrel and
start a trial of ticagrelor instead. A repeat swallow evaluation
was also performed to exclude risk of aspiration in setting of
pharyngeal/laryngeal fibrosis from previous radiation therapy.
TEE was attempted at the recommendation of Vascular medicine,
however it was unsuccessful due to inability to pass probe
through his oropharynx due to fibrosis- no further attempts were
made. He was fitted with a Zio patch cardiac monitor in attempt
to capture any occult arrhythmia as a source of cardioemboli.
Aside from stopping Coumadin and clopidogrel, and starting
ticagrelor, no other medication changes were made. His
neurologic examination at discharge was at baseline.
Transitional issues:
[ ] Please continue aspirin and ticagrelor indefinitely for
carotid artery stent and secondary stroke prevention.
[ ] Please follow up results of Zio patch cardiac monitoring; if
any cardiac arrhythmia found we strongly suggest starting
systemic anticoagulation (please consult with Stroke provider if
this is found).
[ ] Stroke, Neurosurgery and Vascular Surgery followup arranged.
[ ] Patient's home antihypertensives were all resumed with
exception of metoprolol which was halved to 6.25mg BID. Please
continue to monitor and titrate for a long term goal of
normotension.
[ ] Continue atorvastatin for lipid-lowering therapy and obtain
repeat LDL in ___ months. Monitor LFTs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Enalapril Maleate 20 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Amlodipine 5 mg PO DAILY
10. Warfarin 5 mg PO DAILY16
11. Metoprolol Tartrate 6.25 mg PO BID
Discharge Medications:
1. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [___] 90 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*3
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Enalapril Maleate 20 mg PO DAILY
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Metoprolol Tartrate 6.25 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Transient Aphasia/dysarthria, suspected secondary to
microemboli/intracranial atherosclerosis
Diabetes mellitus
Hypercholesterolemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were readmitted for another repeat episode of difficulty
with speech and slurring. Since your blood pressure was found to
be high in the setting of one of these episodes, we do not feel
strongly that hypotension is the main precipitant of your
symptoms.
Instead, we performed a blood test that suggested that Plavix
was not as effective as a medication for you as it should be.
Therefore, we stopped that and started another similar
medication called ticagrelor (brand name ___ which you
should take twice a day (morning and evening), in addition to
the aspirin 81mg daily. You should STOP taking the Coumadin.
Please follow up with Stroke, Neurosurgery, and your PCP.
If you experience additional episodes, please call the Stroke
clinic (number provided below) or your PCP for further
instructions. If your episode is prolonged or different from
your usual episodes, or if you do not return to normal after the
episode, please come to the Emergency Room for further
evaluation.
It was a pleasure taking care of you. We wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19818476-DS-6
| 19,818,476 | 23,914,629 |
DS
| 6 |
2177-09-04 00:00:00
|
2177-09-05 08:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Vaginal Bleeding
Major Surgical or Invasive Procedure:
-bilateral percutaneous nephrostomy tubes
-exam under anesthesia, cervical mass biopsy, cystoscopy,
proctoscopy
History of Present Illness:
Ms. ___ is a ___ yo female with poor medical compliance who
presented to ___ with two weeks of nausea, vomiting,
malaise and abdominal pain and was found to have a large pelvic
mass and ___. Pt has been having intermittent vaginal bleeding
with clots daily for nearly the last year. In addition, she has
been having nausea, vomting, malaise and abdominal pain for the
last two weeks which caused her to seek medical attention. She
felt that she was passing urine over the last few weeks, but was
not sure. She also endorses a 20 pound weight loss since the
___. She denies any chest pain, shortness of breath, fever,
night sweats or chills.
At ___ she had a CT scan that showed a 8 cm pelvic
mass that appears to be arising from the cervix that is causing
bilateral moderate to severe hydronephrosis and hydroureter.
In the ED, initial VS were: 99.1 97 136/65 16 99%. Labs were
notable for hyponatremia to 127, K of 4.9, BUN/Cr of 97/18.5,
WBC of 20.2. Pt was quickly taken to the MICU and then to
interventional radiology for bilateral nephrostomy tubes, which
were placed without complication.
In the ICU,
Past Medical History:
OBHx: G7P2
- SVD x 2, 1 pre-term but otherwise no complications
- SAB x 7, all spontaneously resolved with no D&C required
GynHx:
- post-menopausal x ___ yrs
- denies h/o STIs, cannot remember ever having Pap smears
MedHx: fibroids
SurgHx: oral surgery
Social History:
___
Family History:
unknown
Physical Exam:
Physical Exam on admission:
Vitals: T: 97.2 P: 104 R:16
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, tenderness to palpation in the suprapubic region,
non-distended, bowel sounds present, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities
Physical Exam on discharge:
afebrile, vital signs stable
Gen: NAD, AxO
CV: RRR
Resp: CTAB
Back: bilateral percutaneous nephrostomy tubes in place with
clear yellow urine in both bags, no surrounding erythema
Abd: normoactive bowel sounds, soft, nondistended, minimally
tender to deep palpation lower abdomen, no rebound or guarding
GU: peripad moderately stained with blood, no active vaginal
bleeding
Ext: no ___ edema, calves nontender
Pertinent Results:
CBC:
___ 06:45AM BLOOD WBC-17.5* RBC-3.46* Hgb-9.7* Hct-31.1*
MCV-90 MCH-28.1 MCHC-31.3 RDW-15.0 Plt ___
___ 12:15AM BLOOD WBC-20.6* RBC-3.49* Hgb-9.8* Hct-30.6*
MCV-88 MCH-28.1 MCHC-32.1 RDW-14.6 Plt ___
___ 07:40PM BLOOD WBC-21.3*# RBC-3.67*# Hgb-10.4*#
Hct-32.5*# MCV-88 MCH-28.3 MCHC-32.0 RDW-15.0 Plt ___
___ 08:50AM BLOOD WBC-13.2* RBC-2.63* Hgb-7.2* Hct-23.3*
MCV-89 MCH-27.6 MCHC-31.1 RDW-14.7 Plt ___
___ 02:30AM BLOOD WBC-16.3* RBC-2.68* Hgb-7.2* Hct-23.0*
MCV-86 MCH-27.0 MCHC-31.3 RDW-14.7 Plt ___
___ 11:24AM BLOOD WBC-20.0* RBC-3.09* Hgb-8.6* Hct-28.4*
MCV-92 MCH-27.7 MCHC-30.1* RDW-14.7 Plt ___
___ 06:08AM BLOOD WBC-18.7* RBC-3.00* Hgb-8.3* Hct-26.6*
MCV-89 MCH-27.7 MCHC-31.2 RDW-14.8 Plt ___
___ 12:45AM BLOOD WBC-20.2* RBC-2.92* Hgb-7.9* Hct-25.8*
MCV-89 MCH-27.0 MCHC-30.5* RDW-14.4 Plt ___
___ 08:50AM BLOOD Neuts-85.3* Lymphs-7.9* Monos-4.4 Eos-2.0
Baso-0.4
___ 12:45AM BLOOD Neuts-90.0* Lymphs-4.7* Monos-3.0 Eos-1.9
Baso-0.4
Coags:
___ 06:08AM BLOOD ___ PTT-27.5 ___
___ 12:45AM BLOOD ___ PTT-28.5 ___
Chemistry:
___ 06:45AM BLOOD Glucose-91 UreaN-20 Creat-2.1*# Na-141
K-3.6 Cl-105 HCO3-25 AnGap-15
___ 06:37AM BLOOD Na-137 K-3.9 Cl-102
___ 12:15AM BLOOD Glucose-140* UreaN-46* Creat-5.0*# Na-139
K-4.0 Cl-104 HCO3-23 AnGap-16
___ 07:40PM BLOOD Na-139 K-3.8 Cl-104
___ 08:50AM BLOOD Glucose-89 UreaN-62* Creat-8.7*# Na-138
K-4.4 Cl-102 HCO3-22 AnGap-18
___ 02:30AM BLOOD Glucose-120* UreaN-72* Creat-10.6*#
Na-136 K-4.5 Cl-103 HCO3-19* AnGap-19
___ 08:25PM BLOOD Glucose-137* UreaN-76* Creat-12.4*#
Na-131* K-4.5 Cl-96 HCO3-17* AnGap-23*
___ 01:52PM BLOOD Glucose-86 UreaN-84* Creat-14.9*# Na-134
K-5.0 Cl-100 HCO3-12* AnGap-27*
___ 06:08AM BLOOD Glucose-86 UreaN-94* Creat-18.1* Na-129*
K-5.1 Cl-96 HCO3-14* AnGap-24*
___ 12:45AM BLOOD Glucose-88 UreaN-97* Creat-18.5* Na-127*
K-4.9 Cl-93* HCO3-15* AnGap-24*
___ 06:45AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.4*
___ 12:15AM BLOOD Calcium-8.4 Phos-4.8* Mg-1.8
___ 08:50AM BLOOD Calcium-8.4 Phos-5.6* Mg-2.0
___ 02:30AM BLOOD Calcium-8.3* Phos-5.8* Mg-2.1
___ 08:25PM BLOOD Calcium-8.4 Phos-5.6* Mg-2.2
___ 06:08AM BLOOD Albumin-2.8* Calcium-8.7 Phos-6.9*
Mg-2.9*
___ 12:45AM BLOOD Calcium-8.7 Phos-6.8* Mg-2.6
___ 01:26AM BLOOD ___ pH-7.31*
___ 01:54PM BLOOD Na-143
___ 01:26AM BLOOD Lactate-1.1
___ Blood culture x 2, no growth at time of discharge
summary
Urine:
___ 06:08AM URINE Color-Straw Appear-Clear Sp ___
___ 06:08AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
___ 06:08AM URINE RBC->182* WBC-14* Bacteri-FEW Yeast-NONE
Epi-0
___ 06:08AM URINE CastHy-3*
___ 06:08AM URINE Mucous-RARE
___ 09:28AM URINE Hours-RANDOM Creat-52 Na-43 K-8 Cl-39
___ 06:08AM URINE Hours-RANDOM UreaN-206 Creat-62 Na-48
K-10 Cl-33
___ 09:28AM URINE Osmolal-208
___ 06:08AM URINE Osmolal-213
___ Urine culture negative
___ ___ percutaneous nephrostomy tube report:
ANESTHESIA: Moderate sedation was provided by administering
divided doses of fentanyl (100 mcg) and Versed (2 mg) throughout
the total intraservice time of 35 minutes, during which the
patient's hemodynamic parameters were
continuously monitored.
PROCEDURE: Bilateral percutaneous nephrostomy tube placement.
FINDINGS: After the risks and benefits of the procedure were
explained to the patient, written informed consent was obtained.
The patient was placed prone on the table and her bilateral
flanks were prepped and draped in standard sterile fashion. A
pre-procedure timeout was performed.
LEFT: Under ultrasound and fluoroscopic guidance, a left lower
pole posterior calix was cannulated with a 21-gauge Cook needle
through which a 0.018 wire was advanced into the renal pelvis.
The needle was exchanged for AccuStick sheath. The wire was
removed. Clear urine drained from the catheter. The wire, inner
dilator and metallic shaft of the AccuStick sheath were removed,
and a Amplatz wire was advanced into the renal pelvis. An 8
___ dilator was used to open the tract over the Amplatz wire.
This was followed by successful placement of the 8 ___
nephrostomy tube with pigtail locked within the renal pelvis of
the left kidney. Contrast was injected confirming this location.
The catheter was secured to the skin with 0 silk suture and
StatLock. The catheter was placed to external bag drainage.
RIGHT: Under ultrasound and fluoroscopic guidance, a right lower
pole posterior calix was cannulated with a 21-gauge Cook needle
through which a 0.018 wire was advanced into the renal pelvis.
The needle was exchanged for AccuStick sheath. The wire was
removed. Clear urine drained from the catheter. The wire, inner
dilator and metallic shaft of the AccuStick sheath were removed,
and a Amplatz wire was advanced into the renal pelvis. An 8
___ dilator was used to open the tract over the Amplatz wire.
This was followed by successful placement of the 8 ___
nephrostomy tube with pigtail locked within the renal pelvis of
the right kidney. Contrast was injected confirming this
location. The catheter was secured to the skin with 0 silk
suture and StatLock. The catheter was placed to external bag
drainage.
FINDINGS: Moderate bilateral hydronephrosis/hydroureter.
Obstruction of the bilateral distal third of the ureters
(complete obstruction on the right, minimal contrast passage
into bladder on the left).
There were no immediate complications.
IMPRESSION: Successful bilateral percutaneous nephrostomies with
8 ___
nephrostomy tubes.
___ Pelvic MRI without contrast:
COMPARISON: Outside hospital CT abdomen ___.
FINDINGS:
The uterus and cervix are both enlarged and both are markedly
abnormal in appearance. The cervix has been replaced by
heterogeneously T2 hyperintense tissue which invades into the
posterior vaginal fornix (4:24). This measures approximately 9.3
x 8.6 cm in the axial plane and up to 18 cm in craniocaudal
dimension. In addition, there is extension into the parametrial
tissues diffusely (3:21). Several discrete nodules appear
relatively more T2 hyperintense including several nodules which
have passed through the mesorectal fascia and are within the
mesorectal fat (3:21). In addition, there is a small amount of
tumor which appears to have invaded through the sigmoid wall
(3:15). An additional nodule displaces the bladder anteriorly,
although no frank invasion to the bladder wall can be
appreciated (4:20). The uterus itself is also markedly abnormal
and based on the T2 and diffusion signal characteristics, there
is likely frank invasion of the tumor throughout the uterus.
There is also a 5.9 x 4.7 cm fundal fibroid (3:6). The tumor
within the uterine body appears to be confined to the uterus.
There is 3.1 x 2.6 cm mass along the left pelvic side wall
(3:14), identical in signal intensity to the cervical tumor,
consistent with a lymph node deposit as the small left ovary
appears adjacent. The left ovary could not well defined on this
study though is likely between a dilated right tube and fibroid.
There is a tubular T2 hyperintense structure in the right
adnexal region measuring approximately 7.1 x 3.5 cm. This
contains T2 hypointense debris in a dependent distribution.
Given this appearance, it is most likely reflecting a dilated
fallopian tube. The urinary bladder and rectum are unremarkable
in appearance, although as stated before, there are tumor
deposits extending into the mesorectal fat.
Additional limited in- and out-of-phase T1-weighted images were
obtained of the upper abdomen to assess the left adrenal mass.
This mass measures approximately 3.5 x 3 cm and demonstrates
diffuse loss of signal on out-of-phase compared to in-phase
T1-weighted images, consistent with an adenoma. The visualized
osseous structures are unremarkable.
IMPRESSION:
1. Large cervical mass, replacing both the cervix and uterus
extending into the parametrium, mesorectal fat and likely the
sigmoid colon focally. Overall, this mass measures greater than
18 cm in craniocaudal extent. MRI stage T4 given invasion of the
sigmoid colon.
2. Enlarged abnormal lymph node in the left hemipelvis.
3. Dilated cystic structure in the right adnexa likely
hydrosalpinx with debris.
4. Left adrenal adenoma.
___ PET-CT
HEAD/NECK: There is a 7 mm hypoattenuating non FDG avid left
thyroid lobe nodule. There are no suspicious FDG avid lesions.
CHEST: There is a non FDG avid 1 cm nodule in the right major
fissure of the lungs. There are no suspicious FDG avid lesions.
There is a small pericardial effusion.
ABDOMEN/PELVIS: Stable left adrenal gland adenoma (non FDG avid
- SUV 2.2). Redemonstrated is the large about 9.5 x 8.5 cm
cervical mass with a SUVmax of about 15, with invasion of the
sigmoid colon and mesorectum (as seen on the previous MRI), with
a large left 3.1 x 2.5 cm FDG avid external iliac lymph node
with a SUV max of 14.7 (imag 147). There is a non FDG avid right
hydrosalpinx.
MUSCULOSKELETAL: There are no suspicious FDG avid lesions.
Physiologic uptake is seen in the brain, myocardium, salivary
glands, GI and GU tracts, liver and spleen.
IMPRESSION: 1. Large FDG avid cervical mass and pelvic
lymphadenopathy. 2. 1 cm pulmonary nodule in the right major
fissure, likely represents benign lymph node. However, attention
on follow-up studies is recommended. 3. No suspicious FDG avid
lesions to suggest distant metastatic disease.
___ Cervical mass biopsy and left vulvar biopsy pathology
report
I. Cervix, biopsy (A):
- Squamous cell carcinoma, invasive, moderately differentiated.
- Depth of invasion cannot be assessed.
II. Vulva, biopsy (B):
High grade squamous intraepithelial lesion (Vulvar
Intraepithelial Neoplasia 3).
Brief Hospital Course:
Ms. ___ is a ___ G7P2 woman with poor medical compliance who
presented to ___ with two weeks of nausea, vomiting,
malaise and abdominal pain and was found to have a large pelvic
mass on CT and ___. She was transferred to ___ where she was
admitted to the ICU after bilateral nephrostomy tube placement
by interventional radiology and then transferred to the
gynecologic oncology service for work-up of her pelvic mass when
she was medically stabilized. Her hospital course, by problem,
was as follows:
.
#Acute Kidney Injury: Based on imaging showing bilateral
hydronephrosis and hydroureters, the etiology of her ___ was
largely post-renal from obstruction. The most important
intervention was placement of bilateral nephrostomy tubes. She
quickly had nearly 2 liters of clear urine output after
placement of nephrostomy tubes. She did not have any urgent
indication for dialysis and therefore her electrolytes were
monitored closely q6h for 48 hours with appropriate decrease in
her potassium and phos. Her creatinine decreased from 18.5 on
admission to 2.1 on discharge. She received teaching for care of
her percutaneous nephrostomy tubes prior to discharge, and will
follow-up with nephrology and urology at ___.
.
#Hyponatremia: Likely hypovolemic in etiology from decreased
oral intake and emesis prior to admission. She was given 1L NS
boluses x 2 and sodium was monitored q6h for development of
post-diuresis hypernatremia. She was maintained on D5W with
bicarb to prevent a rapid increase in serum sodium greater than
10 in 24 hours, according to nephrology recommendations. Her Na
on admission was 127, and normalized on the afternoon of
hospital day 2 at which point she was maintained of D5W until
she was taking PO, at which point she was saline locked.
.
# Cervical mass: CT scan at ___ showed a large mass arising
from cervix, bilateral moderate hydronephrosis, and a possible
1cm R lung density. After she was medically stabilized in the
ICU, she was transferred to the gynecologic oncology service on
hospital day 1. On hospital day 2, she was taken to the OR for
an exam under anesthesia, cervical mass biopsy, left posterior
vulvar biopsy, cystoscopy, and proctoscopy. Intraoperative
findings were notable for a large cervical mass extending down
the vagina with parametrial involvement from the sidewall. There
was no evidence of invasion of the bladder or rectal mucosa.
Please refer to Dr. ___ report for details of the
operation. Final pathology is pending at the time of this
discharge summary. A pelvic MRI confirmed the 18cm cervical mass
extending in to the parametrium, mesorectal fat, and likely the
sigmoid colon with enlarged lymph nodes in the left pelvis. A
PET-CT was performed to evaluate for distant metastasis showed
"no suspicious FDG avid lesions to suggest distant metastatic
disease". Her post-operative course was uncomplicated. Her diet
was advanced on post-operative day 1 with no nausea, pain was
controlled with percocet, she had good urine output from both
nephrostomy tubes, and she was ambulating independently without
difficulty.
.
#Anemia: Unclear baseline Hct for pt, Hct of 25.8 in ED. She was
hemodynamically stable, without evidence of active hemorrhage.
Prior to going to the OR on hospital day 2, her HCT decreased to
23, so she was transfused 2 units pRBCs for stabilization prior
to cervical biopsy. Her post-transfusion HCT was appropriate at
32.5. Post-operatively, her cervical bleeding was minimal, and
her HCT on discharge was stable at 31.
.
#Leukocytosis: She presented with a leukocytosis of 20.2.
Differential included complicated urinary tract infection vs.
malignancy/stress reaction. She received 2 doses of ceftriaxone,
which was discontinued after urine culture was negative. Blood
culture were no growth at the time of this discharge summary.
.
#Anion gap metabolic acidosis: Most likely ___ ___ and uremia,
lactate normal at 1.1. VBG on admission revealed a pH of 7.31.
.
#Code status: Patient was okay with intubation but was DNR
.
#Soc: She was seen by social work for her new diagnosis, coping,
and resources.
By hospital day 4/post-operative day 2, her creatinine was
significantly improved, and her electrolytes were normalized.
She was tolerating a regular diet, ambulating independently, and
pain was controlled with percocet. She was then discharged home
in stable condition with plans for outpatient follow-up with
___ urology, ___ Kidney and Hypertension, ___
radiation oncology, and Dr. ___.
Medications on Admission:
none
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
2. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*35 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
-cervical mass concerning for cancer - final pathology pending
-bilateral ureteral obstruction causing acute kidney injury
-hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to the ICU and then transferred to the
gynecologic oncology service for a cervical mass that was
blocking both ureters. You had percutaneous nephrostomy tubes
placed to drain your kidneys, and your kidney function test has
improved. We biopsied the cervical mass, and the final pathology
is pending at this time. A pelvic MRI confirmed the large mass
in your pelvis, and PET-CT was performed but the result is not
finalized yet. Please follow these instructions:
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* Nothing in the vagina (no tampons, no douching, no sex), no
heavy lifting of objects >10lbs for 6 weeks.
* You may eat a regular diet
* Percutaneous nephrostomy tube care as instructed
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19818481-DS-14
| 19,818,481 | 20,932,700 |
DS
| 14 |
2157-04-21 00:00:00
|
2157-04-22 09:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
TEE and direct current cardioversion
History of Present Illness:
This is a ___ yo F with a PMH significant for atrial fibrillation
(diagnosed 1 month prior on coumadin), recent diagnosis of
autoimmune bullous pemphigoid (on prednisone), and depression
who presented to the ED with palpitations and was in afib with a
HR of 140. The patient was recently diagnosed with afib during a
routine PCP ___ 1 month prior when she was noted to have
a fast heart rate. The patient was started on Diltaizem and
Coumadin at that time. She had been doing well until the morning
of admission when she developed palpitations, shortness of
breath, and fatigue after walking up and down a flight of
stairs. The patient notes that these palpitations usually
resolve quickly, but when they persisted she presented to the
hospital. The patient had associated flushing and diaphoresis
with this episode, but no chest pain. The patient has been
compliant with her medications. She does note that over the past
month, she has gotten more palpitations with exertion, but never
as bad as today. Of note, the patient is also on high dose
steroids for a recent diagnosis of bullous pemphigoid. Her
diagnosis of afib was made at a similar time, although the
temporal relationship is unclear. The patient denies chest pain,
orthopnea, PND, weight gain, lighteadedness, or syncope.
.
Of note, the patient's Atrius records reveal similar episodes of
palpitations dating back to ___. These were initially blamed
on medications, however, medical workup and Holter monitoring
were performed with normal results. The patient does have
significant anxiety.
.
In the ED, initial vitals were 124 83/47 16 98%. Labs and
imaging significant for negative troponin, EKG showing Afib with
RVR but no ischemic changes, and CXR showing scoliosis but no
consolidation or effusion. Patient given diltiazem 20mg IV and
30mg PO to reduce her heart rate with good effect. Although she
was hypotensive with SBP 83 on presentation to triage, she was
normotensive by the time she was transferred to an ED bed. The
patient's son states that her HR was going from 140 down to 40
quickly and inexplicably. She does not have a diagnosis of
tachy-brady or SSS, however, and this has not been documented.
.
On arrival to the floor, patient's HR is 75. She feels much
better and is asymptomatic.
.
Of note, the patient is on metformin due to steroid induced
hyperglycemia. She is on lasix for steroid water retention. She
is on Clonazapam for steroid induced insomnia, and omeprazole
for GERD prophylaxis.
.
REVIEW OF SYSTEMS
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.
Past Medical History:
- Afib with RVR on coumadin
- Bullous Pemphigoid on high dose steroids
- OSTEOARTHRITIS
- HYPERCHOLESTEROLEMIA
- DEPRESSIVE DISORDER/Anxiety
Social History:
___
Family History:
Brother ___ disorder
Sister ___ Cancer; ___ disorder
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM
VS: T= 98.1 BP= 123/82 HR= 83 RR= 16 O2 sat= 95% RA Wt 95.5kg
GENERAL: NAD. Speaks ___ and ___. Oriented x3. Mood,
affect appropriate.
HEENT: Dentures, no oral lesions appreciated, no thrush
NECK: Supple with no elevation of JVD. Buffalo Hump.
CARDIAC: Irregular irregular, nl S1, S2, no extra heart sounds,
no MRG, nondisplaced PMI
LUNGS: Resp were unlabored, no accessory muscle use. mild
crackles at bases, cleared with deep breaths, no wheezes,
consolidations
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 1+ ___ edema bilaterally.
NEURO: CN II-XII tested and intact, slight chronic R sided
facial droop, strength ___ throughout, sensation grossly normal.
Gait not tested.
PULSES: equal
DISCHARGE EXAM:
HR 75-90, normal sinus rhythm, intermittent PVCs
Pertinent Results:
___ 07:05AM BLOOD WBC-7.6 RBC-3.36* Hgb-11.4* Hct-37.0
MCV-110* MCH-34.0* MCHC-30.9* RDW-16.2* Plt ___
___ 07:05AM BLOOD ___ PTT-32.8 ___
___ 07:05AM BLOOD Glucose-80 UreaN-19 Creat-0.8 Na-144
K-4.1 Cl-108 HCO3-30 AnGap-10
___ 04:02PM BLOOD cTropnT-<0.01
___ 07:05AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.4
___ 04:02PM BLOOD TSH-0.65
==================
CXR:
FRONTAL AND LATERAL CHEST RADIOGRAPHS: The heart is mildly
enlarged. The
hilar and mediastinal contours are within normal limits. There
is no
pneumothorax, focal consolidation, or pleural effusion. Mild
bibasilar
atelectasis is present. There is moderate dextroscoliosis
centered about the upper thoracic spine. Bridging anterior
osteophytosis is seen throughout the thoracic spine.
==================
TEE: No spontaneous echo contrast or thrombus is seen in the
body of the left atrium/left atrial appendage or the body of the
right atrium/right atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma (4 mm
bordering on complex plaque > 4 mm) in the aortic arch and in
the descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: No echocardiographic evidence of intracardiac
thrombus seen. Simple (bordering on complex) atheroma in aortic
arch seen.
Brief Hospital Course:
This is a ___ yo F with a PMH significant for afib with RVR on
coumadin and Diltiazem who presents with palpitations, shortness
of breath, and fatigue and found to have a HR of 140.
.
1. Atrial Fibrillation: The patient has a one month history of
afib, rate controlled with Diltiazem and on coumadin (CHADS2 =
___. The patient has experienced intermittent palpitations in
the past month with exertion, but the episode on admission
lasted longer. HR on admission was 140, rate controlled with IV
Dilt. The patient underwent a successful TEE/DCCV and was in
normal sinus rhythm post procedure. The patient will discontinue
her Diltiazem and start metoprolol 25mg Qday. She will continue
coumadin for at least one month after DCCV, and maybe longer
depending on risk factors and whether she stays in NSR. The
patient will follow-up with her PCP and cardiologist.
.
2. Fluid Overload: Euvolemic on exam, with only slight ___ edema.
Likely in the setting of high dose prednisone. The patient has
normal EF based on TEE. The patient will continue her lasix 20mg
Qday.
3. Autoimmune Bullous pemphigoid: Continued prednisone 30mg Qday
.
4. Hyperglycemia: In setting of prednisone. Continue metformin
500mg BID
.
5. Depression/Anxiety: Continued fluoxetine
.
6. HL: Continued simvastatin. Decrease dose to 40mg Qday based
on new FDA regulations.
.
TRANSITIONAL ISSUES: none
Medications on Admission:
warfarin 2.5mg daily
furosemide 20mg daily
diltiazem ER 240mg daily
prednisone 30mg daily
metformin 500mg BID
clonazepam 1mg QHS
simvastatin 80mg daily
omeprazole 20mg BID
Vicodin (hydrocodone 5mg - APAP 325mg) 1 tab daily PRN
fluoxetine 80mg daily
Discharge Medications:
1. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Continue taper as directed by other doctor.
4. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. hydrocodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO Q8H (every 8 hours) as needed for back pain.
7. fluoxetine 40 mg Capsule Sig: Two (2) Capsule PO once a day.
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
10. clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Atrial Fibrillation with rapid heart rate
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 because you had a fast heart
rate called atrial fibrillation that made you feel short of
breath, tired, and lightheaded. For some reason, the Diltiazem
that you were on to control the heart rate was not working
great. In the ED, you were given some IV medicines to slow down
the heart rate. Your heart rate was stable overnight without any
highs or lows. In the morning, we decided that the best
treatment to control your symptoms was an electrical
cardioversion of the heart into normal rhythm. You tolerated the
procedure well without any complications and you were back in
the normal heart rhythm.
You will need to follow-up with your regular doctor. You will
need to take all of your medications as prescribed.
MEDICATION CHANGES:
DECREASE Simvastatin from 80mg to 40mg once a day
STOP Diltiazem
START Metoprolol XL 25mg once a day by mouth
Followup Instructions:
___
|
19818481-DS-17
| 19,818,481 | 29,540,096 |
DS
| 17 |
2160-01-02 00:00:00
|
2160-01-02 11:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
OxyContin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with afib on coumadin who presents with abdominal pain.
She is s/p lap R colectomy (benign pathology) by Dr ___
___ c/b bleeding requiring ex-lap and evacuation for
hematoma
___ with no active bleeding found. Her course was further
complicated by afib/RVR, C diff, aspiration PNA, and pulmonary
edema. She was discharged ___. Since that time, she reports
some chronic abdominal pain for which she is taking tylenol and
narcotic pain medications. Over the past 10 days she has had
worsening diffuse abdominal pain, but right greater than left
sided. No nausea or vomiting. Flatus/BM decreased but did have a
small BM the morning of presentation. Due to the worsening pain,
she went to ___ for evaluation. She underwent a
CTA and an NGT was placed. We do not have the reports or the
output from the NGT. She was then transferred to ___ for
further management. She NGT was self d/c'd at ___. She denies
blood in stool, change in urination, or other symptoms.
Hx obtained from patient, pt's son, and health care records. Pt
speaks Portugese primarily but is able to communicate in
___.
Past Medical History:
- C. diff ___
- Afib with RVR on coumadin, s/p DCCV ___.
- Bullous Pemphigoid, previously on high dose steroids ___
- OSTEOARTHRITIS
- HYPERCHOLESTEROLEMIA
- DEPRESSIVE DISORDER/Anxiety
- Resection of acoustic neuroma ___
- Gallstone pancreatitis s/p cholecystectomy ___
- L total knee replacement
Social History:
___
Family History:
Brother w/ ___. Sister w/ ___ at age ___. Daughter w/ ___ at age
___. Daughter w/ celiac disease. Son w/ gastric cancer.
Physical Exam:
On admission:
VS: 98.0, 98, 94/65, 20, 97% RA
Gen: NAD
CV: irregularly irregular HR, no MRG
Pulm: CTA b/l
Abd: incisions healed. nondistended. soft, tender mainly in RUQ
and RLQ. some voluntary guarding upon palpation of RUQ but no
rebound, involuntary guarding, or rigidity.
Ext: no edema
On discharge:
AFVSS
Gen: NAD
CV: irregularly irregular HR, no MRG
Pulm: CTA b/l
Abd: incisions healed. nondistended. soft, nontender. No
rebound, involuntary guarding, or rigidity.
Ext: no edema
Pertinent Results:
___ 05:55AM BLOOD WBC-4.6 RBC-3.80* Hgb-11.2* Hct-34.3*
MCV-90# MCH-29.4 MCHC-32.5 RDW-16.4* Plt ___
___ 05:55AM BLOOD ___ PTT-42.8* ___
___ 05:55AM BLOOD Glucose-77 UreaN-20 Creat-0.9 Na-144
K-4.4 Cl-109* HCO3-28 AnGap-11
___ 05:55AM BLOOD Calcium-7.9* Phos-3.7 Mg-1.9
___ 01:28PM BLOOD Glucose-97 Lactate-0.9 Na-141 K-4.3
Cl-104 calHCO3-29
___ 01:28PM BLOOD Hgb-12.1 calcHCT-36
Brief Hospital Course:
The patient was admitted to the colorectal surgery service on
___ for diffuse abdominal pain concerning for possible
partial bowel obstruction vs anastomotic stricture in the
setting of a prior right colectomy complicated by bleeding
earlier this year requiring ex-lap and evacuation for hematoma.
On this admission, she improved with nonoperative management of
her abdominal pain.
Neuro: The patient was stable from a neurologic standpoint.
CV: The patient was stable from a cardiovascular standpoint;
vital
signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced when appropriate,
which was tolerated well. Patient passed flatus and had a BM
prior to discharge. Intake and output were closely monitored.
ID: The patient was found to have some anastomotic narrowing
with fat stranding on CT concerning for infectious process. She
was started on ciprofloxacin and metronidazole which she will
continue to take orally for 14 days on discharge.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible. Warfarin was held during this hospitalization with INR
of 2.4. On the day of discharge, her INR was 1.7 and she was
restarted on 2.5mg of warfarin. She can continue her home
warfarin dose upon discharge.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, ambulating,
voiding without assistance, and pain was well controlled.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Warfarin 2.5 mg PO 4X/WEEK (___)
2. ClonazePAM 0.25 mg PO QAM
3. ClonazePAM 0.75 mg PO QPM
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
6. Sertraline 200 mg PO DAILY
7. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Sertraline 200 mg PO DAILY
3. ClonazePAM 0.25 mg PO QAM
4. ClonazePAM 0.75 mg PO QPM
5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
6. Simvastatin 40 mg PO QPM
7. Warfarin 2.5 mg PO 4X/WEEK (___)
8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 14 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*28 Tablet Refills:*0
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 14 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Adenoma status post right colectomy
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 with abdominal pain and were found to
have inflammation in the region of your prior bowel anastomosis.
Based on your workup, you did not have any leak or abscess. You
were managed conservatively with IV antibiotics and fluids for
rehydration. You were then transitioned to oral antibiotics and
you are now ready to be discharged home to continue the
remainder of your recovery.
You will be discharged with prescriptions for two different
antibiotics, ciprofloxacin and metronidazole (flagyl). Please be
sure to complete the entire course of antibiotics that is
prescribed to you. You will take a total of 2 weeks of these
antibiotics, starting from the first dose that you received in
the hospital.
Please monitor your bowel function. If you notice that you are
passing bright red blood with bowel movements or having loose
stool without improvement please call the office or go to the
emergency room. If 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, extended constipation, or difficulty with
urination.
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. We look forward to seeing you at your follow-up
visit in clinic.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids.
Please follow up with the Colorectal surgery service in 2 weeks
after you finish your antibiotics.
Please also follow-up with your primary care physician.
Warfarin (Coumadin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider ___:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.
Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your Coumadin/warfarin dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised ___ taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, ___ sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, ___, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: ___, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your ___ dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and ___ when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.
Monitoring:
The doctor decides how much ___ you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When Coumadin/warfarin is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way ___ works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.
Followup Instructions:
___
|
19818664-DS-20
| 19,818,664 | 23,178,195 |
DS
| 20 |
2178-05-25 00:00:00
|
2178-05-25 07:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RLE pain,numbness,and weakness
Major Surgical or Invasive Procedure:
1. Posterior laminectomy, C7, T1; with far lateral
decompression, C7-T1, right side for decompression of
the C8 nerve root.
2. Posterolateral arthrodesis, C5 to T2.
3. Posterolateral instrumentation, C5 to T2.
4. Application and removal of cranial tongs.
5. Application of local autograft.
History of Present Illness:
Patient is a ___ y/o male with history of cervical stenosis and
lumbar stenosis s/p C5-C7 ACDF and lumbar spinal stimulator by
Dr. ___ in ___ with worsening RLE and numbness
weakness x3 days. Patient reports that weakness started on
___. He was able to drive to work, but unable to work. He
was limited by RLE weakness/numbness with the sensation of
inability to remove leg. He called his spine surgeon, who placed
him on a prednisone taper and lyrica. Patient reports this
didn't help. Symptoms did not improve, patient presented to
___, where CT C-spine was concerning for stenosis.
Patient unable to undergo MRI secondary to spinal stimulator. As
such, patient received Decadron and transferred to ___ ED for
spine
evaluation. Patient endorses difficulty with ambulation ___ to
RLE weakness/numbness. He denies recent trauma, bowel
incontinence, bladder incontinence, saddle anesthesia.
Past Medical History:
Cervical Stenosis
Lumbar Stenosis
C5-C7 ACDF
Lumbar spinal cord stimulator
Social History:
___. Denies EtOH, tobacco, illicits.
Physical Exam:
PHYSICAL EXAMINATION per admit note dated ___-
Vitals: T = 98.3, HR = 63, BP = 138/85, RR = ,21 O2Sat = 94% RA
Sensory UE
C5 (Ax) R intact, L intact
C6 (MC) R intact, L intact
C7 (Mid finger) R intact, L intact
C8 (MACN) R intact, L intact
T1 (MBCN) R intact, L intact
T2-L2 Trunk R intact, L intact
Sensory ___
L2 (Groin): R intact, L diminished
L3 (Leg) R intact , L diminished
L4 (Knee) R intact, L diminished
L5 (Grt Toe): R diminished, L diminished
S1 (Sm toe): R diminished, L diminished
S2 (Post Thigh): R intact, L diminished
Motor
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc
R 5 ___ ___ 5 5 5 4 5 5
L 5 ___ ___ 5 5 5 5 5 5
Reflexes
Biceps BR Triceps Patella Achilles
R 3 3 2 3 2
L 3 3 1 3 2
___: Negative bilaterally
Babinski: Upgoing bilaterally
Clonus: None bilaterally
Rectal: Basal tone intact, ability to bear down
___ sensation: intact
Pertinent Results:
___ 07:45AM BLOOD WBC-16.1*# RBC-4.75 Hgb-13.7* Hct-44.2
MCV-93 MCH-28.9 MCHC-31.1 RDW-13.4 Plt ___
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD Glucose-83 UreaN-12 Creat-0.7 Na-138
K-4.2 Cl-100 HCO3-28 AnGap-14
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service, and
scheduled for a CT meylogram of the entire spine to clarify the
source of his symptoms as he is unable to get an MRI. The
myelogram showed severe stenosis at C7-T1 below his prior
cervical fusion and he was taken to the Operating Room for C5-T2
decompression and fusion. Refer to the dictated operative note
for further details. The surgery was without complication and
the patient was transferred to the PACU in a stable condition.
TEDs/pnemoboots were used for postoperative DVT prophylaxis.
Intravenous antibiotics were continued for 24hrs postop per
standard protocol.Initial postop pain was controlled with a PCA.
Diet was advanced as tolerated. The patient was transitioned to
oral pain medication when tolerating PO diet. Foley was removed
on POD#2. Physical therapy was consulted for mobilization OOB to
ambulate, and given persistent ___ ataxia and weakness he was
recommended for spinal cord rehab. 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:
Lyrica
Prednisone taper
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H pain
___ be taken over the counter. No more than 4Grams in 24 Hours
total of Acetaminophen
2. Cyclobenzaprine 10 mg PO TID:PRN pain or spasm
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day
Disp #*64 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
please take while on pain medication
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H pain
Please do not operate heavy machinery, drink alcohol or drive
RX *oxycodone 20 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*14 Tablet Refills:*0
5. Pregabalin 75 mg PO DAILY
6. Zolpidem Tartrate 5 mg PO HS insomnia
7. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*184 Tablet Refills:*0
8. Sulfameth/Trimethoprim DS 1 TAB PO BID UTI
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*2 Tablet Refills:*0
9. Tamsulosin 0.4 mg PO HS urinary retention
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*14
Capsule Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Cervical spondylitic myelopathy.
2. Severe stenosis, C7-T1.
3. Cervical spondylolisthesis, C7-T1.
4. Cervical stenosis C7-T1.
5. Status post anterior cervical diskectomy and arthrodesis
with adjacent segment disease.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Posterior cervical fusion
You have undergone the following operation: Posterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit in a car or chair for more than ~45 minutes without
getting up and walking around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk
for ___ minutes as part of your recovery. You can walk as
much as you can tolerate.
___ Isometric Extension Exercise in the
collar: 2x/day x ___xercises as
instructed.
Cervical Collar / Neck Brace: You need to wear
the brace at all times until your follow-up appointment which
should be in 2 weeks. You may remove the collar to take a
shower. Limit your motion of your neck while the collar is off.
Place the collar back on your neck immediately after the shower.
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 please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___. We are not allowed to call in narcotic
prescriptions (oxycontin, oxycodone, percocet) to the pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision, take baseline x rays and answer any questions.
___ We 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.
Physical Therapy:
-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.
-___ 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.
-You need to wear the brace at all times until your follow-up
appointment which should be in 2 weeks. You may remove the
collar to take a shower. Limit your motion of your neck while
the collar is off. Place the collar back on your neck
immediately after the shower.
Treatments Frequency:
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.
Followup Instructions:
___
|
19818766-DS-7
| 19,818,766 | 21,736,035 |
DS
| 7 |
2145-12-01 00:00:00
|
2145-12-07 17:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Codeine
Attending: ___.
Chief Complaint:
chest pain and dyspnea on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with past medical history of
HCV, Bipolar disorder, IVDA prior left lower extremity staph
infection complicated by tricuspid endocarditis in ___. She
has been IVDU free since ___. She recently presented to
___ on ___ and subsequently
transferred to ___ with chest pressure and dyspnea on
exertion. Her workup included normal cardiac enzymes. TTE showed
moderate to severe tricuspid regurgitation. TTE/TEE did not show
endocarditis. No blood cultures were drawn though she was
afebrile throughout her hospital stay. She was discharged with
plan to follow up with Dr. ___ management of her tricuspid
regurgitation.
She reports not being able to manage activites of daily livings
at home. She reports getting shortness of breath after walking
10 stairs. It takes her twice as long to do everything which led
her to present ED again today. In the ED, initial vitals were:
98.2 84 108/68 16 98%RA. Labs were notable for normal CBC, Chem7
and troponin. CXR showed no acute cardiopulmonary process. ECG
was unchanged compared to prior. She was admitted for futher
evaluation.
On the floor, she reports no other complaints.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, , abdominal pain,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
- History of endocarditis for which she was treated in ___ at
___ (___)
- PTSD with Anxiety and depression
- History of ? bipolar disorder
- History of polysubstance abuse in remission since ___ (Heroin)
- Tobacco abuse
- Hepatitis C
Social History:
___
Family History:
FAMILY HISTORY: Her father and mother are healthy both at age
___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.5 109/62 62 20 100%RA
GEN: Alert. Cooperative. No acute distress
HEENT/NECK: PERRLA. EOMI. Mucous membranes pink/moist. LUNGS:
Clear to auscultation B/L. No wheezes or crackles.
CV: S1, S2 Regular rhythm. ___ systolic murmur loudest at ___,
No gallops/rubs. Pulses ___ throughout. No thrills. "sore" on
palpation over left chest.
ABDOMEN: BS present. Soft. Nontender. Nondistended. No
organomegaly noted.
EXTREMITIES: No gross deformities, clubbing, peripheral edema,
or cyanosis. No splinter hemmorhages or nodules
NEUROLOGIC: Alert and fully oriented. Appropriate thought
content. Motor and sensory grossly intact.
DISCHARGE PHYSICAL EXAM:
VS: T98.9 105/60 p70 R18 100RA (Vitals from day prior to
discharge)
GEN: Alert. Cooperative. In NAD. Talking on cell phone
LUNGS: Clear to auscultation B/L. No wheezes or crackles.
CV: S1, S2 Regular rhythm. ___ systolic murmur loudest at ___,
No gallops/rubs. Pulses 2+ throughout.
ABDOMEN: Soft. Nontender. Nondistended.
EXTREMITIES: No splinter hemmorhages or nodules
NEUROLOGIC: Alert and fully oriented. Motor and sensory grossly
intact.
Pertinent Results:
ADMISSION
___ 06:15PM BLOOD WBC-6.3 RBC-4.98 Hgb-14.5 Hct-43.5 MCV-88
MCH-29.1 MCHC-33.3 RDW-13.1 Plt ___
___:15PM BLOOD Neuts-56.3 ___ Monos-4.5 Eos-4.5*
Baso-1.1
___ 06:15PM BLOOD Glucose-81 UreaN-17 Creat-0.9 Na-139
K-4.0 Cl-101 HCO3-27 AnGap-15
___ 06:15PM BLOOD cTropnT-<0.01
INTERVAL/DISCHARGE:
___ 07:25AM BLOOD WBC-5.7 RBC-4.50 Hgb-13.3 Hct-39.0 MCV-87
MCH-29.5 MCHC-34.0 RDW-13.2 Plt ___
___ 07:25AM BLOOD Glucose-87 UreaN-30* Creat-1.0 Na-139
K-3.9 Cl-104 HCO3-24 AnGap-15
___ 07:25AM BLOOD ALT-88* AST-69* CK(CPK)-41
___ 07:25AM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:25AM BLOOD Calcium-8.5 Phos-5.1* Mg-1.9
___ 07:50AM BLOOD WBC-5.0 RBC-4.30 Hgb-12.4 Hct-37.0 MCV-86
MCH-28.7 MCHC-33.4 RDW-13.2 Plt ___
___ 07:50AM BLOOD Glucose-89 UreaN-27* Creat-0.8 Na-140
K-4.2 Cl-106 HCO3-27 AnGap-11
___ 07:50AM BLOOD ALT-70* AST-50*
MICRO:
___ 7:50 am IMMUNOLOGY
**FINAL REPORT ___
HCV VIRAL LOAD (Final ___: 953,125 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HCV Test.
Linear range of quantification: 43 IU/mL - 69 million
IU/mL.
Limit of detection: 18 IU/mL.
Rare instances of underquantification of HCV genotype 4
samples by
Roche COBAS Ampliprep/COBAS TaqMan HCV test method used
in our
laboratory may occur, generally in the range of 10 to 100
fold
underquantitation. If your patient has HCV genotype 4
virus and if
clinically appropriate, please contact the molecular
diagnostics
laboratory (___) so that results can be confirmed
by an
alternate methodology.
Blood Culture X3, Routine (Final ___: NO GROWTH.
IMAGING:
___ Radiology CHEST (PA & LAT)
FINDINGS: There is no focal consolidation, pleural effusion or
pneumothorax. Cardiomediastinal silhouette is unremarkable.
Osseous structures are intact.
IMPRESSION: No acute cardiopulmonary process
Brief Hospital Course:
___ year old female with past medical history of HCV, Bipolar
disorder, IVDA, prior left lower extremity staph infection
complicated by tricuspid endocarditis in ___ recently
discharged from ___ plans for outpatient follow up.
However the patient returned with continuation of her chest pain
as well as intermittent dyspnea on exertion (10 stairs) and
feelings of lightheadedness/presyncope. Patient fiaxated on
receiving a tricuspid valvular surgery.
Her symptoms were determined most likely to be deconditioning
given MI ruled out and stable EKG. Her cardiologist was
contacted and indicated that her right sided valvular lesion was
unlikely to be causing her symptoms. She was able to ambulate
with ___ without experiencing desaturation. Patient was reassured
that her symptoms were more likely due to deconditioning and
that outpatient follow up was indicated. The patient had mixed
reactions with her various providers given this news (initially
refusing to leave), and Patient Relations was contacted. Cardiac
Surgery evaluated the patient and reaffirmed the findings of the
team, and patient was witnessed leaving the hospital briskly
without any evidence of dyspnea.
ACTIVE ISSUES
# Dyspnea and lightheadedness on exertion - Uncertain etiology
but possibly cardiac in nature vs component of anxiety and pain
management. Her only cardiac risk factors are her history of
smoking and her history of cocaine use. Cardiac enzymes were
negative. ___ worked with patient, who maintained saturations on
1 flight of steps exertion. She did have increase in HR to high
130s briefly, which promptly resolved upon being seated for ___
minutes. Her symptoms were not likely related to her right sided
valvular disease. Most likely cause was deconditioning, and
patient advised to continue outpatient followup. Patient was
reassured, and as above, was witnessed leaving the hospital
briskly without any evidence of dyspnea after discussions with
Patient Relations and Case Management.
# Acute on Chronic intrathoracic vs ?noncardiac chest pain -
Patient has long history of chest pain with incomplete relief
from various pain regimens. Patient at one point complained of
___ chest pain sharp and radiating to her back that kept her
from functioning. Patient was not tachycardic or dyspneic, not
diaphoretic, mentating well. After evaluation by the team who
briefly left the room, patient was witness conversing normally
and comfortably with her fiance and finishing her meal. Upon
return, patient again indicated she was in severe distress.
Likely a component of anxiety vs pain control problems,
especially given her fixation on tricuspid valve surgery. MI
was ruled out as above, dissection and PE were of extremely low
suspicion given lack of objective findings, and patient was
discharged on a regimen of tramadol and naproxen for pain relief
with outpatient followup.
# Mild transaminitis at OSH/History of HCV. HCV viral load was
sent, and since discharge returned HCV VIRAL LOAD (Final
___: 953,125 IU/mL. The patient knew this test was
ordered, but was not aware of this result as it was pending at
time of discharge.
# PTSD with Anxiety and mood disorder - Continued her home
medications. To assess psychosocial issues, discussed her home
situation and she reported she feels safe at her home, has never
felt threatened or abused, and is in a good positive
relationship with her current fiance.
# Tobacco abuse - nicotine patch and counseling given
TRANSITIONAL ISSUES:
1) Evaluation and ?management of HCV given recent viral load.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. hydrOXYzine HCl *NF* 50 mg Oral TID:PRN Anxiety
2. Venlafaxine 225 mg PO QHS
3. LaMOTrigine 100 mg PO QHS
4. Quetiapine Fumarate 25 mg PO QHS
5. traZODONE 75 mg PO HS
6. Naproxen 500 mg PO Q12H
with food
7. TraMADOL (Ultram) 50 mg PO Q6H:PRN Pain
Discharge Medications:
1. HydrOXYzine 50 mg PO TID:PRN Anxiety
2. LaMOTrigine 100 mg PO QHS
3. Quetiapine Fumarate 25 mg PO QHS
4. TraMADOL (Ultram) 50 mg PO Q6H:PRN Pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six hours Disp
#*30 Tablet Refills:*0
5. traZODONE 75 mg PO HS
6. Venlafaxine 225 mg PO QHS
7. Naproxen 500 mg PO Q12H
with food
RX *naproxen [EC-Naprosyn] 500 mg 1 tablet(s) by mouth twice
daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: atypical chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for chest pain and shortness of breath. There
was no apparent cardiac or lung process that was causing your
chest pain. The cardiac surgeons again reviewed your ECHO taken
from your prior admission and do not think that valve
replacement is indicated.
You should continue to monitor your symptoms carefully. If they
worsen or you develop new symptoms that are concerning, please
call your primary care physician or report to the emergency
department.
You also should talk to your primary care physician about
returning to work.
Followup Instructions:
___
|
19819043-DS-5
| 19,819,043 | 20,778,770 |
DS
| 5 |
2172-09-18 00:00:00
|
2172-09-19 14:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
=================
___ 05:02PM WBC-4.6 RBC-5.69 HGB-18.2* HCT-55.5* MCV-98
MCH-32.0 MCHC-32.8 RDW-16.8* RDWSD-58.0*
___ 05:02PM PLT COUNT-156
___ 05:02PM GLUCOSE-112* UREA N-12 CREAT-0.6 SODIUM-141
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-19* ANION GAP-19*
___ 05:02PM ALT(SGPT)-43* AST(SGOT)-47* ALK PHOS-146* TOT
BILI-3.6*
___ 05:02PM ALBUMIN-4.4
___ 05:02PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 07:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 11:15PM ___ PTT-36.0 ___
IMAGING:
================
CXR (___):
No previous images. Cardiac silhouette is mildly enlarged.
Pacer generator
is in place, though the position of the leads is very difficult
to determine.
Extensive metallic coils are seen bilaterally, presumably from
and
interventional procedure.
There is some indistinctness of pulmonary vessels consistent
with elevated
pulmonary venous pressure. No definite pleural effusion or
acute focal
pneumonia.
___ (___):
No evidence of deep venous thrombosis in the right lower
extremity veins.
CXR (___):
1. Pulmonary edema has improved.
2. No focal consolidation or effusions.
3. Stable postsurgical changes in stable position of the
left-sided pacemaker.
DISCHARGE LABS:
=================
No labs obtained day of discharge
Brief Hospital Course:
SUMMARY:
==============
___ with heterotaxy polysplenia syndrome and schizophrenia who
presented for psychiatric evaluation in the setting of
psychosis, increasing agitation, and impulsive behaviors with
refusal to take medications, admitted to medicine on ___
for inability to care for self and initiated on paliperidone,
course c/b AVNRT.
TRANSITIONAL ISSUES:
====================
[] Patient has extensive resources and support offered following
discharge:
-- Patient will follow at ___ for
further injections of Paliperidone. They will contact the family
to arrange a follow-up appointment.
-- His ___ will make daily visits for the first two weeks after
discharge
-- An application was submitted for patient to join the ___
___ program ___ was arranged but a start date is not
currently set)
-- Patient will establish care with a new PCP at ___ with Dr
___ ___ at 10am
-- Family was provided the ___ Crisis Team number
(___)
[] Patient's next IM paliperidone dose is due ___
Maintenance Dose: between 117-234 mg IM (dose to be determined
depending on progress over next month). In order to avoid a
missed dose, patients may be given the injection up to 7 days
before or after the monthly time point (anywhere between
___ and ___
[] Patient is being discharged with three tablets of oral
diltiazem 30mg to use if he should start to feel fast heart
rates again. This decision was made after discussing with his
outpatient cardiology, who plans to follow up with patient in
the next week.
[] Patient is also being discharged with a prescription for oral
Palperidone 3mg as needed for agitation/anxiety per psychiatry
recommendations. Unfortunately, we did not have any available
for him to be discharged with.
ACUTE ISSUES:
====================
# Schizophrenia
Diagnosed in ___, had recent psychiatric admission at ___
in ___ in the setting of med non-compliance. Had been
exhibiting disorganized behavior during recent hospitalization
at ___ for AVNRT and was brought in by EMS after
attempting to flee from family upon discharge. Evaluated by
psychiatry in the ED and determined to meet ___ criteria
for inability to care for self. He was medically cleared for
psychiatric placement and admitted for bed search. He was
maintained on 1:1 sitter. Zyprexa 5mg PO BID was offered but pt
intermittently refused his medications. Psychiatry recommended
starting IM paliperidone. Discussion were held between
outpatient cardiologist, psychiatrist, family, patient, and
medical team and we reached agreement to try paliperidone
despite the risks of tachycardia. He was initially crossed
titrated on PO paliperidone and Zyprexa, eventually transitioned
to IM paliperidone injections. He tolerated the medication with
good effect and was no longer agitated or confused for several
weeks prior to discharge. The decision was made to discharge
patient to home with significant outpatient support and
resources.
# Tachycardia
Hx intermittent episodes of paroxysmal SVT, most have
self-resolved and improved with taking home sotalol. Had
palpitations and tachycardia, treated with IV diltiazem 10 mg,
likely related to side effect of starting paliperidone. He was
continued on home Lasix 20 mg daily. His sotalol was increased
to 120 mg twice daily, with no further episodes.
# Hypoxia ___ heterotaxy syndrome
He had 1 recorded measurement of 76% on RA. Possibly iso
exertion. One evening, pt complained of feeling unwell but O2
sat was within his baseline and he showed no signs of infection.
CXR without effusions or consolidation. EKG reviewed and
appeared NSR with RBBB, atrial paced. Baseline O2 81-88% on RA,
per family report his home pulse ox readings were usually
85-88%.
CHRONIC ISSUES:
===============
# Heterotaxy syndrome
s/p Fontan procedure and revision. S/p PPM ___. Most recent
cath in ___. On rivaroxaban for anticoagulation. He received
Lasix 20mg daily and sotalol 120mg BID as above.
# Fontan associated liver disease
# Elevated transaminases
Stable, continued home rifaximin.
# Erythrocytosis
Likely secondary to chronic hypoxia. Baseline Hgb 17 in ___.
CORE MEASURES
=============
#CODE: Full (presumed)
#CONTACT:
___ (Mother): ___
___ (sister): ___
Social Worker ___): ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Sotalol 80 mg PO BID
3. rifAXIMin 550 mg PO BID
4. OLANZapine 2.5 mg PO QAM
5. OLANZapine 5 mg PO QPM
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Diltiazem 30 mg PO DAILY:PRN fast heart rates Duration: 1
Dose
RX *diltiazem HCl 30 mg 3 tablet(s) by mouth daily prn Disp #*3
Tablet Refills:*0
3. PALIperidone ER 3 mg PO DAILY:PRN agitation
RX *paliperidone 3 mg 1 tablet(s) by mouth daily prn Disp #*3
Tablet Refills:*0
4. PALIperidone Palmitate 156 mg IM Q1MO (TH)
5. Rivaroxaban 20 mg PO/NG DAILY
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
6. Sotalol 120 mg PO BID
RX *sotalol 120 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
7. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. rifAXIMin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Schizophrenia
SECONDARY DIAGNOSES:
==================
Heterotaxy syndrome
Supraventricular tachycardia
Chronic hypoxia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- There was concerning behavior that suggested you were not
acting like yourself.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You received your medications. We also tried giving you some
new medications to help, which seemed to make a big difference.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
- Please call the ___ Crisis Team ___
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19819468-DS-21
| 19,819,468 | 24,055,855 |
DS
| 21 |
2158-12-01 00:00:00
|
2158-12-05 21:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
worsening hydropneumothorax
Major Surgical or Invasive Procedure:
Placement of TPA in Chest Tube
History of Present Illness:
___ year old male h/o SCLC s/p XRT and radiation, HTN, afib,
gout recently admitted with R sided empyema s/p chest tube
placement, ___ currently on CTX who presented to ___ clinic
with worsening hydropneumothroax and loculation.
Pt not feeling more dyspneic than usual. Denies fevers, chills,
N/V, chest pain, pleuritic pain. Endorses mild productive cough
and congestion. Reports only having 25cc drained daily from
chest tube.
Patient had a recent admission to the MICU for right sided
pleural effusion and dyspnea. He had chest tube placed at that
time
In the ED, initial VS were 98.3 ___ 24 98/RA.
Exam notable for:
Decreased breath sounds over R lung field. Mild diffuse
wheezing
Tachycardic. RRR. S1, S2.
Chest tube dressed anteriorly. No tenderness
Labs showed:
11.8 > 9.3/30.5 < 482
133 | 95 | 11
--------------< 88
4.9 | 27 | 0.5
phos 5.4
INR 1.5
Imaging showed
CXR: persistent large, loculated right pleural effusion with
associated air fluid level and locules of pleural gas
CT chest:
-Increase in fluid volume of large probably multiloculated
right hydro pneumothorax, most of which is remote from the plane
of the lateral and anterior position of the tunneled right
pleural drainage catheter.
-New epicardial edema. Even though the volume of right
pericardial effusion is small, it should be monitored with
echocardiography to detect any evidence of developing purulent
pericarditis.
-The bronchus intermedius is stented. Narrowing of the right
main and upper lobe bronchi has improved. Right hilar mass still
occludes right middle and lower lobe bronchi and those lobes are
collapsed.
Interventional Pulmonology was consulted and put tPA through
the chest tube.
Received intrapleural alteplase and dornase Alfa through the
chest tube. Patient also received metoprolol for tachycardia.
Also received 75 cc/hr IVF.
Transfer VS were 98.5 114 108/68 20 96% RA.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient denies any complaints. No
chest pain and no SOB. He says he has been getting around at
home just fine with physical therapy.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
HTN
Hyperlipidemia
Gout
COPD
s/p hernia repair
Deviated septum
SCLC, ___ years ago, s/p chemoradiation + prophylactic cranial
radiation
Social History:
___
Family History:
Mother: thyroid disease
Physical Exam:
PHYSICAL EXAM ON ADMISSION
VS - 97.7 ___ 18 97% RA
GENERAL: NAD, AAOX3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: tachycardic, regular rhythm, S1/S2, no murmurs,
gallops, or rubs
LUNG: slightly decreased breath sounds at right base. Otherwise
CTAB. Chest tube in place
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
PHYSICAL EXAM ON DISCHARGE
Vitals: afebrile, 93/69, 105, 18, 94% RA
GENERAL: NAD, AAOX3
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
CARDIAC: tachycardic, regular rhythm, no murmurs
LUNG: decreased breath sounds at right base extending ___ up R
lung field, dullness to percussion on R. Otherwise CTAB. Chest
tube in place, on suction.
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 ON ADMISSION
___ 12:56PM BLOOD WBC-11.8* RBC-3.50* Hgb-9.3* Hct-30.5*
MCV-87# MCH-26.6 MCHC-30.5* RDW-15.7* RDWSD-49.8* Plt ___
___ 12:56PM BLOOD Neuts-87* Bands-0 Lymphs-6* Monos-5 Eos-2
Baso-0 ___ Myelos-0 AbsNeut-10.27* AbsLymp-0.71*
AbsMono-0.59 AbsEos-0.24 AbsBaso-0.00*
___ 12:56PM BLOOD ___ PTT-40.1* ___
MICRO:
___ URINE CULTURE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL; FUNGAL
CULTURE-PRELIMINARY ___.
___ 11:04 am PERITONEAL FLUID
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
IMAGING/OTHER STUDIES:
___HEST W/O CONTRAST
IMPRESSION:
Slight decrease in overall volume and in the fluid component of
multiloculated right hydro pneumothorax. No change in position
of course of the right pigtail drainage catheter.
Bronchus intermedius stent unchanged in position. Improved
patency to right middle lobe bronchus and right lower lobe
segmental bronchi.
___ Cardiovascular ECHO
Overall left ventricular systolic function is normal (LVEF>55%).
There is mild right ventricular global free wall hypokinesis.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Tiny pericardial effusion, not significantly
changed since the prior study of ___
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
Compared to chest radiographs ___ through ___.
Left PIC line ends in the upper SVC. Restrictive right pleural
thickening
persists but there has been a decrease in the volume of
dependent pleural
effusion. I cannot tell whether this has been replaced by
pleural air or
re-expanded lung. Basal pleural drainage tube is still in
place. Heart size top-normal. Left lung clear.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
In comparison to ___ radiograph, a pleural catheter
is in place in the right hemi thorax, with a persistent large,
loculated right pleural
effusion with associated air fluid level and locules of pleural
gas, more
fully evaluated by recent chest CT performed less than 1 hr
earlier.
Postoperative and post radiation changes in the right hemi
thorax are more
fully evaluated by CT.
___HEST W/O CONTRAST
IMPRESSION:
Increase in fluid volume of large probably multiloculated right
hydro
pneumothorax, most of which is remote from the plane of the
lateral and
anterior position of the tunneled right pleural drainage
catheter.
New epicardial edema. Even though the volume of right
pericardial effusion is
small, it should be monitored with echocardiography to detect
any evidence of
developing purulent pericarditis.
The bronchus intermedius is stented. Narrowing of the right
main and upper lobe bronchi has improved. Right hilar mass
still occludes right middle and lower lobe bronchi and those
lobes are collapsed.
Labs on Discharge:
___ 06:16AM BLOOD WBC-12.8* RBC-3.48* Hgb-9.1* Hct-29.9*
MCV-86 MCH-26.1 MCHC-30.4* RDW-16.0* RDWSD-50.3* Plt ___
___ 06:16AM BLOOD ___ PTT-37.6* ___
___ 06:16AM BLOOD Glucose-91 UreaN-21* Creat-1.4* Na-131*
K-5.1 Cl-92* HCO3-24 AnGap-20
___ 06:16AM BLOOD Calcium-9.6 Phos-7.1* Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ year old male h/o SCLC s/p XRT ___ years ago,
HTN, afib on apixiban, gout recently admitted with complicated
R-sided empyema and presented from ___ clinic for management of
worsening hydropneumothorax and new loculations of this known
empyema. He was recently treated with 6 week course of
ceftriaxone and placement of a chest tube for drainage of the
empyema. Previous pleural fluid culture grew S. pneumo. CT scan
obtained in ___ clinic on the day of admission showed loculations
of the empyema, and he was sent to ___ ED. ___ was held
and TPA placed in the chest tube X 3 with good effect. He was
restarted on a 6 week course of CTX. He was mildly tachycardic
on admission but this resolved with home metoprolol. Plan for
patient to follow-up in clinic regarding continued care of this
complex loculated hydropneumothorax.
Active Medical Issues
======================
#Empyema: Patient presented from ___ clinic for management of
worsening hydropneumothorax and new loculations of this known
empyema. He was recently treated with 6 week course of
ceftriaxone and placement of a chest tube for drainage of the
empyema. Previous pleural fluid culture grew S. pneumo. CT scan
obtained in ___ clinic on the day of admission showed loculations
of the empyema, and he was sent to ___ ED. The patient was
evaluated by Infectious disease who recommended repeat 6 week
course of CTX (anticipated end date ___. Apixiban was held
and TPA placed in the chest tube X 3 with good effect. Of note,
chest CT showed a new mass highly suspicious for recurrence of
small cell lung cancer, which may explain the etiology of the
patient's persistent empyema. Plan for patient to follow-up in
clinic regarding continued care of this complex located empyema
and further workup of lung mass.
#Sinus tachycardia: Patient with history of sinus tachycardia
and Afib. Had afib and pauses on telemetry ___ seconds) on his
last admission at ___. On this admission, found to be in sinus
tach, resolved with resumption of home metoprolol. HD stable.
Home ASA and apixaban were initially held iso tPA infusion,
restarted upon discharge. Home diltiazem was stopped given
patient had intermittent low BPs during hospital course.
#Pericardial effusion: Pt w/ persistent small pericardial
effusion since at least ___, per previous notes.
Patient with tachycardia, however pressures normal and stable w/
negative pulsus paradoxus. TTE on ___ and ___ also
showed very small pericardial effusion, without
echocardiographic signs of tamponade. Patient did show evidence
of new epicardial edema on CT scan ___ concerning for
pericarditis, but patient asymptomatic and EKG w/ no e/o
pericarditis.
Chronic Medical Issues:
=======================
#Gout: Patient notes several acute gout exacerbations per year,
most recently involving L knee. Continued home allopurinol.
#COPD: continued home inhalers, albuterol prn
#HLD: continued home simvastatin, home fenofibrate
#HTN: continued home quinapril, continued home spironolactone.
TRANSITIONAL ISSUES:
=======================================
- Patient should continue Ceftriaxone until Infectious Disease
follow-up appointment on ___
- Diltiazem was held during this admission. Please restart as
needed in the outpatient setting.
- Patient should resume his apixiban on ___.
- Patient should continue to drain chest tube three times per
week.
- Patient will follow-up in Interventional Pulmonary Clinic for
resolution of this complicated empyema as well as lung mass
which in setting of weight loss and hx of small cell lung ca is
concerning for malignancy
CODE: Full Code
COMMUNICATION: Patient
EMERGENCY CONTACT HCP: ___
Relationship: WIFE
Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q6H sob
3. Aspirin 81 mg PO DAILY
4. budesonide-formoterol 160-4.5 x2 puffs inhalation BID
5. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous gluconat) 1 tab oral DAILY
6. CefTRIAXone 1 gm IV Q24H
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Quinapril 20 mg PO DAILY
9. Apixaban 5 mg PO BID
10. Diltiazem Extended-Release 300 mg PO DAILY
11. Spironolactone 25 mg PO DAILY
12. Fenofibrate 134 mg PO DAILY
13. Simvastatin 20 mg PO QPM
14. umeclidinium 62.5 mcg/actuation inhalation DAILY
15. Indomethacin 25 mg PO TID:PRN Pain - Mild
16. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Albuterol Inhaler 2 PUFF IH Q6H sob
4. Allopurinol ___ mg PO DAILY
5. Apixaban 5 mg PO BID
6. Aspirin 81 mg PO DAILY
PLEASE RESTART ___
7. budesonide-formoterol 160-4.5 x2 puffs inhalation BID
8. CefTRIAXone 1 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 1 gram/50 mL 1 gm IV daily
Disp #*800 Intravenous Bag Refills:*0
9. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous gluconat) 1 tab oral DAILY
10. Fenofibrate 134 mg PO DAILY
11. Indomethacin 25 mg PO TID:PRN Pain - Mild
12. Quinapril 20 mg PO DAILY
13. Simvastatin 20 mg PO QPM
14. Spironolactone 25 mg PO DAILY
15. umeclidinium 62.5 mcg/actuation inhalation DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary Diagnosis: Loculated Empyema
Secondary Diagnosis: Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___.
You were admitted for management of infected fluid in your lung.
You received an imaging study (CT Scan) that showed new pockets
of infected fluid in your lung. A medication was placed in your
chest tube to help release this fluid. You will continue your
home antibiotics until your follow-up appointment with the
Infectious Disease clinic. Please also follow-up with your lung
doctors (___) on ___.
Best wishes,
Your ___ Team
Followup Instructions:
___
|
19819686-DS-15
| 19,819,686 | 24,226,963 |
DS
| 15 |
2152-07-19 00:00:00
|
2152-07-20 21:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ with history of dementia (non-verbal at
baseline) and deep venous thrombosis on Coumadin presenting with
fever of unknown origin. She reportedly has been experiencing
intermittent fevers to 102 in the absence of hemodynamic
instability or hypoxia since the new year and has received
Tamiflu, amoxicillin, and Levaquin for possible influenza versus
aspiration pneumonia in the setting of coarse breath sounds,
without resolution of fevers.
In the ED, temperature was 99.4-99.8 in association with heart
rate in ___, blood pressure of 120s-140s/70s-80s, respiratory
rate of ___, and oxygen saturation of 97-100% RA. Admission
labs were notable for sodium of 150, INR of 3.6, and bland
urinalysis. CXR was negative for clear focal infiltrate, and
influenza swab was obtained. She received 1 liter IV normal
saline prior to transfer to the floor.
She lives at ___ and reportedly requires
assistance with all ADLs at baseline. She is typically
incontinent of urine and stool. She has not experienced recent
loose stools, vomiting, or new decubitus ulcers, though there
has been some question of aspiration. Many residents of her
nursing are sick.
Past Medical History:
Deep venous thrombosis
Advanced dementia
Hypertension
History of multiple falls
Osteoarthritis
Osteoporosis
History of heart murmur (?Rheumatic heart disease)
Social History:
___
Family History:
Mother with dementia. Father died of pneumonia. Sister died of
myocardial infarction in her ___.
Physical Exam:
On admission:
VS: 99.4 119/67 68 16 99%RA
GENERAL: chronically ill-appearing in NAD, mildly diaphoretic
HEENT: NC/AT, PERRLA, tracks, sclerae anicteric, dry MM
NECK: supple, no appreciable LAD
LUNGS: limited but anterior fields clear, no r/rh/wh, good air
movement, resp unlabored, no accessory muscle use
HEART: faint SM throughout precordium, no MRG, nl S1-S2
ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES: WWP, no edema bilaterally in lower extremities, no
erythema, induration, or evidence of injury or infection
NEURO: awake
At discharge:
Afebrile/AVSS.
GENERAL: chronically ill-appearing in NAD
HEENT: NC/AT, PERRL, sclerae anicteric, dry MM
NECK: supple, no appreciable LAD
LUNGS: limited, but anterior fields clear, no r/rh/wh, good air
movement, resp unlabored, no accessory muscle use
HEART: RRR, faint SM throughout precordium, nl S1-S2
ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES: WWP, no edema bilaterally in lower extremities, no
erythema, induration, or evidence of injury or infection
NEURO: sleeping comfortably, but awakens to voice, does not
follow commands, winces when cool stethoscope placed on her
chest
SKIN: no cutaneous stigmata of endocarditis, no visible skin
breakdown (decubitus exam deferred)
Pertinent Results:
On admission:
___ 08:20PM BLOOD WBC-5.2 RBC-3.96* Hgb-13.4 Hct-41.6
MCV-105* MCH-33.9* MCHC-32.2 RDW-15.4 Plt ___
___ 08:20PM BLOOD Neuts-53.7 ___ Monos-4.1 Eos-2.1
Baso-0.9
___ 09:07PM BLOOD ___ PTT-38.7* ___
___ 08:20PM BLOOD Glucose-127* UreaN-14 Creat-0.5 Na-150*
K-3.7 Cl-114* HCO3-27 AnGap-13
___ 08:20PM BLOOD ALT-10 AST-14 AlkPhos-62 TotBili-0.4
___ 08:20PM BLOOD Albumin-3.6 Calcium-9.1
___ 08:47PM BLOOD Lactate-1.7
___ 08:20PM BLOOD Lipase-53
___ 09:43PM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:43PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 09:43PM URINE RBC-15* WBC-2 Bacteri-FEW Yeast-NONE
Epi-9
At discharge:
___ 06:00AM BLOOD WBC-5.3 RBC-3.51* Hgb-12.3 Hct-38.4
MCV-109* MCH-34.9* MCHC-31.9 RDW-15.6* Plt ___
___ 06:00AM BLOOD Glucose-121* UreaN-9 Creat-0.5 Na-144
K-4.1 Cl-114* HCO3-23 AnGap-11
___ 06:00AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.1
Microbiology:
Blood cultures x2 (___): No growth to date
Urine culture (___): Mixed bacterial flora consistent with
skin/genital contamination
Direct fluorescent antibody (___): Negative for influenza
A/B
Imaging:
Portable CXR (___):
Supine portable AP view of the chest provided. Evaluation
limited
due to severe dextroscoliotic deformity and kyphotic angulation
of the chest. Allowing for this, no definite signs of pneumonia
or overt CHF. No large effusion or pneumothorax is seen.
Overall, cardiomediastinal silhouette appears essentially
stable.
EKG (___):
Ectopic atrial rhythm. Early R wave transition. Non-specific ST
segment
changes. Left ventricular hypertrophy. Compared to the previous
tracing
of ___ the findings are similar.
IntervalsAxes
___
___
Brief Hospital Course:
Ms. ___ is an ___ with history of dementia (non-verbal at
baseline) and deep venous thrombosis on Coumadin who presented
with fever of unknown origin.
Active Issues:
(1)Fever of unknown origin/goals of care: Source of fever at
rehabilitation remained unclear, but fever did not recur over
the course of admission. There was no clear evidence of
infection in the setting of bland urinalysis, unremarkable CXR,
negative influenza DFA, and blood cultures with no growth by the
time of discharge, and she was otherwise without SIRS/sepsis
physiology. Occult malignancy could not be excluded, though
there was low suspicion for hematologic malignancy, given normal
complete blood count, or primary/metastatic hepatic malignancy,
given normal liver function tests. Ultimately, a family meeting
took place, and the decision was made not to pursue further
evaluation since she would not be a candidate for treatment of
malignancy or autoimmune disease; nevertheless, she remained
full code throughout admission.
Family is considering changing Ms. ___ advance directives to
emphasize comfort care. This will be left to the team at ___
that knows her well to officially make this change.
(2)Hypernatremia: Sodium was found to be 150 on admission,
likely due to poor oral intake with insensible losses in the
setting of fever. Sodium had improved to 144 by the time of
discharge with administration of ___.
Inactive Issues:
(1)Advanced dementia: She remained at reported baseline
throughout admission, rousable to voice, but nonverbal and
unable to follow commands.
(2)Deep venous thrombosis: Coumadin was held throughout brief
admission due to INR of 3.6 on admission and may be resumed as
indicated to maintain INR of ___.
(3)Macrocytosis: Mean corpuscular volume was found to be 105-109
in the absence of
frank anemia. It appears that macrocytosis has been present
since ___, when mean corpuscular volume was 101.
Transitional Issues:
- Coumadin was held throughout brief admission due to INR of 3.6
on admission and may be resumed as indicated to maintain INR of
___.
- Pending studies: Blood cultures.
- Code status: Full.
Medications on Admission:
1. Acetaminophen 650 mg PR Q6H:PRN fever
max dose 4gm/day
2. Bisacodyl 10 mg PR HS:PRN constipation
3. Senna 1 TAB PO BID:PRN constipation
4. Warfarin 2 mg PO DAYS (___)
Discharge Medications:
1. Acetaminophen 650 mg PR Q6H:PRN fever
max dose 4gm/day
2. Bisacodyl 10 mg PR HS:PRN constipation
3. Senna 1 TAB PO BID:PRN constipation
4. Warfarin 2 mg PO DAYS (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fever of unknown origin
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care during your admission
to ___. As you know, you were
admitted for intermittent fevers. Reason for fevers was not
entirely clear. You had numerous studies and tests and none of
the tests suggested an infectious source. We had a family
meeting to discuss your fevers and the decision was made not to
perform any more studies since it would not change management.
The plan is to send you back to rehab.
Medication changes:
-Please hold coumadin until ___. If INR<3 on ___, may resume
home coumadin dose.
Followup Instructions:
___
|
19820096-DS-11
| 19,820,096 | 24,202,809 |
DS
| 11 |
2167-08-12 00:00:00
|
2167-08-13 22:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ HIV+ woman from ___ with h/o toxoplasmosis with left
sided hemiparesis in ___ who presents with episodes of
left-sided facial twitching and left arm tonic posturing. She
says in ___, when she was found to have toxoplasmosis, she had
an episode of complete left hemiparesis. She underwent
treatment with an antiparasitic drug but she does not remember
which one. She was initially treated with Bactrim but has a
severe allergy to this and was transitioned to a different
medication that she does not remember. Since that time she has
been completely normal with no neurological deficits other than
occasionally feeling some weakness on the left side. She walks
unassisted and is able to perform all of her activities of daily
living. She says that around 7 ___ yesterday, she noticed 5
seconds of left facial twitching. She felt as if her lip was
being pulled to the side. About 30 minutes later, it happened
again and lasted longer this time (maybe ___. This morning, she
started to have it happen again and she thinks that it happened
___ times over the day. Each episode lasts approximately 10
seconds. She thinks that if she were to smile, she could smile
through the twitching but nothing makes the twitching stop. She
has a sensation of lightheadedness when the twitching is
occurring. At one point today, she was with her friend when her
left arm became very stiff and flexed up towards her body. She
thinks that this tonic stiffness lasted approximately 30 seconds
to a minute. She had to use her right hand to loosen up the
left hand and release the fingers and arm from the flexed
position. This arm movement only happened once. Because of
these episodes, she presented to ___ and
had a ___ which showed "right parietal lobe hypodense
abnormality which could be acute (infarct or edema) or chronic
(gliosis)." The MRI at ___ is broken so she was transferred to
___ for this imaging. Neurology was consulted for further
management and workup recommendations.
On neuro ROS, episodes of facial twitching and left arm
posturing with some lightheadedness described above, occasional
sensation of left-sided weakness but walks unassisted. The pt
denies headache, loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias.
Past Medical History:
HIV
Depression
Insomnia
Hypercholesterolemia
Genital herpes
s/p abdominal supracervical hysterectomy and left
salpingo-oophorectomy
Social History:
___
Family History:
She denies any family history of toxoplasmosis, seizures, or
strokes
Physical Exam:
ADMISSION PHYSICAL EXAM:
- Vitals: 98 68 115/75 26 98% RA
- General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: No increased work of breathing
- Abdomen: soft
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Able to name both high frequency objects, difficulty
with low-frequency objects but her first language is not
___. Able to read without difficulty. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Able to register 3 objects and recall ___ at 5
minutes. There was no evidence of apraxia or neglect.
- Cranial Nerves:
PERRL 3 to 2mm and brisk. VFF to confrontation both monocular
___ and binocularly. Funduscopic exam performed with good
visualization of the retinas and no evidence of papilledema.
EOMI without nystagmus. Normal saccades. Facial sensation intact
to light touch. No facial droop, facial musculature symmetric.
Hearing intact to voice.
- Motor: Normal bulk and tone throughout. No pronator drift
bilaterally. No adventitious movements such as tremor or
asterixis noted. None of the episodes of the left facial
twitching or arm posturing were observed
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
- Sensory: No deficits to light touch. No extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
- Coordination: Mild clumsiness with left hand wave and finger
tap. Mild dysmetria with left FNF.
- Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem. Left arm posturing with stressed
gait. Minimal sway on Romberg.
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 98.8, HR 50-60s, RR ___, BP 90-106/50-71, >97% RA
- General: sitting up in bed, NAD
- HEENT: NC/AT, dark brown hair, MMM
- Neck: Supple, no meningismus
- Card: RRR, well perfused
- Pulmonary: No increased work of breathing
- Abdomen: soft, ND
- Skin: no rashes
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. Language is fluent
with no paraphasic errors. Able to follow both midline and
appendicular commands. No evidence of apraxia or neglect.
- Cranial Nerves: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. Facial sensation intact to light
touch. Face symmetric. Hearing intact to voice.
- Motor: Normal bulk and tone throughout. Subtle L pronator
drift.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5- ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
- Sensory: No deficits to light touch. No extinction to DSS.
- DTRs: 2+ throughout, plantar response was flexor bilaterally.
Pertinent Results:
___ 04:30AM BLOOD WBC-4.9 RBC-3.67* Hgb-12.3 Hct-35.4
MCV-97 MCH-33.5* MCHC-34.7 RDW-12.2 RDWSD-43.1 Plt ___
___ 04:40AM BLOOD Neuts-57.4 ___ Monos-8.3 Eos-1.5
Baso-0.8 Im ___ AbsNeut-3.06 AbsLymp-1.68 AbsMono-0.44
AbsEos-0.08 AbsBaso-0.04
___ 04:40AM BLOOD WBC-5.3 Lymph-32 Abs ___ CD3%-77
Abs CD3-1302 CD4%-34 Abs CD4-580 CD8%-40 Abs CD8-678
CD4/CD8-0.86
___ 04:30AM BLOOD Glucose-85 UreaN-20 Creat-0.9 Na-137
K-4.0 Cl-104 HCO3-22 AnGap-15
___ 04:30AM BLOOD Calcium-9.0 Phos-4.0 Mg-1.9
___ 04:30AM BLOOD CRP-0.6
___ 04:40AM BLOOD HIV1 VL-2.1*
IMAGING:
MRI Brain ___:
FINDINGS:
There is asymmetric subcortical white matter T2 and FLAIR signal
hyperintensity extending to the subcortical U fibers, most
dominant in the
left frontal lobe and bilateral parieto-occipital lobes. There
is poorly
defined subcortical white matter enhancement involving regions
of the
bilateral frontal, parietal, and temporal lobes. Scattered foci
of
susceptibility artifact correspond to parenchymal calcifications
identified on
recent outside hospital noncontrast head CT. Around the largest
known
calcification in the right mid brain, there is peripheral, rim
enhancement. No
evidence of hemorrhage, infarction, or mass effect. The
ventricles and sulci
are normal in caliber and configuration.
The major vascular flow voids appear patent. On post-contrast
MPRAGE
sequences, there is a probable developmental venous anomaly
draining the right
basal ganglia. The dural venous sinuses are patent. There is
mild mucosal
thickening of the ethmoid air cells.
IMPRESSION:
1. Overall distribution of T2/FLAIR signal hyperintensity
extending to the
subcortical U fibers is most consistent with PML rather than HIV
encephalitis.
2. Relatively subtle subcortical white matter enhancement
involving regions of
the bilateral frontal, parietal, and temporal lobes has an
appearance most
consistent with immune reconstitution inflammatory syndrome.
However, the
documented clinical picture may be more consistent with
progressive
immunocompromise rather than immune reconstitution. In this
setting, it is
conceivable that the subtle enhancement is related to PML,
though PML does not
usually enhance.
3. Peripheral enhancement around a prominent right midbrain
calcification
suggests reactivated toxoplasmosis. However, calcifications as
demonstrated
on prior outside hospital CT suggests there is likely a
superimposed component
of neurocysticercosis.
EEG ___:
IMPRESSION: This is a normal continuous EMU monitoring study.
There are no
epileptiform discharges or electrographic seizures in this
recording.
Brief Hospital Course:
Ms. ___ is a ___ female from ___ with HIV and history of
toxoplasmosis with left sided hemiparesis in ___ that resolved,
who was admitted with several episodes of left-sided facial
twitching and a single episode of left arm tonic posturing
concerning for seizure versus dystonic movements. Her exam was
notable for only mild bilateral triceps weakness and left
posturing on stressed gait.
She had a brain MRI that was concerning for T2/FLAIR
hyperintensities to subcortical U fibers consistent with PML,
subcortical white matter enhancement in bilateral
frontal/parietal/temporal lobes consistent with ___ vs.
progressive immunocompromise; peripheral enhancement around
prominent R midbrain calcification suggests reactivation of
toxoplasmosis, possible superimposed neurocysticercosis. LP was
completed with opening pressure 13cm H20, 3 WBC, 0 RBC, protein
54 and glucose 67. CSF gram stain negative.
She was started on Keppra up to 750mg BID. EEG was negative for
seizures although no events were captured. She had some
intermittent left upper lip twitching that was non-rhythmic,
more likely myokimia than seizure. We recommended continued
hydration and monitoring of these events.
Infectious disease was consulted and continued to follow
closely. She was seen by Ophthalmology who performed a dilated
eye exam that was normal. She was continued on her HAART
therapy. Her CD4 count was 580, indicative of good control of
her HIV. In discussion with her outpatient ID providers at ___,
her CD4 count has not been below 500. Toxo IgG+/IgM- in serum
(indicative of prior infection, less likely reactivation) with
Toxo and Cryptococcus Ag negative in CSF. Serum ___ virus Ab was
positive, but CSF ___ virus PCR negative (making PML unlikely
especially in clinical setting of her well appearance). Beta-2
microglobulin was elevated at 4.41 (normal 0.36-2.56) with flow
cytology negative for malignancy and non-diagnostic cytometry
(not enough cells in CSF). Pending studies include
neurocysticercosis Ab, TB CSF studies and EBV PCR from CSF. She
has an Infectious Disease appointment in 1 week to follow these
studies.
Her presentation was most consistent with a focal motor seizure
so she will stay of Keppra. The etiology of the diffuse white
matter changes is still unknown; she should have repeat imaging
in 3 months to follow and consider repeat lumbar puncture in the
future pending her clinical status. At the time of discharge
she remained afebrile with stable vital signs and intact
neurologic exam with no appreciable weakness or other focal
deficits.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
2. TraZODone 25 mg PO QHS:PRN insomnia
3. Escitalopram Oxalate 10 mg PO DAILY
4. Acyclovir Dose is Unknown PO Q8H
5. Genvoya (elviteg-cobi-emtric-tenofo ala) ___ mg
oral DAILY
Discharge Medications:
1. LevETIRAcetam 750 mg PO BID
RX *levetiracetam [Keppra] 750 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*5
2. Escitalopram Oxalate 10 mg PO DAILY
3. Genvoya (elviteg-cobi-emtric-tenofo ala) ___ mg
oral DAILY
4. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
5. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
HIV, likely 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 due to concern for
seizures. You had a brain MRI that was abnormal due to an
enhancing lesion likely due to prior toxoplasmosis in addition
to diffuse white matter changes, possibly infectious in
etiology, although there is no clear explanation for it at this
time. You should have a repeat MRI in the future to follow
this. You should continue your home medications in addition to
a new medication, Keppra, to prevent seizures. You will have
close follow-up with Infectious Disease and Neurology.
Best,
Your ___ Neurology Team
Followup Instructions:
___
|
19820301-DS-13
| 19,820,301 | 23,955,537 |
DS
| 13 |
2160-04-24 00:00:00
|
2160-04-28 16:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gabapentin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
-EGD ___
-R ___ line placed ___
-Intubated/mechanical ventilation ___
-diagnostic/large volume paracentesis ___ removed.
-diagnostic/large volume paracentesis ___ removed
-diagnostic/large volume paracentesis ___ L removed
History of Present Illness:
___ year old woman with a history of chronic hepatitis C with
cirrhosis, complicated by portal hypertension and ascites, sent
to the ED from initial Liver clinic evaluation for mild hepatic
encephalopathy and shortness of breath in the setting of volume
overload. She is now transferred to the ICU for worsening
respiratory status, tachycardia, hypotension, lactic acidosis,
and progressive encephalopathy.
Patient was recently diagnosed with hepatitis C and cirrhosis
within the past month. She has had increasing abdominal
distention and abdominal pain and underwent at CT scan ___
which showed a cirrhotic liver with large amount of ascites,
cholelithiasis, and diverticulosis. Labs were notable for an HCV
VL of 498,146 on ___. The patient had been on diuretics in
the past with profound weight loss (approx. 40lbs in 2 weeks),
and diuretics had been stopped. It appears that the patient had
stopped taking home diuretics for a wedding but subsequently
restarted on 40 Lasix and 50 mg aldactone BID, however has had
continued weight gain. She has had some nausea as well which was
being treated with Zofran and omeprazole, however per report has
been refractory to these treatments.
The patient has been noted to be unsteady while walking as well
as increasing confusion by her sister.
Of note the patient had been seen by Atrius gastroenterology on
___ with concern for tense ascites, which had been developing
over the past 6 months. She was recommended to go to the ED for
large volume paracentesis though the patient deferred at the
time.
The patient went to a ___ hepatology appointment on the day of
admission where she was short of breath, confused with
significant ascites. She also complained of increased lower
extremity swelling, difficulty walking, and significant
exertional dyspnea and wheezing for a week. She was referred in
to the ___ ED.
In the ED, initial vitals were T 96.5 HR 118 BP 96/58 RR 18.
Exam was notable for non tender distended abdomen. Initial labs
were notable for WBC 13.9, AST 50, ALT 25, Alk phos 138, Tbili
3.5, Albumin 2.5, lipase 19, INR 1.9, Lactate 4.0, VBG
7.41/36/34/24. The patient had a diagnostic paracentesis with
317 WBC (4 Poly, 62 lymph), 422 RBC, protein 1.6, Glucose 104.
RUQ US with dopplers revealed cirrhosis with large volume
ascites. Portal vein was patent. Also noted to have
cholelithiasis without evidence of cholecystitis.
The patient was given: ___ 12:08 IVF 1000 mL NS 1000 mL.
When seen on the floor initially on arrival the patient reported
that she was feeling mildly short of breath. She also reported
stomach discomfort and lower leg. Limited review of symptoms
secondary to mental status was notable for improved nausea (last
emesis reported 4 days prior), as well as mild dysuria for 1
month duration. Patient also reports dark stools in the past,
although not exactly clear when this was.
Shortly after arrival to the floor, she underwent therapeutic
paracentesis. Shortly prior to, and during this procedure she
was becoming increasingly tachypneic, agitated, and flailing
around in bed. Although 3L of ascites was removed, the
paracentesis was stopped due to safety concern given her
agitation. MICU consult was called when she became
progressively more agitated (writing in bed, disoriented,
inattentive, grabbing and lines and monitoring devices),
tachycardia to 140s-150s, tachypneic (RR ___, and hypotensive
to SPB ___. She had no IV access and so was unable to receive
medications.
Past Medical History:
-Chronic Hepatitis C - diagnosed ___
-Cirrhosis c/b esophageal variceal bleed, ascites, SBP, HRS.
-Diverticulosis
-Cholelithiasis
-Morbid obesity
-Tobacco dependence
Social History:
___
Family History:
A maternal uncle has colon cancer. There is no known family
history of liver disease. Mother with uterine cancer, three
maternal aunts died of breast cancer, father with CAD, PVD,
prostate CA and melanoma.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T: 99.6 83/47 HR 120s 30 100% RA
GENERAL: drowsy, arousable to voice, not reliably following
commands
HEENT: dry mm, dilated pupils 4->3 mm, equal, +scleral icterus
NECK: difficult to assess JVP
LUNGS: decreased breath sounds in bases, otherwise CTAB
CV: tachycardic, regular, no murmurs or rubs appreciated
ABD: distended, obese, nontender to palpation, BS+, +ascites,
difficulty to assess for hepatomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: cool in feet bilaterally
NEURO: LUE +clonus, RUE flaccid, withdrawing to pain in all 4
extremities, moving all spontaneously
Pertinent Results:
ADMISSION LABS
==============
___ 10:36AM BLOOD WBC-13.9* RBC-3.43* Hgb-11.2 Hct-33.6*
MCV-98 MCH-32.7* MCHC-33.3 RDW-14.6 RDWSD-52.9* Plt ___
___ 10:36AM BLOOD Neuts-72.3* Lymphs-17.4* Monos-8.4
Eos-0.1* Baso-0.2 Im ___ AbsNeut-10.04* AbsLymp-2.42
AbsMono-1.17* AbsEos-0.01* AbsBaso-0.03
___ 10:36AM BLOOD ___ PTT-33.4 ___
___ 10:36AM BLOOD Glucose-95 UreaN-21* Creat-0.9 Na-134
K-4.5 Cl-101 HCO3-21* AnGap-17
___ 10:36AM BLOOD ALT-25 AST-50* AlkPhos-138* TotBili-3.5*
___ 10:36AM BLOOD Albumin-2.5*
___ 11:43PM BLOOD Calcium-8.8 Phos-3.3 Mg-1.9
___ 10:36AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-18
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:43AM BLOOD Lactate-4.0*
DISCHARGE LABS
==============
___ 03:34AM BLOOD WBC-22.0* RBC-2.73* Hgb-8.9* Hct-27.7*
MCV-102* MCH-32.6* MCHC-32.1 RDW-20.4* RDWSD-72.5* Plt Ct-91*
___ 03:34AM BLOOD ___ PTT-150* ___
___ 03:34AM BLOOD Glucose-88 UreaN-83* Creat-3.0* Na-144
K-4.0 Cl-104 HCO3-19* AnGap-25*
___ 03:34AM BLOOD ALT-20 AST-69* LD(LDH)-228 AlkPhos-38
TotBili-30.6*
___ 03:34AM BLOOD Albumin-4.6 Calcium-9.4 Phos-6.7* Mg-2.7*
LIVER FUNCTION TESTS TREND
==========================
___ 10:36AM BLOOD ALT-25 AST-50* AlkPhos-138* TotBili-3.5*
___ 05:19AM BLOOD ALT-138* AST-453* LD(___)-724* AlkPhos-75
TotBili-5.7*
___ 04:04AM BLOOD ALT-164* AST-368* LD(___)-348* AlkPhos-89
TotBili-5.9*
___ 03:20AM BLOOD ALT-134* AST-221* LD(LDH)-348* AlkPhos-85
TotBili-8.0*
___ 03:16AM BLOOD ALT-109* AST-127* AlkPhos-84
TotBili-10.2*
___ 03:45AM BLOOD ALT-81* AST-81* LD(LDH)-386* AlkPhos-92
TotBili-12.8*
___ 03:51AM BLOOD ALT-56* AST-58* AlkPhos-74 TotBili-15.2*
___ 02:43AM BLOOD ALT-39 AST-62* LD(___)-316* AlkPhos-69
TotBili-19.4*
___ 02:20PM BLOOD TotBili-23.2*
___ 03:49AM BLOOD ALT-31 AST-71* AlkPhos-60 TotBili-25.4*
___ 03:16AM BLOOD ALT-29 AST-79* LD(___)-293* AlkPhos-53
TotBili-26.1*
___ 03:20AM BLOOD ALT-30 AST-81* AlkPhos-55 TotBili-29.4*
___ 03:15AM BLOOD ALT-23 AST-66* AlkPhos-37 TotBili-28.3*
___ 03:34AM BLOOD ALT-20 AST-69* LD(LDH)-228 AlkPhos-38
TotBili-30.6*
URINE STUDIES
=============
___ 01:57PM URINE Color-DkAmb Appear-Hazy Sp ___
___ 01:57PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-SM Urobiln-4* pH-6.0 Leuks-NEG
___ 01:57PM URINE RBC-6* WBC-4 Bacteri-FEW Yeast-NONE
Epi-11
___ 01:57PM URINE CastHy-169*
___ 10:50AM URINE Color-DkAmb Appear-Cloudy Sp ___
___ 10:50AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-LG Urobiln-4* pH-5.5 Leuks-LG
___ 10:50AM URINE RBC-178* WBC->182* Bacteri-MOD Yeast-MANY
Epi-3 TransE-2
___ 10:50AM URINE CastHy-30*
___ 06:41AM URINE Hours-RANDOM UreaN-228 Na-<20
SERUM TOXICOLOGY
================
___ 10:36AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-18
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
URINE TOXICOLOGY
================
___ 01:57PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
PERITONEAL STUDIES
==================
___ 10:38AM ASCITES WBC-317* RBC-422* Polys-4* Lymphs-62*
Monos-13* Atyps-1* Mesothe-1* Macroph-19*
___ 10:38AM ASCITES TotPro-1.6 Glucose-104
___ 05:54PM ASCITES WBC-233* RBC-425* Polys-5* Lymphs-54*
___ Mesothe-2* Macroph-39*
___ 05:54PM ASCITES TotPro-1.5 Glucose-99 LD(LDH)-50
TotBili-0.5 Albumin-0.7
___ 02:26PM ASCITES WBC-616* RBC-1145* Polys-72* Lymphs-25*
Monos-0 Plasma-1* Macroph-2*
___ 02:26PM ASCITES Glucose-124 Creat-0.7 LD(LDH)-135
Albumin-0.9
___ 04:27PM ASCITES WBC-150* RBC-809* Polys-23* Lymphs-30*
Monos-0 Eos-1* Mesothe-2* Macroph-44*
___ 04:27PM ASCITES TotPro-1.0
MICROBIOLOGY
============
___ 5:45 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___:
ESCHERICHIA COLI. RARE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 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
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
IMAGING/PROCEDURES
==================
___: RIGHT UPPER QUADRANT ULTRASOUND
IMPRESSION:
1. Cirrhosis with large volume ascites.
2. Cholelithiasis without evidence of cholecystitis.
___: CT ABDOMEN AND PELVIS WITH CONTRAST
IMPRESSION:
1. No evidence of retroperitoneal hematoma, no definite cause
for patient's hemoglobin and hematocrit drop identified.
2. Cirrhotic appearing liver with 1.5 cm hypodense lesion in
segment ___.
Further evaluation with dedicated MRI is recommended.
3. Left lower lobe consolidation, compatible with underlying
pneumonia or
aspiration. For continued follow-up with chest radiographs.
4. Wall thickening involving the ascending and proximal
transverse colon is likely a reflection of third spacing/ portal
colopathy.
___: CT HEAD WITHOUT CONTRAST
IMPRESSION:
1. Limited examination secondary to patient motion artifact.
Within these
confines, no acute intracranial abnormality.
ATTENDING NOTE: Brain sulci are effaced. There is slight
high-density the tentorium and choroid plexus which may suggest
decreased density of the brain parenchyma. Although basal
cisterns are patent, this appearance may suggest mild cerebral
edema. Followup CTA or MRI can help for further assessment.
___: CT HEAD WITHOUT CONTRAST
IMPRESSION:
1. No interval significant change. Persistent probable mild
cerebral edema without brain herniation.
___: CT HEAD WITHOUT CONTRAST
IMPRESSION:
Unchanged mild cerebral edema without herniation.
___: CT ABDOMEN AND PELVIS WITH CONTRAST
IMPRESSION:
1. Cirrhotic liver with large volume ascites. No organized
collection. The main portal vein is patent.
2. The small hypodense lesion in segment 8 is again appreciated,
though it
appears slightly smaller compared to prior, incompletely
characterized.
3. Thickened distal duodenum and jejunum, suggesting focal
infection/
inflammation.
4. Thickened endometrium given patient's age. Elective pelvic
ultrasound recommended for further evaluation in the absence of
vaginal bleeding.
5. Left lower lobe near complete collapse, with associated
peripheral round parenchymal hypodense lung, which may represent
a pulmonary infection or
infarct.
6. Cholelithiasis.
RECOMMENDATION(S):
Thickened endometrium given patient's age. Elective pelvic
ultrasound
recommended for further evaluation in the absence of vaginal
bleeding.
Brief Hospital Course:
___ year old woman with a history of chronic hepatitis C with
cirrhosis, complicated by portal hypertension and ascites, sent
to the ED from initial Liver clinic evaluation for mild hepatic
encephalopathy and shortness of breath in the setting of volume
overload. She was transferred to the ICU for worsening
respiratory status, tachycardia, hypotension, lactic acidosis,
and progressive encephalopathy secondary to hemorrhagic shock
due to esophageal variceal bleed.
#Goals of Care: Patient presented with hemorrhagic shock
secondary to variceal bleed. Her hospital course was complicated
by spontaneous bacterial peritonitis, encephalopathy,
progressive liver dysfunction (with uptrending bilirubin to 30.6
with progressively progressing INR to 4.2 even with vitamin K
supplementation), persistent leukocytosis (even after broad
spectrum antibiotics with vancomycin and Meropenem), and anuric
renal failure secondary to ATN. Given her critical status a
family meeting took place with patient being confirmed DNR/DNI.
When patient's encephalopathy resolved and patient was able to
communicate, she expressed her desire to remain DNR/DNI. A
meeting took place with Ms. ___ and ___ HCP/sister (___)
to describe her medical condition. During that meeting, it was
indicated that she would likely require dialysis given her
hepatorenal syndrome. After indicating her options for her
progressive liver dysfunction, her progressive kidney
dysfunction, and prognosis, she indicated that she would never
want to be initiated on hemodialysis under any circumstances.
Ms. ___ confirmed that she did not want to undergo any
further invasive procedures, and wanted to eat for comfort. This
was confirmed with her and her healthcare proxy ___ during a
family meeting on ___. Options for comfort care were
explored with Ms. ___ and ___ HCP with decision to move
towards transition to a hospice center. Her status was changed
to DNR/DNI/CMO. Ms. ___ was subsequently discharged to
hospice.
# Hepatitis C Cirrhosis: Complicated by esophageal
varices/esophageal variceal bleed, ascites/SBP, hepatic
encephalopathy, hepatorenal syndrome.
-Hepatic Encephalopathy: presented with acute HE on this
admission with worsening mental status over the course of her
hospital stay. Continued on lactulose and rifaximin with minimal
improvement in mental status.
-Esophageal Varices: The patient presented with bleeding
esophageal varices s/p banding on ___ with hemostasis
achieved. Initially on octreotide gtt and protonix gtt, later
transitioned to protonix BID
-Ascites c/b SBP: The patient has significant abdominal ascites
with therapeutic paracentesis performed on ___ with 6.5L
removed and ___ with 4L removed.
During hospitalization, patient had continued decompensation of
her liver. Bilirubin continued to uptrend to 30.6 with INR
prolonging to 4.2 in spite of vitamin K supplementation.
Etiology of the acute decompensation was thought to be secondary
to septic shock/SBP.
# Anuric Renal Failure Secondary to Hepatorenal Syndrome: In the
setting of SBP and decompensated liver, patient's creatinine
continued to uptrend from a nadir of 0.4 on ___ with rapid rise
to 3.0 on ___, associated with anuria. Urine lytes showed urine
Na less than 20 consistent with HRS. Patient was treated for HRS
with Albumin challenge x 2 days, midodrine 20 mg TID, and
octreotide 100 mcg SC Q8H with subsequent uptitration to
octreotide 200 mcg SC Q8H. As patient developed anuric renal
failure thought to be secondary to HRS, dialysis was likely
needed. After discussion with Ms. ___ and family regarding
dialysis, Ms. ___ indicated she would not want dialysis
under any circumstances. Giver her progressive liver disease and
renal function without dialysis as an outpatient, Ms. ___
decided to move towards comfort focused care. She was
subsequently discharged to hospice.
#Hemorrhagic Shock, Esophageal Variceal bleed: Patient initially
transferred to ICU for hypotension/shock, initiated on levophed
and neo for blood pressure support. Given H/H drop and notable
melena and blood gastric output during intubation there was
concern for upper GIB. GI consulted and EGD performed which
demonstrated bleeding esophageal varices. Patient initiated on
massive transfusion protocol and received 6U pRBC, ___, 1U
plts. Underwent successful esophageal banding and was initiated
on octreotide gtt and protonix BID. Following esophageal
banding, the patient had no evidence of re-bleed for several
days. However, as patient began to experience liver
decompensation, patient's NG output was notable for blood. Given
patient's poor prognosis and medical condition as noted above,
discussion with patient and family took place with decision to
move towards comfort measures without additional interventions.
She moved towards hospice care and was discharged to hospice
with NG tube to suction.
#Septic Shock, SBP: Ascitic fluid on ___ positive for
pan-sensitive E. Coli initially on vanc/cefepime/flagyl later
transitioned to ceftriaxone alone given sensitivities of E.Coli.
Over the course of her hospital stay, the patient remained
encephalopathic with rising TBili and INR concerning for liver
decompensation. To assess etiology of the liver decompensation,
repeat diagnostic paracentesis was performed (___) which showed
persistent elevated WBC, but no organisms. Given concern for
persistent infection, the patient was rebroadened to ___
on ___. Repeat diagnostic paracentesis on ___ improved,
however, patient continued to have persistently elevated
leukocytosis and uptrending bilirubin concerning for continued
liver decompensation, even while on vancomycin/meropenem with
intermittent need for pressors. Other sources of infection were
investigated with blood cultures, urine cultures, CXR not
showing any additional source of infection. As noted above,
given patient's poor prognosis and desire for comfort care,
antibiotics were discontinued and she was discharged to hospice.
#Encephalopathy: Likely multifactorial due to underlying hepatic
encephalopathy, spontaneous bacterial peritonitis, medication
effect, and acute renal failure. CT head showed mild cerebral
edema without herniation which was stable on repeat CT head
imaging x2. EEG negative for seizures. The patient was on
vancomycin and meropenem for SBP and continued on
lactulose/rifaximin for hepatic encephalopathy. Over the course
of her hospital stay, her mental status improved significantly.
As noted above, patient was transitioned to hospice. She was
discharged on lactulose and rifaximin to prevent further hepatic
encephalopathy while at hospice.
#Hypoxemic Respiratory Failure: Likely secondary to aspiration
in the setting of emergent intubation given upper GIB. Abdominal
distension from ascites also contributing. The patient underwent
two paracentesis ___ with 6.5L removed) and ___ with 4 L
removed. Her respiratory status improved and patient was able to
pass SBT. She was subsequently extubated. Following extubation,
she was able to saturate well on 4L nasal cannula.
#Hypernatremia: Occurred in the setting of lactulose and
increased stool output. Improved with D5W and encouraging PO
intake.
#Coagulopathy: Secondary to underlying cirrhosis. Managed with
FFP in the setting of massive GIB later given vitamin K 10mg IV
x3 days once bleeding resolved. However, as noted, above,
patient experienced progressive liver decompensation with rising
INR to 4.2 even with vitamin K supplementation.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Furosemide 40 mg PO BID
3. Spironolactone 50 mg PO BID
4. Omeprazole 20 mg PO BID
Discharge Medications:
1. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q2H:PRN pain
2. Lactulose 30 mL PO TID
3. Rifaximin 550 mg PO BID
4. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- variceal bleed
- decompensated cirrhosis
- hepatorenal failure resulting in renal failure
- spontaneous bacterial peritonitis
- sepsis
- encephalopathy
Secondary:
- hepatitis C
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 Ms. ___,
It was a pleasure caring for you during your recent admission.
You came to the hospital with confusion and shortness of breath,
and unfortunately your hospital course was complicated by a
severe esophageal bleed as well as severe infection of the fluid
in your abdomen: these complications caused your liver to become
much sicker, and after extensive discussion with your and your
family, the decision was made to discharge you to hospice care
so you could focus most on spending time with your family.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19820328-DS-12
| 19,820,328 | 28,672,580 |
DS
| 12 |
2119-07-07 00:00:00
|
2119-07-19 21:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
latex
Attending: ___
Chief Complaint:
ascending numbness
Major Surgical or Invasive Procedure:
lumbar puncture (___)
lumbar puncture (___)
History of Present Illness:
___ is a previously healthy ___ old woman who
noticed four dats ago that her feet were tingly in sneakers like
they were too tight but this feeling persisted after shoes were
off. THe next day (___), she had tightness and cramps in thighs
bilaterally. Then, it progressed to the sensation that numbness
and tingling was intermittently present on thighs. THe day prior
to admission, the humbness spread to her perineum, and she
noticed numbness when using the toilet.
Her gait feels off to her because she cannot feel her feet. She
denies any bowel or bladder incontinence or retention. She
denies any recent illnesses, no fevers, chills, diarrhea,
nausea, vomiting, runny nose or headache.
She saw her PCP. Reportedly, a head CT was obtained and was
negative. She was sent to the hospital.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness. No
bowel or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
none
Social History:
___
Family History:
-Sister recently diagnosed with multiple scerosis. Otherwise
multiple family members with cancer, heart disease, and
diabetes. She does not have any exposures to chemicals.
Physical Exam:
ADMISSION EXAM:
Vitals:
97.8 81 118/81 16 99% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no nuchal rigidity
Pulmonary: Normal work of breathing. Vesicular breath sounds
bilaterally, no wheezes or crackles appreciated.
Cardiac: S1/S2 appreciated, RRR, no M/R/G.
Abdomen: soft, nontender, nondistended
Extremities: no lower extremity edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Able to read without difficulty. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Attentive, able to name ___ backward without
difficulty. Pt. was able to register 3 objects and recall ___
at 5 minutes. The pt. had good knowledge of current events.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, pinprick in all
distributions.
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, and is equal ___ strength
bilaterally as evidenced by tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
- Rectal tone was normal.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2+ 1
R 2 2 2 2 1
- Plantar response was flexor bilaterally.
- Anal wink was absent.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS. Graphasthesia intact.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Feet appear to be slapped directly onto the ground. Able
to walk in tandem without difficulty. Romberg absent.
DISCHARGE EXAM:
Pertinent Results:
ADMISSION LABS:
___ 01:20AM BLOOD WBC-7.5 RBC-3.96* Hgb-12.4 Hct-36.9
MCV-93 MCH-31.4 MCHC-33.7 RDW-13.4 Plt ___
___ 01:20AM BLOOD Neuts-63.4 ___ Monos-6.9 Eos-0.5
Baso-0.5
___ 01:20AM BLOOD Plt ___
___ 01:20AM BLOOD Glucose-104* UreaN-12 Creat-0.7 Na-143
K-4.0 Cl-105 HCO3-28 AnGap-14
___ 05:18PM BLOOD TSH-1.3
___ 10:47PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 10:47PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-RARE Epi-4
CSF Studies:
___ 05:04PM
WBC-1 RBC-1* Polys-0 ___ Macroph-2
TotProt-35 Glucose-68
Arbovirus PCR: PENDING
Borrelia: not performed due to negative serum study
CMV PCR: Not Detected
CMV Ab:
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
53 AU/ML. Reference Range: Negative < 4 AU/ml, Positive
>= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
EBV PCR: Not Detected
EBV Ab:
___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY
EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
HIV-1: Not detected.
HSV ___ PCR: Not Detected
VZV PCR: Not Detected
MS panel: Negative
___ 05:00PM
WBC-270 RBC-11* Polys-21 ___ Monos-4
TotProt-41 Glucose-60
Gram Stain/Culture: Negative
Enterovirus culture: Negative
Enterovirus PCR: Not Detected
HSV ___ PCR: Not Detected
VZV PCR: Not Detected
VDRL: PENDING
Cytology:
ATYPICAL.
Numerous lymphocytes with poor preservation, morphologic
evaluation is limited.
Clinical correlation with consideration of flow cytometry on any
subsequent sample is suggested.
Serum Studies:
___
Anaplasma IgG/IgM: IgG+, IgM-, Past Infection
Leptospira Ab: Negative
Parst S (thick and thin smears for babesia): Negative
___ B Virus Ab:
Test Result Reference
Range/Units
___ B1 AB 1:16 H <1:8
___ B2 AB 1:32 H <1:8 (recent
infection)
___ B3 AB 1:16 H <1:8
___ B4 AB <1:8 <1:8
___ B5 AB 1:16 H <1:8
___ B6 AB 1:16 H <1:8
___
Mycoplasma PNA: Positive (does not differentiate between an
active or past infection)
___:
HIV: Negative
___:
Lyme IgG/IgM: Negative
EQUIVOCAL BY EIA.
NEGATIVE BY WESTERN BLOT.
Autoimmune studies:
___: Negative
CRP: 0.7
ESR: 1
IgA: 243
Ro/La: Negative
GD1B Ab: Negative
Transaminitis Studies:
___ 09:20PM BLOOD ALT-116* AST-108* AlkPhos-96 TotBili-0.3
___ 08:48AM BLOOD ALT-88* AST-64* AlkPhos-89 TotBili-0.4
___ 04:45AM BLOOD ALT-122* AST-125* AlkPhos-85 TotBili-0.2
___ 04:00AM BLOOD ALT-296* AST-321* AlkPhos-110*
TotBili-0.2
___ 05:21AM BLOOD ALT-400* AST-341* AlkPhos-138*
TotBili-0.4
___ 05:01AM BLOOD ALT-424* AST-314* AlkPhos-148*
TotBili-0.5
___ 03:00PM BLOOD
HBsAg-NEGATIVE HBsAb-POSITIVE IgM HBc-NEGATIVE
HAV Ab-POSITIVE IgM HAV-NEGATIVE
HCV Ab-NEGATIVE
IMAGING:
MRI L-spine/T-spine without contrast ___:
IMPRESSION:
No spinal canal or neural foraminal narrowing. No cord signal
abnormalities. No MRI findings to suggest etiology of patient's
symptoms.
MRI C-spine w/ and without contrast ___:
IMPRESSION:
1. No evidence of spinal cord signal abnormality or abnormal
enhancement.
2. Very mild degenerative disease, without spinal canal
narrowing and only moderately severe left and mild right neural
foraminal narrowing at C6-7, with likely exiting left C7 neural
impingement
MRI L-spine w/ and without contrast ___:
IMPRESSION:
1. Diffuse contrast enhancement of the right L2 nerve root
without nodularity, and no evidence for underlying mechanical
compression. This suggests a nonspecific inflammatory process.
2. The visualized distal spinal cord appears normal in
morphology and signal intensity without abnormal enhancement.
3. Mild degenerative changes without spinal canal narrowing,
neural foraminal narrowing, or nerve root impingement.
EMG: ___
IMPRESSION:
Essentially normal study. There is no electrophysiologic
evidence for an acute, inflammatory demyelinating polyneuropathy
(AIDP) (as in Guillain- ___ syndrome). The mild abnormalities
of peroneal motor nerve conductions are of uncertain clinical
significance. Nerve conduction studies may be normal in the
first week of AIDP and the study may be repeated in ___ weeks if
clinically
warranted.
Brief Hospital Course:
___ was admitted to the General Neurology service due
to the concern for four days of ascending numbness in her
bilateral lower extremities. At the time of admission she had
loss of pain and
temperature sensation in a patchy distribution in her lower
extremities and a dense sensory loss in her perineal area. She
was initially evaluated for atypical ___ syndrome
versus spinal cord compression. Her initial MRI of the cervical,
thoracic and lumbar spine was negative and a lumbar puncture
showed CSF which was bland. Her exam continued to evolve and
after her ankle reflexes disappeared, she was started
empirically on IVIg therapy. She develped a band of sensory loss
in the L2 distribution which resolved after one day but which
prompted repeat MRI of the lumbar spine with contrast. This scan
showed isolated contrast enhancement of the L2 nerve root. She
had an EMG which was essentially normal; it was uclear if this
was too early in the course to expect changes, although she had
been symptomatic for more than one week at that time. She
developed a new headache with nausea and vomiting. She was
found to have a transaminitis in a hepatocellular pattern,
workup described below. Her lumbar puncture was repeated and
showed a leukocytosis with 213 WBCs, lymphocytic predominance.
Her IVIg was stopped due to concern for adverse effects
including aseptic meningitis. The infectious disease service was
consulted. Multiple serologies for tick-borne disease, viruses
and bacteria were sent. Her headache was persistent and worsened
with standing up, but her nausea and vomiting resolved. Her
headache was thought to be secondary to aseptic meningitis
versus post-LP headache. She also developed a trunkal rash
which subsequently spread to her neck, face and inner thighs.
Over the course of several days her neurologic symptoms began
gradually to improve and she had the gradual return of sensation
in her perineal area and upper thighs. Her headache likewise
continued to improve and she was discharged to follow up in
primary care and neurology clinics.
She developed diarrhea, nausea and vomiting on the second day of
IVIg. Labs were notable for elevated LFTs in a hepatocellular
pattern. Hepatitis serologies were sent and were negative for
Hepatitis C virus, prior exposure versus vaccination for
Hepatitis B virus, and prior exposure versus vaccination to
Hepatitis A virus. Right upper quadrant ultrasound was normal.
Her transaminitis was attributed to viral versus IVIg adverse
effect.
Overall, her symptoms were thought to be most likely to be
secondary to a viral syndrome which caused polyradiulitis,
aseptic meningitis, hepatitis and rash; alternatively she may
have had an underlying polyradiculitis with subsequent
development of IVIg related adverse effects. After discharge,
her serologies were notable for positive ___ virus titers,
as well as previous exposures to EBV, CMV, and anaplasma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine XR 75 mg PO DAILY
Discharge Medications:
1. Venlafaxine XR 75 mg PO DAILY
2. Outpatient Lab Work
Please draw LFTs (AST, ALT, Alk Phosph, and Tbili) on ___,
___.
Fax results to: ___ MD, fax ___, phone
___.
Discharge Disposition:
Home
Discharge Diagnosis:
lower extremity sensory loss
aseptic meningitis and hepatocellular transaminitis thought to
be secondary to a viral process.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro exam = patchy sensory loss (pain/temperature) in distal
aspects of feet bilaterally. Otherwise WNL.
Discharge Instructions:
You were admitted to the hospital for numbness in your legs and
groin. While you were here we performed multiple tests to
determine the cause of your symptoms. You were briefly treated
with IVIG because we suspected you might have Guillain ___
Syndrome. After being on IVIG for a few days, you developed a
headache, nausea, malaise, back pain and a rash. We believe many
of your symptoms were a side effect of the IVIG, so this
medication was stopped.
We saw that you had inflammatory cells in your spinal fluid and
elevated liver enzymes as well.
Unfortunately, we are not certain of your diagnosis. We suspect
that you have had a viral infection which has caused your
symptoms. We do not think that you have any condition that
requires treatment at this time, but we anticipate that your
symptoms will improve with time. We are discharging you home,
but if you have any new symptoms or worsening of your symptoms
you should contact your primary care doctor immediately as you
may need to return to the hospital.
While you were here we treated you with IVIG because we were
concerned that you had ___ syndrome.
Followup Instructions:
___
|
19820328-DS-14
| 19,820,328 | 26,312,545 |
DS
| 14 |
2120-05-29 00:00:00
|
2120-06-02 19:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
latex
Attending: ___.
Chief Complaint:
Sensory changes
Major Surgical or Invasive Procedure:
Lp (___)
History of Present Illness:
Ms. ___ is a ___ year old woman with history of
polyradiculopathy of unclear etiology who presented with chief
complaint of three days of sequentially progressive numbness in
left leg, parasthesias in right thigh, numbness in left thumb
and
forearm.
Today she is coming in with three days of sequentially
progressive symptoms. She first noticed a cool sensation in her
left calf which has progressed to numbness and temperature loss
in her left leg from the knee down. The leg feels like its
asleep. subsequently developed hypersensitivity with allodynia
in right thigh, today with numbness and parasthesias in left
thumb and lateral forearm. She does not feel weak.
One week ago she had an outbreak of cold sores, in upper and
lower lips inside the mouth and on the lips themselves. She had
attributed this to the sun but did not have any other symptoms
of
sun exposure such as sunburn. There was no other mucosal
involvement. They resolved after a week. They looked like crusty
blisters on the lips. On the inside of her mouth they looked
like
blisters but not canker sores. She has gotten cold sores for her
entire life, usually with sun exposure, illness, or stress.
She has not had any fevers, aches or malaise nor any infectious
symptoms aside from the cold sores. Her vision appears stable.
Two months ago her head was very itchy and she thought she might
have lice. She went to the ED and was told she did not have
lice.
She says that she has a rash on the scalp and back of her neck,
red and bumpy, with pruritus. She stopped a lot of her hair
products without change in her symptoms.
She denies genital ulcers.
Her period has become irregular and wonders if she is starting
menopause.
Prior Neurologic history per recent DC summaries:
She was admitted to the general neurology service from ___
for ascending numbness and a concern for GBS. During this
admission she had patchy pain and temperature sensation loss in
the lower extremities, as well as L2 and perianal sensory loss.
Initial MRI of the entire spine with and without contrast was
normal, as was her initial lumbar puncture. She had a normal
EMG. She got two doses of IVIG ___ and ___, which was stopped
due to development of headache, nausea, vomiting, transaminitis
and truncal rash. Repeat MRI L-spine for L2 sensory loss after
IVIG showed enhancement of the L2 nerve root. Repeat LP also
after IVIG showed WBC 270, 75% lymphocytes, again with normal
protein and glucose (thought to be aseptic meningitis ___ IVIG).
Workup was positive only for detection of serum ___ virus,
for which she has seen ID in clinic, the significance of which
is
uncertain. She had many other studies done including infectious
(VDRL, arbovirus, enterovirus, VZV, HSV, CMV, EBV, borellia,
HIV,
Lyme, leptospira, mycoplasma), immunologic (sed rate, CRP, ___,
ro, la) which were all normal/negative.
Her neurologic symptoms (including numbness, parasthesias and
headache) began to improve and she was discharged home with a
presumed viral syndrome, and by follow up on ___, her
symptoms were mainly resolved and have not recurred.
___
Ms. ___ was hospitalized for five days of visual changes,
specifically bilateral
visual field defects. At the time of admission, she described
having a "bright" spot in each visual field in the temporal side
of each field, not obscuring her peripheral vision.
Additionally, she reported a bifrontal headache and some
photophobia. Her neurological exam was otherwise normal, and her
visual field defect was completely stable over the course of her
admission. She was initially evaluated for vasculitis vs.
sarcoidosis, with empiric coverage for HSV/VZV encephalitis
given her symptoms and a cold sore present on her lip at the
time of admission. Acyclovir was later stopped once HSV PCR came
back negative.
Her initial MRI showed an ill-defined 8 mm focus of FLAIR
hyperintensity with slowed diffusion and enhancement in the left
medial temporal lobe, with multifocal narrowing of the bilateral
ACAs and the right MCA; these findings were concerning for
vasculitis, with demyelinating disease lower on the
differential. She was started on verapamil for cerebral
vasospasm prophylaxis. A lumbar puncture was completed under
fluoroscopy, and neuro-opthalmology was consulted.
Neuro-opthalmology localized the deficit to the optic chiasm
based on central bitemporal defects on formal visual field
testing (initial and follow-up testing), and opthalmologic exam
was otherwise normal, including specialized macular testing
(optical coherence tomography). Dedicated MR imaging of the
chiasm and orbits was completed and was unremarkable. An
autoimmune work-up was initiated (all negative), as well as a
paraneoplastic workup including CT torso, which was
unremarkable. A cerebral angiogram was completed, which was
normal, and the decision was made to begin a 5-day course of IV
solumedrol, the final dose of which was to be administered after
discharge at a local facility on ___.
Overall, her symptoms were thought to be due to inflammation vs.
very localized ischemia at the optic chiasm, causing her
specific central bitemporal visual field defect. There was no
evidence of an anatomic issue at the chiasm, no evidence of cord
compression, myelitis, or meningitis, no evidence of systemic or
cerebral vasculitis, no evidence of malignancy or
para-neoplastic process, and no other concerning neurological
symptoms.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion.
Denies difficulty with producing or comprehending speech.
Denies loss of vision, blurred vision, diplopia, vertigo,
tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies muscle weakness.
Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss.
Denies chest pain, palpitations, dyspnea, or cough.
Denies nausea, vomiting, diarrhea, constipation, or abdominal
pain.
Denies dysuria or hematuria.
Denies myalgias, arthralgias.
Past Medical History:
- Anxiety
- Polyradiculopathy, aseptic meningitis, and hepatitis of
unclear etiology ___, resolved).
Social History:
___
Family History:
- Acenstry: ___
- Lives on ___. Works as a ___. Lives with her partner,
her ___ old son, and her partner's child who stays with them
on the weekends.
- Tobacco: Remote occasional smoking history, not currently
smoking.
- EtOH: 12 drinks per month.
- Illicits: Denies.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS T: 97.6 HR: 81 BP: 126/80 RR: 18 SaO2: 98%
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus
Cardiovascular: RRR, no M/R/G
Pulmonary: Equal air entry bilaterally, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable pulses
Skin: erythematus nodules on neck and scalp
Neurologic Examination:
- Mental Status -
Awake, alert, oriented x 3. Attention to examiner easily
attained
and maintained. Concentration maintained when recalling months
backwards. Recalls a coherent history. Structure of speech
demonstrates fluency with full sentences, intact repetition, and
intact verbal comprehension. Able to read. Content of speech
demonstrates intact naming (high and low frequency) and no
paraphasias. Normal prosody. No dysarthria. Verbal registration
and recall ___. No apraxia. No evidence of hemineglect. No
left-right agnosia.
- Cranial Nerves -
I. not tested
II. briskly reactive pupils, right 4-2mm, left 3.5-2mm. Visual
fields were full to finger counting. On more detailed testing,
the patient has enlarged blind spots bilaterally.
III, IV, VI. smooth and full extraocular movements without
diplopia or nystagmus.
V. facial sensation was intact, muscles of mastication with full
strength
VII. face was symmetric with full strength of facial muscles
VIII. hearing was intact to finger rub bilaterally.
IX, X. symmetric palate elevation and symmetric tongue
protrusion
with full movement.
XI. SCM and trapezius were of normal strength and volume.
- Motor -
Muscule bulk and tone were normal. No pronation, no drift. No
tremor or asterixis.
Delt Bic Tri ECR IO IP Quad Ham TA Gas ___
L 5 5 ___ 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
- Sensation -
Diminished light touch, pinprick, and temperature sensation in
left calf and left thumb and left lateral forearm. Diminished
light touch in right thigh. Proprioception and vibration intact.
- DTRs -
Bic Tri ___ Quad Gastroc
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response flexor bilaterally.
- Cerebellar -
No dysmetria with finger to nose testing bilaterally. Good speed
and intact cadence with rapid alternating movements.
- Gait -
Not tested.
=
=
================================================================
DISCHARGE PHYSICAL EXAM
Mental status - Alert oriented x3
CN - PERRL, EOMI, very mild blurry vision in bitemporal visual
fields, Face symmetric both motor and sensation.
Motor - 4+/5 symmetric in APB, IP, ___.
Sensory - Decreased pinprick sensation in L lateral forearm,
thumb, and sometimes patchy involvement of the rest of the hand,
left anterior leg, b/l lateral thighs
Reflexes - +Crossed adductor b/l
Gait - normal narrow based, steady gait
Pertinent Results:
___ 05:35AM BLOOD WBC-9.1 RBC-4.10 Hgb-12.5 Hct-38.8 MCV-95
MCH-30.5 MCHC-32.2 RDW-13.0 RDWSD-45.1 Plt ___
___ 05:40AM BLOOD Neuts-57.0 ___ Monos-8.5 Eos-1.9
Baso-0.5 Im ___ AbsNeut-4.47 AbsLymp-2.51 AbsMono-0.67
AbsEos-0.15 AbsBaso-0.04
___ 11:59PM BLOOD ___ PTT-32.5 ___
___ 05:35AM BLOOD Glucose-99 UreaN-13 Creat-0.7 Na-139
K-4.7 Cl-101 HCO3-32 AnGap-11
___ 10:30PM BLOOD ALT-23 AST-29 AlkPhos-95 TotBili-0.3
___ 05:40AM BLOOD Calcium-9.4 Phos-4.4 Mg-1.9
___ 05:40AM BLOOD Cryoglb-NO CRYOGLO
___ 05:40AM BLOOD VitB12-___ Ferritn-16
___ 05:40AM BLOOD ANCA-NEGATIVE B
___ 05:40AM BLOOD ___
___ 05:40AM BLOOD RheuFac-8 CRP-0.3
___ 05:40AM BLOOD C3-130 C4-17
ADDITIONAL WORKUP NOTED IN DC SUMMARY
EKG - Sinus rhythm. Low precordial lead voltage. Compared to the
previous tracing
of ___ no diagnostic interim change.
IMAGES
MRI BRAIN WITH CONTRAST
Continued interval signal normalization of the left mesial
temporal cortex
lesion with questionable punctate FLAIR signal hyperintensity at
the lesion
site which may represent mild residual FLAIR signal
hyperintensity versus
background noise. No evidence of new or progressive lesions.
MRI C, T, AND L SPINE
1. Short-segment T2 hyperintense enhancing lesion at the right
lateral aspect
of the T11-T12 thoracic cord, as described, which is new in
comparison to
prior study from ___. The signal characteristics,
morphology, and
location favor a demyelinating process such as multiple
sclerosis, however
this is nonspecific.
2. Mild degenerative changes within the cervical and lumbar
spine, as
described, without spinal cord or nerve root compression.
CSF PATHOLOGY AND CYTOLOGY
Pathology pending
Cytology negative.
Brief Hospital Course:
Ms. ___ is a ___ yo woman with history of bilateral patchy
sensory loss, aseptic meningitis ___ to IVIG, optic
chiasmopathy, prior ACA narrowing on CTA head, who presented
with new patchy sensory loss involving multiple peripheral and
nerve roots. Prior MRI Brain showed a FLAIR hyperintensity in
the left temporal lobe that was initially enhancing but on
repeat scan in ___ no longer is. Prior CTA was concerning for
ACA narrowing and possibly consistent with vasculitis. She has
had an extensive neurological workup during prior admissions,
without a clear etiology of her symptoms.
Initial differential was broad but given her extensive negative
workup inflammatory/autoimmune demyelinating condition or
vasculitis ___ to autoimmune vs inflammatory conditions
including Behcets, Histiocytosis X, Wegeners, Polyarteritis
nodosa, cryoglobulinemia, sarcoidosis. Infectious etiology
including mycoplasma.
Her MRI was significant for T12 enhancing spinal cord lesion as
well as stable prior temporal lobe lesion.
An extensive workup was sent as detailed below that was only
positive lymphocytic pleocytosis with mildly high protein in
CSF:
- LFTs wnl, coags wnl
- TB quant gold wnl, ANCA wnl, ESR wnl, CRP wnl, C3 wnl, C4 wnl,
___ neg, cryoglobulin wnl, ACE wnl, RF wnl, mycoplasma IgG and
IgM sent, ferritin wnl, Vit E wnl, B12 wnl, copper wnl, serum
lyme was negative.
- MRI Brain, C/T/L spine w/wo contrast - T12 spine enhancing
lesion consistent with demyelination. MRI Brain with old
temporal lesion unchanged.
- LP showed lymphocytic pleocytosis with slightly high protein
(48) and normal range glucose (60). Tube 1 WBC 41, RBC 10, 94%
lymphocytes and Tube 2 showed WBC 19, RBC 2, 95% lymphocytes. MS
panel pending at the time of discharge, CSF ACE pending, CSF
lyme was not run because serum was negative, CSF mycoplasma
pending, Paraneoplastic panel pending, CSF VDRL neg, HSV PCR and
Varicella PCR negative.
- Pathergy test ___ negative. Performed via two venipunctures
at two different sites at the antecubital area with skin cleaned
with ETOH swab prior to puncture.
During her admission Ms ___ sensory symptoms remained
fairly stable with sensation of parasthesias and pinprick
sensation deficit involving her left lateral forearm extending
in a patchy distribution in her hand, her bilateral lateral
thighs, and her left foot. She was not given any treatment for
her symptoms and as she was very functional and with largely
minimal sensory symptoms we discharged her home with outpatient
follow up for review of the testing she had in the hospital.
Unfortunately, because of the pending labs at the time of
discharge, the cause of her symptoms was not determiend on this
admission.
She was also found to have lice on her scalp while she was an
inpatient and was treated with lindane shampoo x2.
**Transitional issues:
Needs outpatient follow up and had many lab tests pending at the
time of discharge. She was instructed to return to the hospital
if her symptoms changed or if she developed any concerning
worsening of her symptoms.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. Venlafaxine 37.5 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. B12 (cyanocobalamin-cobamamide) ___ mcg sublingual DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
2. Venlafaxine 37.5 mg PO DAILY
3. B12 (cyanocobalamin-cobamamide) ___ mcg sublingual DAILY
4. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Sensory Polyneuropathy of unclear etiology
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for numbness. The workup so far has been
negative, and it is unclear what is causing your numbness. Your
home medications were not changed. We recommend you follow up
with your outpatient neurologist.
During you stay, you were found to have lice. You were treated
with lindane shampoo, and no more treatments are needed.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19820328-DS-15
| 19,820,328 | 29,902,472 |
DS
| 15 |
2120-06-04 00:00:00
|
2120-06-17 16:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
latex
Attending: ___
Chief Complaint:
RLE weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ F w PMHx of polyradiculopathy of
unclear etiology who presents 24hrs of new RLE numbness and
weakness.
Ms. ___ states that her symptoms began on the morning of
___.
She first noted a "tingling" in her right foot and then a
"novacaine" sensation over her anterior right thigh. It is
difficult for her to precisely describe the sensation but says
that her legs feel "like jello." She also complains that the
right leg feels weak and "heavy." She states that when she was
at
work earlier in the day she was trying to flex the leg at the
knee, bringing her heel to her buttocks, and had some trouble
maintaining it in that position. She is quite clear that she has
never had any weakness before with her prior symptoms.
She denies any bowel or bladder symptoms. She denies any bulbar
symptoms. She reports that the previous symptoms for which she
was admitted are still present and largely stable.
Of note, Ms. ___ was recently discharged from the general
Neurology Service on ___. She presented on ___ with three
days of sequentially progressive symptoms. She first noticed a
cool sensation in her left calf which progressed to numbness and
temperature loss from the left knee down. She then developed
hypersensitivity with allodynia over right thigh, and finally
numbness and parasthesias in left thumb and lateral forearm. She
denied any weakness at that time.
Ms. ___ underwent MRI of the neuro-axis, revealing a new
T2-intense T11-12 enhancing lesion as well as a stable to
improved FLAIR hyperintense temporal lobe lesion. Extensive lab
evaluation (as copied from discharge summary) was notable for:
TB
quant gold wnl, ANCA wnl, ESR wnl, CRP wnl, C3 wnl, C4 wnl, ___
neg, cryoglobulin wnl, ACE wnl, RF wnl, mycoplasma, ferritin
wnl,
Vit E , B12 wnl, copper wnl.
Lumbar puncture during that admission showed lymphocytic
pleocytosis with slightly high protein and normal range glucose.
MS panel reported 7 oligoclonal bands. Ms. ___ was discharged
prior to return of OCBs, and diagnosis was somewhat unclear.
For more distant and comprehensive neurologic history, please
see
recent admission and discharge summary.
Past Medical History:
- Anxiety
- Polyradiculopathy, aseptic meningitis, and hepatitis of
unclear etiology ___, resolved)
- Transverse myelitis
- Optic chiasmopathy
Social History:
___
Family History:
Sister diagnosed with multiple sclerosis
-- on one of the "new" medications
-- ___ years older and lives in ___.
No other family history of autoimmune disease. Multiple
family members with cancer, heart disease, and diabetes.
Physical Exam:
VS T97.3 HR71 BP124/72 RR14 Sat100%RA
GEN - NAD, lying in bed comfortably.
HEENT - NC/AT, MMM
NECK - Supple, no nuchal rigidity, no meningismus
CV - NSR
PULM - normal WOB
ABD - Soft, NT, ND, +BS, no guarding
EXTR - WWP, atraumatic
NEUROLOGICAL EXAMINATION:
MS - Awake, alert, oriented x 3. Attention to examiner easily
attained and maintained. Concentration maintained when recalling
months backwards. Recalls a coherent history. Structure of
speech
demonstrates fluency with full sentences, intact repetition, and
intact verbal comprehension. Able to read. Content of speech
demonstrates intact naming (high and low frequency) and no
paraphasias. Normal prosody. No dysarthria. No apraxia. No
evidence of hemineglect. No left-right agnosia.
CN - II. briskly reactive pupils, right 4-2mm, left 3.5-2mm.
III, IV, VI. smooth and full extraocular movements without
diplopia or nystagmus. V. facial sensation was intact, muscles
of
mastication with full strength. VII. face was symmetric with
full
strength of facial muscles VIII. hearing was intact to voice.
IX,
X. symmetric palate elevation. XI. SCM and trapezius were of
normal strength and volume. XII. tongue protrudes in midline
with
full ROM.
MOTOR - Normal bulk and tone. No pronation, no drift. No
tremor or asterixis.
Delt Bic Tri ECR IO IP Quad Ham TA Gas
L 5 5 ___ 5 5 5 5 5
R 5 5 ___ 4+ 5 5 5 5
SENSATION: Decriment to pinprick over left calf, left thumb, and
left lateral arm up to mid-forearm, ~25% of normal (stable from
prior). Allodynia to pin over B/L feet and soles (stable from
prior). Right anterior thigh with decriment to PP, 70% of normal
over the anterior and lateral surface, 60% of normal over the
medial surface. R medial calf with decriment to PP, 80%of
normal.
No spinal level to PP bilaterally. Proprioception and vibration
intact.
REFLEXES -
Bic Tri ___ Quad Gastroc
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response flexor bilaterally.
COORD - No dysmetria with finger to nose testing bilaterally.
Good speed and intact cadence with rapid alternating movements.
GAIT - Normal intiation, narrow based, and normal stride length.
The gait is not smooth, however, and she is lurching mildly to
the right.
.
Discharge: Noted RLE weakness at IP, ham, EDB, ___ (and ___
but b/l ___ weak prior admission).
Pertinent Results:
___ 09:05AM BLOOD WBC-8.1 RBC-4.14 Hgb-12.6 Hct-39.1 MCV-94
MCH-30.4 MCHC-32.2 RDW-13.0 RDWSD-44.6 Plt ___
___ 01:50AM BLOOD Neuts-57.4 ___ Monos-10.1 Eos-1.5
Baso-0.4 Im ___ AbsNeut-5.32 AbsLymp-2.80 AbsMono-0.94*
AbsEos-0.14 AbsBaso-0.04
___ 09:05AM BLOOD Plt ___
___ 09:05AM BLOOD ___ PTT-34.8 ___
___ 09:05AM BLOOD Glucose-84 UreaN-7 Creat-0.7 Na-138 K-4.5
Cl-102 HCO3-25 AnGap-16
___ 09:05AM BLOOD ALT-41* AST-22 LD(LDH)-140 CK(CPK)-52
AlkPhos-94 TotBili-0.8
___ 09:05AM BLOOD CK-MB-1 cTropnT-<0.01
___ 09:05AM BLOOD Albumin-4.2 Calcium-9.4 Phos-3.3 Mg-2.0
.
MRI C/T spine ___:
Short-segment enhancing lesion within the right lateral aspect
of the conus medullaris at the T11-T12 level which has mildly
increased in size and degree of conspicuity as compared to prior
study suspicious for a demyelinating lesion.
.
1. Unremarkable MRI of the brain without evidence of acute
intracranial
abnormality. No evidence of multiple sclerosis.
2. Normal appearance of the left mesial temporal cortex with
resolution of previously described signal abnormality.
Brief Hospital Course:
Brief course: We repeated an MRI of the brain and spine to look
for new areas of inflammation to account for RLE weakness but
this only re-demonstrated the previously seen area of cord
inflammation, which was slightly more avidly enhancing and
possibly slightly larger. We suspected this was the cause of the
right leg weakness. We had previously not treated with steroid
given limited extent, indolent course, and sensory symptoms
only. Since there was now a deficit in strength we did decide to
treat but since the weakness was relatively mild and she did not
have any major radiographic change, we did not need to keep her
in the hospital for intravenous steroids or physical therapy. We
discharged her with 25 tablets of prednisone, each one 20mg.
Days ___: Take 3 tabs (60mg) once a day
Day 8: Take 2 tabs (40mg)
Day 9: Take 1 tab (20mg)
Days ___ & ___: Take ___ tab (10mg)
Then stop prednisone
We informed her of possible side effects including high blood
sugar; since pt not diabetic or otherwise ill we did not think
this would be an issue even if mildly elevated but asked her to
see PCP ___ 3 days for finger stick. We recommended 2 TUMS a
day while on steroids.
.
She has a follow-up appointment with Dr. ___ on ___
(see below) and at that point they can decide whether or not an
EMG would be useful. Since underlying diagnosis is not
completely clear, evidence of peripheral nerve problems (with
EMG) would be helpful in understanding your condition. Though
bands from recent hospitalization were positive, this is quite
atypical for MS given the isolated low cord lesion and chiasm
without characteristic findings elsewhere. Further, she may have
peripheral involvement as well. DDx includes Langerhans
histiocytosis and Behcet's (though pathergy negative x1 could
repeat). CRMP-5 titer was < 1:2 but titers lower than ___ be
detectable by recombinant CRMP-5 western blot analysis,
available by request on stored spinal fluid and recommended in
cases of chorea, vision loss, cranial neuropathy and myelopathy.
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Venlafaxine 37.5 mg PO DAILY
3. Cyanocobalamin ___ mcg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. PredniSONE 60 mg PO DAILY Duration: 7 Doses
Start: Today - ___, First Dose: Next Routine Administration
Time
This is dose # 1 of 4 tapered doses
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*25 Tablet
Refills:*0
6. PredniSONE 40 mg PO ONCE Duration: 1 Dose
Start: After 60 mg DAILY tapered dose
This is dose # 2 of 4 tapered doses
7. PredniSONE 20 mg PO ONCE Duration: 1 Dose
Start: After 40 mg ONCE tapered dose
This is dose # 3 of 4 tapered doses
8. PredniSONE 10 mg PO ONCE Duration: 1 Dose
Start: After 20 mg ONCE tapered dose
This is dose # 4 of 4 tapered doses
Discharge Disposition:
Home
Discharge Diagnosis:
Transverse myelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
We repeated an MRI of your brain and spine to look for new areas
of inflammation which might account for your right leg weakness
but we found none. The location of the previously identified
area of inflammation seems to be the cause of your right leg
weakness and is a little more obvious on this scan than it was
on the prior (however, there is no dramatic change). Since the
deficit in strength is relatively mild and you do not have any
major radiographic change, we do not need to keep you in the
hospital for intravenous steroids or physical therapy. However,
we would like to give you a course of steroids by mouth to
prevent the inflammation from worsening.
You will have 25 tablets of prednisone, each one 20mg.
Days ___: Take 3 tabs (60mg) once a day
Day 8: Take 2 tabs (40mg)
Day 9: Take 1 tab (20mg)
Days ___ & 11: Take ___ tab (10mg)
Then stop prednisone
I think that this will improve the inflammation in your spinal
cord. You may have some waxing/waning of your symptoms, but
please come back if you have marked worsening or strength,
inability to walk, urinary retention or incontinence.
You have a follow-up appointment with Dr. ___ on ___
(see below) and at that point they can decide whether or not an
EMG would be useful. Since your underlying diagnosis is not
completely clear, evidence of peripheral nerve problems (with
EMG) would be helpful in understanding your condition.
Followup Instructions:
___
|
19820328-DS-16
| 19,820,328 | 21,748,478 |
DS
| 16 |
2120-06-24 00:00:00
|
2120-06-24 16:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
latex
Attending: ___
Chief Complaint:
Weakness, numbness, urinary incontinence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman with a history of transverse
myelitis who presents with
She was recently discharged on ___ with a prednisone taper for
mild RLE weakness. She was then seen in clinic by Dr. ___
Dr. ___, with the full interval history detailed in Dr.
___ from ___ - for full details, please refer to
that note.
In summary, she has developed urinary incontinence 4 times
(unable to control her flow but had normal sensation) and now
toilets more frequently to avoid accidents; constipation; a
buzzing sensation that travels down her right leg and her groin
every 4 seconds; and wobbly legs. During this entire time she
has
also had headaches, for the past 4 days. She thinks the
headaches
are due to her glasses. It is all over her head, dull, constant.
Tylenol at night helps the headache.
Per Dr. ___,
"She has had three episodes in thirteen months with
lesions separated in time and space: lumbar polyradiculopathy
and
aseptic meningitis; optic chiasmatic lesion with concern for
vasculitis; thoracic myelitis with clinical evidence of
mononeuritis multiplex vs polyradiculitis and positive
oligoclonal bands."
She was sent to the ED from clinic because of concern over her
worsening symptoms despite steroid treatment.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, or abdominal
pain. No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- Anxiety
- Polyradiculopathy, aseptic meningitis, and hepatitis of
unclear etiology ___, resolved)
- Transverse myelitis
- Optic chiasmopathy
Social History:
___
Family History:
Sister diagnosed with multiple sclerosis
-- on one of the "new" medications
-- ___ years older and lives in ___.
No other family history of autoimmune disease. Multiple
family members with cancer, heart disease, and diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals:
T= 97.7F, BP= 129/83, HR= 76, RR= 16, SaO2= 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Neck: Supple, no nuchal rigidity.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Speech was not dysarthric. Able to follow both midline
and appendicular commands. Attentive, able to name ___ backward
without difficulty. Pt. was able to register 3 objects and
recall ___ at 5 minutes. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3mm, both directly and consentually; brisk
bilaterally. R pupil has more hippus than left. VFF to
confrontation. Funduscopic exam revealed no papilledema,
exudates, or hemorrhages. OD ___, OS ___.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, pinprick in all
distributions
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ 5 4+ ___ 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 1 2 0 0
R 2 1 2 0 0
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: Left leg: decreased FT, cold sensation from inguinal
crease to above knee, then hypersensitivity down to foot;
decreased pinprick from T12 to knee, then hypersensitivity from
knee down to foot. Right leg: intact to cold. decreased FT from
inguinal crease down. decreased pinprick from T12 down. Intact
proprioception throughout. FT, pinprick, cold intact in upper
extremities.
-Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally.
-Gait: Not tested.
DISCHARGE PHYSICAL EXAM:
Neurologic:
-Mental Status: INTACT
-Cranial Nerves: INTACT
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ 5 4+ ___ 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory:
Left leg: Decreased pinprick sensation from inguinal crease to
above knee, then hypersensitivity down to foot, now with gain of
sensation over lateral thigh;
Right leg: Intact to cold. Decreased FT from inguinal crease
down. decreased pinprick from T12 down. Intact proprioception
throughout. FT, pinprick, cold intact in upper extremities.
-Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally.
-Gait: Not tested.
DISCHARGE PHYSICAL EXAM:
Alert, oriented, speech and language are normal. EOMS are full,
___ 3mm, face symmetric. Fields suggest a subjective field
defect in the centro-temporal regions bilaterally but not able
to map it on confrontation testing. Motor strength testing
continues to be ___ in IP, hamstrings, and foot dorsiflexors and
___ are 4 bilaterally. DTRs normal in the UE, are 2+ at the
knees, AJ 1+. Plantars flexor. Allodynia at the left ___ below
the knee as earlier, vibrating sensation RLE, and sensory level
appears to be lower- not consistently felt on the torso any
more- she still has some perianal tingling and numbness.
Pertinent Results:
ADMISSION LABS:
================
___ 11:15PM BLOOD WBC-12.8*# RBC-4.07 Hgb-12.9 Hct-37.6
MCV-92 MCH-31.7 MCHC-34.3 RDW-13.1 RDWSD-44.2 Plt ___
___ 11:15PM BLOOD Neuts-62.0 ___ Monos-7.9 Eos-0.6*
Baso-0.1 Im ___ AbsNeut-7.97* AbsLymp-3.68 AbsMono-1.01*
AbsEos-0.08 AbsBaso-0.01
___ 11:15PM BLOOD ___ PTT-30.2 ___
___ 11:15PM BLOOD Glucose-92 UreaN-11 Creat-0.7 Na-138
K-3.9 Cl-101 HCO3-27 AnGap-14
___ 11:15PM BLOOD ALT-28 AST-20 AlkPhos-92 TotBili-0.3
___ 11:15PM BLOOD Albumin-4.1 Calcium-9.1 Phos-3.8 Mg-2.2
DISCHARGE LABS:
================
___ 05:10AM BLOOD WBC-10.0 RBC-4.13 Hgb-12.6 Hct-38.7
MCV-94 MCH-30.5 MCHC-32.6 RDW-13.1 RDWSD-44.5 Plt ___
___ 04:52AM BLOOD WBC-18.7*# RBC-4.40 Hgb-13.4 Hct-41.6
MCV-95 MCH-30.5 MCHC-32.2 RDW-13.1 RDWSD-45.0 Plt ___
___ 05:55AM BLOOD WBC-6.1# RBC-4.03 Hgb-12.2 Hct-38.4
MCV-95 MCH-30.3 MCHC-31.8* RDW-12.9 RDWSD-44.8 Plt ___
___ 09:45AM BLOOD WBC-5.7 RBC-4.34 Hgb-13.4 Hct-40.5 MCV-93
MCH-30.9 MCHC-33.1 RDW-12.8 RDWSD-44.4 Plt ___
___ 06:10AM BLOOD WBC-5.8 RBC-4.20 Hgb-12.8 Hct-40.0 MCV-95
MCH-30.5 MCHC-32.0 RDW-13.1 RDWSD-45.2 Plt ___
___ 05:30AM BLOOD WBC-6.0 RBC-4.21 Hgb-12.8 Hct-40.5 MCV-96
MCH-30.4 MCHC-31.6* RDW-13.2 RDWSD-46.9* Plt ___
___ 05:55AM BLOOD Neuts-58.3 ___ Monos-14.7*
Eos-1.0 Baso-0.3 Im ___ AbsNeut-3.54# AbsLymp-1.52
AbsMono-0.89* AbsEos-0.06 AbsBaso-0.02
___ 05:10AM BLOOD Plt ___
___ 04:52AM BLOOD Plt ___
___ 05:55AM BLOOD ___ PTT-32.9 ___
___ 05:55AM BLOOD Plt ___
___ 09:45AM BLOOD Plt ___
___ 06:10AM BLOOD Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:10AM BLOOD Glucose-99 UreaN-10 Creat-0.7 Na-141
K-4.7 Cl-104 HCO3-29 AnGap-13
___ 04:52AM BLOOD Glucose-91 UreaN-16 Creat-0.7 Na-139
K-4.4 Cl-100 HCO3-28 AnGap-15
___ 05:55AM BLOOD Glucose-111* UreaN-12 Creat-0.8 Na-140
K-5.1 Cl-104 HCO3-30 AnGap-11
___ 09:45AM BLOOD Glucose-117* UreaN-9 Creat-0.7 Na-135
K-4.9 Cl-100 HCO3-26 AnGap-14
___ 06:10AM BLOOD Glucose-108* UreaN-11 Creat-0.8 Na-137
K-5.0 Cl-102 HCO3-27 AnGap-13
___ 05:30AM BLOOD Glucose-105* UreaN-9 Creat-0.7 Na-136
K-5.1 Cl-101 HCO3-27 AnGap-13
___ 05:10AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.3
___ 04:52AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.1
___ 05:55AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1
___ 09:45AM BLOOD Calcium-9.7 Phos-3.2 Mg-2.0
___ 05:30AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.1
NMO/AQP4-IgG CBA Negative
Brief Hospital Course:
Ms. ___ is a ___ yo woman with a history of transverse
myelitis who presents with new sensory symptoms, gait
unsteadiness, and urinary incontinence. On MRI spine she was
found to have a new T2 hyperintensity, as well as chronic
lesions concerning for MS.
1. Neuro: Multiple sclerosis.
In terms of Imaging her MRI full spine w/wo contrast performed
showing: New focus of abnormal enhancement identified in the
cervical spinal cord at the level of C5, suggestive of
demyelination, with no significant cord expansion. Unchanged
Shore segment of abnormal enhancement and high-signal intensity
on T2 and STIR sequences in the lower thoracic spine at the
level of T11 and T12 on the right, also suggestive of
demyelination. The lumbar spine appears unchanged, with minimal
degenerative changes at L4/L5. Her brain MRI showed an unchanged
punctate focus of high intensity signal is again identified on
FLAIR sequence on the right frontal lobe , this finding is
nonspecific and may represent gliotic focus and of doubtful
clinical significance. Also normal appearance of the left
temporal mesial temporal cortex, with apparent resolution of the
previously described signal abnormality.
She was treated with five day course of IVIG, which she has
tolerated well. ___ services consulted and determined no acute
___ needs as safe for d/c home without services. Her Gabapentin
has been increased to 200mg PO TID. Her motor and sensory
symptoms continued to improve. She will be discharged with a
follow up appointment at Dr. ___ for discussion of
disease modifying medications.
Transitional issues: None.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Cyanocobalamin 1000 mcg PO DAILY
3. Venlafaxine 37.5 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Cyanocobalamin 1000 mcg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Venlafaxine 37.5 mg PO DAILY
5. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
1. Multiple Sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with worsening of your sensory
symptoms gait unsteadiness, and urinary incontinence. You had a
brain, and full spine MRI. Both of these studies showed new
lesions, as well as resolution of some of yur old ones. During
this admission you were diagnosed with multiple sclerosis. You
were treated with a five day course of intravenous immunogloulin
which you ave tolerated well. Your symptoms continue to improve.
You will be discharged home with outpatient follow up at doctor
___ clinic to discuss if disease modifying therapies are an
option in your case.
Instructions:
1. Please continue all your medications as directed by this
document.
2. Please keep all your appointments as below.
3. Please do not hesitate to call with any questions.
It has been a pleasure taking care of you,
Your ___ Neurologists
Followup Instructions:
___
|
19820537-DS-10
| 19,820,537 | 29,614,508 |
DS
| 10 |
2114-04-10 00:00:00
|
2114-04-10 08:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Fiberoptic Laryngoscopy
History of Present Illness:
Patient is a ___ with PMH T2N2bM0 ___ epiglottis who is status
post endoscopic partial laryngectomy, bilateral neck dissections
with Dr. ___ recurrence due to continued smoking
resulting
in chemoradiation therapy from ___. Most recently had
DLB in ___ which showed dysplasia in the supraglottis.
Patient was doing well up until approximately 24 hours ago, at
which time he became dyspneic and noticed accompanying stridor
and hoarseness. He presented to an OSH at about 0200 this AM
(___) where he was found to be acutely stridulous, was given a
dose of steroids, and had a CT neck done which demonstrated
diffuse edema of the supraglottic region. Subsequently he was
transferred to ___ for further care.
Past Medical History:
PMH:
Laryngeal carcinoma
Hypothyroidism
CRC
HLD
PSH:
Partial Laryngectomy
Tonsillectomy/Adenoidectomy/Myringotomy
Left Wrist Repair
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission PE:
Vitals: AVSS, oxygen saturation 97% on room air
General: NAD, A&Ox3, well developed & nourished patient
Voice: hoarse
Respiratory Effort: mildly labored with biphasic stridor
Eyes: EOMI
CN: Grossly intact
Face: no gross lesions.
Ears: no external lesions
Nose/Nasopharynx: see scope exam
Oral Cavity/Oropharynx: edentulous along maxilla with multiple
mandibular teeth also missing. No evidence of mass in oral
cavity
or oropharynx.
Salivary: parotid glands normal, no tenderness, swelling or
masses. Submandibular glands normal size and shape, no
tenderness.
TMJ: NTTP
Neck: no masses, adenopathy or tenderness. Trachea midline.
Pertinent Results:
___ 06:28AM BLOOD WBC-12.5* RBC-4.92 Hgb-15.0 Hct-44.7
MCV-91 MCH-30.5 MCHC-33.6 RDW-12.1 RDWSD-40.4 Plt ___
___ 06:28AM BLOOD Neuts-95.2* Lymphs-2.4* Monos-1.4*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-11.94* AbsLymp-0.30*
AbsMono-0.18* AbsEos-0.02* AbsBaso-0.03
___ 06:28AM BLOOD Plt ___
___ 05:10AM BLOOD ___ PTT-28.5 ___
___ 05:10AM BLOOD Glucose-122* UreaN-17 Creat-0.8 Na-140
K-5.2 Cl-101 HCO3-26 AnGap-13
___ 6:29 am BLOOD CULTURE
Blood Culture, Routine (Pending):
Brief Hospital Course:
Mr. ___ is a ___ status post partial laryngectomy ___
into the hospital with concerns for airway closure. In the ED,
he was found to have biphasic stridor with tripodding. ENT was
consulted and called to the bedside and performed a scope,
finding diffuse, beefy red edema with true vocal cords barely
visible. He was administered Unasyn and Dexamethasone with
continuous saline nebs with great improvement. he was then
transferred to the ICU for airway monitoring, with symptoms
improved overnight. ENT cleared patient for solid food
consumption on HD2, and recommended continuing steroids and
unasyn.
At time of discharge, he was ambulating, this time we feel you
are now safe for discharge. Please return to the Emergency
department if you have any new concerns for your airway. If you
are unable to tolerate your secretions or feel your throat
closing please come back immediately.
Discharge Medications:
Augmentin
Medrol
Discharge Disposition:
Home
Discharge Diagnosis:
Upper respiratory infection, airway swelling
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came into the hospital with concerns for airway closure. You
were given steroids and antibiotics and your airway improved.
You were evaluated by ENT multiple times during your stay and at
this time we feel you are now safe for discharge. Please return
to the Emergency department if you have any new concerns for
your airway. If you are unable to tolerate your secretions or
feel your throat closing please come back immediately.
Followup Instructions:
___
|
19820565-DS-17
| 19,820,565 | 21,753,063 |
DS
| 17 |
2121-07-27 00:00:00
|
2121-07-27 17:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
headaches, nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o F with history of meningitis, deafness and post
meningitic hydrocephalus s/p VP shunt at age ___ years old and
revision at ___ years old presents with headaches, nausea and
vomiting, and pain along VP shunt tract x 5 months. Patient was
recently admitted and evaluated for VP shunt malfunction and
discharged home asymptomatic. She returns to the ED stating that
her symptoms have worsened once again. With interpreter, she
states that her symptoms are similar to the symptoms she
experienced as a child prior to the revision of shunt. She
states
that the n/v and headaches started 4 days ago and she feels like
her head is going to explode when she vomits. She also reports R
sided weakness and tenderness. She states that she is now
experiencing difficulty ambulating due to weakness. The patient
was discharged on oxycodone and Fioricet with no relief of
headaches. She also reports loss of appetite.
She denies any numbness, tingling, or changes in vision.
Past Medical History:
childhood meningitis
HCP s/p VPS
Deafness
Social History:
___
Family History:
NC
Physical Exam:
On the day of ___
O: T:99.7 BP:128/91 HR: 99 R: 18 O2Sats: 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: atraumatic, mild erythema along VP shunt tract
Pupils: 4-3mm bilaterally EOMs: intact
Neck: tender to palpation along VP shunt catheter
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power R side ___, otherwise ___. No
pronator drift
Sensation: Intact to light touch
___: on the day of discharge:
alert and oriented to person/place/time
baseline deaf
strength on left ___
on right ___ throughout leg and arm possible limited due to
pain.
patient ambulated independently without difficulty
Pertinent Results:
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
3:58 ___
IMPRESSION:
Intact right ventriculostomy catheter terminating in unchanged
position in the right frontal horn. Stable ventricular size and
configuration without new ventriculomegaly. No intracranial
hemorrhage.
Brief Hospital Course:
This is a ___ year old female with history of meningitis,
deafness and post
meningitic hydrocephalus s/p VP shunt at age ___ years old and
revision at ___ years old presents with headaches, nausea and
vomiting, and pain along VP shunt tract x 5 months. The patient
was evaluated by the neurosurgery service and admitted for
further evaluation and work up. On ___ there was a non
contrast head CT performed that was consistent with intact
right ventriculostomy catheter terminating in unchanged position
in the
right frontal horn. Stable ventricular size and configuration
without new
ventriculomegaly. No intracranial hemorrhage. The patient was
observed on the floor with every 4 hour neurological
assessments.
On ___, the patient was found to be neurologically stable.
After careful review of the Head CT. There was no indication
for urgent or emergent surgery. This was discussed with the
patient and decision as made to discharge the patient home with
follow up in the ___ clinic at a later date.
Discharge Medications:
1. Paroxetine 20 mg PO DAILY
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg ___ tablet(s) by mouth every four
(4) hours Disp #*45 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*40 Capsule Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QAM
12 hours on, 12 hours off
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) lidocaine 5% Patch 1
patch q am Disp #*30 Patch Refills:*1
5. Lidocaine 5% Patch 1 PTCH TD QAM pain
12 hours on, 12 hours off
Discharge Disposition:
Home
Discharge Diagnosis:
headache
Discharge Condition:
alert and oriented to person/place/time
baseline deaf
strength on left ___
on right ___ throughout leg and arm possible limited due to
pain.
patient ambulated independedntly without difficulty.
Discharge Instructions:
Please call the Neurosurgery Office ___ on ___ for
your cerebral spinal fluid culture results now pending from
___.
¨ 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.
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:
___
|
19820782-DS-25
| 19,820,782 | 26,703,668 |
DS
| 25 |
2157-08-14 00:00:00
|
2157-08-14 17:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Sulfa (Sulfonamide Antibiotics) / Lisinopril / Reglan
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old woman with a PMH significant for CLL,
HTN, HLD, CAD s/p CABG ___, now presenting with confusion and
urinary frequency.
Her history was obtained mainly from her son who presented with
the patient. He reports that she became sick several weeks ago
with URI symptoms of bronchitis. She was started on prednisone
taper by her PCP for potential COPD/wheezing and completed a 5
day course this past ___. However, she had persistent
wheezing and her PCP decided to continue her on a prolonged
steroid course with plan for 16 days of treatment. On ___,
her family noted that she became increasingly confused, unable
to manage her medications (normally very mentally sharp,
independent, & manages her and her husbands medications at
baseline). Her son also noted her to frequently repeaty herself
with poor short term memory, which was out of character for her.
On ___ morning, she reported to her son that she had been
up all night urinating, and did not get any sleep, no complaints
of dysuria but did describe generalized weakness. Her son
brought her to her PCP on ___, who noted that pt had likely
been taking prednisone 80 mg over the past 5 days, rather than
40 mg. Her PCP discontinued pred, did not send UA in office.
This morning, son noted patient to be even more confused,
thought it was ___, didn't know where she was, so he brought
her to the ED. She denies abdominal pain, N/V, diarrhea or
constipation. Her cough improved prior to presentation without
complaints of chest pain or shortness of breath. She had a
temperature of 99.4F on the day prior to admission.
In the ED, initial VS were: 97.6 80 194/80 100%. Labs were
remarkable for: WBC 12.1 with 85.1%Neutophils; Lactate 2.1;
potassium 5.6 with repeat K 4.8. UA significant for moderate
leuokocyte esterase, WBC 14, few bacteria. Urine culture and
blood cultures x2 were sent. CXR PA/lat without acute pulmonary
process. EKG showed: NSR @ 70 bpm, LBBB. Patient was given
ceftriaxone 1 g IV.
VS on floor transfer were: T-97.9 P-67 BP-192/77 RR-18 O2-98%.
On arrival to the floor, she was A&O x ___ (person, place, ___, not date), able to name president, days of week backwards.
She stated she felt slightly better, though still not back to
normal self, unable to articulate any specific complaints other
than being tired.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies rashes or skin changes.
Past Medical History:
1. CLL (___) - Initial asymptomatic leukocytosis (18.6) in
___ and ___ (22, 60% lymphocytes). Immunophenotyping of
peripheral blood consistent with CLL (+ for CD5, CD19-dim, CD20
and CD23 and - for CD10 and FCM7).
2. Hypertension
3. Hyperlipidemia
4. Cataract surgery
5. CAD s/p CABG in ___
6. Sciatica s/p L4-L5 laminectomy
7. Cholecystitis s/p gallbladder removal (___)
8. Appendicitis s/p appendectomy (___)
9. "gynecologic mass" s/p uterine hysterectomy, ovaries still in
tact (___)
10. Osteoarthritis s/p bilateral total knee replacement.
11. Community Acquired Pneumonia (___) c/b Cdiff
(___)
12. Diet controlled diabetes: HbA1c 6.3
Social History:
___
Family History:
Notable for a mother who died of lung cancer. Father had died of
an MI.
Physical Exam:
Physical exam on admission:
VS: T-98.3 BP-109/73 P-79 RR-16 O2-100% RA
GENERAL: well appearing elderly woman
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&O x ___ (person, place, ___, not date),
able to name president, days of week backwards, CNs II-XII
grossly intact, muscle strength ___ throughout, sensation
grossly intact throughout, full ROM of right hip without pain
Physical Exam Prior to Discharge:
T-98.2, BP-151/68, P-86, RR-18, O2-98%
Gen: well appearing, pleasant, NAD, reports sensorium at
baseline
HEENT: moist membranes
Cardiac: RRR, NO MRG
Lungs: CTAB, no wheeze or rhonchi or crackles
Abdomen: soft, NT, ND
Extremities: +2 radial and DP pulses, WWP, non-edematous
Neuro: AAOx3, attention good, speech fluent non-pressured,
sensation grossly intact throughout
Pertinent Results:
___ CXR: No acute cardiopulmonary process
___ 06:03PM BLOOD WBC-12.1*# RBC-4.76 Hgb-14.2 Hct-43.1
MCV-91 MCH-29.9 MCHC-33.0 RDW-14.1 Plt ___
___ 07:20AM BLOOD WBC-12.2* RBC-4.48 Hgb-13.6 Hct-40.3
MCV-90 MCH-30.4 MCHC-33.9 RDW-14.0 Plt ___
___ 06:03PM BLOOD Glucose-135* UreaN-18 Creat-1.0 Na-138
K-5.6* Cl-98 HCO3-23 AnGap-23*
___ 07:20AM BLOOD Glucose-129* UreaN-17 Creat-0.9 Na-138
K-3.7 Cl-103 HCO3-23 AnGap-16
___ 07:20AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.3
___ 06:10PM BLOOD Lactate-2.1* K-4.8
___ 05:52PM URINE RBC-1 WBC-14* Bacteri-FEW Yeast-NONE
Epi-1
___ 05:52PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-MOD
___ 05:52PM URINE Color-Straw Appear-Hazy Sp ___
___ URINE URINE CULTURE-PENDING EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
Brief Hospital Course:
___ year old female with CLL, HTN and recent bronchitis episode
with recent high dose steroid taper presents for acute AMS and
urinary frequency. She was started on IV Ceftriaxone for presume
urinary tract infection with resolution of her delirium.
#Delirium. The patient presented with AMS with confusion and
weakness per familial report. This comes in the setting of
potentially inadvertent steroid overdose (80mg ingested as
opposed to 40mg per PCP prescription for wheezing/bronchitis
symptoms) as well as probable UTI. In the hospital she was
hemodynamically stable with clinical improvement in cognitive
ability with time progression. She was discontinued from
steroids and given empiric antibiotic coverage for UTI via
Ceftriaxone 1gIV. Likewise, as she is on home Gabapentin &
Dilaudid for Sciatic pain, both medicines were held as an
inpateint with plans to retart as outpatient. She was evaluated
by the physical and occupational therapy servcies which
recommended that she be further managed with home ___ services
and occupational services as an outpatient.
#UTI: The patient reports symptoms of polyuria and urinary
frequency per family without blood or pain. She had evidence of
bacteria, leukocyte esterase and nitrite on Urinalysis in the
ED. She was started on ceftriaxone 1g IV in the ED. Throughout
her hopsitalization, she continued to experience polyuria
without urgency, dysuria or blood. She was prescribed
Ciprofloxacin for a 2 day course (total of 3 days of
antibiotics) for presumed uncomplicated urinary tract infection.
--> Need follow up of urine culture
#HTN: The patient has a history of medically managed
hypertension for which she was maintained on her home doses of
Amlodipine 5mg and Atenolol 50mg.
# Hyperlipidemia/CAD: The patient has a history of dyslipidemia
and coronary artery disease. She was kept on her home aspirin
regimen of 81mg. She was changed from Simvastatin 40mg to
Atorvastatin 20 mg due to potential drug-drug interactions with
amlodipine. She was advised to return to her home regimen of
Simvastatin 40mg and to follow-up with her PCP for further
management.
# CLL: The patient was diagnosed in ___ with CLL. As an
inpatient, it was an inactive issue.
# Sciatica: The patient has history of sciatic pain for which
she takes Gabapentin and Dilaudid. As an inpatient, those
medications wer held. She did not expreience a recurrence of her
pain. She was advised to resume her home regimen for neuropathic
pain but to monitor her symptoms closely and follow-up with her
PCP as to the ongoing dose titrations for her analgesia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Calcium Carbonate 500 mg PO QID:PRN indigestion
4. Atenolol 50 mg PO DAILY
5. Citalopram 40 mg PO DAILY
6. Gabapentin 100 mg PO BID
7. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
8. Meclizine 25 mg PO DAILY:PRN vertigo
9. Omeprazole 40 mg PO BID
10. Simvastatin 40 mg PO DAILY
11. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Calcium Carbonate 500 mg PO QID:PRN indigestion
5. Citalopram 40 mg PO DAILY
6. Omeprazole 40 mg PO BID
7. Gabapentin 100 mg PO BID
8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
9. Simvastatin 40 mg PO DAILY
10. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
11. Meclizine 25 mg PO DAILY:PRN vertigo
12. Ciprofloxacin HCl 500 mg PO Q12H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Altered Mental Status
Urinary Tract Infection
Secondary Diagnoses:
Hypertension
Dyslipidemia
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized for the evaluation of altered mental
status. It is thought that your confusion is owed to a multitude
of reasons. The first being your most recent use of high dose
steroids. You were advised to discontinue your prednisone per
your primary care doctor's request.
In the hospital, you were also found to have signs consistent
with a urinary tract infection. You were started on antibiotic
medications to treat these signs. It is possible that this
infection played a role in your confusion and weakness prior to
coming to the hospital.
Lastly, from your history of sciatic back and leg pain, we
discussed the potential role of your home prescriptions for
Dilaudid (Hydromorphone) and Neurontin (Gabapentin) as
contributors to your confusion. It is advised that you adhere to
your PCP's instruction for their continued use but to also
monitor for potential medication side effects and interactions
with other drugs.
You were evaluated by the physical therapy and occupational
therapy services as an inpatient. It has been strongly
recommended that you begin home occupational therapy with ___
services to help optimize the completion of your activites of
daily living at home.
New Medications: You left the hospital with a prescirption for
Ciprofloxacin. This antibiotic should be used for only 2 days.
It is intended to treat your urinary tract infection.
Followup Instructions:
___
|
19820782-DS-26
| 19,820,782 | 26,887,131 |
DS
| 26 |
2161-05-14 00:00:00
|
2161-05-14 19:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Sulfa (Sulfonamide Antibiotics) / Lisinopril / Reglan
Attending: ___.
Chief Complaint:
Dizziness/lightheadedness
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ is an ___ year old woman with a history of CLL in
remission, CVA incidentally found on neuroimaging, CAD s/p CABG,
HTN, dementia, HFpEF who presents to the ___ today with a chief
complaint of lightheadedness and gait instability. Per the
patient and her son, Ms. ___ was otherwise in her usual state
of health until this morning, when she stood up from a chair and
immediately felt very lightheaded, as if she were about to
faint. She did not black out and was able to sit down on her
chair, after which she felt slightly better, but not all that
much. She called her son after these symptoms persisted, who was
concerned and decided to bring her to the ___ for further
evaluation. Of note, the patient sustained a fall on ___ when
she slipped while walking outside with her son. She did not feel
lightheaded prior to this fall. She apparently fell on her
bottom without head strike. She was immediately able to stand
back up without issues and was able to walk home, though she
endorsed mild back pain today. Additionally, Ms. ___ underwent
a ___ scan ___ for evaluation of a 40 pound weight loss
which incidentally found a chronic right temporoparietal stroke.
Her PCP obtained an MRI in ___ to evaluate both for the PET
finding as well as memory difficulty which revealed multiple
strokes. No further workup for etiology was done at this time.
She also has a complex cystic lesion in the left adnexa which
appears to be consistent with a cystic ovarian neoplasm. Denies
fever/chills, n/v/d, dysuria, loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness,numbness, parasthesiae. No bowel
or bladder incontinence or retention.
In the ___, initial vital signs were: 97.7 61 154/130 18 100% RA
- Exam notable for: ***see neuro note for very thorough
evaluation thinks its 1960s, as at baseline nonfocal neuro exam
though unsteady on transfer RRR CTAB abd soft
- Labs were notable for: 140 / ___ AGap=20
------------- 4.___ / 0.8 wbc 7.9 hgb 11.0 plat 183 ___: 10.7
PTT: 27.1 INR: 1.0 Urinalysis: +leuk/nitr, WBC 24 Urine culture
pending
- Studies performed include CT Head W/O Contrast [299] -- Full
Report No acute intracranial process. Chronic right temporal
parietal and corona radiata infarcts, unchanged from MRI on
___ 13:01 Chest (Pa & Lat) [4] -- Full Report
AP upright and lateral views of the chest provided. Midline
sternotomy wires mediastinal clips are again noted. Clips are
noted in the right upper quadrant. Cardiomediastinal silhouette
appears unchanged. There is mild hilar congestion without overt
edema. No focal consolidation concerning for pneumonia. No large
effusion or pneumothorax. Bony structures appear intact.
- Patient was given: Ceftriaxone Upon arrival to the floor, the
patient is comfortable, pleasant and accompanied by her two
sons. They emphasize that her balance has been worse yesterday
than her previous "slightly unsteady" baseline and more dizzy.
At one point lowered her self to the ground w/o head strike or
LOC. Review of Systems: (+) per HPI
Past Medical History:
- Coronary artery disease s/p CABG in ___
- Chronic lymphocytic leukemia
- GERD
- Hypertension
- Dementia
- Mitral regurgitation with mild pulmonary hypertension
- Thyroid nodule s/p FNA in ___ nodules stable in ___
- Stroke
- Shingles
- C. Dif enterocolitis
- Anxiety
- Prediabetes, A1C on ___ was 6.3%
- Heart failure with preserved ejection fraction
- Parkinsonism ___ Reglan
Surgical Hx:
- Open cholecystectomy
- Open appendectomy
- Supracervical hysterectomy (?open)
- CABG
- Vein stripping
Social History:
___
Family History:
Mother with lung cancer and heart disease. Denies
h/o breast, ovarian, uterine, cervical, or colon cancers.
Physical Exam:
ADMISSION EXAM
==============
Vitals: 98.0 58 140/55 12 96%RA
General: Awake, pleasant, cooperative, NAD. AOx1
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal
rigidity.
Mild cervical muscle spasm
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, suprapubic tenderness, normoactive bowel sounds,
no masses or organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
*Please see excellent neurology note for examination
Labs, Microbiology: reviewed, please see attached
DISCHARGE EXAM
==============
98.6, 152/59, 63, 20, 94% on RA
General: Pleasant elderly female in NAD
HEENT: PERRRL, EOMI. Sclerae anicteric, conjunctiva not pale.
OP clear with MMM.
Lymph: No cervical, submandibular, supraclavicular LAD.
CV: s1 s2, RRR, no MRG.
Lungs: CTABL, good inspiratory effort.
Abdomen: Normoactive BS throughout. Soft, non-distended,
non-tender. No HSM.
Ext: WWP, 1+ pulses throughout, no ___.
Neuro: AOx2. CN2-12 intact. Strength ___ and symmetrical,
sensation intact to light touch throughout. No dysmetria.
Skin: Scattered seborrheic keratoses over neck, back, and
forehead.
Pertinent Results:
ADMISSION LABS
==============
___ 12:46PM BLOOD WBC-7.9 RBC-3.79* Hgb-11.0* Hct-34.0
MCV-90 MCH-29.0 MCHC-32.4 RDW-13.6 RDWSD-44.6 Plt ___
___ 12:46PM BLOOD Neuts-82.7* Lymphs-8.6* Monos-6.5
Eos-0.8* Baso-0.8 Im ___ AbsNeut-6.54* AbsLymp-0.68*
AbsMono-0.51 AbsEos-0.06 AbsBaso-0.06
___ 12:46PM BLOOD ___ PTT-27.1 ___
___ 12:46PM BLOOD Plt ___
___ 12:46PM BLOOD Glucose-170* UreaN-15 Creat-0.8 Na-140
K-4.4 Cl-103 HCO3-21* AnGap-20
___ 02:21PM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:21PM URINE Blood-SM Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 02:21PM URINE RBC-4* WBC-24* Bacteri-MANY Yeast-NONE
Epi-1 TransE-<1
PERTINENT LABS
==============
___ 06:30AM BLOOD %HbA1c-7.2* eAG-160*
___ 06:30AM BLOOD Triglyc-171* HDL-31 CHOL/HD-3.5
LDLcalc-44
___ 06:30AM BLOOD TSH-2.3
MICRO
=====
___ 2:21 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 6:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
STUDIES/IMAGING
===============
CXR ___
FINDINGS:
AP upright and lateral views of the chest provided. Midline
sternotomy wires mediastinal clips are again noted. Clips are
noted in the right upper quadrant. Cardiomediastinal silhouette
appears unchanged. There is mild hilar congestion without overt
edema. No focal consolidation concerning for pneumonia. No
large effusion or pneumothorax. Bony structures appear intact.
IMPRESSION:
As above.
CT HEAD WO CONTRAST ___
FINDINGS:
There is no acute hemorrhage, edema, or mass effect. There is
no CT evidence for an acute major vascular territorial
infarction. Large right inferior parietal/ occipital/ posterior
temporal chronic infarct with encephalomalacia and foci of
gyriform hyperdensity indicating pseudolaminar necrosis, and a
small right corona radiata chronic infarct with
encephalomalacia, are again noted. Ventricles and sulci are
enlarged due to global age-related parenchymal volume loss, with
superimposed ex vacuo enlargement of the frontal horn, atrium
and temporal horn of the right lateral ventricle.
No osseous abnormalities seen. There is minimal mucosal
thickening in the
ethmoid air cells. Mastoid air cells are well aerated. There
is evidence of bilateral cataract surgery.
IMPRESSION:
1. No evidence for acute intracranial abnormalities.
2. Large chronic right inferior parietal parietal/ occipital/
posterior
temporal temporal infarct and small chronic right corona radiata
infarcts are again demonstrated.
DISCHARGE LABS
==============
___ 07:10AM BLOOD WBC-4.0 RBC-3.31* Hgb-9.6* Hct-30.3*
MCV-92 MCH-29.0 MCHC-31.7* RDW-13.8 RDWSD-46.2 Plt ___
___ 10:11AM BLOOD Glucose-170* UreaN-11 Creat-0.7 Na-138
K-3.8 Cl-101 HCO3-24 AnGap-17
Brief Hospital Course:
This is an ___ year old female with past medical history of CLL,
dementia, CVA, CAD, admitted ___ with episode of
presyncope secondary to orthostasis, also found to have acute
bacterial UTI, volume repleted and status post completion of
antibiotic course, with resolution of symptoms, able to be
discharged home with 24 hour care
# Presyncope secondary to Orthostatic Hypotension - Patient
presented with episode of presyncope on standing. On
admission, workup was notable for orthostasis (123/50s ->
81/50s upon standing, HR 66 -> 75), as well as UTI (as below).
ECG at baseline. CT head in ___ was NEG for any acute
intracranial abnormalities, showed known R temporoparietal/R
corona radiata infarcts. Patient was seen by neurology who
felt that no acute neurologic processes were ongoing, but
recommended outpatient neurologic follow-up for history of
prior strokes. Patient was given IV fluids due to suspected
dehydration. UTI treated (as below). Patient was monitored on
telemetry without tachyarrhythmias, although notable for
borderline sinus bradycardia (although able to augment heart
rate with exertion), prompting decrease of Metoprolol from 25mg
daily to 12.5mg daily. Patient subsequently seen by ___ and
able to ambulate without symptoms. Of note, subsequently
patient still noted to have mild orthostasis by vitals signs
and without symptoms--this was felt to relate to mild
dysautonomia related to her age and dementia. Discussed
behavioral interventions with family and patient to help with
minimizing symptoms.
# Acute bacterial UTI - In setting of above symptoms, patient
was found to have a positive UA and urine culture with Ecoli.
Patient was initially treated with CTX 1g IV q24h, then
transitioned to cefpodoxime 200mg po BID following culture
return with pan-sensitive Ecoli.
# Vascular dementia secondary to history of stroke - Patient
with history of identification of prior strokes as part of
outpatient dementia workup. As above, patient was seen by
neurology during this admission, who recommended 3 month
neuro/stroke follow-up and consideration of outpatient MRA head
and neck without contrast to evaluate for vessel stenosis, and
TTE to evaluate for thrombus. Continued Rivastigmine and
Citalopram while inpatient. OT assessed patient, recommended
increased supervision at home to ensure safety. Patient's sons
are aware, have agreed to discharge home with ___ discuss
hiring in home ___ moving forward.
# Thrombocytopenia - Platelets noted to be 135k during this
admission; suspected to be secondary to acute illness (as
above). Would consider recheck as outpatient
# Ovarian Mass - Patient with known ovarian mass, previously
followed by ___ gyn-onc. She had missed recent outpatient
follow-up. Team arranged for GYN-onc follow-up with Dr. ___.
----------------
CHRONIC ISSUES:
----------------
# Chronic lymphocytic leukemia - WBC 7.9. Status post
fludarabine, Cytoxan and Rituxan therapy in ___, completing a
total of four cycles. Follows with Dr. ___
# Chronic Diastolic CHF - - Fractionated Metoprolol while
inpatient, decreased succinate to 12.5mg qd on day of discharge.
# Coronary artery disease s/p CABG in ___ - Continued ASA,
atorva, metop
# HLD - Continued Atorvastatin 80 mg PO QPM
# HTN - On fosinopril at home, was on Lisinopril while
inpatient, resumed home fosinopril at discharge
# GERD - Continued Omeprazole 40 mg PO BID
# Vit D Def - Continued Vitamin D ___ UNIT PO DAILY
TRANSITIONAL ISSUES
===================
- Patient found to have asymptomatic orthostasis during this
admission; would continue to educate caregivers regarding
behavioral management--rising slowly from lying to standing
- Patient noted to be thrombocytopenic to ~135, most likely in
setting of acute infection, should continue to monitored as
outpatient, esp given hx of CLL
- OT assessed patient, recommended increased supervision at
home to maintain safety, patient discharged with ___
- Patient discharged on cefpodoxime to complete a 3-day course
of antibiotics
- There needs to be further code status discussion between
patient, sons, and PCP. Patient's son stated that his mother
previously stated wish to have 'no major life saving
interventions,' though he needed to discuss the matter further
with his brother.
- Scheduled for outpatient neuro/stroke follow-up with above
recommended outpatient workup
=======================================
#Code Status: Full (but sons to discuss)
#Emergency Contact/HCP: sons ___ - ___ ___ -
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. fosinopril 10 mg oral DAILY
2. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. rivastigmine tartrate 3 mg oral BID
6. Omeprazole 40 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Citalopram 40 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 1 Dose
Last dose ___
RX *cefpodoxime 200 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
2. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Citalopram 40 mg PO DAILY
6. fosinopril 10 mg oral DAILY
7. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
8. Omeprazole 40 mg PO BID
9. rivastigmine tartrate 3 mg oral BID
10. Vitamin D ___ UNIT PO DAILY
11.Rolling Walker
Orthostatic Hypotension I95.1
Prognosis Good
Length of need: 13mos
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Presyncope secondary to Orthostatic Hypotension
# Ecoli Acute bacterial UTI
# Vascular Dementia secondary to history of stroke
# Thrombocytopenia
# Ovarian Mass
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 Ms. ___,
You were admitted to the hospital because you were feeling dizzy
and lightheaded at home. The most likely cause of your symptoms
is an abrupt change in blood pressure when you go from lying to
standing (orthostatic hypotension). In order to ___ minimize
your symptoms, it is important that you maintain good fluid
intake, sit on the edge of bed for several minutes prior to
standing up in the morning, and wear compression stockings. The
dose for your beta blocker (Metoprolol) was also decreased to
12.5mg daily as a slower heart rate may worsen your symptoms.
Your heart was monitored throughout your admission and there
were no episodes of abnormal heart rates/rhythms. The
neurologists examined you and felt that your symptoms were not
consistent with a stroke. It is important, however, that you
follow-up with your new neurologist as scheduled below given
your history of prior stroke.
You were found to have a urinary tract infection, which you have
also had in the past. You were treated with intravenous
antibiotics. Please take 1 additional dose of cefpodoxime to
complete your course.
It was a pleasure taking care of you!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19820782-DS-27
| 19,820,782 | 21,368,464 |
DS
| 27 |
2162-07-16 00:00:00
|
2162-07-16 16:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Sulfa (Sulfonamide Antibiotics) / Lisinopril / Reglan
Attending: ___.
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
Cardiac Catheterization (___)
History of Present Illness:
Ms. ___ is an ___ year old woman with dementia, CAD/CABG ___,
HFpEF, LBBB, MR, mild pHTN, DM, CLL in remission, remote c diff,
who presented to the ED with vomiting. The history was obtained
from the chart and from the patient's sons, as her dementia
precluded her from providing a comprehensive history.
The patient we reportedly in her usual state of health until
yesterday, when she developed new vomiting. She had 2 episodes
(first at 4 ___, which were nonbloody per report but potentially
bilious. Per report she was TTP in RUQ on initial presentation
to
urgent care, although her son stated that pain was not a primary
complaint. She was also reportedly confused beyond her baseline,
although per report of her son she is now back to baseline.
While in the ED the patient was afebrile and BPs were in
___ with HRs initially in ___ but subsequently
up to 110s-130s and irregular with baseline LBBB, which improved
back to ___ after receiving fluids. Satting 97-100% on room air.
She presented with a leukocytosis - WBC 15.6, normal LFTs, mild
hyponatremia at 133 initially (135 after fluids). Lactate
1.9->1.5. UA with 11 WBCs and mod leukocyte esterase. Flu
negative. She underwent CT in the ED which showed mild left
hydronephrosis from what appeared to be a crossing vessel, and
she was seen by urology. Started on ceftriaxone in ED, as well
as
IV fluids and Tylenol. While in the ED she reportedly had not
TTP
in abdomen and denied CP or dyspnea.
Her troponin was initially <0.01, but then increased to 0.08 and
then to 0.042 (resulted after departure from ED), with CK-MB
trending from 6->35 and CK from 115->429. Per review of the ED
records she was tachycardic at least from 7AM-11AM on ___
(although unclear exactly when tachycardia started).
When seen on the medical unit she endorsed mild abdominal
discomfort but denied significant chest pain or dyspnea. She
endorsed stable chronic back pain andmild abdominal pain.
Her sons reported that she was at baseline mental status.
She had a negative stress echo in ___.
Past Medical History:
- Coronary artery disease s/p CABG in ___ (LIMA to the LAD,
SVGs to D1/OM1 [s/p DES ___, SVGs to RCA)
- Multifocal mostly L ACA embolic stroke (___)
- Chronic lymphocytic leukemia
- GERD
- Hypertension
- Dementia
- Mitral regurgitation with mild pulmonary hypertension
- Thyroid nodule s/p FNA in ___ nodules stable in ___
- Stroke
- Shingles
- C. Dif enterocolitis
- Anxiety
- Prediabetes, A1C on ___ was 6.3%
- Heart failure with preserved ejection fraction
- Parkinsonism ___ Reglan
Surgical Hx:
- Open cholecystectomy
- Open appendectomy
- Supracervical hysterectomy (?open)
- CABG
- Vein stripping
Social History:
___
Family History:
Mother with lung cancer and heart disease. Denies
h/o breast, ovarian, uterine, cervical, or colon cancers.
Physical Exam:
ADMISSION EXAM
==============
BP: 100/57 HR: 75 RR: 18 O2 sat: 98% O2 delivery: RA Dyspnea: 0
RASS: 0 Pain Score: ___
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
MMMs
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, mild TTP in epigastrium, RUQ,
and suprapubic areas, BS+
GU: +suprapubic tenderness
MSK: No swollen or erythematous joints
SKIN: No rashes or ulcerations noted
EXTR: wwp, minimal edema
NEURO: Alert, interactive, face symmetric, gaze conjugate with
EOMI, speech fluent, motor function grossly intact/symmetric.
oriented to year but not month initially (corrected after seeing
calendar), oriented to BI but confused about being admitted -
stating she is getting ready to go home
PSYCH: pleasant, appropriate affect
DISCHAGE EXAM
=============
VS: 97.7 115/60 65 20 93 Ra
GEN: NAD, pleasant, leaning to the left
HEENT: NCAT, PERRL, EOMI, sclera anicteric, no OP erythema
NECK: supple, no visible JVD
CV: RRR, s1/s2, no MGR
PULM: CTAB, crackles on the right side no wheezes
ABD: Soft, NDNT, no rebound/guarding, no HSM
EXT: No ___ edema b/l
SKIN: Multiple acrochordons across the chest
NEURO: AOx1
Cranial Nerves: CN II, III, IV, V, VI, VII, VIII, IX, XI, XII in
tact bilaterally.
Extremity: RIGHT - ___ flexors and extensors on ___. 0+
patellar (knee replaced), no ankle clonus, 2+ bicep reflex
LEFT - ___ flexors and extensors on ___. Occasional myoclonic
in ___. 0+ patellar (knee replaced), no ankle clonus, 4+ bicep
reflex
Equal sensation b/l (On ___ - decreased sensation on ___ as
compared to the R ___. Could not assess gait as she is unable to
ambulate.
Pertinent Results:
ADMISSION LABS
===============
___ 09:05PM BLOOD cTropnT-<0.01
___ 09:05PM BLOOD ALT-11 AST-18 AlkPhos-80 TotBili-0.8
___ 09:05PM BLOOD Glucose-167* UreaN-20 Creat-1.0 Na-133*
K-3.9 Cl-96 HCO3-21* AnGap-16
___ 09:05PM BLOOD WBC-15.6* RBC-3.57* Hgb-9.8* Hct-31.0*
MCV-87 MCH-27.5 MCHC-31.6* RDW-13.8 RDWSD-43.0 Plt ___
STUDIES
=======
MRI HEAD ___
1. Acute right ACA territory infarct involving the
posterosuperior right
frontal gyrus.
2. A few scattered punctate acute infarcts involving the right
frontal, left
parietal, left occipital lobes and right cerebellum are likely
of involve
etiology.
3. Large old right parietal lobe infarct with associated volume
loss.
4. Extensive white matter small vessel disease.
CATH REPORT ___
left main 99% distal
LCX 99% stenosed
LAD 99% ostial stenosis
RCA occluded mid
SVG_RCA patent
___ patent with 70% proximal hazzy with
thrombus--.stented with distal protection--.excellent
result with normal flow
LIMA patent with occluded LAD distal to ___ touchdown
ECG ___: sinus with LBBB
ECG ___: LBBB morphology likely atrial fibrillation with
HR in the 130s versus sinus with frequent PACs although former
felt more likely, more prominence of STD in inferolateral leads
from baseline non-specific findings
___ ___:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF = 45%) secondary to hypokinesis of the inferior
septum, inferior free wall, and posterior wall, with focal
posterobasal akinesis. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are mildly thickened (?#). There is no aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
Severe (4+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___,
focal wall motion abnormalities, along with markedly increased
mitral reguritation, are now seen.
CT A/P ___
IMPRESSION:
1. Left UPJ obstruction with moderate hydronephrosis, new
compared to prior, likely due to a crossing renal artery.
2. ___ solid and cystic lesion within the left adnexa
measuring up to 5.7 cm, concerning for an epithelial neoplasm,
and should be evaluated with a pelvic ultrasound or MRI on a
nonemergent basis.
3. Other incidental findings include a small hiatal hernia,
diverticulosis, and an ectatic infrarenal abdominal aorta.
RECOMMENDATION(S): Pelvic ultrasound or MRI on a nonemergent
basis.
___ ___ EF 60%, biatrial enlarmgent, normal RV size and
motion, 2+ MR, 1+ TR and mild PA systolic HTN. Compared to prior
image, LV dyssynchrony is reduced, MR reduced, LV EF increased.
___: Stress ___
5.25 minutes Gervino protocol. Stopped for fatigue. MET 3.3
Progressive asymptomatic drop in systolic BP with exercise.
___ to 126/58.
EF 45-50%, 2+ MR, mod pa systolic HTN 47-67 .
Peak stress images, severe mitral regurgitation with substantial
exercise induced pulmonary hypertension - exercise induced sever
mitral regurgiation and pulmonary hypertension.
DISCHARGE LABS
==============
___ 07:00AM BLOOD WBC-9.4 RBC-3.40* Hgb-9.0* Hct-29.8*
MCV-88 MCH-26.5 MCHC-30.2* RDW-14.8 RDWSD-47.1* Plt ___
___ 07:00AM BLOOD Glucose-134* UreaN-15 Creat-0.7 Na-138
K-4.3 Cl-100 HCO3-25 AnGap-13
Brief Hospital Course:
Ms. ___ is an ___ year-old female with a history of HFpEF, 2+/3+
Mitral Regurgitation, T2DM, CAD s/p CABG ___, LIMA to the LAD,
SVGs to D1/OM1 [s/p DES ___, SVGs to RCA), LBBB, moderate
pHTN, and CLL p/w emesis, found to have UTI and mild Lt hydro
course c/b NSTEMI in setting of new Afib, hospital course
further complicated by new multifocal embolic strokes (most
prominently in the R ACA).
-CORONARIES: CAD s/p CABG ___, LIMA to the LAD, SVGs to
D1/OM1 [s/p DES ___, SVGs to RCA)
-PUMP: LVEF 45%
-RHYTHM: LBBB +/- AFib
#Acute embolic strokes (greatest in R ACA): Patient left leaning
starting on ___ with decreased sensation on LLE. CTA Head and
Neck was unrevealing. MRI (___) showing multifocal embolic
appearing infarcts R>L, the largest being in the territory of
the R ACA while on triple therapy (ASA/Plavix/lovenox while
bridiging to warfarin). Given the distribution these were felt
to be embolic related to her atrial fibrillation, unfortunately
occurring despite therapeutic anticoagulation with
lovenox/ASA/Plavix. R ICA has only 50% stenosis so unlikely to
have carotid genesis. 24h EEG (___) showed no seizure activity.
ACE inhibitor was held for permissive hypertension.
#Dementia
#Goals of Care:
The patient was ambulatory prior to her strokes above, and
unfortunately developed L sided weakness and had difficulty
ambulating independently after the strokes. ___ evaluated her and
recommended Rehab. Her family expressed questions regarding
rehab placement vs. options for placement at home, and
ultimately a rehab bed within her current facility was obtained.
Palliative care met with patient's son to discuss options in
long term planning, and they may benefit from palliative care
involvement in the future pending patient's clinical course. Her
Code status was also changed to DNR/DNI on ___.
#CAD s/p CABG
#NSTEMI s/p DES
#Chronic LBBB
Pt with Type II ischemia iso tachycardia +/- Afib (likely ___
UTI) on admission with EKG with equivocal new ST-depressions. On
Day 2, rising trops and MB with new RWMAs and worsened MR on
___. She was taken to LHC (___) s/p ___. Highest
troponin measured was 1.22.
Discharge regimen:
-Atorva 80
-ASA 81 + Plavix 75 + warfarin for 3 months (___)
-Clopidogrel + warfarin indefinitely (___-)
-Metop succinate 25 PO
-Held home fisinopril during hospital course and holding for
discharge (permissive HTN after stroke)
#Afib/RVR (CHADSVASC 7)
New onset Afib with RVR. AF may have been in the setting of new
NSTEMI vs UTI. Per interventional fellow, unclear if blockage
was thrombus or clot, raising suspicion for Afib.
-metop as above
-Patient was bridged to lovenox
-INR goal: 1.9-2.5
#Severe MR
#Chronic Diastolic CHF
Pt w/mild evidence of volume overload on exam, +JVD, not on
diuretics at home. ___ showing new RWMAs, worsened LVEF to 45%,
severe MR 4+.
PRELOAD: No diuresis as above
AFTERLOAD: restarting home ACEI as above
NHBK: metop as above
#E coli UTI
#Mild Lt hydronephrosis
#Sepsis
Pt p/w emesis, likely ___ UTI, had leukocytosis/tachycardia in
ED, started on CTX. Found to have Lt hydro on CT A/P, likely ___
blood vessel crossing, urology rec'd
conservative management, deferring intervention.
-s/p ___
-s/p ___
-augmentin (___)
#Pulmonary infiltrates
#?Pneumonia
New right paramediastinal RLL concerning for pneumonia, possibly
aspiration on ___ before cath. Minimally symptomatic.
-Abx as above
#Anemia
#Thrombocytopenia
#Hx of CLL
Had been stable as an outpt, overall stable here did not require
transfusions
CHRONIC ISSUES
==============
#DM2: HISS while inpatient
#Dementia/psych
#Metabolic encephalopathy: Continued home rivastigmine 3 BID
(nonformulary) and citalopram 40mg qd
#GERD: changed home omeprazole to pantoprazole for interactions
with plavix
#Orthostatic hypotension: Holding home meclizine o/n
#Insomnia: ramelteon prn for sleep
#Adnexal lesion
___ solid and cystic lesion within the left adnexa
measuring up to 5.7 cm, concerning for an epithelial neoplasm,
and should be evaluated with a pelvic ultrasound or MRI on a
nonemergent basis"
TRANSITIONAL ISSUES
===================
[] Redose warfarin for INR goal 1.9-2.5. PLEASE CHECK ON ___
AS THE LEVELS HAVE BEEN BOUNCING UP AND DOWN
[] Patient already received her warfarin dose for ___ prior to
discharge (2.5mg)
[] Pelvic ultrasound or MRI as an outpatient via PCP to evaluate
___ solid and cystic lesion with in the left adnexa
(5.7 cm) c/w possible epithelial neoplasm if within goals of
care for patient/family
[] Consider further discussions regarding GoC. Son and pt signed
MOLST (DNR/DNI) on this admission. In the future they may be
interested in Palliative Care, who met with them this admission.
[] Consider addition of maintenance diuretic if she gains
weight. Weights were stable in house.
[] If BPs are high, consider re-adding fisinopril (lisinopril
allergy: Nausea/Vomiting), held for permissive HTN after stroke
[] Plan discussed with her cardiologist for anticoagulation was
ASA/Plavix/Warfarin x3 months -> Plavix/Warfarin indefinitely
[] Neuro f/u for tx of myoclonus if it is a barrier to pt's
quality of life
[] changed omeprazole to pantoprazole to avoid interactions with
Plavix.
DISCHARGE WEIGHT: 67.6 kg (149.03 lb)
DISCHARGE INR: 3.0
>30 minutes on discharge planning/coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. fosinopril 5 mg oral DAILY
2. Atorvastatin 80 mg PO QPM
3. rivastigmine 3 mg oral BID
4. Citalopram 40 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Meclizine 12.5 mg PO QID
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
2. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
3. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Citalopram 40 mg PO DAILY
7. rivastigmine 3 mg oral BID
8. Vitamin D ___ UNIT PO DAILY
9. HELD- Omeprazole 20 mg PO BID This medication was held. Do
not restart Omeprazole until primary care physician
___:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
UTI
Pneumonia
NSTEMI
SECONDARY
=========
CLL
DEMENTIA
Embolic stroke (L ACA and diffuse)
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 Ms. ___,
It was a pleasure taking care of you here at ___
___.
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had nausea and vomiting and were
found to have a urinary tract infection and a pneumonia which we
treated an antibiotic
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You developed a blockage in your coronary arteries that we
intervened on with a cardiac catheterization
- You developed a stroke while you were here even with all of
the anticoagulation we were giving you after your cardiac
catheterization
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Make sure not to drink more than 2L of fluid a day
- Restrict your sodium intake to at most 2 grams a day
-Your weight at discharge is ***. Please weigh yourself today
at home and use this as your new baseline
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs
- If you notice any difficulty in speaking, moving arms or legs
or any change in sensation
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
It was a pleasure participating in your care. We wish you the
best!
-Your ___ Care Team
Followup Instructions:
___
|
19820782-DS-28
| 19,820,782 | 26,348,942 |
DS
| 28 |
2162-07-28 00:00:00
|
2162-07-28 17:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Sulfa (Sulfonamide Antibiotics) / Lisinopril / Reglan
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with hx of recent urosepsis, NSTEMI and stroke
one week prior to admission presenting with unwitnessed fall.
Patient presenting following unwitnessed fall at ___
___. Per report, she was sitting in an arm
chair at rehab on day of admission and tried to get up, fell
forward hitting her face on the floor. She does not walk at
baseline since her stroke. Patient does not recall any pre- or
post-dromal
symptoms.
Notably, found to have a large hematoma to forehead and taken in
for evaluation.
She is confused and AOx2 at baseline, at current mental status
per her son at bedside.
Notably, the patient was admitted was admitted from ___ to
___ service. During that admission, she was diagnosed with
acute embolic strokes (greatest in R ACA, presumed due to
a-fib), STEMI s/p ___ on ___, E. coli UTI.
Discharged to rehab.
Past Medical History:
- Coronary artery disease s/p CABG in ___ (LIMA to the LAD,
SVGs to D1/OM1 [s/p DES ___, SVGs to RCA)
- Multifocal mostly L ACA embolic stroke (___)
- Chronic lymphocytic leukemia
- GERD
- Hypertension
- Dementia
- Mitral regurgitation with mild pulmonary hypertension
- Thyroid nodule s/p FNA in ___ nodules stable in ___
- Stroke
- Shingles
- C. Dif enterocolitis
- Anxiety
- Prediabetes, A1C on ___ was 6.3%
- Heart failure with preserved ejection fraction
- Parkinsonism ___ Reglan
Surgical Hx:
- Open cholecystectomy
- Open appendectomy
- Supracervical hysterectomy (?open)
- CABG
- Vein stripping
Social History:
___
Family History:
Mother with lung cancer and heart disease. Denies h/o breast,
ovarian, uterine, cervical, or colon cancers.
Physical Exam:
Admission Physical Exam:
========================
GENERAL: NAD
HEENT: 3x3cm hematoma on left forehead, no active bleeding;
PERRL
HEART: RRR, S1/S2, ___ systolic murmur loudest at apex; tender
to palpation over left chest wall
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: Nondistended, nontender in all quadrants
EXTREMITIES: No cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox2 (to ___, but year ___, strength ___ bilaterally
though left leg limited by pain, CN II-XII intact
SKIN: Warm and well perfused
Discharge Diagnosis:
====================
GENERAL: NAD
HEENT: 3x3cm hematoma on left forehead, no active bleeding;
PERRL
HEART: RRR, S1/S2, ___ systolic murmur loudest at apex; tender
to palpation over left chest wall and shoulder
LUNGS: mild bibasilar crackles
ABDOMEN: Nondistended, nontender in all quadrants
EXTREMITIES: No cyanosis, clubbing, or 1+ non pitting edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox2 (strength ___ bilaterally though left leg limited
by pain, CN II-XII intact
SKIN: Warm and well perfused
Pertinent Results:
Admission Labs:
___ 01:25PM BLOOD WBC-9.4 RBC-3.12* Hgb-8.4* Hct-27.2*
MCV-87 MCH-26.9 MCHC-30.9* RDW-15.1 RDWSD-47.8* Plt ___
___:25PM BLOOD Neuts-81.7* Lymphs-7.3* Monos-8.3 Eos-1.5
Baso-0.5 Im ___ AbsNeut-7.64* AbsLymp-0.68* AbsMono-0.78
AbsEos-0.14 AbsBaso-0.05
___ 01:25PM BLOOD ___ PTT-29.3 ___
___ 01:25PM BLOOD Glucose-151* UreaN-19 Creat-0.8 Na-138
K-4.4 Cl-102 HCO3-21* AnGap-15
___ 01:25PM BLOOD cTropnT-0.04*
___ 06:01AM BLOOD CK-MB-2 cTropnT-0.03*
___ 06:01AM BLOOD Calcium-8.4 Phos-4.2 Mg-1.7
___ 04:10PM BLOOD Lactate-1.4
Microbiology:
=============
Time Taken Not Noted Log-In Date/Time: ___ 2:40 pm
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
CITROBACTER KOSERI. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER ___
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- ___ I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Imaging:
=======
CT Head W/out Contrast ___:
IMPRESSION:
1. Large left frontal subgaleal hematoma measuring up to 1.3 cm
without
underlying fracture.
2. No acute intracranial hemorrhage or definite acute large
territorial
infarction identified.
3. Redemonstration of known early chronic right ACA and chronic
right PCA
distribution infarcts.
4. Paranasal sinus disease with findings suggestive of acute
sinusitis, as
described.
CT C-SPINE W/O CONTRAST ___:
IMPRESSION:
1. Diffuse osteopenia limits evaluation for acute fractures.
2. No definite evidence of acute fracture.
3. Multilevel degenerative changes as described above, most
notable for mild canal narrowing at C7-T1. If clinically
indicated, consider cervical spine MRI for further evaluation.
4. Limited imaging lungs demonstrate bilateral pleural effusions
and
nonspecific patchy opacities. If clinically indicated, consider
correlation with dedicated chest imaging.
5. Left 1.8 x 1.7 cm thyroid nodule, grossly unchanged compared
to prior
cervical spine CT, better visualized on ___
thyroidultrasound.
6. Nonspecific subcentimeter lymph nodes as described.
ANKLE (AP, MORTISE & ___:
IMPRESSION:
No acute fracture.
CT Chest ABD Pelvis W Contrast ___:
IMPRESSION:
1. Acute nondisplaced fracture through the anterolateral left
seventh rib. No other fracture or evidence of acute
intrathoracic or intra-abdominal injury.
2. Patchy bilateral ground-glass opacities in the mid upper
lungs which likely reflects pulmonary edema though superimposed
infection cannot be excluded.
3. Moderate bilateral pleural effusions.
4. Persistent left UPJ obstruction with moderate hydronephrosis,
similar in appearance to prior.
5. Multi-septated left adnexal lesion measuring up to 5.1 cm on
today's
examination which could reflect malignancy given patient's age
and should be further characterized with pelvic ultrasound or MR
on ___ nonemergent basis.
Discharge Labs:
___ 06:00AM BLOOD Glucose-127* UreaN-16 Creat-0.8 Na-139
K-3.5 Cl-101 HCO3-24 AnGap-14
___ 05:35AM BLOOD ___ PTT-90.0* ___
Brief Hospital Course:
ASSESSMENT: Ms. ___ is a ___ with hx of recent urosepsis,
NSTEMI and stroke one week prior to admission presenting with
fall complicated by forehead hematoma and left 7th rib fracture.
She was evaluated by surgery with no plan for urgent surgery.
She was subsequently admitted to medicine for workup of fall and
found to have a UTI and subtheraputic INR. She was bridged to a
therapeutic INR prior to discharge and discharged on warfarin
2.5mg daily. Her hematoma was observed and was stable.
ACUTE ISSUES:
# Sub-galeal hematoma
# Left 7th rib fracture
# Unwitnessed fall:
The patient presented with a fall. she was observed on telemetry
for 24 hours without evidence of arrhythmia. Orthostatic vital
signs were checked on admission and were negative. She was found
to have a UTI which likely worsened patients confusion and
leading to fall. The patient has dementia at baseline and often
gets confused and tries to get out of her chair/bed. The
patients rib fracture does not need surgery follow-up. The
patients was found to have a subglial hematoma on her left
forehead. She had a head CT which showed no intracranial bleed.
Surgery was consulted and did not recommended observation. The
patients hematoma was stable during hospitalization and will
likely resolve in the coming weeks. Her neurological exam was
unchanged from baseline. She was discharged with cefpodoxime to
complete a 5 day course for UTI.
#UTI
The patient was found to have UTI for CITROBACTER KOSERI. The
patient did not have dysuria but did have increased urinary
frequency. Of note, the patient has dementia and frequently asks
to use the restroom as part of a tic from her dementia. She was
initially treated with ceftriaxone on ___ and was
transitioned to cefpodomixe to complete ___trial Fibrillation
The patient has a known history of atrial fibrillation with a
Chadsvasc of 7. She was found to have subtheraputic INR. She was
bridged to a therapeutic INR on heparin and was discharged on a
warfarin dose of 2.5mg with an INR goal of ___. She was
continued on home metoprolol with good rate control.
# Left leg spasticity
- The patient had had leg spasticity since her stroke recently.
She was previously treated with clonazepam at night. However
with her recent fall this was held to limit deliriogenic
medications. Neurology suggested trial of baclofen at night to
reduce leg spasms. This was used with good effect. The patient
will follow up with neurology as an outpatient for further
management
CHRONIC ISSUES
==============
# Embolic strokes (greatest in R ACA):
Patient with stable neurology exam from last admission. She was
continued on home anticoagulation with follow up as an
outpatient
# Severe MR
# Chronic Diastolic CHF: TTE last admission showing new RWMAs,
worsened LVEF to 45%, severe MR 4+. This admission with
bilateral pleural effusions but clinically dry on exam, not on
diuretics at home. Bed weight 145 from 149lb on last discharge.
She was diuresed with 20mg IV furosemide once and did not have
reaccumulation of swelling.
# CAD s/p CABG
# Chronic LBBB
The patient was continued on home Atorvastatin, ASA, Plavix and
Metoprolol. Warfarin was bridged as above and continued at 2.5mg
daily as an outpatient with an INR goal of ___ for atrial
fibrillation.
# Anemia
# Thrombocytopenia
# Hx of CLL: Had been stable as an outpt. Patient did not
require transfusion.
# Dementia/psych
# Metabolic encephalopathy:
Held home rivastigmine 3 BID (given nonformulary), continued
home citalopram 40mg QD
# GERD:
Continued home pantoprazole
# Insomnia:
Continued ramelteon prn for sleep
# Goals of Care: During previous admission, palliative care met
with patient's son to discuss options in long term planning,
felt they may benefit from palliative care involvement in the
future pending patient's clinical course. Her Code status was
changed to DNR/DNI on ___.
Transitional Issues:
====================
[] Patient discharged to complete a 5 day course (___) of
cefpodoxime 200mg BID for citrobacter UTI.
[] Recommend fall precautions.
[] Began baclofen 2.5 mg QHS for leg spasm at night, which can
be further uptitrated as needed. Clonazepam was stopped.
[] Patient discharged on warfarin 2.5mg daily for afib.
Discharge INR 2.0, with goal ___. INR should be checked on ___,
and then as needed to ensure this is an adequate dose
[] Final blood cultures pending at time of discharge, to be
followed by inpatient team.
# Code - DNR/DNI
# Contact - ___ (son) - ___
>30 minutes spent coordinating discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Citalopram 40 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
5. Metoprolol Succinate XL 25 mg PO DAILY
6. rivastigmine 3 mg oral BID
7. Pantoprazole 40 mg PO Q24H
8. Vitamin D ___ UNIT PO DAILY
9. ClonazePAM 0.5 mg PO DAILY Left leg spasm
10. Warfarin 2.5 mg PO DAILY16
11. TraZODone 12.5 mg PO QHS
Discharge Medications:
1. Baclofen 2.5 mg PO QHS
2. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 3 Days
3. Ramelteon 8 mg PO QHS:PRN insomnia
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Citalopram 40 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. rivastigmine 3 mg oral BID
11. TraZODone 12.5 mg PO QHS
12. Vitamin D ___ UNIT PO DAILY
13. Warfarin 2.5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
Sub-galeal hematoma
Left 7th rib fracture
Mechanical fall
UTI
Chronic Conditions
==================
Embolic strokes
Afib/RVR (CHADSVASC 7)
Severe MR
___ CHF
___
Diabetes Mellitus type II
Dementia/psych
GERD
Insomnia
Goals of Care
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to be a part of your care team at ___
___. You were admitted after you had a fall
and hit your head. A cat scan of your head showed that you did
not have any bleeding in your head, but you do have a rib
fracture. You were seen by the surgery team, and it was
determined that thankfully you do not need any surgery. We also
found that you have a urinary tract infection, and treated you
with antibiotics, which you should continue to take at rehab.
Please see below for your medications and follow up
appointments.
Again, it was very nice to meet you, and we wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19820893-DS-13
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DS
| 13 |
2131-06-30 00:00:00
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2131-07-12 15:03:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
N/V, abdominal pain
Major Surgical or Invasive Procedure:
EGD
Findings:
Esophagus:
Mucosa:Severe esophagitis with exudate in mid esophagus, and
erythema/friability in the lower esophagus.
Stomach:
Excavated LesionsA few small shallow ulcers were seen in the
stomach body.
Duodenum:
Excavated LesionsA 3 cm ulcer without high risk stigmata of
bleeding was found in the duodenal bulb.
Impression:Esophagitis
Gastric ulcer
Ulcer in the duodenal bulb
Otherwise normal EGD to third part of the duodenum
Recommendations:High dose PPI bid.
Please send stool for H.pylori.
Repeat upper endoscopy in 10 weeks.
History of Present Illness:
Mr. ___ is an ___ y/o male w/ HTN, DMII, PUD s/p clips several
years prior ___ EGD: gastric antral ulcer and linear
esophagel ulcer near GE
junction), diverticulosis, ESRD on HD (TTS), COPD not on O2
(FVC57%), ischemic cardiomyopathy w/ 35-40%EF, AS, HLD who
presented to the ED with abdominal discomfort and nausea.
History was taken both with the patient with an in-person
___ interpreter, as well as with the family present (sons,
wife).
Patient reports that his abdominal "discomfort" started 2 days
after in the evening. It was not associated with food intake,
and ___ experienced moderately diffuse discomfort. ___ vomited 1
time that was non-bloody and mostly clear. Yesterday, his
abdomen felt about the same but ___ did not vomit. Due to
persistently not feeling well, his family brought him to the
hospital for an
evaluation.
On presentation, ___ again vomited twice, with faint tinges of
blood. ___
continues to deny abdominal pain. In the ED note, it was
documented that patient had RLQ pain but upon further history
taking, ___ adamantly denied this component of the history. ___
denied any acid reflux, recent dietary changes, or new travel
history. ___ denied any diarrhea, melena, or active hematemesis.
This has never happened to him before and ___ is not certain of
any particular exacerbating factors. Patient also denies fever,
chills, night sweats, weight loss. Last bowel movement was 2
days ago and "yellow".
In the ED, initial vitals were: T 97.7, HR 94, BP 119/54, RR 22,
97% NC (unknown amount). Labs were notable for a WBC 17.3 (PMN
90%), Hb 11.1, PLT 205, Na 131, K 6.4 (on repeat 6.1 x2), BUN
68, Cr 9.6, glucose 201, trop 0.07, lactate 2.1, LFTs wnl.
Patient received insulin 10U, dextrose and calcium. Also
received flagyl 500 mg IV, cipro 400 mg, Zofran 4 mg and
morphine 2 mg x1.
CT abdomen showed cholelithiasis with mild thickening of the
gallbladder wall and mild pericholecystic fat stranding. There
was also evidence of a partially calcified lesion 2.7x1.6x1.4cm
along the small bowel mesenteric root (recommended a nonurgent
CTA). Also showed b/l AVN. RUQ US showed cholelithiasis without
cholecystitis. CXR showed no evidence of pneumonia or edema.
Surgery was consulted and did not recommend cholecystectomy at
this time.
On the floor, patient seen with his sons. The history was once
again taken in hemodialysis with an in-person ___
interpreter, and also later with the two children. Patient was
appearing uncomfortable with mild abdominal discomfort, but
otherwise no complaint of abdominal pain. ___ denied any
worsening symptoms since last night, but does not feel well.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, diarrhea. No recent
change in bowel or bladder habits. No dysuria. Denies
arthralgias
or myalgias.
Past Medical History:
- ESRD on HD
- DM type II on insulin
- CAD presumed based on fixed infarcts seeb on prior MIBI; never
had catheterization given nephrotoxicity of contrast dye, with
ischemic cardiomyopathy
- Ischemic cardiomyopathy w/ LVEF of 35-40% in ___ at ___
- COPD (not on home O2); ___ records indicate FVC 57%, FEV1
62%, FEV1/FVC 106% in ___
- Pulmonary Hypertension, severe at 67 mmHg with TTE ___
- Dyslipidemia
- Hypertension
- Aortic stenosis; moderate in ___
- PVD
- Anemia from CKD
- Gout
- Diverticular disease
- Hx PUD ___ EGD: gastric antral ulcer and linear
esophagel
ulcer near GE junction)
- hx Atheroembolic disease in ___ in setting of angiographic
procedure for acute occlusion of right common femoral artery (___
___
- hx Difficult intubation
Social History:
___
Family History:
No cancer, no bleeding disorders, father had diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 97.9, 130-150/___, ___, 20, 98%2L NC
General: AAOx3, conversant, appeared moderately uncomfortable
HEENT: Poor dentition, Sclera anicteric, MMM, oropharynx clear,
EOMI, PERRL, neck supple, JVP not elevated
CV: RRR, ___ SEM
Lungs: CTAB, with mild bibasilar crackles
ABD: +BS, obese, non-tender, non-distended, neg murphys, no
rebound tenderness, no HSM. Neg Rovsings.
GU: No foley
Ext: Warm, well perfused, 1+ pulses on LLE pedal, all other ___
pulses doplerable, no clubbing, cyanosis or edema. Bilateral
great toes amp
Neuro: A&Ox3. At baseline. Non-focal. Sensation mildly decreased
in b/l feet.
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DISCHARGE PHYSICAL EXAM:
Vital Signs: 98.2, 110s/30s-50s, 80s, 20, 98% RA, CPAP
at night
General: AAOx3, in no respiratory distress.
HEENT: Poor dentition, Sclera anicteric, MMM, oropharynx clear,
EOMI, PERRL, neck supple, JVP not elevated
CV: RRR, stable ___ SEM @ RSB
Lungs: Interval improvement, now grossly CTAB with very faint
wheeze in mid lung field. No crackles. Good air movement. No
accessory muscle use.
ABD: +BS, obese, interval improvement in abdominal distention.
Less tympanic. Now softer on palpation. No rebound tenderness.
No
palpable masses. Non-tender, neg murphys. No palpable hernias in
his L inguinal region.
GU: No foley
Ext: Warm, well perfused, 1+ pulses on LLE pedal, 2+ pulses
otherwise, no clubbing, cyanosis or edema. Bilateral great toes
amp
Neuro: A&Ox3. At baseline. Non-focal. Sensation mildly decreased
in b/l feet.
Pertinent Results:
Labs on Admission:
___ 08:50AM BLOOD WBC-17.3*# RBC-3.46*# Hgb-11.1*#
Hct-34.0*# MCV-98 MCH-32.1* MCHC-32.6 RDW-13.1 RDWSD-47.0* Plt
___
___ 08:50AM BLOOD Neuts-90.3* Lymphs-2.0* Monos-7.0
Eos-0.0* Baso-0.1 Im ___ AbsNeut-15.61* AbsLymp-0.34*
AbsMono-1.21* AbsEos-0.00* AbsBaso-0.02
___ 08:50AM BLOOD Neuts-90.3* Lymphs-2.0* Monos-7.0
Eos-0.0* Baso-0.1 Im ___ AbsNeut-15.61* AbsLymp-0.34*
AbsMono-1.21* AbsEos-0.00* AbsBaso-0.02
___ 08:50AM BLOOD ___ PTT-25.6 ___
___ 08:50AM BLOOD Glucose-201* UreaN-68* Creat-9.6*#
Na-131* K-6.4* Cl-89* HCO3-22 AnGap-26*
___ 08:50AM BLOOD ALT-20 AST-33 CK(CPK)-246 AlkPhos-127
TotBili-0.7
___ 08:50AM BLOOD CK-MB-3
___ 09:04AM BLOOD cTropnT-0.07*
___ 08:50AM BLOOD Lipase-66*
___ 08:50AM BLOOD Albumin-4.3 Calcium-9.1 Phos-2.7 Mg-1.6
___ 09:32AM BLOOD K-6.1*
=
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================================================================
Interval Labs:
___ 07:00AM BLOOD WBC-14.6* RBC-2.85* Hgb-9.0* Hct-29.3*
MCV-103* MCH-31.6 MCHC-30.7* RDW-13.2 RDWSD-49.9* Plt ___
___ 10:00AM BLOOD WBC-13.8* RBC-2.67* Hgb-8.5* Hct-27.5*
MCV-103* MCH-31.8 MCHC-30.9* RDW-13.2 RDWSD-49.7* Plt ___
___ 06:23AM BLOOD WBC-16.7* RBC-2.81* Hgb-8.9* Hct-28.3*
MCV-101* MCH-31.7 MCHC-31.4* RDW-13.2 RDWSD-48.8* Plt ___
___ 09:30PM BLOOD WBC-17.8* RBC-2.85* Hgb-9.2* Hct-29.4*
MCV-103* MCH-32.3* MCHC-31.3* RDW-13.2 RDWSD-49.2* Plt ___
___ 09:30PM BLOOD Neuts-90.7* Lymphs-1.7* Monos-6.1
Eos-0.2* Baso-0.1 Im ___ AbsNeut-16.15* AbsLymp-0.30*
AbsMono-1.08* AbsEos-0.03* AbsBaso-0.02
___ 07:07AM BLOOD Neuts-92* Bands-1 Lymphs-1* Monos-6 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-23.81* AbsLymp-0.26*
AbsMono-1.54* AbsEos-0.00* AbsBaso-0.00*
___ 08:25AM BLOOD Glucose-146* UreaN-40* Creat-5.6*# Na-133
K-5.0 Cl-92* HCO3-23 AnGap-23*
___ 07:00AM BLOOD Glucose-60* UreaN-52* Creat-8.4*# Na-134
K-3.8 Cl-92* HCO3-26 AnGap-20
___ 06:28AM BLOOD Glucose-108* UreaN-54* Creat-8.5*#
Na-131* K-4.0 Cl-91* HCO3-26 AnGap-18
___ 10:00AM BLOOD Glucose-199* UreaN-40* Creat-6.2* Na-134
K-4.1 Cl-95* HCO3-25 AnGap-18
___ 08:00AM BLOOD Glucose-169* UreaN-39* Creat-6.1*# Na-137
K-4.2 Cl-96 HCO3-22 AnGap-23*
___ 06:23AM BLOOD Glucose-135* UreaN-68* Creat-8.2* Na-128*
K-4.5 Cl-88* HCO3-23 AnGap-22*
___ 07:00AM BLOOD ALT-23 AST-28 AlkPhos-111 TotBili-0.9
___ 10:00AM BLOOD ALT-27 AST-37 AlkPhos-127 TotBili-0.9
___ 08:00AM BLOOD ALT-28 AST-42* AlkPhos-117 TotBili-0.9
___ 07:07AM BLOOD ALT-25 AST-32 AlkPhos-114 TotBili-1.3
___ 07:00AM BLOOD Calcium-7.9* Phos-5.1* Mg-2.0
___ 06:28AM BLOOD Calcium-8.0* Phos-5.4* Mg-1.9
___ 08:00AM BLOOD Calcium-8.0* Phos-4.8* Mg-2.0
___ 06:23AM BLOOD Calcium-7.6* Phos-5.1* Mg-1.9
___ 09:30PM BLOOD Calcium-7.8* Phos-5.1* Mg-1.9
___ 07:14PM BLOOD Lactate-1.6
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Labs on Discharge:
___ 10:30AM BLOOD WBC-11.6* RBC-2.43* Hgb-7.8* Hct-25.1*
MCV-103* MCH-32.1* MCHC-31.1* RDW-13.1 RDWSD-49.1* Plt ___
___ 10:30AM BLOOD Plt ___
___ 10:30AM BLOOD Glucose-197* UreaN-72* Creat-7.9*#
Na-131* K-4.2 Cl-90* HCO3-22 AnGap-23*
___ 10:30AM BLOOD Calcium-8.1* Phos-4.2 Mg-2.2
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Micro:
___ 1:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
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================================================================
Studies/Radiographic Imaging:
___: EGD
Findings:
Esophagus:
Mucosa: Severe esophagitis with exudate in mid esophagus, and
erythema/friability in the lower esophagus.
Stomach:
Excavated Lesions A few small shallow ulcers were seen in the
stomach body.
Duodenum:
Excavated Lesions A 3 cm ulcer without high risk stigmata of
bleeding was found in the duodenal bulb.
Impression: Esophagitis
Gastric ulcer
Ulcer in the duodenal bulb
Otherwise normal EGD to third part of the duodenum
Recommendations: High dose PPI bid.
Please send stool for H.pylori.
Repeat upper endoscopy in 10 weeks.
___: KUB
IMPRESSION:
1. Mild distension of the stomach.
2. No evidence of obstruction or ileus
___: CXR
IMPRESSION:
Increasing pleural effusions and bibasilar atelectasis.
___: U/S Abd
IMPRESSION:
Percutaneous cholecystostomy tube insertion canceled by the
treating team
shortly after beginning planning ultrasound portion of the
procedure. No
cholecystostomy tube insertion was performed.
___: CTA Abd/Pelvis
IMPRESSION:
1. Partially calcified mesenteric mass once again appreciated.
A benign
etiology is favored and differential considerations include
prior mesenteric injury or very small sclerosing mesenteritis.
Carcinoid is less favored given the absence of small bowel
abnormality and jejunal location. This lesion is not amenable
for biopsy.
2. Gallstones within the gallbladder neck with associated
gallbladder wall
thickening, distention, pericholecystic fluid and stranding, as
well as
hyperemia within the gallbladder fossa, compatible with acute
cholecystitis.
3. Similar appearance of bilateral avascular necrosis of the
femoral heads.
4. Small bilateral pleural effusions with associated
subsegmental atelectasis, new compared to prior.
5. Calcifications within the pancreatic parenchyma, likely
sequelae of chronic pancreatitis.
6. Bilateral macronodular adrenal hyperplasia.
___: HIDA Scan
FINDINGS: Serial images over the abdomen show homogeneous uptake
of tracer into the hepatic parenchyma.
The gallbladder is not visualized at 1 hour or 4 hours post
injection. Tracer activity was noted in the small bowel at 10
minutes.
IMPRESSION: Nonvisualization of the gallbladder. These
findings compatible with acute cholecystitis.
___: U/S Abd
IMPRESSION:
Cholelithiasis without evidence of cholecystitis.
___: CT Abd/Pelvis
IMPRESSION:
1. Cholelithiasis with mild thickening of the gallbladder wall
and mild
pericholecystic fat stranding. Please correlate clinically,
ultrasound if
needed to further assess.
2. Partially calcified lesion measuring 2.7 x 1.6 x 1.4 cm along
the small
bowel mesenteric root is indeterminate, differential
considerations include calcified aneurysm versus mesenteric
mass. linical correlation advised. A CTA may be performed to
further assess on a nonemergent basis.
3. Bilateral femoral head avascular necrosis.
4. Severe atherosclerosis.
___: CXR
IMPRESSION:
No acute findings.
Brief Hospital Course:
___ y/o male w/ HTN, DMII, PUD s/p clips several years prior,
diverticulosis, ESRD on HD (TTS), COPD not on O2 (FVC57%),
ischemic cardiomyopathy w/ 35-40%EF, OSA on CPAP,
AS, HLD who presented to the ED with abdominal discomfort and
nausea ___ esophagitis/gastric and duodenal ulcer, as well as
acute cholecystitis, with hospital course c/b mild COPD flair
and constipation.
#Acute cholecystitis: Patient presented with abdominal pain and
N/V, with RUS showing stones and a HIDA showing a non-visualized
gallbladder that is diagnostic of acute cholecystitis. CTA of
the abdomen and pelvis also showed hyperenhancement of adjacent
liver parenchyma, which is also consistent with acute
cholecystitis. Patient's abdominal exam remained stable and ___
did not have any guarding, rebound tenderness or ___ sign.
Additionally, patient's abdominal pain resolved after the first
day of presentation and ___ remained asymptomatic. Patient
otherwise remained AFVSS, with downtrending leukocytosis (11 on
discharge), as well as negative blood cultures. Per ACS, will
defer inpatient cholecystectomy, and recommended medical
management. Patient was treated with cipro/flagyl
(___) per Dr. ___ recommendations. Patient
was well-appearing with a very stable abdominal exam on the day
of discharge. ___ will follow-up with ACS in the outpatient
setting for evaluation and planning of cholecystectomy.
#Duodenal ulcer, gastric ulcer, esophagitis: On presentation,
patient had N/V that included a few streaks of blood. ___ did not
have any melena. ___ was evaluated by the inpatient GI team who
performed an EGD, which showed a 3 cm ulcer without high risk
stigmata of bleeding was found in the duodenal bulb. Patient was
also found to have a few small shallow ulcers in the stomach
body, severe esophagitis in the mid esophagus, and friability in
the lower esophagus. Patient was managed conservatively with IV
PPI followed by transitioning to PO PPI. H pylori testing was
negative. Per GI, patient would benefit from repeat endoscopy in
10 weeks. This was discussed with patient and family with aid of
interpreter who cited understanding and will arrange outpatient
follow up for repeat EGD. Patient did not have any evidence of
GIB while ___ was hospitalized.
#Leukocytosis: Patient with leukocytosis that peaked at 25.6 but
subsequently downtrended to 11.6 on the day of discharge. This
is likely in the setting of acute cholecystitis.
# Acute on chronic COPD exacerbation: During this admission,
patient developed mild-to-moderate shortness of breath with
wheezing on exam that was likely due to a COPD flair. ___ was
briefly started on 1L NC and as his wheezing/respiratory status
improved, was weaned to room air. Patient was treated with
standing duonebs with PRN albuterol, as well as a ___t the time of discharge, his respiratory
exam was clear bilaterally, ___ was satting well on RA, and had
an ambulatory O2 >96%. Patient was resumed on his home COPD
regimen on discharge.
#Calcified abdominal mass: Patient was found on CT Abd/Pelvis to
have a partially calcified lesion measuring 2.7 x 1.6 x 1.4 cm
along the small bowel mesenteric root is indeterminate. The
differential considerations include calcified aneurysm versus
mesenteric mass. This lesion is not amenable for biopsy. On the
CTA Abd/pelvis, this was again visualized at the branch of the
SMA in the mid-abdomen. Per radiology, this was likely due to a
thrombosed aneurysm and chronic. Carcinoid is less favored given
the absence of small bowel abnormality and jejunal location.
Based on read seems most likely benign and is in a location
which is not amenable to biopsy limiting our ability to work it
up further. This was discussed with patient and family with aid
of interpreter who cited understanding.
#ESRD on HD: Patient with ESRD on HD ___. ___ was continued on
his HD while hospitalized at ___. We continued his home
sevelamer and nephrocaps. ___ will continue his outpatient HD
schedule.
#Hyperkalemia: Patient was hyperkalemic on admission to 6.4,
although it was hemolyzed. Patient did not have any EKG changes.
Hyperkalemia in the setting of ESRD. Patient received HD during
this hospitalization and potassium was 4.2 on discharge.
#Hyperphosphatemia : Patient was hyperphosphatemic (up to 5.4)
during this admission in the setting of ESRD. Patient received
HD during this hospitalization and phos was 4.2 on discharge.
#Chronic Anemia in setting of ESRD: Patient with chronic anemia
(MCV 98-101) in the setting of ESRD. ___ was given EPO during HD
while ___ was inpatient. On discharge, patient's hgb was 7.8.
Patient was found on CT abd/pelvis to have divercula. However,
___ did not have any melena, and there was no evidence of any
bleeding at the time of discharge.
#Constipation: While patient was hospitalized, ___ was
constipated and did not have a bowel movement for several days.
This was resolved with senna/Colace/miralax. Patient was
discharged on miralax PRN for constipation.
CHRONIC ISSUES:
#Ischemic cardiomyopathy, EF35-40%: Current exam with stable
volume status. We continued patient on BB, aspirin, atorva.
Patient was continued on HD as described above and remained
euvolemic. ___ was discharged with a dry weight of 270lb.
#CAD: We continued patient on home metoprolol 25mg XL, aspirin,
atorva.
#PVD: We continued patient on home aspirin and atorvastatin.
#HTN: We continued patient on home metop. His blood pressure
largely remained at goal during this hospitalization.
#DMII: We continued patient's home insulin regimen while
inpatient and SSI as needed. Patient's sugar levels remained
largely well-controlled while inpatient. ___ will follow-up with
outpatient PCP and was resumed on his home regimen at the time
of discharge.
#GERD: we switched patient to PO pantoprazole BID in the setting
of duodenal ulcer diagnosis per GI recommendations.
#OSA: we continued patient on home CPAP. ___ was discharged on
room air.
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
Transitional Issues:
1. Please follow-up on patient's duodenal/gastric ulcer, severe
esophagitis. ___ was discharged on high dose PPI.
2. Please follow-up on patient's cholecystitis, patient was
asymptomatic at the time of discharge and will follow-up with
general surgery to determine optimal time for cholecystectomy.
4. Please follow-up on patient's pulmonary status. ___ had
episodes of wheezing during this hospitalization and was started
on a 5 day steroid burst with improvement.
5. The patient was given prescriptions for cipro and flagyl to
complete a 2 week total course of antibiotics for cholecystitis.
Last day of antibiotics ___.
6. Patient was discharged on dry weight 270lbs.
7. Patient was found on CT abd/pelvis to have colonic
diverticula, but ___ did not have any episodes of bleeding.
Please follow-up on this as an outpatient.
8. Patient was found on CT abd/pelvis to have small fat
containing left inguinal hernia. ___ was asymptomatic on
discharge without any evidence of strangulation or
incarceration.
9. Patient was found on CT abd/pelvis to have chronic bilateral
femoral head avascular necrosis. ___ was ambulatory independently
on discharge and will receive home ___.
10. Patient was found on CT abd/pelvis to have "extensive
atherosclerosis", locations unspecified.
11. Patient was found on CT abd/pelvis to have bilateral
macronodular adrenal hyperplasia.
12. Please obtain repeat CBC during outpatient setting and
assess Hgb (7.8 on discharge).
# CODE: Full (confirmed)
# CONTACT: HCP ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Fish Oil (Omega 3) 1000 mg PO BID
3. Metoprolol Succinate XL 25 mg PO QHS
4. Docusate Sodium 100 mg PO BID
5. Senna 8.6 mg PO BID
6. Atorvastatin 10 mg PO QPM
7. sevelamer CARBONATE 800 mg PO TID W/MEALS
8. Omeprazole 40 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
11. Tiotropium Bromide 1 CAP IH DAILY
12. Humalog ___ 28 Units Breakfast
Humalog ___ 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Nephrocaps 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Humalog ___ 28 Units Breakfast
Humalog ___ 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Metoprolol Succinate XL 25 mg PO QHS
8. Nephrocaps 1 CAP PO DAILY
9. Senna 8.6 mg PO BID
10. sevelamer CARBONATE 800 mg PO TID W/MEALS
11. Tiotropium Bromide 1 CAP IH DAILY
12. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
13. Omeprazole 40 mg PO DAILY
14. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
15. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*19 Tablet Refills:*0
16. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth once a
day Disp #*6 Tablet Refills:*0
17. Bisacodyl ___AILY:PRN constipation
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
19. PredniSONE 40 mg PO DAILY Duration: 2 Days
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
1. Acute cholecystitis
2. Duodenal ulcer
3. Calcified mesenteric mass
4. Hyponatremia
5. Hyperkalemia
6. Hyperphosphatemia
7. ESRD on HD
Secondary Diagnosis:
1. Anemia
2. CAD
3. DMII
4. HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at ___
___. You were admitted to the hospital after you
presented with abdominal pain and nausea/vomiting. We performed
a CT scan of you abdomen that showed you had gallstones in you
gallbladder. We then performed another study that showed you had
an infection within your gallbladder, which we started
antibiotics for. You tolerated this treatment well and did not
have any more abdominal pain for the remainder of your
hospitalization. You were evaluated by the surgeons who
recommended that you follow-up with a surgeon in clinic in a few
weeks to discuss removing your gallbladder to prevent another
problem like this.
In addition, we performed an endoscopic procedure that showed
you had an ulcer in your intestine and severe inflammation in
your esophagus. You were started on medications for your ulcer,
and you tolerated it well. We also tested you for a bacteria
called H Pylori, and the results were still not back at the time
of discharge. You will need to follow up with the
gastroenterologist and may need to have a repeat endoscopy
procedure. Please continue the high dose acid-reducing
medication (pantoprazole 40mg twice per day) instead of your
omeprazole until you follow up with the gastroenterologist.
You were continued with your dialysis while you were
hospitalized. We also found that you had a calcified mass in
your abdomen, which was likely a calcified out-pouching of one
of your blood vessels. This is stable and does not appear to be
anything dangerous.
Finally, you were seen by the physical therapists who
recommended home ___ for further rehabilitation.
Please follow up with your doctors at the ___ listed
below. Please be sure to take all medications are instructed.
We wish you the very best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19820893-DS-15
| 19,820,893 | 29,060,004 |
DS
| 15 |
2134-04-19 00:00:00
|
2134-04-19 21:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient presented to his dialysis session today and was normal
on arrival. After dialysis, patient appeared to be confused,
mumbling his speech, dysarthric. Son was called to evaluate
patient being home, on arrival, patient appeared persistently
confused. Patient denies chest pain, shortness of breath,
dizziness, weakness, or visual changes. Patient is noted to have
a wet cough. No fevers noted at home.
In the ED, vitals were: T: 97.8; HR:40; BP:122/52; RR: 18; SpO2:
94% RA
Exam:
Con: fatigued
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact without nystagmus
Resp: Crackles bilaterally, no tachypnea or distress
CV: Regular rate and rhythm, normal ___ and ___ heart sounds, 2+
distal pulses. Capillary refill less than 2 seconds.
Abd: Soft, Nontender, Nondistended
GU: No costovertebral angle tenderness
MSK: No deformity or edema
Skin: No rash, Warm and dry
Neuro: AOx3, CN II-XII intact, strength ___ diffusely, light
touch sensation intact, no FTN dysmetria, +dysarthria
Psych: Normal mood/mentation
Labs:
12.7>11.9/39.4<218 | ___ 11.7 | INR 1.1
ALT: 85 | AST 99 | AP 276 | T bili 1.4 | Alb 4.4
CK 317 | MB 4 | Trops 0.14
Na:137 | K:4.2 | Cl:99
TCO2:29 | Glu:81 | Creat:5.8
Studies:
NCHCT - ___
No acute intracranial process.
CXR - ___
1. Mild pulmonary vascular congestion and trace left pleural
effusion with chronic right pleural thickening.
2. Patchy opacification in the lung bases, more so on the right,
could reflect aspiration or infection in the correct clinical
setting.
On the floor, son present at the bedside and helps with
interpretation. He states that the dialysis center contacted his
brother as they thought Mr. ___ was confused. Son states that
he
thought his dad was at baseline and did not think his speech was
labored and changed from baseline but they were worried and
that's why they came to the hospital.
Past Medical History:
- ESRD on HD
- DM type II on insulin
- CAD presumed based on fixed infarcts seen on prior MIBI;
never had catheterization given nephrotoxicity of contrast dye
- Ischemic cardiomyopathy w/ LVEF of 35-40% in ___ at ___
- COPD (not on home O2); ___ records indicate FVC 57%,
FEV1 62%, FEV1/FVC 106% in ___
- Pulmonary Hypertension, severe at 67 mmHg with TTE ___
- Dyslipidemia
- Hypertension
- Aortic stenosis; moderate in ___
- PVD
- Anemia from CKD
- Gout
- Diverticular disease
- Hx PUD ___ EGD: gastric antral ulcer and linear
esophageal ulcer near GE junction)
- hx Atheroembolic disease in ___ in setting of angiographic
procedure for acute occlusion of right common femoral artery (___
___
- hx Difficult intubation
- Cholecystitis with medical management
Social History:
___
Family History:
No cancer, no bleeding disorders, father had diabetes.
Physical Exam:
ADMISSION EXAM
==================
T: 97.8PO; BP:132/53 L Lying; HR:78 RR:18 SpO2: 97 on RA
GENERAL: AOx3; comfortable; pleasant man
HEENT: PERRL, EOMI. senile arcus
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Could
not appreciate ejection systolic murmur although AS on echo.
LUNGS: Decreased air entry at the bases. Diffuse crackles/rales
bilaterally that partially clears upon coughing.
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.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. CN2-12
intact. ___ strength throughout. Normal sensation. Gait is
normal.
DISCHARGE EXAM
===================
___ 1058 Temp: 97.2 PO BP: 112/61 L Sitting HR: 82 RR: 20
O2
sat: 96% O2 delivery: Ra FSBG: 132
GENERAL: AOx3; comfortable; Cantanese speaking
HEENT: PERRL, EOMI.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Could
not appreciate ejection systolic murmur although AS on echo.
LUNGS: Decreased air entry at the bases. Faint expiratory
wheezes
bilaterally. No crackles.
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.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. CN2-12
intact. ___ strength throughout. Normal sensation.
Pertinent Results:
ADMISSION LABS:
=================
___ 01:10PM BLOOD WBC-12.7* RBC-3.70* Hgb-11.9* Hct-39.4*
MCV-107* MCH-32.2* MCHC-30.2* RDW-15.6* RDWSD-61.4* Plt ___
___ 01:10PM BLOOD Neuts-91.5* Lymphs-1.3* Monos-6.2
Eos-0.2* Baso-0.2 Im ___ AbsNeut-11.59* AbsLymp-0.17*
AbsMono-0.78 AbsEos-0.03* AbsBaso-0.02
___ 01:10PM BLOOD Plt ___
___ 01:10PM BLOOD ___ PTT-35.9 ___
___ 01:10PM BLOOD UreaN-23*
___ 01:19PM BLOOD Glucose-81 Creat-5.8* Na-137 K-4.2 Cl-99
calHCO3-29
___ 01:10PM BLOOD ALT-85* AST-99* CK(CPK)-317 AlkPhos-276*
TotBili-1.4
___ 06:00PM BLOOD cTropnT-0.12*
___ 01:10PM BLOOD cTropnT-0.14*
___ 01:10PM BLOOD Albumin-4.4
___ 01:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS:
==================
___ 06:50AM BLOOD WBC-6.3 RBC-3.57* Hgb-11.6* Hct-38.3*
MCV-107* MCH-32.5* MCHC-30.3* RDW-15.2 RDWSD-60.4* Plt ___
___ 06:50AM BLOOD Glucose-89 UreaN-39* Creat-7.4*# Na-137
K-5.1 Cl-97 HCO3-24 AnGap-16
___ 06:50AM BLOOD ALT-62* AST-74* LD(LDH)-262* AlkPhos-229*
TotBili-1.0
___ 06:50AM BLOOD Albumin-3.8 Calcium-8.7 Phos-4.9* Mg-1.9
IMAGING:
==============
___ Head CT w/out contrast===
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: Suspected stroke with acute neurological deficit.//
Please
exclude ICH, signs of early ischemic stroke, large vessel
occlusion, or other vascular abnormality.
TECHNIQUE: Contiguous axial images of the brain were obtained
without
contrast. Coronal and sagittal reformations as well as bone
algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy
(Head) DLP = 802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: MRI from ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
There is
prominence of the ventricles and sulci suggestive of
involutional changes.
Dense atherosclerotic calcifications noted within the
intracranial ICAs.
There is no evidence of fracture. The mastoids are poorly
pneumatized
bilaterally and are opacified on the right. Right middle ears
also opacified.
There is mucosal thickening in the maxillary sinuses which are
small,
particularly on the left potentially due to sinus atelectasis.
The visualized portion of the paranasal sinuses are otherwise
clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
___ Chest X Ray===
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with cough// eval PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are low. Mild cardiac enlargement is
re-demonstrated. Aortic
knob calcifications are again seen. Crowding of bronchovascular
structures is present with mild pulmonary vascular engorgement.
Chronic right pleural thickening is re-demonstrated, with a
probable trace left pleural effusion noted. Patchy
opacification within the lung bases, more so on the right, may
reflect aspiration or infection. No pneumothorax. Bilateral
vascular stents are noted within both axillary regions and in
the left subclavian region..
IMPRESSION:
1. Mild pulmonary vascular congestion and trace left pleural
effusion with
chronic right pleural thickening.
2. Patchy opacification in the lung bases, more so on the right,
could reflect aspiration or infection in the correct clinical
setting.
Brief Hospital Course:
___ year-old male with history of ESRD (dialysis tues, thurs,
sat), HTN, DMII, HLD, ischemic HFrEF (35-40% EF on TTE ___,
moderate aortic stenosis, transferred from outpatient dialysis
center with weakness, changes in mental status that rapidly
resolved.
# Altered mental status:
# Dysarthria:
Patient was referred from his outpatient dialysis ___
"altered mental status and dysarthria", though upon review of
history w/ patient and his son it was described more as
dizziness/unsteadiness without dysarthria. Per patient, he does
not recall being confused though he does endorse being very
tired after HD on ___. His son reports his father was unsteady
and very tired-appearing, but not confused or altered. The son
also clarified that his speech was normal when he met his father
at HD. In the ___ ED, the patient was had normal mental status
and no dysarthria. A non-contrast head CT did not show evidence
of stroke. Neurology assessed patient in the ED and scored 1 on
NIHSS for dysarthria, but the patient is ___ speaking only
and it is unclear how they judged this dysarthria. TIA cannot be
completely ruled out, but resolution of any deficit within hours
does rule out stroke. Regarding other causes of changes in
mental status and weakness, the patient was afebrile without
identified infectious source. CXR showed pulmonary congestion
but no consolidation, and patient was maintaining O2 sats on
room air. On the morning of ___, the patient felt well with no
complaints. Taken in context, this episode is best explained as
hypotension iso fluid shifts following dialysis. Recommend close
management of volume status with outpatient HD center.
# Mild Pulmonary edema:
# ESRD on HD:
CXR on admission showed mild pulmonary vascular congestion and
trace left pleural effusion along with patchy opacification in
the lung bases, more so on the right. This likely represents
pulmonary edema iso heart failure and ESRD. Dry weight appears
to be 61-62 kg per records, admitted with weight of 65 kg (bed
weight). Given patient was maintaining O2 sat on room air,
recommend on-going titration of ultrafiltration and fluid
management with outpatient HD center. Patient likely became
hypotensive due to fluid shifts as above, but also has evidence
of pulmonary edema on CXR.
# Chronic Combined Systolic/Diastolic HF (EF35-40%): Continue
volume management per HD and metoprolol on non-HD days.
# Chronic Anemia in setting of ESRD: Patient with chronic anemia
(MCV 107) in the setting of ESRD. No evidence of active bleed.
Likely anemia of chronic disease. CBC stable.
# Chronic constipation: Continued home senna/Colace.
# CAD: Continued home metoprolol 25mg XL, aspirin, atorvastatin.
# PVD: Continued home aspirin and atorvastatin.
# DMII: A1C 5.3 on ___ on atrius records. Continue home
regiment Humalog 75/25: 42 U in AM and 20 in ___. Consider
lowering insulin dose given A1C of 5.3%.
# OSA: Continued home CPAP at night.
Transitional Issues:
======================
[ ] Remove volume as able per HD given mild pulmonary vascular
congestion on CXR.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath
2. Pantoprazole 40 mg PO Q24H
3. Metoprolol Succinate XL 12.5 mg PO 4X/WEEK (___)
4. Atorvastatin 10 mg PO QPM
5. Humalog ___ 42 Units Breakfast
Humalog ___ 20 Units Dinner
6. Fish Oil (Omega 3) 1000 mg PO BID
7. Senna 17.2 mg PO BID:PRN Constipation - First Line
8. Docusate Sodium 100 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Humalog ___ 42 Units Breakfast
Humalog ___ 20 Units Dinner
7. Metoprolol Succinate XL 12.5 mg PO 4X/WEEK (___)
8. Nephrocaps 1 CAP PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Senna 17.2 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
Altered Mental Status
End-stage Renal Disease on Dialysis
Pulmonary Vascular Congestion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital because you were feeling weak, and
your dialysis center was concerned about you.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were evaluated by the neurology team who did not think you
were having a stroke.
- You had a CT scan of your head that did not show any strokes
or bleeding.
- Your blood work was all reassuring, and your oxygen levels
were normal.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Continue talking with your dialysis team about symptoms you
experience after dialysis.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19821197-DS-7
| 19,821,197 | 29,970,615 |
DS
| 7 |
2122-11-14 00:00:00
|
2122-11-15 15:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with HCV/EtOH cirrhosis decompensated by
hepatic encephalopathy, ascites, and esophageal varices s/p TIPS
who presented to outside hospital with back pain, however had a
sudden onset AMS.
CT head at OSH showed hypodensity and posterior cerebral edema
concerning for acute stroke. He was not felt to be a tPA
candidate, so he was sent to ___ for possible endovascular
tPA.
Upon presentation to ___ ED, patient was obtunded and
lethargic
however he would withdraw to pain. A code stroke was called.
Head
imaging, including a CTA head and neck, was negative for acute
stroke. The neurology team did not think this was consistent
with
acute stroke and felt that this was more consistent with toxic
metabolic encephalopathy, likely in the setting of his known
decompensated cirrhosis.
Despite initial concern that the patient would require
intubation
in the ED, his mental status improved and intubation was
deferred.
Of note, patient was recently admitted to ___ from ___
with bleeding esophageal varices. Hospital course was
complicated
by hepatic encephalopathy, portal hypertensive gastropathy,
enterococcus UTI, and malnutrition. Review of the discharge
summary shows multiple recent hospitalizations for
decompensations of his cirrhosis, which was first diagnosed only
a few months ago.
In the ED, initial vitals were: 97.8 55 96/62 12 100%
Non-Rebreather
- Exam notable for: Obtunded, lethargic on presentation but
improved. Withdraws and verbalizes to painful stimuli.
- Labs notable for:
Hgb 9.7, plts 95, Cr 0.7, INR 1.3
AST 45 ALT 20 AP 92 Tbili 0.8 Alb 3.1
Ammonia 90
- Imaging was notable for:
NONCONTRAST HEAD CT: (preliminary read)
No acute intracranial abnormality.
CTA HEAD NECK: (preliminary read)
The circle of ___ and its principal branches are patent. The
dural venous sinuses are patent. The carotid and vertebral
arteries are patent.
Final read pending completion of 3D reformats.
CXR - No acute cardiopulmonary abnormality. Metallic body is
seen
projecting in the expected location of the stomach. This could
be
due to prior surgery versus ingested foreign body. Clinical
correlation.
- Patient was given:
Upon arrival to the floor, patient confirms the above history.
On
review of systems, patient denies fevers, chills, nausea,
vomiting, diarrhea, constipation, dysuria. Notes that he has
some
intermittent epigastric pain that improves with food.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
- Bleeding varix with severe esophagitis
- Acute toxic/metabolic encephalopathy
- Chronic HCV
- Decompensated HCV/alcohol cirrhosis (ascites, esophageal
varices, superior mesenteric vein thrombosis, gynecomastia)
- Arrhythmia
- Elevated BP without dx of HTN
- Hyperlipidemia
- Morbid obesity
- Vit D deficiency
- B/l low back pain with sciatica
Social History:
___
Family History:
- Mother: Died in ___ of lung CA
- Father: ___ abuse, died in ___ of throat CA
- Brother: ___ abuse, died of liver dz
- Sister: Died of CA around age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: 97.8 132 / 81 58 17 97% RA
GENERAL: Well-developed male laying in bed. Sheets covered in
feces. NAD
HEENT: Normocephalic, atraumatic. PERRLA. EOMI. Sclera
anicteric.
NECK: Supple. No JVD
CARDIAC: RRR, normal S1/S2. No murmurs, rubs, or gallops.
LUNGS: CTAB, no wheezes, rales, or rhonchi.
ABDOMEN: Soft, nontender, nondistended. No organomegaly noted.
No signs of ascites. No rebound or guarding.
EXTREMITIES: Warm and well-perfused. No ___ edema.
NEUROLOGIC: Oriented to person only. CNII-XII grossly intact.
Moving all 4 extremities with purpose. + asterixis.
SKIN: No lesions or rashes noted.
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
Admission Labs:
----------------
___ 07:21AM BLOOD WBC-5.4 RBC-3.87* Hgb-9.7* Hct-31.3*
MCV-81* MCH-25.1* MCHC-31.0* RDW-17.6* RDWSD-51.4* Plt Ct-95*
___ 07:21AM BLOOD Neuts-55.0 ___ Monos-15.9*
Eos-2.5 Baso-1.0 Im ___ AbsNeut-2.83 AbsLymp-1.30
AbsMono-0.82* AbsEos-0.13 AbsBaso-0.05
___ 07:21AM BLOOD ___ PTT-31.2 ___
___ 07:21AM BLOOD Glucose-109* UreaN-19 Creat-0.7 Na-140
K-4.6 Cl-102 HCO3-26 AnGap-12
___ 07:21AM BLOOD ALT-20 AST-45* AlkPhos-92 TotBili-0.8
___ 07:21AM BLOOD cTropnT-<0.01
___ 07:21AM BLOOD Albumin-3.1* Calcium-8.4 Phos-2.9 Mg-1.8
___ 07:21AM BLOOD TSH-6.4*
___ 10:32AM BLOOD Ammonia-90*
___ 07:21AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:35AM BLOOD ___ pO2-23* pCO2-50* pH-7.39
calTCO2-31* Base XS-2
___ 07:35AM BLOOD Lactate-1.5
Microbiology:
-------------
URINE CULTURE (Final ___: NO GROWTH.
Imaging:
--------
CTA HEAD AND NECK WITH CONTRAST ___
IMPRESSION:
1. No acute intracranial abnormality.
2. No evidence of abnormal CT perfusion.
3. No stenosis, dissection, aneurysm or occlusion of the head,
neck CTA.
4. Paraseptal emphysema upper lungs.
CHEST XRAY ___
IMPRESSION:
No acute cardiopulmonary abnormality. Metallic body is seen
projecting in the expected location of the stomach. This could
be due to prior surgery versus ingested foreign body. Clinical
correlation.
RUQ Ultrasound ___
IMPRESSION:
1. Patent TIPS.
2. Cirrhotic liver with borderline spleen size.
3. Patent portal vein. No ascites.
Discharge Labs:
----------------
___ 05:15AM BLOOD WBC-4.4 RBC-3.60* Hgb-9.3* Hct-28.7*
MCV-80* MCH-25.8* MCHC-32.4 RDW-17.7* RDWSD-50.5* Plt ___
___ 05:15AM BLOOD ___ PTT-42.2* ___
___ 05:15AM BLOOD Glucose-91 UreaN-15 Creat-0.6 Na-140
K-4.0 Cl-102 HCO3-28 AnGap-10
___ 05:15AM BLOOD ALT-18 AST-34 AlkPhos-79 TotBili-0.7
___ 05:15AM BLOOD Albumin-3.0* Calcium-8.7 Phos-4.4 Mg-1.9
Brief Hospital Course:
Summary:
---------
Mr. ___ is a ___ year-old man with recently diagnosed
HCV/EtOH cirrhosis complicated by esophageal varices,
Spontaneous bacterial peritonitis, portal hypertensive
gastropathy, and hepatic encephalopathy s/p TIPS, who presented
as a transfer from an outside hospital with altered mental
status and obtunded from hepatic encephalopathy.
ACTIVE ISSUES:
---------------
# Toxic metabolic encephalopathy
# Hepatic encephalopathy
The patient was noted have a known history of hepatic
encephalopathy and presented elevated ammonia on admission. A
code stroke was initially called, as the patient was obtunded,
however neurology felt that presentation was more consistent
with toxic
metabolic encephalopathy. There was no evidence of stroke on CT
head or CTA head and neck. The patient is a high risk for
hepatic encephalopathy given his TIPS, which was evaluated via
ultrasound and patent. The most likely etiology of
decompensation is noncompliance with lactulose and rifaximin as
patient stated he was unaware he should be taking medications.
Infectious workup was negative. The patient's mental status
completely cleared within 1 day with regular lactulose and
rifaximin. On discharge, he was alert, oriented, conversant and
ambulating without assistance.
# Decompensated HCV/EtOH cirrhosis
Diagnosed in ___. Childs Class B, MELD-Na on admission
9. The patient was noted to have previous admission in ___
with discharge instructions to follow up without outpatient
gastroenterologist, Dr. ___ HCV viral load testing and
genotyping. There was no ascites on exam. TIPS was patent. The
patient was evaluated by nutrition and educated on the
importance of a low sodium diet. The patient will need to follow
up with PCP as he would greatly benefit from a case manager in
the community.
CHRONIC ISSUES:
----------------
# Thrombocyotpenia
Likely secondary to cirrhosis with possible additional
components of alcohol abuse.
and acute infection. No active signs of bleeding. The patient
did NOT require platelet transfusion.
# Chronic normocytic anemia
Improved since previous discharge. Given medical history, this
was likely secondary to anemia of chronic disease and
alcoholism.
# History of variceal bleeding
# Portal hypertensive gastropathy
The patient was noted to have a recent admission to ___
___ service with evidence of variceal bleeding s/p
banding and oozing from portal hypertensive gastropathy. There
was no evidence of active variceal bleeding during the
admission.
The patient's propranolol was held, as he is s/p TIPS.
# Coagulopathy
Likely secondary to cirrhosis. INR was monitored and near
baseline.
# Malnutrition
Albumin was slightly low on presentation (3.1), likely
consistent with malnutrition. Nutrition was consulted and
recommended >3 Ensure EnLives daily.
# Alcohol use disorder
The patient was seen by social work, who gave resources for
alcohol relapse counseling. The patient was also treated with
thiamine, folate, and MVI during the admission.
TRANSITIONAL ISSUES:
[] Outpatient follow up with Dr. ___ and Dr.
___ PLEASE ___ PATIENT TO SCHEDULE
APPOINTMENTS.
[] Unstable housing - the patient was discharged to Shelter in
___, as his previous shelter in ___ was full.
[] Case Management: The patient demonstrated unstable housing
and inability to manage his home medications. He would greatly
benefit from outpatient case manager.
[] HCV Cirrhosis:
- The patient will require HCV genotyping as an outpatient
- The patient will need screening EGD for variceal banding
within one month
[] Stopped Meds:
Propanolol because he has TIPS this medication is no longer
needed
[] New Meds:
Rifaximin 550 mg PO/NG BID
[] Code Status: Full (presumed)
[] CONTACT/HCP: ___ (Niece) Phone number:
___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 15 mL PO TID
2. Multivitamins 1 TAB PO DAILY
3. Propranolol 10 mg PO TID
4. Spironolactone 50 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Thiamine 100 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 mL by mouth three times a day
Disp #*7 Bottle Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) [Vitamin B-1] 100 mg 1 tablet(s)
by mouth daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hepatic Encephalopathy
Cirrhosis due to Hepatitis C and Alcohol
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were confused and unconscious
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You received medications to clear toxins that your liver
couldn't get rid of (Lactulose and Rifaximin)
WHAT SHOULD I DO WHEN I GO HOME?
-Please weigh yourself every morning, before you eat or take
your medications. ___ your MD if your weight changes by more
than 3 pounds
-Please stick to a low salt diet and monitor your fluid intake
-Take your medications as prescribed
-Keep your follow up appointments with your team of doctors
___ for letting us be a part of your ___!
Your ___ Team
Followup Instructions:
___
|
19821558-DS-11
| 19,821,558 | 28,543,755 |
DS
| 11 |
2148-03-23 00:00:00
|
2148-03-26 17:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Diabetic Ketoacidosis
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
History of Present Illness:
___ year old male with history of T1DM (HBA1C 8.1 ___
followed by ___, HTN, HLD, Anemia who presented to ED with
persistent nausea/vomitting.
In the ED initial vitalwere 97.6, HR 106, BP 132/76, RR 16, 96%
RA. FSBG 359. Patient apparentely had small amount of hematemsis
while ED that unwitnessed, had no abdominal discmofort on exam.
Labs significant for HCO3 14 (AG 26), WBC 8.2, Hg 12.7, Plt 153,
Chem w/ cre 1.3 (baseline 1.0), LFTs wnlm UA w/ + glucose, 150
ketonesm and protein. Abd x-ray unrevealing.
Patient was enrolled in DKA pathway, given insulin gtt at 3/hr
for majority of time. Received 6L iVF. Once his gap closed, drip
was stopped abruptly and then lantus 3 units given, in addition
to 6 units of humalog. Subsequently finger stick increased from
230 to 310 so ED gave another 10 units insulin the transferred
patient to floor. PPI was given for apparent hematemsis. Zofran
given for nausea.
On admission to medicine, FSG was 267
On arrival to the medical floor, the patient reports that he
developed nausea/vomitting on ___. He notes his vomit
appeared phlegm like. He ___ any hematemsis though there was
concern for this in the ED and his mother present at time of
this interview was also concerned taht it appeared blood tinged.
He notes that he has had not had associated abdominal pain,
diarrhea, fever, chills, howeever with nausea/vomitting. He
denies any recent sick contacts, eating out, or other indiviuals
in the family having similar symptoms to him. As a result of his
nausea/vomitting he has been unable to tolerate normal amounts
of food and has not been able to ___ any of his insulin
including lantus since ___.
He denies any other sympstoms liek dizziness, headache, blurry
vision, rash , join pain, fever, chills, chest pain, or
shortness of breath. He does note an unproductive cough with
emesis but not otherwisae. He denies dhyruia. Continues to pas
gas but has not had BM for 3 days and usually has bowel movement
on a daily basis. He has had a prior appendectomy.
He does endorse one prior episode of DKA aimilar to this ___ year
ago at ___ treated with IVF and antiemetics.
Past Medical History:
TIDM--diagnosed at age ___, takes insulin at home, ___ for
care
HTN
HLD
Anemia (elevaeted HbF, neg ___ in ___ folate and
B12 wnl)
Appendectomy
Social History:
___
Family History:
Sister with type ___ DM
Cousins: with breast and pancreatic cancer
sister: cervical cancer
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
============================
VS: 98.2, BP 119/55, P 75, RR 16, 95% RA
General: well-appearing, no acute distress
HEENT: EOMI, PEERL, dry appearing mucous membranes
Lungs: clear bilaterally
CV: RRR, no murmus
Abd: soft, non-tender to palaption
GU: negative CVA tenderenss
EXT: 2+ peripheral pulses, warm, no edema
Skin: no rash
Neuro: CN ___ intact, ___ strength in upper and lower
extremities
PHYSICAL EXAM ON DISCHARGE:
============================
VS: 97.6 132/64 76 18 96
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; right radial cath access site nontender without erythema
or bleeding
SKIN: no rash
NEURO: CN ___ intact, ___ strength in upper and lower
extremities
Pertinent Results:
LABS ON ADMISSION:
====================
___ 02:00PM BLOOD Glucose-91 UreaN-27* Creat-1.0 Na-144
K-3.6 Cl-111* HCO3-29 AnGap-8
___ 11:40PM BLOOD CK-MB-5 cTropnT-0.02*
___ 07:00AM BLOOD CK-MB-15* cTropnT-0.21*
___ 02:00PM BLOOD CK-MB-14* MB Indx-5.2 cTropnT-0.35*
___ 07:10PM BLOOD CK-MB-9 cTropnT-0.29*
___ 02:00PM BLOOD Calcium-8.2* Phos-1.2*# Mg-2.0
___ 08:37PM BLOOD ___ pO2-67* pCO2-36 pH-7.23*
calTCO2-16* Base XS--11
___ 02:09PM BLOOD ___ pO2-73* pCO2-44 pH-7.41
calTCO2-29 Base XS-2 Comment-GREEN TOP
KEY RESULTS:
-------------
___ 11:40PM BLOOD CK-MB-5 cTropnT-0.02*
___ 02:00PM BLOOD CK-MB-14* cTropnT-0.35*
___ 07:10PM BLOOD CK-MB-9 cTropnT-0.29*
___ 07:00AM BLOOD CK-MB-5 cTropnT-0.19*
___ 04:36PM BLOOD CK-MB-3 cTropnT-0.15*
___ 04:36PM BLOOD %HbA1c-10.5* eAG-255*
URINALYSIS:
------------
___ 08:30PM URINE Color-Straw Appear-Clear Sp ___
___ 08:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 08:30PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 08:30PM URINE CastHy-6*
LABS ON DISCHARGE:
====================
___ Cardiac Cath Report: Significant RCA and LCX disease
with moderate LAD disease. Recommendations - medical management.
___ 08:08AM BLOOD WBC-6.9 RBC-3.65* Hgb-12.1* Hct-34.9*
MCV-96 MCH-33.0* MCHC-34.5 RDW-12.9 Plt ___
___ 08:08AM BLOOD Glucose-229* UreaN-14 Creat-0.7 Na-135
K-3.9 Cl-97 HCO3-32 AnGap-10
___ 08:08AM BLOOD Calcium-8.8 Phos-2.5* Mg-1.8
STUDIES:
==========
___ Abdominal X-ray:
IMPRESSION:
Mildly prominent stool. No findings suggestive of obstruction
or free air. Calcified vas deferens, frequently seen with
diabetes mellitus.
___ ECG: Sinus rhythm. Right bundle-branch block. Left
anterior fascicular block. Cannot exclude prior inferior wall
myocardial infarction. Compared to tracing #2 no diagnostic
interim change.
___ TTE: The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with focal hypokinesis of the basal to mid inferior wall. The
remaining segments contract normally (LVEF = 55 %). Doppler
parameters are indeterminate for left ventricular diastolic
function. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis and aortic regurgitation are not present. The
mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Left ventricular systolic dysfunction with mild
regional variation c/w probable CAD. Normal right ventricular
cavity size and systolic function. No pathologic valvular
abnormalities. Aortic root dilatation.
Brief Hospital Course:
___ PMH of T1DM (HbA1c 8.1 ___, followed by ___, HTN,
HLD, Anemia (unknown cause) who presented to ED with persistent
nausea and vomiting found to have DKA with ___ and ___.
# Diabetic Ketoacidosis, type I DM
Patient with history of recently poorly controlled type I DM
(HgbA1c 10.5% ___ to be in diabetic ketoacidosis on
admission likely secondary to viral illness given antecedent
nausea/vomiting versus silent MI. He reported being unable to
take insulin including lantus in the days prior to admission due
to symptoms. After admission he was initiated on treatment with
insulin gtt with rapid closure of anion gap. He was then
transitioned to home lantus and humalog insulin sliding scale.
___ was consulted and followed along while inpatient. He had
several BG lows early in admission so lantus was decreased.
Subsequently after resumption of more normal diet he became
hyperglycemic, which was treated by increasing dose of lantus to
4U BID and increasing HISS with good effect. BG remained stable
thereafter and he was discharged on this regimen. He will have
close follow up with ___ after discharge.
# ___, type ___:
Patient chest pain free without prior history of ACS but
concerning for atypical presentation in the setting of DM on
admission. For this reason trop/MB was checked and noted to rise
to peak of 0.35 before downtrending. No ischemic changes on EKG.
These findings were concerning for ___, likely demand
ischemia, and cardiology was consulted. Patient received daily
aspirin and high dose atorvastatin 80 mg. Echocardiogram was
obtained that showed focal inferior wall motion abnormality.
Heparin gtt was initiated. Pt was taken for cardiac
catheterization on ___ that revealed multivessel disease with
mid RCA 80%, LCx with mid occlusion and diffuse 20% LAD disease
without focal lesion amenable to stenting. Per recommendations
from Cardiology, treated with medical management. Heparin gtt
stopped after cath. BP remained well-controlled and he was
initiated on metoprolol 25mg daily for rate control. Will need
repeat BP and HR checks in outpatient setting with uptitration
of beta-blocker as tolerated. He was discharged with Cardiology
follow-up. ___ recommends consideration of outpatient Cardiac
rehab in the future.
___:
Cr elevated at 1.6 on admission (from baseline 0.9) with BUN/Cr
ratio > 20 suggestive of pre-renal etiology. Cr downtrend with
IVF to 0.7 prior to discharge. ACE held initially due to ___ and
___ to allow BP room for metoprolol for rate control.
Risks/benefits of ACE-inhibitor will need to be reassessed in
the outpatient setting.
#Nausea/vomiting:
Patient presented with nausea/vomiting. Most likely secondary to
DKA, although possible that viral infection such as
gastroenteritis precipitated DKA. LFTs and lipase were all
within normal limits. Treated with zofran. Symptoms resolved
shortly after presentation and correction of BG.
# Orthostatic hypotension:
Pt found to be orthostatic by vital signs after working with ___,
pt remained asymptomatic. Likely contribution from hypovolemia
initially given excess urine output in the setting of
hyperglycemia. Remained orthostatic despite rehydration with
several liters of IVF. Given long history of type 1 DM most
likely component of autonomic dysfunction as well. Remained
stable and asymptomatic prior to discharge.
TRANSITIONAL ISSUES:
====================
-Discharged on insulin regimen of glargine 4U BID and humalog
sliding scale at increased doses. Will need close BG follow-up
as an outpt.
-As part of medication optimization after ___ pt was started
on metoprolol succinate at 25mg. He will need recheck of BP and
HR as an outpatient with uptitration of beta blocker as
tolerated.
-Transitioned to high dose statin with atorvastatin to replace
simvastatin.
-Lisinopril was held on discharge to allow blood pressure room
for metoprolol. Consider restarting as an outpatient.
-Follow up with Cardiology (Dr. ___ on ___. ___ felt that
patient would benefit from outpatient cardiac rehab so please
assess on this appt and make referral if appropriate.
-Follow up with ___ (Dr. ___ on ___
-CODE: FULL
-CONTACT: Mother (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Simvastatin 20 mg PO QPM
4. Multivitamins 1 TAB PO DAILY
5. Aspart Unknown Dose
Glargine 3 Units Breakfast
Glargine 3 Units Bedtime
Insulin SC Sliding Scale using Lantus Insulin
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Glargine 4 Units Breakfast
Glargine 4 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Diabetic Ketoacidosis (type I diabetes)
___
Secondary:
Hypertension
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You presented to the hospital with nausea and vomiting and you
were found to have diabetic ketoacidosis, a condition where your
blood sugar rises very high in the absence of insulin, which can
be life-threatening. You were treated with insulin and your
blood sugars improved. You continued having some high blood
sugars to the team from ___ helped to adjust
your insulin regimen before you went home. It is very important
in the future that you contact your doctor when your blood sugar
is persistently >300 or <60 or when you are ill and unable to
take your insulin.
You were also found to have evidence of decreased blood flow to
your heart based on lab testing and an ultrasound of your heart.
A cardiac catheterization was performed that showed blockages in
several blood vessels that supply your heart. The Cardiology
team felt that the best treatment for you at this time would be
medications so they did not place any stents. You were started
on two new medications called atorvastatin (to replace
simvastatin) to lower your cholesterol and metoprolol to help
with your heart rate. You will have a follow up appointment with
Cardiology after discharge.
It was a pleasure being involved in your care.
Your ___ Team
Followup Instructions:
___
|
19821558-DS-18
| 19,821,558 | 25,558,499 |
DS
| 18 |
2151-06-25 00:00:00
|
2151-06-25 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:
dyspnea cough febrile neutropenia
Major Surgical or Invasive Procedure:
bronchoscopy, thoracentesis ___
History of Present Illness:
Mr. ___ is a ___ year old M with
AML t(8;21) s/p 7+3 induction followed by two cycles of MIDAC
consolidation (C2D1 ___, T1DM, CAD and ICM (EF 40%),
adrenal
insufficiency, who presents with fever to TM 101.7 F at home,
malaise, L pleuritic chest pain, and dry cough x 1 day with
imaging showing new region of consolidation in the superior
segment of the left lower lobe suggesting new pneumonia with
continued hypoxia.
Past Medical History:
TREATMENT HISTORY:
-___ BMBX diagnosis of AML (8,21) without additional
molecular
abnormalities
--___ Enrolled to ___ INDUCTION Dauna 60 with Cytrabine 100 mg/m2
--- D+14 marrow chemoablation
-___ D+30 Count recovery with BMBx consitent with remission,
---MRD positive
-___ repeat BMBx (MRD negative)
-___ MIDAC ___ mg/m2 D1-5
---severe orthostatic hypotension
--- admitted from ___ for neutropenic fever 2 to PNA
PMH/PSH
--------------
1. Type 1 diabetes since age of ___
-Diabetic retinopathy
-Diabetic Neuropathy
2. Pulmonary nodule.
3. Chronic Anemia.
4. Right bundle-branch block.
5. Hypertension
6. NSTEMI ___ (managed medically)
7. Hyperlipidemia
8. Cataract surgery both eyes around ___
9. Laser surgery on eyes
Social History:
___
Family History:
Mother died recently, she was in her ___
Father died at age ___ from emphysema (smoker)
Sister is age ___ and has type 2 DM
4 brothers and 3 sisters with no history of CAD or stroke.
Physical Exam:
ADMISSION PHYSICAL EXAM ===
VITALS: T 98.5 F | 96/51 | 86 | 95% RA
General: Chronically ill appearing elderly gentleman, lying 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:
___ hip flexion, knee extension/flexion, plantar and
dorsiflexion
Sensation intact to light touch over UE and ___. Endorses chronic
numbness/tingling to mid calves bilaterally
Alert and oriented x 3 ___ building" "the ___
HEENT: Oropharynx clear without lesions. No palpable
cervical/supraclavicular adenopathy
Cardiovascular: RRR no murmurs
Chest/Pulmonary: Decreased breath sounds at left base with scant
overlying crackles.
Abdomen: Soft, nontender, nondistended.
Pelvis/GU: No CVA tenderness
Extr/MSK: No peripheral edema.
Skin: 2 pink-red papules (1-1.5 cm in diameter) over the right
deltoid. Nontender to palpation. No rashes seen elsewhere over
torso, back, arms, legs
Pressure ulcer over left heel with overlying eschar, nontender
to
palpation, no surrounding erythema or drainage
Access: R double lumen POC is c/d/I and nontender to palpation,
no surrounding erythema
DISCHARGE PHYSICAL EXAM:
VS T 98.0 BP 145/74 HR 74 RR 18 O2 95%
General: Chronically ill appearing,NAD
HEENT: Oropharynx clear without lesions. No palpable
cervical/supraclavicular adenopathy. Resolved facial swelling
Cardiovascular: RRR. no murmurs
Chest/Pulmonary: Decreased breath sounds at bilateral bases with
scant crackles L>R, s/p removal of Left CT c/d/i
Abdomen: Soft, non-tender/non-distended
Pelvis/GU: No CVA tenderness
Extr/MSK: No peripheral edema.
Skin: 2 pink-red papules on right upper lip improving.
Non-tender
to palpation. No rashes seen over torso, back, arms, legs.
Pressure ulcer over right heel with no surrounding erythema or
drainage, covered with gauze dressing
Neuro: Gross non-focal. Endorses chronic numbness/tingling to
mid
calves bilaterally. Tandem gait abnormal at baseline
Access: R DL POC non-tender to palpation, no surrounding
erythema
or discharge
Pertinent Results:
___ 12:00AM BLOOD WBC-5.9 RBC-2.67* Hgb-8.4* Hct-26.3*
MCV-99* MCH-31.5 MCHC-31.9* RDW-17.9* RDWSD-61.5* Plt ___
___ 08:20AM BLOOD WBC-0.1* RBC-2.33* Hgb-7.8* Hct-23.2*
MCV-100* MCH-33.5* MCHC-33.6 RDW-19.0* RDWSD-68.7* Plt Ct-5*
___ 12:00AM BLOOD Neuts-54 Bands-0 Lymphs-15* Monos-31*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-3.19 AbsLymp-0.89*
AbsMono-1.83* AbsEos-0.00* AbsBaso-0.00*
___ 08:20AM BLOOD Neuts-ND Lymphs-ND Monos-ND Eos-ND
Baso-ND AbsNeut-ND AbsLymp-ND AbsMono-ND AbsEos-ND
AbsBaso-ND
___ 12:00AM BLOOD Glucose-139* UreaN-23* Creat-0.8 Na-141
K-4.4 Cl-99 HCO3-31 AnGap-11
___ 08:20AM BLOOD UreaN-25* Creat-0.7 Na-136 K-4.2 Cl-97
HCO3-29 AnGap-10
___ 12:00AM BLOOD ALT-30 AST-24 LD(___)-283* AlkPhos-145*
TotBili-<0.2
___ 08:20AM BLOOD ALT-27 AST-15 LD(LDH)-185 AlkPhos-94
TotBili-0.6 DirBili-<0.2 IndBili-0.6
___ 12:00AM BLOOD Albumin-3.0* Calcium-8.6 Phos-3.1 Mg-2.0
___ 08:20AM BLOOD TotProt-6.3* Albumin-3.6 Globuln-2.7
Calcium-9.0 Phos-2.5* Mg-1.6 UricAcd-2.5*
Brief Hospital Course:
___ yo M with AML t(8;21) s/p 7+3 induction
followed by two cycles of MIDAC consolidation, T1DM, CAD and ICM
(EF 40%), adrenal insufficiency, who presents with febrile
neutropenia with imaging c/f LLL PNA with persistent hypoxia.
ACUTE ISSUES
---------------
#Neutropenic Fever:
#LLL consolidation c/f PNA:
#Hypoxia:
#Pleural Effusions:
On admission, patient was noted for complaint of L sided
pleuritic chest pain, dry cough, and consolidation on CTA.
Neutropenic fever source most c/f PNA. No PE or aortic
abnormality. His pleuritic chest pain resolved. Initiated
vancomycin ___ (D1: ___, added
posaconazole for fungal coverage (D1: ___ but
discontinued
posaconazole ___ as was no longer neutrapenic and negative
fungal markers. Albeit w/ symptomatic improvement and aggressive
diuresis, he remained hypoxic (requiring ~ ___ of supplemental
02), prompting pulmonary consultation on ___. Repeat imaging
with CT chest ___ showed radiographic progression of LLL
consolidation despite antibacterial (since admission) and fungal
therapy (5D prior to repeat imaging). Pulmonary thinks his lung
findings are likely fungal in etiology given nodular opacity vs.
likely some component of aspiration though would not expect to
see such progression on CT with antibiotics. Given this,
bronchoscopy with BAL was performed on ___ for further
evaluation. Additionally, patient was noted to have
parapneumonic
effusions on CT; therefore, IP was consulted per pulmonology
recommendations and placed a Left CT, sent fluid for pleural
analysis on ___. Patient drained ~450ml and tube was removed
on ___ per IP. In the context of neutropenia resolution, low
suspicion for aspiration pneumonia and prolonged anti-bacterial
therapy, changes were made to his regimen as below. He has been
requiring 02 supplementation overnight while asleep but on RA
during the day. Recent CXR ___ did not show worsening PTX or
re-accumulation of pleural effusion
-Cefepime(D1: ___ Vancomycin ___ restarted
Posaconazole ___ post BAL but d/c per ID recs on ___
-Flagyl (D1: ___ was added ___ per pulmonary recs due
to aspiration PNA concern; however, patient developed
significant
GI effects and given low aspiration PNA suspicion, medication
was
discontinued on ___.
-Repeat fungal markers ___ negative
-Barium swallow evaluation ___ did not show clear evidence
of
aspiration
-Appreciate PULM recs: regarding hypoxia at night, thinks likely
due to atelectasis or ? sleep apnea. scheduled sleep study
outpatient ___ along with PFTs. He will be d/c with 02
supplementation
which can be weaned off outpatient with improvement. Needs
repeat
CT chest in 4 weeks, requested ___ before ___ appointment
-IP signed off
-Consulted ID ___: guidance on course of antifungal therapy;
thinks no indication for antibacterial or antifungal therapy
given substantial improvement since admission therefore off all
empiric ABX at discharge
#Heart failure with reduced ejection fraction:
#Left Sided Chest Pain and DOE:
#Hypoxia
#Coronary artery disease, triple vessel disease:
Patient complained of new intermittent left sided chest pain on
___ which differed from his initial presentation on this
admission (see below). EKG notable for sinus tachycardia at 100
BPM. LAD. Widened QRS in RBBB pattern (not new). QTc calculated
at 407. Cardiac enzymes showing flat CK-MB and normal trops. Of
note, he had a type II NSTEMI attributed to severe anemia during
his initial AML diagnosis. CXR ___ imaging suggested
pulmonary congestion as well as small pleural effusions. Weight
was up ~7lbs from admission and patient was noted to be hypoxic
requiring ___ of supplemental 02. His BNP was also elevated.
Given this, we were concerned about volume overload likely
related to frequent transfusions which likely exacerbated known
HFrEF. Patient was actively diuresed throughout admission
-Received 40mg IV Lasix ___ and below baseline weight (118lb
from 123lb baseline) so held off since ___. He remains
intermittently hypoxic as above but suspect less likely from
volume overload.
___ between MD ___ patient agree to home O2"
Pt has CHF and is in a chronic and stable state, not
experiencing acute illness/exacerbation. Alternative treatments
have been tried and failed in improving hypoxia (weaning off O2,
drainage of pleural effusion, bronchoscopy with no infectious
source found) Pt requires long term home and portable oxygen
therapy to improve hypoxia related symptoms.
#AML (___):
#Pancytopenia in s/o MIDAC:
He is s/p 7+3 and 2C MIDAC consolidation and currently D+32
presenting with neutropenic fever. Previous course of MIDAC c/b
neutropenic fever also c/f pulmonary source. He has signs of
counts recovery.
-Transfuse hgb <7 and/or Plt <10
-Continue acyclovir ppx
-Active T&S
-Received pepfilgrastim on ___, counts recovered as of ___
#Hyperglycemia in s/o acute stress/neutropenic fever:
#Pseudohyponatremia in s/o hyperglycemia:
#T1DM with labile blood sugars:
Improved. Requiring ___ consults over last couple
hospitalizations when receiving dexamethasone. Resistant
hyperglycemia on this admission needing far more than usual
insulin without any steroids on board which may be likely driven
by stress of underlying pulmonary infection. Consulted ___
for
recommendation given recent hypoglycemia ___.
-Continue lantus and sliding scale w/ Humalog per ___
modifications
-Diabetic diet
#Lip lesion: Significantly improved. R upper lip of unclear
etiology originally thought secondary to folliculitis although
consider HSV as potential cause. Initiated higher dose acyclovir
5x daily (d1 ___ and monitor for improvement continue x5d
course (___) now back to prophylactic dosing.
#Neuropathic Ulcer: On R heel. Wound nurse consulted. Continue
with daily dressing changes as recommended. Does not appear
acutely infected. Monitor closely.
#Hypomagnesaemia/Hypophosphatemia: Normalized. Was likely
exacerbated in the setting of diuresis. Monitoring lytes
CHRONIC/RESOLVED/STABLE CONDITIONS
#Acute Chest Pain, chest-tube site: Resolved, associated with
chest tube placement. Improved with opioids. Continue to assess
for re-occurrence.
#Pneumothorax: Resolved, trace left apical pneumothorax noted
per
imaging following chest tube removal on ___. Patient without
worsening chest discomfort and/or increasing 02 supplementation.
CXR on ___ showed resolution of PTX.
#Nausea/Vomiting: Resolved, attributed to medication effect
(flagyl?). Continues with zofran as needed.
#Constipation: continues on bowel regimen, adjust as needed
#Adrenal Insufficiency:
#Autonomic Dysfunction:
-Continue daily 5mg of prednisone
-Consider escalating to stress dose steroids as above
-Home midodrine has been weaned off but consider adding back if
persistently orthostatic
-___ following
#CAD w/ triple vessel disease, history of type 2 NSTEMI, CHF (EF
40%). Holding lisinopril given soft BPs on admission.
#GERD: Continue home pantoprazole
Prophylaxes:
#Access: POC placed ___
#PPX: TEDs. Hold pharmacologic given thrombocytopenia
#FEN: Diabetic diet, continue home vitamin D supplementation
#Pain control: as needed
#Bowel regimen: standing
Emergency Contact: ___ to be HCP ___
#Code Status: FC
#Disposition: f/u Dr ___ ___ f/u pulm ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Lisinopril 2.5 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. PredniSONE 5 mg PO DAILY
6. Vitamin D ___ UNIT PO 1X/WEEK (___)
7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID
8. Pegfilgrastim Onpro (On Body Injector) 6 mg SC ONCE
9. Glargine 5 Units Breakfast
Glargine 5 Units Bedtime
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Discharge Medications:
1. Glargine 20 Units Breakfast
Glargine 5 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. Acyclovir 400 mg PO Q12H
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Pantoprazole 40 mg PO Q24H
5. PredniSONE 5 mg PO DAILY
6. Vitamin D ___ UNIT PO 1X/WEEK (___)
7. HELD- Lisinopril 2.5 mg PO DAILY This medication was held.
Do not restart Lisinopril until outpatient team tells you to
stop
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
AML
pneumonia
febrile neutropenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___
You were admitted due to fever when your blood counts were low.
You were found to have pneumonia with improved with antibiotics
time and count improvement. You were also found to have an
effusion (fluid in your lungs) which was drained. You will
follow up with the pulmonary team outpatient for sleep study and
repeat imaging. You will be discharged home and follow up with
Dr. ___ as stated below. It was a pleasure taking care of
you.
Followup Instructions:
___
|
19821560-DS-15
| 19,821,560 | 22,937,682 |
DS
| 15 |
2140-05-01 00:00:00
|
2140-07-19 14:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L ___ rib fractures and small L hemopneumothorax
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ slipped on wet stairs on ___ (3 days prior to
presentation), grabbed the rail and hit his left side into the
wall, with the chest taking the brunt of the impact against the
railing. He has overall been doing well at home, but has been
having left sided chest pain with cough, but no fevers, no SOB.
He otherwise is having some hip pain and forearm pain where he
has some additional bruising.
Past Medical History:
Gout
Tonsillectomy as a child
Social History:
___
Family History:
Non-contributory
Physical Exam:
Gen: Awake and alert
CV: RRR
Resp: CTAB, bruising on L chest
Abd: Soft, nontender, nondistended
Ext: WWP
Pertinent Results:
___
15:06
133 97 12 101 AGap=23
3.1 16 0.8
Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes
estGFR: >75 (click for details)
Ca: 10.0 Mg: 1.8 P: 3.3
94
19.0 ___ 12.3 192
35.7
N:81.0 L:9.2 M:5.8 E:3.0 Bas:0.3 ___: 0.7 Absneut: 15.34
Abslymp: 1.75 Absmono: 1.10 Abseos: 0.57 Absbaso: 0.06
___: 10.0 PTT: 27.5 INR: 0.92
Brief Hospital Course:
Mr. ___ presented to the ED 3 days after falling down wet
stairs and hitting his left side on the railing. He was
hemodynamically stable upon arrival and complained of left sided
pain. A chest x-ray was performed, which showed several left rib
fractures and associated chest wall hematomas, as well as a
small pleural effusion. Chest CT revealed multiple left sided
rib fractures, small L hemopneumothorax, pulmonary contusions
bilaterally, LLL collapse and a 4mm LUL pulmonary nodule. He
remained stable from a respiratory standpoint, and was placed on
4L nasal cannula. Over the next several days, his pain was
well-controlled with IV and eventually oral pain medication. He
continued to tolerate a regular diet. His oxygen requirement was
weaned after better pain control was obtained, and he was given
nebulizers to help with coughing and wheezing. On HD #2, a
repeat CXR showed interval resolution of the LLL collapse, and a
small persistent pneumothorax. On HD #3, he was able to maintain
his saturations while walking and without oxygen. His CXR was
improved, and he was dicharged home with oral pain medication.
He will follow-up in ___ clinic in 2 weeks, and was also
instructed to follow-up with a repeat CT scan in 6 months for
evaluation of his incidentally found lung nodule.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
do NOT exceed 3gm in 24 hours
2. Docusate Sodium 100 mg PO BID
please hold for loose stool
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. Morphine SR (MS ___ 15 mg PO Q12H
do NOT drive while taking this medication
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN breakthrough
pain
do NOT drive while taking this medication
Discharge Disposition:
Home
Discharge Diagnosis:
Mechanical fall: Left ___ rib fractures, left lower lung
collapse, left hemothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You presented to ___ on ___ after a fall. You had a CT
scan of your chest which showed you to have multiple left sided
rib fractures and a small left lung hemothorax (bleeding from
the impact to the lung). You were admitted to the Trauma/Acute
Care Surgery team for further medical managment.
Your injuries were managed conservatively. You practiced with
the incentive spirometer and your lung function improved. You
have ambulated and your pain is controlled with oral pain
medication. You are now medically cleared to be discharged to
home to continue your recovery.
Please note the following discharge instructions:
* Your injury caused left ___ 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:
___
|
19821560-DS-17
| 19,821,560 | 24,154,640 |
DS
| 17 |
2144-07-06 00:00:00
|
2144-07-06 23:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left eye visual disturbance
Major Surgical or Invasive Procedure:
No
History of Present Illness:
Mr. ___ is a ___ right-handed man with history
notable for left carotid artery occlusion s/p stent placement,
gout, and COPD presenting for evaluation of acute-onset left eye
visual disturbance.
Mr. ___ reports noticing abrupt onset of "blurriness" in his
left eye at 10:30 this morning, reminiscent of the episodic
vision loss in his left eye that preceded his TCAR in ___. He notes that his visual disturbance has remained
unchanged
at time of evaluation, with normal vision in his right eye; he
denies associated headache, though recalls a sharp left frontal
headache with his last presentation last year. He presented to
his primary care provider for these symptoms (though at that
time
described them as a "curtain pulling over" his eye), who
recommended presentation to the ED for further evaluation.
On review of systems, aside from the above, Mr. ___
denies
recent dizziness, speech disturbance, diplopia, dysarthria,
dysphagia, focal weakness, paresthesiae, bowel or bladder
incontinence, gait disturbance, fevers, chills, nausea,
vomiting,
cough, chest discomfort, abdominal pain, changes in bowel or
bladder habits, or rash.
Past Medical History:
Gout
Anemia
Tonsillectomy as a child
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical exam on the day of admission
PHYSICAL EXAMINATION
Vitals: T: 98.8 HR: 110 BP: 133/70 RR: 17 SpO2: 98% RA
General: NAD
HEENT: NCAT
___: RRR
Pulmonary: No tachypnea or increased WOB
Abdomen: Soft, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to time and place. Able
to relate history without difficulty. Speech is fluent with
intact comprehension and naming. No dysarthria. No apparent
hemineglect. Able to follow both midline and appendicular
commands.
- Cranial Nerves: PERRL (3 to 2 mm ___, though irregular on
left).
Altitudinal left superior hemifield defect OS, without visible
plaque on fundoscopy (though limited by pupil size). EOMI, no
nystagmus. V1-V3 without deficits to light touch bilaterally. No
facial movement asymmetry. Hearing intact to conversation.
Palate
elevation symmetric. Trapezius strength ___ bilaterally. Tongue
midline.
- Motor: No pronator drift.
[Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA]
L 5 5 5 5 5 4+ 5 5 5
R 4+* 5 5 5 5 4+ 5 5 4
*Pain-limited
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 1+ 0
R 2+ 2+ 2+ 1+ 0
- Sensory: Decreased to PP in BLE in ascending gradient. No
deficits to LT, no extinction to DSS. Negative Romberg.
- Coordination: No dysmetria with FNF or HKS testing
bilaterally.
- Gait: Deferred.
Physical exam at the date of discharge
PHYSICAL EXAMINATION
General: NAD
HEENT: NCAT
___: RRR
Pulmonary: No tachypnea or increased WOB
Abdomen: Soft, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to time and place. Able
to relate history without difficulty. Speech is fluent with
intact comprehension and naming. No dysarthria. No apparent
hemineglect. Able to follow both midline and appendicular
commands.
- Cranial Nerves: PERRL No visual fields defects noted EOMI,
no nystagmus. V1-V3 without deficits to light touch bilaterally.
Slight right facial droop.. Hearing intact to conversation.
Palate elevation symmetric. Trapezius strength ___ bilaterally.
Tongue midline.
- Motor: No pronator drift.
[Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA]
L 5 5 5 5 5 4+ 5 5 5
R 4+* 5 5 5 5 4+ 5 5 4
*Pain-limited
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 1+ 0
R 2+ 2+ 2+ 1+ 0
- Sensory: No deficits to LT, no extinction to DSS. Negative
Romberg.
- Coordination: No dysmetria with FNF or HKS testing
bilaterally.
- Gait: Deferred.
Pertinent Results:
___ 05:51AM BLOOD WBC-11.6* RBC-3.05* Hgb-9.1* Hct-27.9*
MCV-92 MCH-29.8 MCHC-32.6 RDW-15.7* RDWSD-52.4* Plt ___
___ 01:35PM BLOOD WBC-11.3* RBC-3.17* Hgb-9.3* Hct-29.4*
MCV-93 MCH-29.3 MCHC-31.6* RDW-15.8* RDWSD-53.8* Plt ___
___ 01:35PM BLOOD Neuts-67.4 Lymphs-18.2* Monos-8.7 Eos-4.1
Baso-1.1* Im ___ AbsNeut-7.64* AbsLymp-2.06 AbsMono-0.99*
AbsEos-0.46 AbsBaso-0.12*
___ 10:05AM BLOOD ___ PTT-51.0* ___
___ 05:51AM BLOOD ___ PTT-58.6* ___
___ 05:51AM BLOOD Glucose-103* UreaN-10 Creat-0.7 Na-138
K-4.0 Cl-102 HCO3-22 AnGap-14
___ 01:35PM BLOOD ALT-20 AST-49* AlkPhos-242* TotBili-0.3
___ 05:51AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.4* Cholest-134
___ 05:51AM BLOOD Triglyc-326* HDL-30* CHOL/HD-4.5
LDLcalc-39
___ 05:51AM BLOOD %HbA1c-5.0 eAG-97
___ 01:35PM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
___ 01:42PM BLOOD Glucose-78 Creat-0.7 Na-135 K-3.9 Cl-107
calHCO3-19*
Brief Hospital Course:
___ right-handed man with history notable for left
carotid artery occlusion s/p stent placement, gout, and COPD
presenting for evaluation of acute-onset left eye visual
disturbance.
MRI was done and showed, no acute intracranial abnormality, left
frontal cortical and left deep watershed area small gliotic
changes related to remote ischemic injuries. CTa showed interval
development of left common and internal carotid artery mural
thrombus along the posterolateral wall of the carotid stent.
There is up to 75% narrowing of the internal carotid artery on
TA, secondary to the stent and the thrombus, but carotid u/s
showed <40% occlusion.
Upon discussion his case with vascular, aspirin and clopidogrel
started. Brilinta was considered but was $300 per month, so he
was continued on asa and clopidogrel.
Ophthalmology evaluated him and found his to have high
intraocular pressure left eye. They recommended to start Cosopt
BID , ALphagan BID and latenaprost qhs till he will see
ophthalmology. They recommended follow up in 1 week with
ophthalmology.
Upon the last day of hospitalization, patient developed flair of
gout of his knee. He was started on Colchicine 0.6 mg daily. He
will continue with 0.6 mg daily for 3 days.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
RX *brimonidine 0.15 % 1 drop left eye at bedtime Disp #*5
Milliliter Milliliter Refills:*0
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
4. Colchicine 0.6 mg PO DAILY Duration: 3 Doses
RX *colchicine 0.6 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
RX *dorzolamide-timolol 22.3 mg-6.8 mg/mL 1 drop left eye twice
a day Disp ___ Milliliter Milliliter Refills:*0
6. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
RX *latanoprost 0.005 % 1 drop left eye at bedtime Disp #*2.5
Milliliter Milliliter Refills:*0
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Thiamine 100 mg PO DAILY
9. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
10. Allopurinol ___ mg PO DAILY
11. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
12.Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Branch retinal artery occlusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of acute left eye visual
disturbance resulting from an ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
History of left carotid artery occlusion s/p stent placement
Hyperlipidemia
Please see your medication list for changes.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19821602-DS-23
| 19,821,602 | 27,822,096 |
DS
| 23 |
2189-07-16 00:00:00
|
2189-07-16 17:51:00
|
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
Stridor, Dysphagia, RUE Weakness
Major Surgical or Invasive Procedure:
___ - EGD
___ - EGD with variceal banding
History of Present Illness:
As per admitting MD:
Ms. ___ is a pleasant ___ w/ breast cancer, initially dx
___, s/p mastectomy/xrt/several lines of therapy w/ progressive
disease, now mets to mediastinal/supraclavicular nodes and bone,
currently on capecitabine/trastuzumab, who presents with one
week of dysphagia and stridor in clinic.
Pt recently returned from ___ yesterday where she has been
residing. During the last week, she started to develop a cough
with taking solids and liquids. She would have SOB during this
episode like the "wind pipe was closing." This has resulted in
significantly decreased PO intake. She also has worsening R
shoulder pain that radiates from the R neck into R occiput and
proximal RUE into the bicep (has been ongoing for several
weeks). Has taken advil/heat packs w/o relief. Admits to limited
ROM due to pain and weakness.
Today while in her ___ clinic, pt developed this coughing
attack incidentally while laying flat. She tells me the nurse
told her she heard her having "stridor." She was sent in to ED
for expedited evaluation.
Denies f/c/n/v/cp/abd pain/urinary or bowel symptoms. Pt also
notes 2 weeks of R shoulder pain and weakness in extremity.
In ED, 84 124/71 18 100% RA. She tolerated CT scan well with ___
stridor upon lying supine. She received Fentanyl 25 mcg x 3 IV
for pain with short lasting relief and then morphine with
effective relief of her pain but with resultant nausea.
Past Medical History:
As per admitting MD:
PAST ONCOLOGIC HISTORY:
- ___: Right-sided breast cancer 2.5cm, IDC, grade 2, positive
and extensive LVI, 3 positive LN (___), ER positive. s/p
excision, CAF, XRT, and tamoxifen.
- ___: Local recurrence within the right breast, IDC, ER
positive. s/p mastectomy with reconstruction. Continued on
tamoxifen at that time.
- ___: Right axillary recurrence s/p excision which showed IDC,
grade 1, ER positive, HER2 negative. Endocrine therapy switched
to Arimidex; Celebrex ___ also started because of data
suggesting that it has anti-angiogenic activity.
- ___: Symptoms of decreased appetite, early satiety, and
epigastric pain prompted CT Abd which revealed extensive hepatic
mets. Biopsy was completed and confirmed metastatic carcinoma
c/w ductal carcinoma, ER positive, PR negative, HER2 equivocal
by IHC (2+) and positive by ALTERNATE probe FISH. Snapshot
performed on this specimen revealed positive ESR1 mutation.
- ___: Started Eribulin but received 1 cycle after
alternative probe FISH testing returned positive. Switched to
CLEOPATRA regimen of Taxotere, trastuzumab, and pertuzumab x6
cycles.
- ___: Taxotere discontinued, continued HP.
- ___: Rise in tumor markers and LFTs. Started weekly Taxol +
Herceptin/Pertuzumab.
-___: Liver disease was progressing on imaging. Repeat liver
biopsy completed to reassess HER2 status. Again this showed met
disease c/w with breast carcinoma, ER positive, PR positive.
HER2 was negative by FISH. Herceptin and Pertuzumab
discontinued, weekly taxol continued.
- ___: Weekly Adriamycin initiated until she reached 450mg/m2
cumulative dose in ___.
- ___: Fulvestrant + palbociclib initiated.
- ___: Rising LFTs prompted ___ liver biopsy which revealed
Liver parenchymal changes suggestive of nodular regenerative
hyperplasia (NRH).
- ___: Transaminitis, palbociclib discontinued.
- ___: Eribulin initiated, Herceptin added in view of
previous positive alternative probe HER2 FISH testing.
- ___: Restaging scans showed some new disease in the chest
with a mixed response in her liver. In light of restaging scans
and severe neuropathy Eribulin was discontinued. Started Gemzar.
- ___: progressive disease on PET/CT with new FDG avid
bone lesions and left supraclavicular lymph nodes. Started
weekly Navelbine.
- ___: PET/CT with progressive disease in bones, liver, and
supraclavicular LNs; mediastinal, abdominal, retroperitoneal and
LAD was unchanged. Navelbine discontinued and started on
capecitabine 3 tablets TOTAL per day (1 tablet TID). Course
complicated by severe hypercalcemia requiring hospital admission
___. Switched to denosumab therapy.
- ___: Xeloda increased to 5 tabs per day 14 days ON/ 7 OFF,
remains on to-date.
- ___: Second hospital admission for ascites and
hypotension. Dr. ___ consulted during this admission
and ascites ultimately felt r/t pseudocirrhosis and he
discontinued nadolol and started on Lasix and spironolactone.
- ___: Continuing Capecitabine up to ___.
PAST MEDICAL HISTORY:
- Grade 2 varices
- Hypothyroidism
- GERD
- Osteopenia
- Diverticulosis
- Hypertension
Social History:
___
Family History:
As per admitting MD
___ known family history of cancer.
Physical Exam:
========================
Admission Physical Exam:
========================
VS: Temp 97.8, BP 133/80, HR 80, RR 18, O2 sat 97% RA.
General: NAD, Resting in bed comfortably but appears tired,
husband at bedside, in ___ resp distress, ___ stridor, speaking in
full sentences.
HEENT: MM dry, ___ OP lesions, mallampati III, ___ edema noted,
voice is hoarse but ___ stridor.
CV: RR, NL S1S2 ___ S3S4 ___ MRG.
PULM: CTAB, ___ C/W/R, ___ respiratory distress.
ABD: BS+, soft, NTND, ___ peritoneal signs.
LIMBS: WWP, ___ tremors.
SKIN: ___ notable rashes on trunk nor extremities.
NEURO: CN III-XII intact, strength ___ LUE, 4+ RUE, sensation
grossly intact in b/l UE, she has sig limited ROM of the RUE due
to pain and weakness, unable to actively move arm >90.
PSYCH: Thought process logical, linear, future oriented.
ACCESS: Left chest wall port without erythema.
========================
Discharge Physical Exam:
========================
General: Chronically fatigued-appearing woman, sitting in bed,
in
___ acute distress, with family at bedside (sons and husband),
calm, pleasant
HEENT: MMM, ___ OP lesions, voice is hoarse/soft but ___ stridor.
occasional cough
NECK: supple
CV: RRR, normal distal perfusion without edema
PULM: CTA. ___ respiratory distress. normal RR, ___ increased WOB.
cough intermittent
ABD: Soft, non-tender, non-distended, positive bowel sounds.
LIMBS: WWP, ___ tremors. decreased muscle bulk. left
ankle
is without visual or palpable abnormalities, normal ROM, ___ pain
with active/passive ROM, normal pulses, warm to touch
SKIN: ___ notable rashes on trunk nor extremities.
NEURO: A&Ox3, strength ___ LUE, RUE weakness with significant
muscle wasting of RUE and right shoulder. Sensation to touch
intact.
ACCESS: Left chest wall port without erythema.
PSYCH: Normal mood, insight, judgment, affect
Pertinent Results:
===============
Admission Labs:
===============
___ 11:30AM BLOOD WBC-3.7* RBC-2.94* Hgb-11.1* Hct-32.3*
MCV-110* MCH-37.8* MCHC-34.4 RDW-22.5* RDWSD-90.8* Plt Ct-90*
___ 11:30AM BLOOD UreaN-22* Creat-0.5 Na-136 K-4.0 Cl-99
HCO3-23 AnGap-14
___ 11:30AM BLOOD ALT-69* AST-95* LD(LDH)-333* AlkPhos-201*
TotBili-3.7*
___ 11:30AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.5 Mg-2.0
___ 11:30AM BLOOD ___ Folate-13 Hapto-<10*
___ 11:30AM BLOOD TSH-0.94
___ 11:30AM BLOOD CEA-10.7*
Discharge Labs:
___ 05:03AM BLOOD WBC-7.6 RBC-2.47* Hgb-9.4* Hct-27.1*
MCV-110* MCH-38.1* MCHC-34.7 RDW-19.7* RDWSD-79.4* Plt Ct-73*
___ 05:03AM BLOOD Glucose-137* UreaN-10 Creat-0.4 Na-136
K-3.4* Cl-100 HCO3-25 AnGap-11
___ 05:03AM BLOOD ALT-32 AST-38 AlkPhos-150* TotBili-2.4*
___ 05:03AM BLOOD Calcium-7.7* Phos-2.1*
Mg-1.8===============
=============
Microbiology:
=============
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 8:50 pm BLOOD CULTURE Source: Line-port 1 OF 2.
Blood Culture, Routine (Pending):
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
========
Imaging:
========
CXR ___:
___ definite radiographic evidence for pneumonia. Mild pulmonary
vascular
congestion. Osseous metastatic disease, better assessed on
prior CT chest.
CTA Chest ___
1. ___ evidence of pulmonary embolism or aortic abnormality.
2. Re-demonstrated mediastinal and supraclavicular
lymphadenopathy.
3. Diffuse osseous metastatic disease with increased compression
of a pathologic compression fracture involving T6 vertebral
body.
4. Pseudocirrhosis with ascites, incompletely evaluated on
current study.
5. Airways appear patent throughout.
CT Neck w/ Contrast ___
1. Nonspecific thickening of the aryepiglottic folds and mild
effacement of the piriform sinuses may suggest nonspecific
supraglottic inflammation. ___ evidence of significant airway
narrowing, subglottic airway inflammation, or epiglottitis.
2. Findings suggestive of right-sided vocal cord paralysis.
3. 1.1 cm rounded enhancing focus in the right cerebellar
hemisphere, potentially a metastasis, for which nonemergent
brain MRI is recommended.
4. Cervical spine metastases, similar to the prior PET-CT.
5. Patulous proximal esophagus which could suggest esophageal
dysmotility.
RUQ Ultrasound ___
1. Diffuse and markedly heterogeneous liver, as seen on prior
MRI liver. MRI is better for detection of metastases.
2. Patent portal vasculature.
3. Splenomegaly, as on prior.
MRI Head w/ and w/o Contrast ___
Impression: 3 cerebellar metastatic lesions the largest in the
superior aspect of the right cerebellar hemisphere measuring 9 x
11 x 13 mm. Multiple calvarial metastatic lesions. Bilateral
globus pallidus T1 hyperintensity is nonspecific, but is most
commonly seen in hepatic failure, hyperalimentation and
prolonged parenteral nutrition.
MRI C-Spine w/ and w/o Contrast ___
Impression: Extensive cervical, upper thoracic spine as well as
rib metastatic disease. There is lytic destruction of the right
aspect of the C3 vertebral body as well as the right pedicle and
anterior aspect of the right transverse process as seen on prior
CT neck done ___. Preserved right vertebral artery flow
void. There is ___ compromise of the cervical cord in the spinal
canal. Neural foraminal narrowing as described above. 3
posterior fossa metastatic cerebellar lesions were better
visualized on prior MR brain done ___. Reference is made
to that report.
EGD ___
Esophagus: 4 cords of grade III varices were seen in the mid and
distal esophagus with red whale sign. The varices were not
bleeding.
Stomach: Diffuse congestion, petechiae, and musoaic pattern of
the mucosa with ___ bleeding noted in the stomach fundus and
stomach body. These findings are compatible with portal
hypertensive gastrophaty.
Duodenum: Normal mucosa was noted in the whole examined
duodenum.
EGD ___:
5 cords of grade IV varices banded, diffuse congestion in
stomach
compatible with portal hypertensive gastropathy
MRI Brachial Plexus w/ and w/o Contrast ___
1. ___ mass identified along the course of the right or left
brachial plexus.
2. Incompletely characterized hepatic lesions and osseous
metastatic disease. Notable metastatic lesion in the C3
vertebral body involves the right neuroforamen, better
characterized on cervical spine MRI, dated ___.
3. Small volume ascites.
CXR ___
Impression: Heart size and mediastinum are unremarkable.
Port-A-Cath catheter tip is in the proximal right atrium. Lungs
are overall clear. The patient is after right most likely breast
surgery. Abnormally looking right posterior seventh rib is
re-demonstrated. It is reflecting the known focus of metastatic
disease. ___ interval progression in pulmonary consolidations or
development of pleural effusion is noted. ___ pulmonary edema is
seen.
Video Swallow ___
Impression: There was shallow penetration of cracker and pudding
mixed with residue just before the swallow ___ a swallow delay
and delayed laryngeal vestibule closure. Penetration cleared
before the height of the swallow. There was trace deeper
penetration of thin and nectar thick and thin liquids just
before the swallow ___ delayed laryngeal vestibule closure which
cleared at the height of the swallow. Toward the end of the
study, there was trace penetration after the swallow during
subsequent swallows due to residue from pyriform sinuses falling
into the airway. Penetration appeared to consistently clear at
the height of the swallow except possibly on one occasion with
thin liquids she may have had some trace aspiration. Unable to
fully rule in or out aspiration given presence of surgical
clips. She had a consistent throat clear response to deep
penetration. She had one cough response when using a thin liquid
rinse after the cracker, but unfortunately the patient was not
in the view of the camera so unable to observe in the patient
aspirated or not.
Brief Hospital Course:
___ PMH of Metastatic Breast Cancer (s/p mastectomy, XRT, and
multiple lines of therapy with progressive disease and
metastatic to mediastinal/supraclavicular nodes and bone
currently on
capecitabine/trastuzumab) who presented with one week of
dysphagia and stridor in clinic with hospitalization complicated
by cystitis, healthcare associated pneumonia vs aspiration
pneumonitis, now s/p EGD with banding, who was ultimately
discharged home on hospice with outpatient oncology followup
#Fevers
#Aspiration pneumonia vs aspiration pneumonitis vs HCAP PNA
Developed fever to 101.3 on ___ and new opacity on CXR
concerning for pneumonia. Given risk of resistant organisms she
was started on broad spectrum Abx. However, given subsequent
Xray which favors atelectasis it is possible that fever
reflected aspiration pneumonitis and not pneumonia. While
aspiration pneumonitis is very plausible given stable
respiratory status and lack of persistent fevers, or large
infiltrate on CXR, she is functionally immunosuppressed ___
malignancy so was treted for HCAP to be cautious. She is s/p
switch from Vanc/Ceftaz to high dose levofloxacin on ___, which
she will continue until ___ for 8 day course
# Stridor/Dysphagia/aspiration:
CT neck without significant airway narrowing but did show
findings suggestive of right-sided vocal cord paralysis. Given
history of cough after eating significant concern for
aspiration. Concern for nerve involvement as cause of symptoms.
Likely related to cervical metastatic disease. ENT consulted,
performed bedside scope notable for bilateral VC hypomobility
(right less mobile than left) but ___ glottic gap seen and patent
airway. Recommend follow-up in ___ clinic ___ weeks after
discharge. Speech and Swallow consulted, bedside exam with
signs/symptoms of aspiration and recommended NPO as diet. Video
swallow showed all diets with risk for aspiration. Decision made
for patient to continue full liquid diet with acceptance of risk
of aspiration as even if she was NPO she would aspirate her
secretions with oropharyngeal bacteria so risk of PNA would be
unchanged. Also is not a candidate for NGT or PEG as has
esophageal varices and portal gastropathy so would be high risk
for bleeding event with either implement. Dr ___ that
only after subsequent EGD's if varices had completely resolved
would she be a candidate for NGT (which would take weeks to
months). Given significant coughing/regurgitation with meals,
patient was discharged with suction to help clear food that
doesn't go down properly. She was discharged with hospice who
plans to do every other day fluid boluses to maintain her
hydration status. She was instructed to monitor for abdominal
distension (ascites), difficulty breathing or leg edema. If any
occur, she was instructed to discuss discontinuing fluids.
# Right Upper Extremity/Shoulder Pain and Weakness:
Exam notable for right arm weakness with muscle wasting. She had
a large lytic lesion involving the right aspect of the C3 likely
causing cervical root compression. Radiation Oncology consulted,
patient has since been started on XRT to cervical spine and will
continue in ___ as an outpatient for a total of 10 doses
#Acute uncomplicated cystitis:
Developed symptoms the early AM of ___ with UA positive for
UTI, urine culture which grew pan sensitive EColi. Was treated
with antibiotics as above.
#Severe Protein-Calorie Malnutrition:
Patient with weight loss, decreased PO intake ___ dysphagia, and
muscle wasting on exam. As above, nutrition limited in that was
not candidate for feeding implement, and had limited PO intake
in light of aspiration/coughing. Dr ___ that unless
she improves her nutritional status further chemotherapy would
not be offered. Patient plans to attempt to improve her
nutritional status with PO intake, but is understanding that it
may not succeed and was discharged with hospice services.
# Brain Metastases:
Brain MRI showed 3 cerebellar lesions. ___ localizing cerebellar
findings on neuro exam. Unlikely to explain presenting symptoms.
Should patient's clinical status improve, or become a chemo
candidate, then she may need f/u in brain tumor clinic
# Metastatic Breast Cancer:
Metastatic to bone and liver as well as brain now. Previously on
capecitabine and trastuzumab.
Dr ___ that unless she improves her nutritional
status further chemotherapy would not be offered. Patient plans
to attempt to improve her nutritional status with PO intake, but
is understanding that it may not succeed and was discharged with
hospice services.
# Pseudocirrhosis:
# Ascites:
# Esophageal Varices:
# Transaminitis:
EGD on ___ with 4 cords of grade III esophageal varices with
red whale sign. ___ active bleeding. Patient is s/p repeat EGD
with banding on ___ which she tolerated well. She was
discharged on Carafate 2gm BID for 2 weeks, omeprazole BID x 6
weeks, and nadolol indefinitely with plan to have repeat EGD in
1 month. Transaminitis/Hyperbilirubinemia stable during hospital
course, RUQUS without acute finding.
# Anemia/Thrombocytopenia:
Chronic and stable. Likely from antineoplastic therapy,
inflammatory blockade, and osseous metastatic disease. TSH, B12,
and folate wnl. Haptoglobin < 10 which may represent some degree
of microangiopathy from malignancy. During remainder of hospital
course, both indices remained stable. CBC can be trended in
___ clinic to ensure Hgb/plt remain stable.
Transitional Issues
1. Patient with right arm/shoulder pain and weakness. Patient to
complete course of radiation to cervical spine and nerve roots.
Discharged with liquid morphine and lidocaine patches for pain
control.
2. She was discharged with hospice who plans to do every other
day fluid boluses to maintain her hydration status. She was
instructed to monitor for abdominal distension (ascites),
difficulty breathing or leg edema. If any occur, she was
instructed to discuss discontinuing fluids.
3. Dr ___ that unless she improves her nutritional
status further chemotherapy would not be offered. Patient plans
to attempt to improve her nutritional status with PO intake, but
is understanding that it may not succeed and was discharged with
hospice services.
4. Should patient's clinical status improve, or become a chemo
candidate, then she may need f/u in brain tumor clinic
5. For varices, pt was discharged on Carafate 2gm BID for 2
weeks, omeprazole BID x 6 weeks, and nadolol indefinitely with
plan to have repeat EGD in 1 month.
6. CBC can be trended in ___ clinic to ensure Hgb/plt
remain stable.
I personally spent 46 minutes preparing discharge paperwork,
coordinating care with outpatient providers, educating patient
and answering questions
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO QHS
2. Levothyroxine Sodium 137 mcg PO DAILY
3. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia
4. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
5. Spironolactone 50 mg PO DAILY
6. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
7. Capecitabine 1000 mg PO BID
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QPM apply to R neck
RX *lidocaine 5 % Apply 1 patch to affected area daily. Disp
#*30 Patch Refills:*0
3. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q4H:PRN
Pain - Moderate
___ cause sedation. Do not drive.
4. Nadolol 10 mg PO DAILY
RX *nadolol 20 mg 0.5 (One half) tablet(s) by mouth daily Disp
#*15 Tablet Refills:*0
5. Omeprazole 20 mg PO Q12H
RX *omeprazole 20 mg 1 capsule(s) by mouth every twelve (12)
hours Disp #*60 Capsule Refills:*1
6. Sucralfate 2 gm PO BID
RX *sucralfate 1 gram/10 mL 20 mL by mouth every twelve (12)
hours Disp #*560 Milliliter Refills:*0
7. Acetaminophen (Liquid) 650 mg PO Q8H:PRN Pain - Mild
8. Gabapentin 300 mg PO QHS
9. Levothyroxine Sodium 137 mcg PO DAILY
10. LORazepam 0.5 mg PO Q6H:PRN
nausea/vomiting/anxiety/insomnia
11. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
12. Spironolactone 50 mg PO DAILY
13.IVF
Patient is to receive 1 liter of Normal Saline over ___ hours,
every other day to maintain her hydration status. It should be
discontinued if significant ascites, leg edema, or SOB
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Dysphagia/Aspiration
- HCAP vs aspiration pneumonitis
- Right Upper Extremity/Shoulder Pain and Weakness
- Metastatic Breast Cancer
- Brain Metastases
- Severe Protein-Calorie Malnutrition
- Pseudocirrhosis
- Ascites
- Esophageal Varices s/p banding
- Anemia
- Thrombocytopenia
- Cystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital for
difficulty swallowing and right arm and shoulder pain with
weakness.
Your trouble swallowing is likely due nerve dysfunction (vagus
nerve) which controls your voice, swallowing, and GI function.
You were seen by the Speech Therapy team. You had a video
swallow which showed that you were at risk for aspiration for
all types of diets. Unfortunately, there is ___ other possible
way for us to improve your nutrition as the dilated blood
vessels in your esophagus and stomach prevent you from getting a
nasogastric or gastric feeding tube. Instead, you will have to
try to improve your nutritional status by eating. As our speech
and swallow team suggested, you can try to alternate between
liquids and solids in order to help swallow. You were discharged
with suction to help you clear your throat when you feel the
food gets stuck or causes coughing. Our speech and swallow team
also recommended:
-Performing excellent oral care (toothbrush, toothpaste,
mouthwash) multiple times per day, particularly before meals, to
minimize risk of pna.
-Coughing if you feel you need to cough, and coughing if you
feel that something went down the wrong way.
- Take medications crushed in applesauce followed by sips of
liquid or give in liquid form.
- Perform oral care prior to meals.
- Sit fully upright to eat/drink and remain sitting upright for
1 hour after finishing the meal.
- Alternate bites/sips.
- Go slow, give yourself time to swallow multiple times.
- Sleep at an incline to reduce aspiration and reflux.
Your outpatient hospice team will provide you with fluids every
other day in order to prevent you from being dehydrated. If you
find that the fluids are causing you to have abdominal bloating
or are causing swollen legs or difficulty breathing you should
have them given less frequently or discontinued. If you find
that despite the fluids you are very thirsty, with dry mouth,
you should hold your aldactone and call Dr ___ office to
inform them of your clinical change.
For your pneumonia, you were treated with a course of
antibiotics which ends in 2 days.
Your right arm pain and weakness is also likely due to nerve
impingement of the nerves exiting the spinal cord. You had a
cervical spine MRI. You were seen by Radiation Oncology and
started your radiation treatments. You will finish the rest of
your treatments at ___. You were also started on pain
medications. We are hopeful that the radiation will help with
both your swallowing as well as the pain and weakness.
You had an endoscopy (EGD) during your stay that showed large
esophageal varices. You were restarted on nadolol and had
banding to help resolve the varices. You will need to continue
sucralfate for 2 weeks and omeprazole for 6 weeks. You will need
to schedule a repeat endoscopy with Dr ___ in 1 month to
reassess varices.
You also had a brain MRI which showed some lesions in your
cerebellum. These are small and likely not causing any symptoms.
You should follow-up in clinic for monitoring of these.
Lastly, you developed a urinary tract infection while you were
here. You were treated with antibiotics which successfully
treated it.
It was a pleasure meeting you, I wish you and your family the
best!
Followup Instructions:
___
|
19821643-DS-14
| 19,821,643 | 21,964,039 |
DS
| 14 |
2179-08-23 00:00:00
|
2179-08-25 03:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Haldol / Amitriptyline / azithromycin / bupropion / clotrimazole
/ levofloxacin
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
exploratory laparotomy, lysis of adhesions, total abdominal
hysterectomy, bilateral salpingooophorectomy, radical resection
pelvic tumor, rigid proctoscopy and partial omentectomy
History of Present Illness:
___ G2P2 postmenopausal with history of COPD, PVD, asthma and
fibromyalgia who presented to the ED for abdominal pain. Patient
reports that for the past 2 weeks she has been experiencing
worsening lower abdominal pain. Lower abdominal pain R > L which
started two weeks prior to admission described as sharp, worse
with lying flat on her back and improved when laying on her
side. The pain acutely worsened last evening and so presented to
___ ED where CT revealed a large abdominopelvic
mass concerning for malignancy so transferred to ___ for GYN
ONC evaluation.
Patient states she has had abdominal pain for the last few
weeks. Pain is constant and worsening in severity, not
associated with eating or drinking. She has no vaginal bleeding
or discharge, she is still passing gas and having bowel
movements. She is intermittently nauseous but no vomiting. No
fevers or chills at home. Last PO intake was day prior to
admission. Last BM day prior to admission and was normal. She is
not having dysuria or abnormal vaginal discharge, vaginal
bleeding.
Also, of note, patient was recently hospitalized at ___
___ for cholecystitis and treated with flagyl & cefpodoxime
s/p course completion. Plan for outpatient elective CCY.
In the ED, initial vitals were: 7 98.2 56 132/67 16 97% RA. Labs
notably for Cr of 1.3 but otherwise largely normal. CT from OSH
read by radiologist and interpreted as a large Ill-defined
hypoattenuating pancreatic head lesion, enlarged since ___.
20.6 cm predominantly cystic lesion with nodular solid
components extending from the pelvis into the mid abdomen,
concerning for adnexal malignancy. Pelvic lesion causes mass
effect on the ureters, causing severe right and mild left
hydronephrosis, as well as on the adjacent bowel loops, causing
segmental small and large bowel dilatation. OB/GYN consulted who
recommended sending tumor markers. CA 125 returned elevated.
Patient received albuterol, Zofran and Morphine.
On the floor, the patient appears uncomfortable, wincing and
withdrawing from even minimal palpation over lower abdomen,
specifically over RLQ. She is tearful at times when talking
about her pain.
Review of systems:
(+) Per HPI also for 100lb intentional weight loss
(-) Denies night sweats. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies cough, shortness of breath.
Denies chest pain or tightness,palpitations. Denies arthralgias
or myalgias.
Past Medical History:
PMH
- COPD
- Peripheral vascular disease
- Fibromyalgia
- H/o pancreatic cysts s/p drainage (benign cytology) in ___
- Chronic LBP
- Anxiety
- Arthritis
- H/o small bowel obstruction
- GERD
- Sciatica
- Meniere's disease.
PSH:
small bowel resection after "a blood clot burst in my bowels"
via exlap @ ___ in ___, BTL, T&A, D&C x 2
PGynhx:
- denies h/o abnl Pap, thinks she is up-to-date
- LMP many years ago
- denies STIs
- not currently sexually active
- uptodate with mammogram
- uptodate with colonoscopy (within past ___ yrs)
- urge incontinence, followed by Dr. ___ in Urogyn
OB: G2P2, SVDx2
Social History:
___
Family History:
- No family history of gynecologic cancers.
- Mother with lung cancer
- Maternal grandmother with congestive heart failure.
- Brother with diabetes and "heart valve problems".
Physical Exam:
Admission Exam:
Vitals: 98.0 140/66 61 18 95%RA
Pain Scale: ___
General: Patient appears uncomfortable, upset and tearful at
times. Alert, oriented and in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP low, no LAD appreciated
Lungs: Good air movement bilaterally with diffuse wheezing and
coarse breath sounds throughout the is breathing comfortably and
non-labored.
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality, ___ systolic murmur heard throughout precordium
Abdomen: Redundant skin folds evidence of significant weight
loss. Tense abdomen and withdraws to pain, jumping and smacking
hand away even with minimal palpation of lower abdomen.
Exquisite tenderness with minimal palpation. Palpable mass in
lower abdomen over RLQ predominantly. No epigastric or RUQ
tenderness
Ext: Warm, well perfused, full distal pulses, no clubbing,
cyanosis or edema
Neuro: CN2-12 grossly intact
On day of discharge:
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Abd: soft, appropriately tender, nondistended, incision opened
approx 10cm in superior portion of incision and 3 cm over pubic
portion of midline incision, both sites packed with wet to dry
dressing and covered with ABD. Staples were removed and wound
with healthy appearing tissue.
___: nontender, bilateral 1+ edema, symmetric
Pertinent Results:
REPORTS:
CT A/P from ___ ___
1. Complex cystic and solid mass arising from the pelvis
extending into the mid abdomen measuring up to 20.6 cm. This
mass is concerning for a primary GYN malignancy and biopsy is
advised.
2. Ill-defined hypoattenuating pancreatic head lesion, enlarged
since ___ and incompletely characterized. MRCP is recommended
for further evaluation.
3. New bilateral hydronephrosis, right greater than left,
secondary to
extrinsic compression of the ureters by the pelvic mass.
Surgical or
interventional decompression should be considered.
4. Indeterminate left adrenal gland lesion, not fully
characterized but
stable in morphology since ___. Further evaluation via MRI may
be performed.
___ CXR: Prominent apical scarring and emphysema. No focal
consolidation. In light of the abdominal findings, a chest CT is
recommended for staging purposes.
___ Chest CT:
- No evidence of pulmonary metastases.
- Apical predominant branching parenchymal calcifications may be
seen in the setting of disseminated pulmonary calcification,
which is associated with a number of secondary diagnoses,
including chronic renal failure and
hyperparathyroidism.
- Mild to moderate apical predominant centrilobular emphysema.
___ pelvic US
Incompletely imaged large predominantly cystic mass with nodular
solid
components in the pelvis may represent a solitary mass or
separate bilateral masses larger on the right than the left. The
imaging appearance is most consistent with an ovarian malignancy
and is much less likely to represent Krukenberg tumor.
___ lower extremity doppler
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
___ 07:10AM BLOOD CEA-2.2 CA125-54*
___ 07:10AM BLOOD WBC-5.1 RBC-4.18* Hgb-12.5 Hct-38.1
MCV-91 MCH-30.0 MCHC-32.9 RDW-16.0* Plt ___
___ 07:15AM BLOOD WBC-6.5 RBC-4.00* Hgb-11.8* Hct-36.2
MCV-90 MCH-29.4 MCHC-32.5 RDW-15.8* Plt ___
___ 08:00PM BLOOD WBC-9.8 RBC-3.36* Hgb-9.9* Hct-31.0*
MCV-92 MCH-29.5 MCHC-32.0 RDW-15.9* Plt ___
___ 07:10AM BLOOD WBC-12.0* RBC-3.26* Hgb-9.5* Hct-29.8*
MCV-92 MCH-29.1 MCHC-31.9 RDW-15.2 Plt ___
___ 06:47AM BLOOD WBC-10.8 RBC-3.24* Hgb-9.5* Hct-30.1*
MCV-93 MCH-29.4 MCHC-31.7 RDW-15.5 Plt ___
___ 06:50AM BLOOD WBC-6.2 RBC-3.23* Hgb-9.4* Hct-29.3*
MCV-91 MCH-29.2 MCHC-32.1 RDW-15.5 Plt ___
___ 06:40AM BLOOD WBC-10.4# RBC-2.94* Hgb-8.6* Hct-26.4*
MCV-90 MCH-29.4 MCHC-32.8 RDW-15.9* Plt ___
___ 07:55AM BLOOD WBC-8.2 RBC-3.21* Hgb-9.2* Hct-28.7*
MCV-90 MCH-28.7 MCHC-32.0 RDW-16.0* Plt ___
___ 06:23AM BLOOD WBC-7.5 RBC-3.37* Hgb-9.7* Hct-30.8*
MCV-91 MCH-28.6 MCHC-31.4 RDW-15.9* Plt ___
___ 07:10AM BLOOD Neuts-53.8 ___ Monos-9.0 Eos-2.6
Baso-0.3
___ 07:10AM BLOOD Neuts-85* Bands-2 Lymphs-10* Monos-3
Eos-0 Baso-0 ___ Myelos-0
___ 07:00AM BLOOD Neuts-69.9 ___ Monos-9.5 Eos-1.9
Baso-0.3
___ 06:50AM BLOOD Neuts-67.0 ___ Monos-8.0 Eos-3.5
Baso-0.2
___ 06:40AM BLOOD Neuts-76.3* Lymphs-15.3* Monos-5.7
Eos-2.5 Baso-0.2
___ 06:45AM BLOOD Neuts-67.0 ___ Monos-8.2 Eos-3.6
Baso-0.2
___ 06:23AM BLOOD Neuts-58.8 ___ Monos-9.5 Eos-3.2
Baso-0.4
___ 07:10AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 07:10AM BLOOD ___ PTT-28.7 ___
___ 07:30AM BLOOD ___
___ 07:10AM BLOOD Glucose-91 UreaN-9 Creat-1.3* Na-135
K-4.7 Cl-100 HCO3-25 AnGap-15
___ 07:15AM BLOOD Glucose-74 UreaN-11 Creat-1.5* Na-131*
K-4.4 Cl-98 HCO3-24 AnGap-13
___ 08:00PM BLOOD Glucose-103* UreaN-12 Creat-1.3* Na-134
K-4.5 Cl-100 HCO3-22 AnGap-17
___ 07:10AM BLOOD Glucose-82 UreaN-11 Creat-1.2* Na-136
K-5.2* Cl-101 HCO3-26 AnGap-14
___ 07:00AM BLOOD Glucose-101* UreaN-8 Creat-1.0 Na-132*
K-4.1 Cl-97 HCO3-30 AnGap-9
___ 06:40AM BLOOD Glucose-76 UreaN-11 Creat-1.1 Na-126*
K-4.3 Cl-90* HCO3-28 AnGap-12
___ 03:20PM BLOOD Glucose-96 UreaN-10 Creat-1.3* Na-138
K-3.9 Cl-100 HCO3-33* AnGap-9
___ 07:55AM BLOOD Glucose-93 UreaN-8 Creat-1.2* Na-138
K-3.8 Cl-101 HCO3-33* AnGap-8
___ 06:23AM BLOOD Glucose-71 UreaN-9 Creat-1.3* Na-137
K-4.2 Cl-99 HCO3-34* AnGap-8
___ 07:10AM BLOOD ALT-17 AST-33 AlkPhos-119* TotBili-0.3
___ 07:30AM BLOOD ALT-12 AST-19 AlkPhos-109* TotBili-0.3
___ 07:05AM BLOOD ALT-12 AST-20 AlkPhos-117* TotBili-0.2
___ 03:30PM BLOOD ALT-12 AST-23
___ 07:10AM BLOOD Lipase-16
___ 12:50AM BLOOD proBNP-540*
___ 07:30AM BLOOD Calcium-8.7 Phos-4.3 Mg-1.6
___ 06:47AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.8
___ 06:50AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8
___ 01:30AM BLOOD Calcium-7.8* Phos-3.6 Mg-1.6
___ 03:30PM BLOOD Calcium-8.2* Phos-2.6* Mg-1.6
___ 06:40AM BLOOD TSH-2.7
___ 06:40AM BLOOD T4-4.5*
___ 06:40AM BLOOD Cortsol-15.3
Brief Hospital Course:
Ms ___ is a ___ G2P2 postmenopausal with history of COPD,
PVD and fibromyalgia who presented to the ED for abdominal pain
found to have large abdominal mass, likely arising for adnexa,
also with likely pancreatic mass. She was initially admitted to
the medicine service and gynecologic oncology was consulted for
her adnexal mass, which was likely malignant with undetermined
primary, possible ovarian vs pancreatic. Further workup showed
elevated CA-125 and normal
CEA suggesting ovarian primary. Pelvic US ___ showed large
predominantly cystic mass with nodular solid components in the
pelvis consistant with ovarian malignancy. Patient was also
found to have acute renal failure with Cr of 1.3 from unknown
baseline, likely secondary to pelvic mass compression given
bilateral hydronephrosis found on CT. Given the symptomatic
pelvic mass of likely ovarian malignancy and hydronephrosis,
plan was made to proceed with surgical treatment by the
gynecologic oncology team. General surgery was consulted
regarding the pancreatic lesion with decision to defer further
workup of the pancreatic lesion until after her more urgent
pelvic mass is addressed.
On ___, Ms. ___ was admitted to the gynecology oncology
service after undergoing exploratory laparotomy, lysis of
adhesions, total abdominal hysterectomy, bilateral
salpingo-oophorectomy, and partial omentectomy for her ovarian
mass. Please see the operative report for full details.
Her post-operative course is detailed as follows. Immediately
postoperatively, her pain was controlled with a local TAP block,
IV acetaminophen and PCA hydromorphone. Diazepam and lidocaine
patch were subsequently added. Her diet was advanced without
difficulty. There was difficulty in transitioning her to oral
pain medications given history of chronic narcotic use for
fibromyalgia and back pain. She was ultimately transitioned to
oral percocet, gabapentin and diazepam with adequate pain
control.
# Acute renal failure
- She was admitted with Cr of 1.3 from unknown baseline, with
evidence of bilateral hydronephrosis based on CT related to
large pelvic mass.
- She was producing adequate urine and foley was removed on
post-operative day #3. However, she did not void and the Foley
was replaced for closer urine output monitoring. Her urine
output improved with IV fluids and the foley was removed on post
operative day 5. She was able to void spontaneously. Her Cr also
improved from 1.5 to 1.0 by post operative day 4. However, her
Cr subsequently gradually increased to 1.3 in the setting of
Lasix diuresis for her hypervolemic hyponatremia, which would
likely improve once Lasix is no longer needed.
# hypervolemic hyponatremia
- On postoperative day 4, she was noted to be asymptomatically
hyponatremic to 127 and was hypervolemic with ___ edema and JVD.
Medicine was consulted and she was fluid restricted and diuresed
with IV Lasix. Her electrolytes were repleted accordingly. She
was monitored with BID electrolyte labs and her hyponatremia
resolved by post operative day 6.
# wound seroma
- On post operative day 7, serous wound drainage was noted and
her wound was probed and opened. Her fascia was intact and there
was no evidence of infection. Her wound was packed with wet to
dry dressing and changed BID. Wound vacuum was ordered for
visiting nursing service to place once she is discharged home.
# Anxiety/depression
- She was recently started on citalopram for depression by her
PCP and her medication was restarted once the team was informed
of the medication upon communication with the PCP. She was seen
by social work during her stay and psychiatry. Psychiatry
recommended continuing her citalopram dosing while inpatient
with possible increase in dosage in the outpatient setting. She
will follow-up with her PCP.
# Pancreatic lesion
- planned for further workup after ovarian malignancy is
addressed with possible MRI, ERCP.
# COPD: Chronic, stable, not O2 dependent at home. She was
continued on Spirova, Advair, as symbicort is non-formulary,
and albuterol nebs prn with control of her COPD.
# Peripheral Vascular Disease: Chronic, stable. Not on home
meds. She had increased bilateral ___ edema noted after her
surgery, likely secondary to her hypervolemia that improved with
Lasix diuresis. She underwent bilateral lower extremity dopplers
on ___ which were negative for DVTs.
# physical therapy: She was evaluated by physical therapy with
home physical therapy planned.
# PPX: Heparin SC, Pneumoboots, Famotidine, incentive
spirometry, ambulation
By post-operative day ___, she was tolerating a regular diet,
voiding spontaneously, ambulating with assistance, and pain was
controlled with oral medications. She was then discharged home
with services in stable condition with outpatient follow-up
scheduled.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Diazepam 5 mg PO Q12H
3. Magnesium Oxide ___ mg PO DAILY
4. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
5. Omeprazole 40 mg PO BID
6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
8. Tiotropium Bromide 1 CAP IH DAILY
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation Daily
10. Cyanocobalamin 1000 mcg PO BID
11. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Cyanocobalamin 1000 mcg PO BID
3. Diazepam 5 mg PO Q12H
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*2
5. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation Daily
6. Tiotropium Bromide 1 CAP IH DAILY
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
8. Magnesium Oxide ___ mg PO DAILY
9. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
10. Omeprazole 40 mg PO BID
11. Ibuprofen 400 mg PO Q6H:PRN pain
RX *ibuprofen 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*40 Tablet Refills:*1
12. Gabapentin 300 mg PO Q8H pain
RX *gabapentin [Gralise] 300 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*90 Tablet Refills:*1
13. Ferrous Sulfate 325 mg PO DAILY
may take colace if constipated on iron
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*2
14. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drive while taking oxycodone/narcotics.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
15. Acetaminophen 650 mg PO Q6H
do not exceed 4g tylenol/acetaminophen in 24 hrs
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
16. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
17. Citalopram 10 mg PO DAILY
RX *citalopram 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
18. Famotidine 20 mg PO DAILY
RX *famotidine 20 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ovarian cancer
pancreatic lesion
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 gynecologic oncology service after
undergoing the procedures listed below. You have recovered well
after your operation, and the team feels that you are safe to be
discharged home. Please follow these instructions:
.
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 12
weeks.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* It is safe to walk up stairs.
.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* You should remove your port site dressings ___ days after your
surgery. If you have steri-strips, leave them on. If they are
still on after ___ days from surgery, you may remove them.
* If you have staples, they will be removed at your follow-up
visit.
* You will have nurses come by your home tomorrow morning to
place a wound-vac for you. In the meantime please try to keep
your abdominal wound covered with the dressings we have put in
place for you.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19821643-DS-16
| 19,821,643 | 22,450,635 |
DS
| 16 |
2181-03-19 00:00:00
|
2181-03-20 15:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Haldol / Amitriptyline / azithromycin / bupropion / clotrimazole
/ levofloxacin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
EGD/EUS
Colonoscopy/EUS with biopsy
History of Present Illness:
___ yo F with complex PMH, including COPD, distant mesenteric
ischemia s/p SBR, chronic pain on opioids, Stage IIB ovarian
serous adenocarcinoma, s/p TAH-BSO with omentectomy ___, known
mucinous cyst of pancreas, who presents with persistent
abdominal pain of 3 weeks.
Pt reports b/l LQ pain, worst in LLQ, different from her chronic
abdominal pain. This pain is intermittent, severe, sharp and
radiates down thighs bilaterally. Sometimes feels
numbness/tingling. Worse with walking. She thinks the pain is
located where her ovaries used to be. She denies nausea,
vomiting, fevers, chills, constipation, diarrhea or bloody BM's.
She reports 10 lb weight gain. No clear precipitating or
alleviating factors. She denies CP, SOB, LH or palps. She
reports dependent lower extremity edema. This is a chronic
problem, but has gotten worse recently.
She initially presented to ___ ___ and was
admitted with CT scan showing mid to distal 3.5cm segment of
sigmoid wall and 3.7cm segment of proximal sigmoid thickening
concerning for malignancy. She then underwent C-scope with Dr.
___ on ___ with no evidence of mass, but did note
redundant sigmoid, which could account for CT scan findings.
She also had 6 polyps (4 tubular, 1 sessile serrated) removed.
Internal hemorrhoids were also noted. She was given a
presumptive diagnosis of mild ischemic colitis and started on
baby ASA, and discharged to home on ___ on her chronic pain
regimen.
Pt reports that her pain never improved and remained persistent,
so she saw her Oncologist Dr ___ referred her back to
the ___ again on ___. Routine lab work unremarkable
except for mild elevated Alk Phos 128. VS notable only for mild
tachycardia of 111. She was given IV morphine for pain. She
underwent b/l ___ ultrasound to eval b/l edema, negative for DVT.
She had CT A/P with contrast (prior on ___ without contrast
due to CKD), which showed similar thickening of sigmoid colon,
but also noted 1.5 cm x 2.2 cm x 3 cm pancreatic head complex
cystic mass. Given prior evaluation of the mass at ___, pt
transferred to ___ for further w/u, consideration of EUS vs
MRCP.
In ___ ED, routine labs were repeated, which were similar to
___ labs. She had CXR which confirmed port placement.
No other interventions in ___ ED.
On arrival to the floor, pt currently complains of sleepiness.
Her pain is stable. She denies N/V. She is a little anxious
and overwhelmed.
ROS: 10-point ROS negative except as noted above in HPI
Past Medical History:
PMH
- Stage IIB left ovarian serous adenocarcinoma, grade III s/p
TAH/BSO omentectomy ___ ___, c/b post-op wound infection,
s/p chemotherapy with Dr. ___ (___),
completed in ___
- Mucinous pancreatic cyst s/p drainage in EUS ___, had high
CEA
- COPD, active tobacco use, no home O2, last PFT's unknown
- Peripheral vascular disease with right subclavian stenosis
(seen on ___ ___
- Fibromyalgia
- chronic abdominal pain
- Chronic LBP due to lumbar DJD with sciatica
- Anxiety
- GERD with hiatal hernia
- Meniere's disease
- Hearing loss
- Gallstones
- urge incontinence / overactive bladder, followed by Dr. ___ in
Uro-Gyn
- Chronic lower extremity edema
- Chronic kidney disease, baseline Cr 1.2 - 1.5 (? ___
obstruction from pelvic mass)
- Depression, has therapist (social worker)
- genital warts / HPV infection
- OSA, on CPAP
- left adrenal hyperplasia
PSH:
s/p ex-lap TAH/BSO with omentectomy ___ (___)
s/p anorectal repair ___
s/p mesenteric embolus with small bowel ischemia, s/p emergency
ex-lap with SBR ___
s/p bilateral tubal ligation
s/p D&C x ___
s/p T&A
OB hx: G2P2, SVDx2
Social History:
___
Family History:
- No family history of gynecologic cancers (?uterine cancer)
- Mother with lung cancer
- Maternal grandmother with congestive heart failure.
- Brother with diabetes and "heart valve problems".
- No FH of pancreatic cancer
Physical Exam:
Admission Physical Exam:
VS: 98.4, 150/66, 18, 97% on RA
Gen: sleepy, NAD
HEENT: dry MM, anicteric
CV: RRR, no murmur
Pulm: CTAB, no wheeze or crackles
Abd: well healed midline incision, +TTP in b/l lower quadrants,
ND, NABS, no inguinal hernias appreciated
Ext: trace b/l ___ edema
Skin: no rash
Neuro: AAOx3, fluent speech
MSK: negative bilateral straight leg raise; + TTP of lumbar
spine
Psych: anxious, teary
Discharge Physical Exam:
GEN: NAD, ambulating, occasionally wincing from pain
EYES: PERRL, EOMI, conjunctiva clear, anicteric
ENT: moist mucous membranes, no exudates
NECK: supple
CV: RRR s1s2 nl, no m/r/g
PULM: CTA, no r/r/w
GI: well healed midline incision, +TTP in b/l lower quadrants,
ND, NABS, no inguinal hernias appreciated
EXT: warm, no c/c/e
SKIN: no rashes
NEURO: alert, oriented x 3, answers ? appropriately, follows
commands, non focal.
BACK: negative bilateral straight leg raise; + TTP of lumbar
spine
PSYCH: mildly anxious, otherwise calm, cooperative
ACCESS: PIV
FOLEY: absent
Pertinent Results:
___
===============================
LABS:
Notable only for Cr 1.4, Albumin 3.3, AlkP 128, PLT 154
IMAGING:
___ Bilateral ___ ultrasound - Negative for DVT
___ CT ABD/PELVIS with contrast
1. Stable 1cm right hepatic cysts and stable few subcentimeter
hypodensities in left hepatic lobe
2. Stable mild intrahepatic and extrahepatic ductal dilatation
3. Pancreati head 1.5 cm AP x 2.2 cm transverse x 3 cm superior
inferior complex cystic mass
4. Two regions of segmental thickening of the wall of the
sigmoid colon, suspicious of neoplasms, without significant
change since ___.
___
===============================
ADMISSION LABS:
___
WBC 5.3, HCT 32.6, PLT 147
Chem-7 notable for Cr 1.4
AST, ALT, T. Bili, Lipase - WNL, AlkP 128
Coag's - WNL
Albumin 3.2
___ 05:00AM URINE
Color-Straw Appear-Clear Sp ___ Blood-NEG Nitrite-NEG
Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG
pH-6.5 Leuks-NEG
Creat-42.3 TotProt-4 Prot/Cr-0.1
___ IMAGING:
# OSH Abd CT (___): 1. Stable 1cm right hepatic cysts and
stable few subcentimeter hypodensities in left hepatic lobe 2.
Stable mild intrahepatic and extrahepatic ductal dilatation 3.
Pancreati head 1.5 cm AP x 2.2 cm transverse x 3 cm superior
inferior complex cystic mass
4. Two regions of segmental thickening of the wall of the
sigmoid colon, suspicious of neoplasms, without significant
change since ___.
- ___ opinion read (___): 1. Two areas of wall thickening in
the sigmoid colon as described above with adjacent soft tissue
nodules. This is concerning for in metastatic disease (serosal,
peritoneal and omental implants) from ovarian carcinoma. (these
may be accessible to CT-guided biopsy if warranted, particularly
the anterior lesion on series 2, ___ 53) 2. 2.4 cm cystic mass
in the uncinate process of the pancreas is minimally increased
in size compared to ___ and complex, containing
multiple septations. MRCP is recommended for further
evaluation. 3. Two lung nodules in the right lower lobe are new
from ___. Differential diagnosis includes infectious process
versus metastatic disease. Full chest CT is recommended 4.
Liver lesions are too small to characterize although likely
represent cysts. 5. A common bile duct dilated to 1 cm with mild
intrahepatic biliary ductal dilatation. This is unchanged and
in the absence of a mass suggests ampullary sphincter stenosis.
# CXR (___): 1. Right Port-A-Cath tip ends in the L BCV prior
to
the SVC confluence. 2. No obvious pulmonary mass. Given the
patient's history, dedicated Chest CT would be recommended
evaluate for metastatic lesions. 3. Persistent prominently
biapical calcified micronodular pattern, better characterized on
the prior chest CT from ___. 4. Emphysema. 5. Mild
cardiomegaly and pulmonary vascular congestion but no overt
edema.
# LS Spine X-ray (___): 1. Moderate lumbar spine degenerative
changes. 2. Air-filled distended loops of large bowel best
characterized on the prior CT.
.
# TTE (___): Mild symmetric left ventricular hypertrophy with
normal cavity size and biventricular systolic function.
Increased PCWP. At least moderate (Grade II-III) diastolic
dysfunction
# MRI T/L spine (___): 1. Please note the lumbar spine portion
of the study is moderately degraded by motion. 2. Degenerative
changes throughout the spine, worse at L4-5 resulting severe
spinal canal stenosis, crowding the cauda equina. At L3-L4,
there is moderate spinal canal narrowing.
# EGD (___): Food in the pylorus, antrum, stomach body and
fundus. The procedure was aborted due to the risk of aspiration
# Sigmoidoscopy (___): Three lymph nodes were noted in
___ region 20-25 cm form the anus. These measured
between 0.5 and 1 cm in maximum diameter. The lymph nodes were
hypoechoic and homogenous in echotexture. The borders were
well-defined. No central intra-nodal vessels were seen. This was
staged N 1 by EUS criteria.
The sigmoidal mucosa at the level of 20 cm seems to be thickened
with high suspicion of tumor invasion into the sigmoid wall Due
to poor preparation Bx were not performed.
# Chest CT (___): 3 sub cm soft tissue lung nodules, new since
___ could be metastases. Progressive ossification, but
no overall growth of nonaggressive, midline subdiaphragmatic
lesion in the anterior abdominal fat. Could be a benign
teratoma or ossifying hematoma. If the patient is being
evaluated for possible metastatic ovarian carcinoma, the lesion
should be evaluated by PET-CT scan.
New mild multi focal bronchiolitis, most commonly seen with
non-tuberculous mycobacterial infection.
Persistent, severe, unexplained bronchovascular calcification,
some associated with non suppurative, bronchiectasis
predominantly upper lobes, not appreciably changed since ___.
Moderate emphysema.
# EUS (___):
Mucosa:Normal mucosa was noted up to the sigmoid colon. A
focused EUS examination was performed from 20 to 25 cm with the
forward viewing echoendoscope. A 15 mm hypoechoic mass adjacent
to the colon wall with some adjacent lymphadenopathy was noted.
FNB was performed with a 22 gauge Shark Core needle. A total of
3 passes were made into the mass. The specimen was sent to
pathology.
Impression:
Normal mucosa was noted up to the sigmoid colon.
A focused EUS examination was performed from 20 to 25 cm with
the forward viewing echoendoscope.
A 15 mm hypoechoic mass adjacent to the colon wall with some
adjacent lymphadenopathy was noted.
FNB was performed with a 22 gauge Shark Core needle.
A total of 3 passes were made into the mass.
The specimen was sent to pathology.
Brief Hospital Course:
___ yo F with complex PMH, including COPD, distant mesenteric
ischemia s/p SBR, chronic pain on opioids, Stage IIB ovarian
serous adenocarcinoma, s/p TAH-BSO with omentectomy ___, known
mucinous cyst of pancreas, who presents with persistent
abdominal pain of 3 weeks.
# Abdominal pain, lower quadrant, persistent
# Mucinous pancreatic cyst, with high CEA
# h/o Stage IIB ovarian serous adenocarcinoma
Ms. ___ was admitted with worsening bil LQ abd pain over the
past 3 weeks. The OSH CT scan was re-read by the ___
radiologist and was notable for sigmoid thickening concerning
for metastatic implant of ovarian CA on outside wall. To
corroborate this diagnosis, CA 125 was checked and noted to be
elevated at 105 (previously 10's per outpt oncologist). To
obtain a tissue biopsy, Ms. ___ underwent Sigmoidoscopy/EUS
guided biopsy of the mass - the result of the biopsy is
presently pending. Chest CT also revealed 3 sub cm soft tissue
lung nodules (new since ___ which could represent
metastases. There was also progressive ossification, but no
overall growth of nonaggressive, midline subdiaphragmatic lesion
in the anterior abdominal fat. This was felt to be a benign
teratoma or ossifying hematoma but can be evaluated with a
PET-CT scan as an outpt to evaluate for possible metastatic
ovarian carcinoma.
She was seen by Gyn Oncology - and it was felt that
recurrence of the ovarian CA was likely. Surgery was not
considered an option - and she was recommended to follow up with
her oncologist for consideration of chemotherapy.
The pain was attributed to this colonic infiltration and not
pancreatic mass/cyst. Nevertheless, an EUS of the pancreas was
also performed (simultaneous to the sigmoidoscopy) due to
increase in size and concern for pancreatic malignancy. The
Lower EUS showed a mass adjacent to the sigmoid colon concerning
for ovarian CA recurrence. Biopsies results were pending at the
time of discharge.
No changes were made to the patients pain medications as
increases in doses resulted in oversedation.
# Chronic Lower Extremity Edema
Long standing history. OSH ___ negative for DVT. TTE
revealed Grade II-III diastolic dysfunction but no clear signs
of RV failure. She was given compression stockings. She
appeared euvolemic during this hospitalization. Patient was
discharged a 2 gram Na restricted diet.
# Thrombocytopenia, mild
# Anemia, macrocytic: B12/folate, Fe panel unremarkable
- on Fe supplementation
- anemia and plt# both stable
# COPD
# OSA
Unknown PFT's, still smoking, no home O2. No evidence of acute
flare. Encourage tobacco cessation. On home CPAP. She was
continued on home inhalers. She declined a nicotine patch. CPAP
was continued.
# Chronic Kidney Disease Stage III-IV: Cr at baseline. Cont to
monitor. ___ benefit from ___ therapy, but would defer to
outpt provider.
# GERD with hiatal hernia: stable, continue home PPI regimen.
# Urge incontinence / overactive bladder: stable, continue
oxybutynin.
# Depression: Has outpt therapist. Continued on home
medications.
TRANSITION:
- Biopsy results will be followed by Dr. ___ (her
oncologist) and communicated by the ___ team
- Consider PET/CT scan for evaluation of lung nodules and
subdiaphragmatic lesion if this would change the ultimate
management of her disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Potassium Chloride 10 mEq PO DAILY
3. Morphine SR (MS ___ 30 mg PO Q12H
4. Morphine SR (MS ___ 15 mg PO Q12H
5. Percocet (oxyCODONE-acetaminophen) 7.5-325 mg oral QID:PRN
pain
6. Diazepam 5 mg PO Q12H:PRN spasm
7. Docusate Sodium 100 mg PO BID
8. Tiotropium Bromide 1 CAP IH DAILY
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
10. Polyethylene Glycol 17 g PO DAILY
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN sob
12. oxybutynin chloride 10 mg oral DAILY
13. Omeprazole 40 mg PO BID
14. Citalopram 40 mg PO DAILY
15. Ondansetron 4 mg PO Q6H:PRN nausea
16. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Polyethylene Glycol 17 g PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. Omeprazole 40 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Citalopram 40 mg PO DAILY
7. Diazepam 5 mg PO Q12H:PRN spasm
8. Ferrous Sulfate 325 mg PO DAILY
9. Ondansetron 4 mg PO Q6H:PRN nausea
10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
11. oxybutynin chloride 10 mg oral DAILY
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN sob
13. Potassium Chloride 10 mEq PO DAILY
14. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
15. Percocet (oxyCODONE-acetaminophen) 7.5-325 mg oral QID:PRN
pain
16. Morphine SR (MS ___ 30 mg PO Q12H
17. Morphine SR (MS ___ 15 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
recurrence of ovarian CA (infiltration of colon)
pancreatic cyst
Chronic Diastolic Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure looking after you. As you know, you were
transferred from ___ to ___ after imaging
revealed a pancreatic cyst which may have increased in size.
This imaging (CT scan) was reviewed by the ___ Radiologists
and there was signs of colon thickening which suggested the
possibility of ovarian cancer recurrence. For these reasons,
you underwent an endoscopic procedures to both evaluate the
pancreatic cyst and the colon. Biopsies were obtained and the
results of these tests will be available likely next week. The
results will be forwarded to Dr. ___ - who ___ determine
what next steps should be taken for treatment. In addition,
there was a couple of nodules on the CT scan of your chest. This
will need further work-up as an outpatient.
To further evaluate your abdominal/thigh pain, we obtained a MRI
of the spine. This showed narrowing in the spine which may lead
to compression of the nerves. However, your symptoms are more
consistent with the mass/thickening in the colon rather than
nerve compression. You will need to take your medications and
discuss further pain management with your primary doctor. Please
do not drive or operate heavy machinery while on these
medications.
Lastly you underwent an ultrasound of heart which shows that it
does not relax normally. As a result, you are at risk for
retaining fluid. As such, you should restrict your salt intake
to 2 grams per day.
Followup Instructions:
___
|
19821716-DS-13
| 19,821,716 | 27,424,866 |
DS
| 13 |
2165-11-12 00:00:00
|
2165-11-13 17:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Clindamycin
Attending: ___.
Chief Complaint:
Erythema and itching of right toe and dorsum of foot
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with CAD, DMII with peripheral neuropathy,
presents with erythema and itching of right toes and foot. He
has tinea pedis and chronic onychomycosis and has had several
foot infections in the past. Erythema began one day prior to
admission. Pruritis is located in between digits ___ and
erythema extends from ___ interdigitary space. No pain, although
he has chronic peripheral neuropathy. Associated fever today
100.2F. He wears compression stockings for chronic ___ edema
which have increased the moisture on his feet/toes lately. He is
using clotrimazole cream.
In the ED, initial VS were: 100.4 80 154/73 18 95%. Labs notable
for WBC 8.6, Cr 1.3 (@baseline). Received Vanco, levofloxacin
and flagyl. Vitals prior to admission: 98.9 °F (37.2 °C), 66,
18, 139/63, 97, O2 RA.
On arrival to the floor, he is comfortable, afebrile and denies
pain.
REVIEW OF SYSTEMS:
+ nasal congestion, occasional cough, chornic constipation
Denies night sweats, headache, vision changes, sore throat,
chest pain, abdominal pain, nausea, vomiting, diarrhea, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Anxiety
- Osteoarthritis of knees and pelvis
- BPH - s/p transurethral prostatectomy
- cataracts
- CAD
- MDD
- Diverticulosis
- GERD
- Hypogonadism
- DM2, insulin dependent, with nephropathy and neuropathy
- Irritable bowel syndrome
- Nephropathy
- Neuropathy
- Seasonal allergies
- Sleep apnea
- Dyspnea on exertion with PFTs showing mixed restrictive and
obstructive pattern with elevated DLCO in ___, no ILD on CT;
triggers are cold air and humidity
- HNPCC, followed by Dr. ___
- Chronic constipation
- Hearing loss, using hearing aids
- H/O dysplastic nevus ___
- H/O sarcoidosis (hepatic)
- H/O Polycythemia secondary to OSA and testosterone therapy
- s/p penile implant ___
- s/p left rotator cuff repair
- s/p left varicose vein stripping
- s/p cholecystectomy ___
Social History:
___
Family History:
mother with ovarian cancer, sister with breast cancer, father
died of colon cancer and DM2.
Physical Exam:
GENERAL: NAD, well appearing, very pleasant
HEENT: PERRL, EOMI, MMM
NECK: no LAD
LUNGS: CTAB, no W/R/R
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Obese, NT, NABS, no organomegaly
EXTREMITIES: Erythema extending linearly from ___
interdigitary space of right foot. No pain to palpation.
Increased warmth. Normal capillary refill. Tinea pedis present
in interdigitary spaces as well as distal plantar surface.
Decreased sensation in lower extremities. Venous stasis changes
bilateral ___. 1+ pitting edema to knees bilaterally.
NEUROLOGIC: A+OX3, CN2-12 intact, ___ strength
Pertinent Results:
Labs upon admission:
___ 05:00PM BLOOD WBC-8.6 RBC-5.63 Hgb-16.3 Hct-48.7 MCV-87
MCH-29.0 MCHC-33.6 RDW-14.4 Plt ___
___ 05:00PM BLOOD Neuts-76.8* Lymphs-11.8* Monos-8.1
Eos-2.5 Baso-0.9
___ 05:00PM BLOOD Glucose-201* UreaN-15 Creat-1.3* Na-136
K-4.0 Cl-98 HCO3-30 AnGap-12
___ 05:11PM BLOOD Lactate-1.9
Labs upon discharge:
___ ___:
Foot xray ___:
Brief Hospital Course:
___ year old man with CAD, DMII with peripheral neuropathy,
presented with non-ulcerating right foot cellulitis with
associated fever. He was initially treated with IV vancomycin,
then transitioned to PO doxycycline on the afternoon of HD #1.
He has associated tinea pedis and oncomycosis, the former was
treated with ketoconazole cream. He had ___ of his right
lower extremity due to edema which was negative for DVT. He was
seen by podiatry because his fifth digit became erythematous and
purple. Podiatry unroofed a small piece of skin on the plantar
surface of his toe with resultant serosanguinous discharge (no
pustular exudate). He was discharged on ___ with plans for
a 10 day course of oral doxycycline with close follow up with
his PCP.
He was continued on his home medications for his chronic medical
issues including diabetes mellitus, anxiety, hypertension, and
hyperlipidemia.
He was FULL code for this admission.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
2. Amlodipine 10 mg PO DAILY
3. BuPROPion (Sustained Release) 150 mg PO BID
4. darifenacin *NF* 15 mg Oral daily
5. Escitalopram Oxalate 15 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Ibuprofen 800 mg PO Q8H:PRN pain
9. Glargine 70 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Lorazepam 1 mg PO BID
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Omeprazole 20 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY
14. Pravastatin 10 mg PO DAILY
15. testosterone cypionate *NF* 200 mg/mL Injection qweek
16. traZODONE 100 mg PO HS:PRN insomnia
17. Valsartan 320 mg PO DAILY
18. Aspirin 81 mg PO DAILY
19. Cyanocobalamin 500 mcg PO DAILY
20. Glucosamine *NF* (glucosamine sulfate) 1500 mg Oral daily
21. Loratadine *NF* 10 mg Oral daily
22. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Tinea Pedis
Diabetes mellitus
Neuropathy
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital because of an infection (cellulitis) of
your right foot which was likely caused by your athlete's foot.
Please take the entire course of antibiotics perscribed along
with the topical antifungal cream. Please call your primary
care doctor if the redness worsens, pain develops, or you have
any questions or concerns.
Followup Instructions:
___
|
19821716-DS-14
| 19,821,716 | 24,149,387 |
DS
| 14 |
2165-11-21 00:00:00
|
2165-11-25 11:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Clindamycin
Attending: ___.
Chief Complaint:
Swelling and redness of the right foot.
Major Surgical or Invasive Procedure:
Debridement of right ___ digit with closure (___)
History of Present Illness:
Mr. ___ is a ___ male with a hx of CAD, DMII with
peripheral neuropathy with recent admission for R foot
non-ulcerating cellulitis, who is re-presenting for increasing
swelling and redness of the right foot. The patient also became
concerned because he felt that the medial aspect of his right
foot (near his malleolus) was becoming "swollen," and he noted
tenderness and some mild redness on the anterior aspect of his
lower leg. He notes that while his skin does have some chronic
changes on his lower legs, the redness is new and so is the
tenderness. He also notes a rash on his bilateral ankles, which
he relates to starting doxycycline.
The patient was admitted ___ and received IV Vancomycin
but was transitioned to PO Doxycycline on HD#1, and was
discharged with plan for 10 days of Doxycycline. However, the
patient reports that he has had worsening of the erythema and
swelling of the foot,with associated fevers at home. During his
recent hospitalization, the patient's associated tinea pedis and
oncomycosis were felt to be contributing to his cellulitis.
Tinea pedis was treated with Ketoconazole. A ___ of his RLE was
negative for DVT. He was seen by podiatry because his fifth
digit became erythematous and purple. Podiatry unroofed a small
piece of skin on the plantar surface of his toe with resultant
serosanguinous discharge (no pustular exudate).
In the ED, initial VS were: 98.7 57 138/61 16 97% RA
On arrival to the floor, patient appeared very well.
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:
- Anxiety
- Osteoarthritis of knees and pelvis
- BPH - s/p transurethral prostatectomy
- cataracts
- CAD
- MDD
- Diverticulosis
- GERD
- Hypogonadism
- DM2, insulin dependent, with nephropathy and neuropathy
- Irritable bowel syndrome
- Nephropathy
- Neuropathy
- Seasonal allergies
- Sleep apnea
- Dyspnea on exertion with PFTs showing mixed restrictive and
obstructive pattern with elevated DLCO in ___, no ILD on CT;
triggers are cold air and humidity
- HNPCC, followed by Dr. ___
- Chronic constipation
- Hearing loss, using hearing aids
- H/O dysplastic nevus ___
- H/O sarcoidosis (hepatic)
- H/O Polycythemia secondary to OSA and testosterone therapy
- s/p penile implant ___
- s/p left rotator cuff repair
- s/p left varicose vein stripping
- s/p cholecystectomy ___
Social History:
___
Family History:
Mother with ovarian cancer, sister with breast cancer, father
died of colon cancer and diabetes mellitus type 2.
Physical Exam:
Admission Physical Exam:
VITALS: 97.9 154/68 53 18 97% RA
GENERAL: well appearing gentleman. Obese.
HEENT: PERRL, EOMI
NECK: large neck precludes evaluation of JVD.
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, obese.
EXTREMITIES: RLE with erythema starting between ___ and ___
toes, extending back towards the leg with a width of about 4cm
(outlined). Between the toes is notable for erythema with clear
deliniations. There is a gauze bandage in place over the left
___ digit, which has serous drainage. There is 2+ pitting edema
bilaterally. There are bilateral skin changes c/w chronic venous
stasis, but there is overlying erythema on the right leg which
is not seen on the left and the patient is tender in this area.
There are sub-centimeter macular papular erythematous lesions
scattered on the patient's bilateral ankles.
NEUROLOGIC: A+OX3
Discharge Physical Exam:
Vitals: Tm 98.7 Tc 98.7, HR 54-60, BP 142-163/61-66, RR 18, O2
96-98%(RA)
I/O: 1200/750
___: 169 108 44 74 86 147
Gen: NAD, ambulating in hallway
CV: RRR, normal S1/S2, no m/r/g
Pulm: CTAB
Abd: Soft, non-distended, non-tender.
Ext: R ___ digit dressing c/d/i. No tenderness in heel, ankle or
leg. 2+ radial and DP pulses.
Neuro: Motor and sensory grossly intact.
Pertinent Results:
Labs on admission:
___ 03:00AM BLOOD WBC-7.4 RBC-5.49 Hgb-15.7 Hct-48.1 MCV-88
MCH-28.5 MCHC-32.5 RDW-14.4 Plt ___
___ 03:00AM BLOOD ___ PTT-31.8 ___
___ 03:00AM BLOOD Glucose-140* UreaN-18 Creat-1.3* Na-141
K-4.1 Cl-101 HCO3-33* AnGap-11
___ 03:00AM BLOOD ALT-34 AST-24 AlkPhos-91 TotBili-1.1
___ 03:24AM BLOOD Lactate-1.1
Labs on discharge:
___ 05:57AM BLOOD Vanco-13.4
Imaging:
FOOT AP,LAT & OBL RIGHT (___): In comparison with the study
of ___, it is difficult to evaluate the distal phalanx of the
fifth digit due to overlying bandage. No definite bony
destruction is seen, though osteomyelitis cannot be excluded.
No definite erosions are seen involving the fifth digit.
FOOT AP,LAT & OBL RIGHT PORT (___): Comparison is made to
prior study from ___. Since the previous study, the
patient has undergone resection of the distal aspect of the
fifth toe at a site of a previously fused fifth DIP joint. There
is soft tissue swelling at the site of the surgery. No acute
fractures are seen. There are vascular calcifications and a
calcaneal spur dentified.
Micro:
___ 3:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:15 am BLOOD CULTURE # 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:31 pm SWAB Source: right ___ digit .
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 3:37 pm TISSUE RIGHT ___ TOE BONE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
Pathology:
Procedure date Tissue received Report Date Diagnosed
by
___ ___. ___
Previous biopsies: ___ G I BIOPSIES (3 JARS).
___ SKIN MIDLINE MID BACK (1 JAR)
___ GI BX (1 JAR)
___ SKIN: LEFT MID-BACK (1 JAR)
(and more)
DIAGNOSIS:
Fifth toe bone, right (A, B):
1. Skin and subcutaneous tissue with ulceration and necrosis.
2. Bone with adjacent fibrosis and acute and chronic
inflammation.
Brief Hospital Course:
___ year old male with a history of diabetes mellitus type 2,
coronary artery disease with peripheral neuropathy presented
with cellulitis. He was readmitted after failing home
doxycycline treatment. Podiatry completed bedside debridement
of the plantar surface of his right ___ digit. Cultures grew
MSSA. Infectious disease was consulted and he was treated with
vancomycin, ciprofloxacin and flagyl initially. Antibiotics
were narrowed to vancomycin alone once MSSA cultures returned.
Given suspicion for distal ___ digit osteomyelitis given ulcer
that probed to bone after initial podiatry debridement and
elevated inflammatory markers, he went to the OR on ___ for
bone debridement and closure. Infectious disease recommended
continuing with IV vancomycin for a total of 3 weeks (note he
has a penicillin allergy and there is no acceptable oral
substitute that would safely clear his infection). His
vancomycin was titrated for goal trough ___. He will follow
up with his PCP and podiatrist as an outpatient, with home
infusion therapy of vancomycin.
All other chronic issues, including diabetes mellitus type 2,
hypertension, obstructive/restrictive lung disease, obstructive
sleep apnea, hyperlipidemia and anxiety/depression were treated
with continuation of home medications.
The patient was Full Code throughout admission.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. BuPROPion (Sustained Release) 150 mg PO BID
5. Cyanocobalamin 500 mcg PO DAILY
6. darifenacin *NF* 15 mg Oral daily
7. Escitalopram Oxalate 15 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO BID
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Glucosamine *NF* (glucosamine sulfate) 1500 mg Oral daily
12. Glargine 70 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Loratadine *NF* 10 mg Oral daily
14. Lorazepam 1 mg PO BID
15. Omeprazole 20 mg PO BID
16. Polyethylene Glycol 17 g PO DAILY
17. Pravastatin 10 mg PO DAILY
18. traZODONE 100 mg PO HS:PRN insomnia
19. Valsartan 320 mg PO DAILY
20. Ketoconazole 2% 1 Appl TP BID
to toes and interdigitary space
21. Ibuprofen 800 mg PO Q8H:PRN pain
22. MetFORMIN (Glucophage) 1000 mg PO BID
23. testosterone cypionate *NF* 200 mg/mL Injection qweek
24. Furosemide 20 mg PO BID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. BuPROPion (Sustained Release) 150 mg PO BID
5. Cyanocobalamin 500 mcg PO DAILY
6. Escitalopram Oxalate 15 mg PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO BID
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Furosemide 20 mg PO BID
11. Ketoconazole 2% 1 Appl TP BID
to toes and interdigitary space
12. Lorazepam 1 mg PO BID
13. Omeprazole 20 mg PO BID
14. Polyethylene Glycol 17 g PO DAILY
15. Pravastatin 10 mg PO DAILY
16. traZODONE 100 mg PO HS:PRN insomnia
17. Valsartan 320 mg PO DAILY
18. Acetaminophen 650 mg PO Q6H:PRN Pain
19. Vancomycin 1750 mg IV Q 12H Duration: 10 Doses
Continue taking until ___ (you started ___
RX *vancomycin 500 mg 1750 mg twice a day Disp #*28 Unit
Refills:*0
20. darifenacin *NF* 15 mg Oral daily
21. Glucosamine *NF* (glucosamine sulfate) 1500 mg Oral daily
22. Ibuprofen 800 mg PO Q8H:PRN pain
23. Loratadine *NF* 10 mg Oral daily
24. MetFORMIN (Glucophage) 1000 mg PO BID
25. testosterone cypionate *NF* 200 mg/mL Injection qweek
26. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q6H PRN Disp #*20 Tablet
Refills:*0
27. Glargine 70 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
28. Outpatient Lab Work
Please have the labs checked on ___ and ___: CBC with
differential (weekly), Chem 7 (weekly), BUN/Cr(weekly), AST/ALT
(weekly), Alk Phos (weekly), Total bili (weekly), ESR/CRP
(weekly), Vancomycin trough weekly
Please have results faxed to ___
R.N.s at ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Osteomyelitis
Cellulitis
Secondary Diagnosis:
Anxiety
Coronary Artery Disease
GERD
Diabetes Mellitus Type 2
Chronic Kidney Disease
Neuropathy
Sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for an infection of your right fifth
toe. While you were in the hospital, you received antibiotics
and two procedures by podiatry to remove the infected tissue.
You have been discharged with a PICC line (central line) in
place, which you will need to use to continue the antibiotics
until ___. We have also scheduled you for an MRI on ___
evaluate for any residual infection. You will be getting weekly
laboratory work sent to infectious disease. It was our pleasure
to take care of you while you were an inpatient here. Please do
not hesitate to contact us with any questions, comments or
concerns.
Warm Regards,
Your Inpatient Medicine Team
Followup Instructions:
___
|
19821716-DS-17
| 19,821,716 | 27,901,250 |
DS
| 17 |
2170-06-11 00:00:00
|
2170-06-18 14:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Clindamycin / vancomycin
Attending: ___
Chief Complaint:
Dyspnea and Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with h/o Lynch syndrome and metastatic
urothelial carcinoma who presents for weakness, dehydration and
poor PO intake. Pt reports that he has been very weak over the
past few days, and he associated this with his decrease in PO
intake. He denies abdominal pain, nausea, emesis, constipation
or diarrhea. He reports stable shortness of breath, which he has
been dealing with for about a month now. He denies CP, DOE, or
pleuritic chest pain. He denies sick contacts, new sputum
production, or cough.
Patient started feeling generally unwell in ___. Imaging
performed was notable for a large pancreatic tail mass invading
the splenic hilum, numerous ill-defined hepatic lesions
concerning for metastases, as well as extensive retroperitoneal
lymphadenopathy. There was also a new lobulated left renal hilar
mass concerning for RCC. On discovery of imaging findings, PCP
ordered CEA and CA ___, which returned elevated at 61.7 and
4562, respectively.
Patient established care in ___ clinic on ___, and he
was admitted to ___ from ___ to ___ for management of
hypercalcemia, coagulopathy, and expedited workup of likely
metastatic malignancy. Patient received IVF and a single dose of
zoledronic acid for hypercalcemia and vitamin K and FFP for
coagulopathy. He underwent core needle biopsy of liver lesion on
___. Final pathology returned consistent with metastatic
poorly-differentiated urothelial carcinoma. Patient saw hem/onc
as an outpatient and he has endorsed dizziness and shakiness
with difficulty feeding himself. He has overall felt more weak
since previous discharge on ___ and notes urinary
incontinence requiring diapers. SOB and dry cough were stable at
visit on ___.
In the ED, initial vitals were: T 98.4, P 82, BP 136/49, RR 15,
and O2sat 96% on RA.
Exam notable for: Lower and middle lung fields with rales and
rhonchi, no wheezing, mild abdominal tenderness, no rebound or
guarding, skin turgor remarkable for tenting.
Labs notable for:
- INR 1.8
- WBC 22.3, N 80%
- Hgb 10.2
- Ca 7.1
- Mg 2.1
- P 1.4
- Na 132
- Bicarb 20
- BUN/Cr ___
Imaging was notable for:
- CXR: Mediastinal lymphadenopathy and multiple small pulmonary
nodules seen on prior chest CT were better assessed on CT, a
more sensitive study. No new focal consolidation. Persistent
slight blunting of the posterior left costophrenic angle, which
could be due to a trace pleural effusion or pleural fat. No
large pleural effusion. Central pulmonary vascular engorgement
without overt pulmonary edema.
Patient was given:
- ___ 12:00 IVF NS 1 mL
- ___ 14:25 IV CeftriaXONE 1 g
- ___ 14:35 PO/NG LORazepam 1 mg
- ___ 15:42 PO BuPROPion (Sustained Release) 150 mg
- ___ 18:04 IV Azithromycin 500 mg
Past Medical History:
- Lynch syndrome
- Metastatic urothelial carcinoma
- Type 2 diabetes
- Coronary artery disease
- OSA on BiPAP
- Stage II chronic kidney disease
- GERD
- Diverticulosis
- Irritable bowel syndrome
- Sarcoidosis
- Peripheral neuropathy
- Hypogonadism
- Hypothyroidism
- Benign prostatic hyperplasia
- Osteoarthritis
- Anxiety and depression
- Seasonal allergies
- BPH s/p TURP
- Cholecystectomy
- Penile implant
Social History:
___
Family History:
- Father with colon cancer (died at ___)
- Mother with colon cancer and ovarian cancer (died at ___)
- Sister with breast cancer (died at ___)
- Multiple grandparents, aunts, and uncles with colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
VITAL SIGNS: T 98.7, BP 164/79, P 84, RR 20, O2sat 95% on RA
GENERAL: Mild tachypnea, resting comfortably in bed, speaking in
full sentences
HEENT: PERRL, EOMI, OP clear without lesions or thrush
NECK: supple, no JVD
CARDIAC: RRR, no MRG
LUNGS: bibasilar crackles, bilateral lower lung fields with
diffuse rales, soft, scattered end expiratory wheezing
throughout
ABDOMEN: moderately distended, soft, nontender,
hepatosplenomegaly
EXTREMITIES: wwp, 1+ bilateral pitting edema
SKIN: no rashes
DISCHARGE PHYSICAL EXAM:
=============================
VS - T 98.6, BP 119/63, P ___, RR 20, O2sat 96% on RA
General: NAD, sitting in bed
HEENT: PERRL, sclera noninjected
CV: RRR, no m/r/g
Lungs: Lungs clear to auscultation, no wheezing
Abdomen: Protuberent, tender, no shifting dullness, or
detectable fluid wave, +
Ext: No edema of bilateral lower extremities
Neuro: grossly intact
Pertinent Results:
ADMISSION LABS:
===================
___ 11:09AM BLOOD WBC-22.3* RBC-4.41* Hgb-10.2* Hct-33.7*
MCV-76* MCH-23.1* MCHC-30.3* RDW-20.1* RDWSD-54.4* Plt ___
___ 11:09AM BLOOD Neuts-80.7* Lymphs-5.1* Monos-10.4
Eos-2.2 Baso-0.3 Im ___ AbsNeut-18.01* AbsLymp-1.13*
AbsMono-2.31* AbsEos-0.48 AbsBaso-0.07
___ 11:09AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+
Schisto-1+ Burr-OCCASIONAL
___ 11:09AM BLOOD ___ PTT-27.8 ___
___ 11:09AM BLOOD Glucose-87 UreaN-17 Creat-1.1 Na-132*
K-4.7 Cl-99 HCO3-20* AnGap-18
___ 11:09AM BLOOD Calcium-7.1* Phos-1.4* Mg-2.1
___ 10:30AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
OTHER RELEVANT LABS:
=======================
___ 06:30AM BLOOD WBC-18.9* RBC-4.09* Hgb-9.3* Hct-31.5*
MCV-77* MCH-22.7* MCHC-29.5* RDW-19.8* RDWSD-55.3* Plt ___
___ 06:20AM BLOOD WBC-18.9* RBC-4.29* Hgb-9.8* Hct-32.9*
MCV-77* MCH-22.8* MCHC-29.8* RDW-19.8* RDWSD-54.4* Plt ___
___ 06:20AM BLOOD ___ PTT-26.7 ___
___ 06:30AM BLOOD Glucose-135* UreaN-14 Creat-1.0 Na-135
K-4.7 Cl-102 HCO3-18* AnGap-20
___ 03:05PM BLOOD Glucose-243* UreaN-16 Creat-1.2 Na-134
K-4.7 Cl-99 HCO3-20* AnGap-20
___ 06:20AM BLOOD Glucose-173* UreaN-15 Creat-1.1 Na-132*
K-4.6 Cl-101 HCO3-19* AnGap-17
___ 06:30AM BLOOD ALT-18 AST-17 LD(___)-198 AlkPhos-269*
TotBili-0.9
___ 06:20AM BLOOD ALT-17 AST-18 LD(___)-218 AlkPhos-261*
TotBili-0.8
___ 06:30AM BLOOD Albumin-2.2* Calcium-6.5* Phos-1.6*
Mg-2.4
___ 03:05PM BLOOD Calcium-7.3* Phos-1.9* Mg-2.0
___ 06:20AM BLOOD Albumin-2.3* Calcium-7.2* Phos-1.7*
Mg-1.9
___ 03:51PM BLOOD pH-7.30* Comment-GREEN TOP
___ 03:51PM BLOOD freeCa-0.97*
DISCHARGE LABS:
=======================
___ 06:11AM BLOOD WBC-19.0* RBC-4.56* Hgb-10.4* Hct-35.6*
MCV-78* MCH-22.8* MCHC-29.2* RDW-20.0* RDWSD-54.9* Plt ___
___ 06:11AM BLOOD ___ PTT-25.2 ___
___ 06:11AM BLOOD Glucose-184* UreaN-20 Creat-1.2 Na-137
K-5.1 Cl-101 HCO3-19* AnGap-22*
___ 06:11AM BLOOD Calcium-7.1* Phos-2.1* Mg-2.0
CXR (___) IMPRESSION: Mediastinal lymphadenopathy and multiple
small pulmonary nodules seen on prior chest CT were better
assessed on CT, a more sensitive study. No new focal
consolidation. Persistent slight blunting of the posterior left
costophrenic angle, which could be due to a trace pleural
effusion or pleural fat. No large pleural effusion. Central
pulmonary vascular engorgement without overt pulmonary edema.
Brief Hospital Course:
Mr. ___ is a ___ with h/o Lynch syndrome and metastatic
urothelial carcinoma who presents for weakness, dehydration and
poor PO intake. It was thought that patient's shortness of
breath and weakness were multifactorial in etiology due to
metastatic disease, volume overload, some days of poor PO
intake, hypocalcemia and hypophosphatemia. Patient was flu
negative and CXR showed no e/o PNA. Patient had evidence of
volume overload on exam and was diuresed with 40 mg IV lasix x2,
with improvement in respiratory status noted. Patient was
subsequently weaned from O2 to RA. Patient's phosphate and
calcium were repleted and patient's diet was supplemented with
Ensure. He was evaluated by ___ and did not have any acute rehab
needs. Patient was restarted on his home diuretics to maintain
euvolemia (he was discharged on Lasix 40 mg daily). Patient's
antihypertensive medications were held given his SBP < 160 with
plans to resume medications as needed as an outpatient. Given
recent dx of widely metastatic cancer and extensive medication
list, patient and PCP were previously engaging in simplifying
medication list prior to admission. Patient was resumed on
metformin on ___ given that he no longer had evidence of ___.
As insulin requirements in house were ___ units per day, he will
lilely no longer require ISS as an outpatient.
TRANSITIONAL ISSUES:
================
-Restarted medications: metformin, Lasix
-Stopped medications: amlodipine, valsartan, hydralazine,
insulin; can resume as needed on an outpatient basis. If
patient's BP > 160, can consider restarting amlodipine.
-Please continue to engage in simplifying medication list
-Scheduled for administration of atezolizumab on ___
-Palliative care evaluated patient while in the hospital and
recommended considering outpatient palliative care appointment
(patient was given number)
-Continue visits with social worker for coping/support as needed
-Consider outpatient TTE given last TTE in ___
-Recheck TSH after discharge
-Monitor weights daily and call PCP if weight increases more
than 3lb in 24h.
-F/u BP's/Glucose/fluid status/thyroxine dosing with PCP
-___ glucose BID and call PCP ___ > 250.
Medications on Admission:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
2. BuPROPion (Sustained Release) 150 mg PO BID
3. Escitalopram Oxalate 20 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. HydrALAZINE 25 mg PO BID
7. LORazepam 1 mg PO BID:PRN anxiety
8. Omeprazole 20 mg PO BID
9. Tamsulosin 0.4 mg PO QHS
10. TraZODone 100 mg PO QHS:PRN insomnia
11. Aspirin 81 mg PO DAILY
12. Cyanocobalamin 500 mcg PO DAILY
13. Fish Oil (Omega 3) 1000 mg PO BID
14. Loratadine 10 mg PO DAILY
15. menthol-camphor-antarth cb#1 0.5-0.5% topical TID:PRN
16. Pravastatin 20 mg PO QPM
17. Vitamin D 1000 UNIT PO DAILY
18. Levothyroxine Sodium 50 mcg PO DAILY
19. Valsartan 320 mg PO DAILY
20. Insulin SC Sliding Scale
Insulin SC Sliding Scale using Novolog Insulin
21. amLODIPine 10 mg PO DAILY
22. Testosterone Cypionate 200 mg IM QWEEK
Discharge Medications:
1. Furosemide 40 mg PO DAILY Duration: 1 Dose
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
4. Aspirin 81 mg PO DAILY
5. BuPROPion (Sustained Release) 150 mg PO BID
6. Cyanocobalamin 500 mcg PO DAILY
7. Escitalopram Oxalate 20 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO BID
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Levothyroxine Sodium 50 mcg PO DAILY
12. Loratadine 10 mg PO DAILY
13. LORazepam 1 mg PO BID:PRN anxiety
14. menthol-camphor-antarth cb#1 0.5-0.5% topical TID:PRN
15. Omeprazole 20 mg PO BID
16. Pravastatin 20 mg PO QPM
17. Tamsulosin 0.4 mg PO QHS
18. Testosterone Cypionate 200 mg IM QWEEK
19. TraZODone 100 mg PO QHS:PRN insomnia
20. Vitamin D 1000 UNIT PO DAILY
21. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until instructed to by your PCP
22. HELD- HydrALAZINE 25 mg PO BID This medication was held. Do
not restart HydrALAZINE until instructed to by your PCP
23. HELD- Insulin SC Sliding Scale
Insulin SC Sliding Scale using Novolog Insulin This medication
was held. Do not restart Insulin until you discuss with your PCP
if this medicine is necessary.
24. HELD- Valsartan 320 mg PO DAILY This medication was held.
Do not restart Valsartan until instructed to by your PCP
___:
Home
Discharge Diagnosis:
Primary:
Weakness
Dyspnea
Metastatic urothelial carcinoma
Hypocalcemia
Hypophosphatemia
Hypertension
Secondary
Type 2 Diabetes Mellitus
Coronary Artery Disease
Obstructive sleep apnea
Coagulopathy
Microcytic Anemia
Hypothyroidism
Anxiety
Depression
Gastroesophageal reflux disease
Benigh prostatic hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted because you were feeling short of breath and
had weakness. We gave you medications that helped remove fluid
from your lungs to help your breathing. You also had low vitamin
levels that may have contributed to your weakness so we gave you
vitamins. Please follow-up with your PCP and oncologist after
discharge.
For the site of your liver biopsy:
1.Cleanse with wound cleanser, gently pat dry with gauze.
2.Apply sacral Border(heart shape) mepilex to sacral area.
Change Q3 days, PRN.
4. Encouraged Frequent repositioning while awake, Q2 hours.
5. Use Waffle cushion while sitting up in chair& continue to
shift positions while sitting. Support nutrition and hydration.
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
19821716-DS-18
| 19,821,716 | 20,398,472 |
DS
| 18 |
2170-07-07 00:00:00
|
2170-07-07 16:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Clindamycin / vancomycin
Attending: ___
Chief Complaint:
Weakness, cough, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with h/o Lynch syndrome and metastatic
urothelial carcinoma who presents with fevers, fatigue,
weakness, dehydration, cough and shortness of breath. He reports
that after his recent discharge 4 weeks ago, he had been gaining
strength and ambulating with a walker. However, over the last
few days, he developed a dry cough. Yesterday, he began having
generalized weakness, subjective fevers, and was unable to get
out of bed without assistance. Today, he fell on his bottom
while trying to get out of bed, and a ___ called an ambulance.
He has chronic GI symptoms for several years after a
cholecystectomy, but denies any new abdominal pain, nausea,
vomiting, diarrhea, dysuria, and urinary frequency.
From previous excellent admission note, summarizing oncologic
history:
"Patient started feeling generally unwell in ___. Imaging
performed was notable for a large pancreatic tail mass invading
the splenic hilum, numerous ill-defined hepatic lesions
concerning for metastases, as well as extensive retroperitoneal
lymphadenopathy. There was also a new lobulated left renal hilar
mass concerning for RCC. On discovery of imaging findings, PCP
ordered CEA and CA ___, which returned elevated at 61.7 and
4562, respectively.
Patient established care in ___ clinic on ___, and he
was admitted to ___ from ___ to ___ for management of
hypercalcemia, coagulopathy, and expedited workup of likely
metastatic malignancy. Patient received IVF and a single dose of
zoledronic acid for hypercalcemia and vitamin K and FFP for
coagulopathy. He underwent core needle biopsy of liver lesion on
___. Final pathology returned consistent with metastatic
poorly-differentiated urothelial carcinoma. Patient saw hem/onc
as an outpatient and endorsed dizziness and shakiness
with difficulty feeding himself."
He was recently admitted in ___ for poor PO intake and
was found to have volume overload. He was diuresed, and his
electrolytes were replaced before discharge.
In the ED, initial vitals: Temp 99, HR 125, BP 96/58, RR 18, O2
97% NC
- Exam notable for: Clear lungs, normal abdominal exam, sacral
decub grade II.
- Labs were notable for: WBC 51.7 (92% neutrophils), Hgb 10.3,
Cr 1.0, ALT/AST ___, Lactate 7.2, VO2 72, pH 7.42, Flu
negative, UA with 7 WBC and few bacteria.
- Imaging: CT Chest/Abdominal/Pelvis w/ contrast concerning for
pancreatic tail malignancy, unchanged left renal lobulated mass,
progressive metastatic disease, mild mediastinal
lymphadenopathy.
- Patient was given: Linezolid and Cefepime, along with NS
On arrival to the MICU, vitals were T 98.0, HR 91, BP 124/67, RR
17, O2 94% RA. He was a&ox3, mentating well.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Otherwise negative
Past Medical History:
- Lynch syndrome
- Metastatic urothelial carcinoma
- Type 2 diabetes
- Coronary artery disease
- OSA on BiPAP
- Stage II chronic kidney disease
- GERD
- Diverticulosis
- Irritable bowel syndrome
- Sarcoidosis
- Peripheral neuropathy
- Hypogonadism
- Hypothyroidism
- Benign prostatic hyperplasia
- Osteoarthritis
- Anxiety and depression
- Seasonal allergies
- BPH s/p TURP
- Cholecystectomy
- Penile implant
Social History:
___
Family History:
- Father with colon cancer (died at ___)
- Mother with colon cancer and ovarian cancer (died at ___)
- Sister with breast cancer (died at ___)
- Multiple grandparents, aunts, and uncles with colon cancer.
Physical Exam:
DISCHARGe EXAM:
VITALS: T 98.2 BP 125 / 69 HR 95 RR 18 O2 sat 94 ra
GENERAL: NAD, resting
HENT: NCAT, supple
EYes: EOMI
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTA Bilaterally
ABDOMEN: obese, soft, midline well-healed surgical scar,
nontender to palpation, hard bony knob in the RUQ
NEURO: CN II-XII intact, ___ strength in upper and lower
extremities, sensation intact to light touch
Pertinent Results:
Admission labs:
___ 12:00PM BLOOD WBC-51.7*# RBC-4.28* Hgb-10.3* Hct-33.9*
MCV-79* MCH-24.1* MCHC-30.4* RDW-21.8* RDWSD-60.7* Plt ___
___ 12:00PM BLOOD Neuts-92* Bands-2 Lymphs-2* Monos-2*
Eos-1 Baso-0 ___ Myelos-1* AbsNeut-48.60*
AbsLymp-1.03* AbsMono-1.03* AbsEos-0.52 AbsBaso-0.00*
___ 03:13AM BLOOD ___ PTT-31.7 ___
___ 12:00PM BLOOD Glucose-113* UreaN-21* Creat-1.0 Na-133
K-5.0 Cl-96 HCO3-21* AnGap-21*
___ 12:00PM BLOOD ALT-22 AST-32 AlkPhos-321* TotBili-1.3
___ 03:13AM BLOOD Calcium-7.8* Phos-2.0* Mg-1.8
___ 12:15PM BLOOD Lactate-7.2*
___ 03:07PM BLOOD Lactate-6.5*
___ 09:37PM BLOOD Lactate-5.9*
___ 03:31AM BLOOD Lactate-5.7*
Discharge Labs
___ 07:10AM BLOOD WBC-24.9* RBC-4.05* Hgb-9.9* Hct-32.3*
MCV-80* MCH-24.4* MCHC-30.7* RDW-22.8* RDWSD-63.2* Plt ___
___ 07:10AM BLOOD Glucose-106* UreaN-15 Creat-0.8 Na-136
K-4.3 Cl-101 HCO3-24 AnGap-15
___ 03:13AM BLOOD ALT-20 AST-32 LD(LDH)-193 AlkPhos-254*
TotBili-0.8
Blood and urine cultures no growth to date
Imaging:
- CXR (___):
Possible mild left asymmetric pulmonary vascular congestion.
Otherwise, similar appearance of the chest. Known mediastinal
lymphadenopathy and pulmonary nodules better assessed on CT.
- CT Chest/Abdomen/Pelvis w/contrast (___):
1. Pancreatic tail heterogeneous attenuation invading the spleen
remains concerning for pancreatic tail malignancy.
2. Unchanged left renal lobulated mass, incompletely
characterized in the absence of intravenous contrast, grossly
unchanged.
3. Progressed metastatic disease with numerous ill-defined
hepatic lesions appear increased in size, enlarging aortocaval
adenopathy, increased size of omental nodules, and increased
amount of abdominal free fluid layering within the pelvis.
4. Simple fluid collection inseparable from and inferior to the
third portion of the duodenum, unchanged, may reflect lymphocele
or seroma.
5. Mild mediastinal lymphadenopathy is stable relative to prior
chest CT dated
Brief Hospital Course:
Mr. ___ is a ___ with h/o Lynch syndrome and metastatic
urothelial carcinoma who presents with fevers, fatigue,
weakness, dehydration, cough and shortness of breath, with
laboratory values concerning for severe infection.
# Severe Sepsis: There was no clear source of infection on
admission. UA in ED was mildly positive, but pt denies dysuria,
frequency, and abdominal pain. CT Chest does not show evidence
of pulmonary infection. His symptoms of weakness and fatigue may
be due to worsening tumor burden. Given leukocytosis,
tachycardia, weakness, report of fever at home, and
significantly elevated lactate, he was empirically started on
linezolid/cefepime, which was narrowed to just cefepime on day
2. His vital signs remained stable and he was afebrile
throughout his ICU stay. He was transferred to the medical
floor and started on oral ciprofloxacin and remained stable
overnight. All cultures remained negative; unclear source of
sepsis, but cipro continued for presumed urinary source for a
complicated UTI to complete a 10 day course
# Metabolic gap acidosis: On admission, his AG was 16 consistent
with lactic acidosis. His elevated lactate may be non-hypoxia
related due to thiamine deficiency and/or malignancy. He was
given 1L IVF in the ED, and started on thiamine in the ICU. His
lactate downtrended.
# Metastatic urothelial carcinoma, poorly differentiated:
Diagnosed based on core needle biopsy of metastatic liver
lesion, on ___. CT scan shows numerous metastatic lesions.
# Goals of Care: Discussed at length with patient and wife and
PCP. Patient does not want additional chemotherapy. He feels
that his energy, well being is declining as his cancer
progresses. MOLST form given to patient and he is DNR/DNI, no
artificial feeding/nutrition, no HD. IN regards to
rehospitalization, patient chose to be re-hospitalized for
infection, etc.
# Microcytic anemia: Hgb is at his baseline. Microcytic, likely
represents an element of iron deficiency from poor PO intake
along with ACD.
# Essential Hypertension - controlled - will hold valsartan,
hydralazine, amlodipine on discharge as pt has SBP 120s-140s
over hospital stay while off medications
# ___ swelling - at home, this improved during the
hospitalization, dc'd on Lasix 40 mg with taking ___ tab at
home as needed
Chronic issues:
# CAD: on statin, but can consider stopping given goals of care,
will leave up to Dr. ___ with discussions
# T2DM- controlled: continued metformin
# Stage II CKD: Creatinine 1.0 on admission. CTM
# GERD: Continued home omeprazole
# BPH: Continued home tamsulosin
# Hypothyroid: Continued home levothyroxine 50 mcg
# Anxiety and depression: Continue home bupropion, escitalopram,
Ativan 1 mg PO BID:prn anxiety. He spoke to psychiatrist when
hospitalized and will continue to meet with her or speak over
the phone.
# Asthma: Continue home albuterol, fluticasone
# Code STatus: DNR/DNI, home on hospice. Ok for CPAP, No HD, no
artificial nutrition/hydration in end stage of life.
Stopped amlodipine, valsartan, vitamins, hydralazine
Take ___ tab of Lasix 40 mg prn at home
F/U with Dr. ___ set up for home, plan to deliver hospital bed next week
Patient requested to go home today prior to 24 hours of
monitoring on po antibiotics due to inclement weather in next ___
hours. He has close f/u and a visiting nurse this evening as
well as Dr. ___ is currently on call this weekend. Pt and
family understood risks and requested to d/c home.
Total time on this discharge was >30 minutes with arranging
medications, counseling, and outpatient f/u.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Testosterone Cypionate 200 mg IM QWEEK
2. Valsartan 320 mg PO DAILY
3. mometasone 0.1 % topical BID 2 weeks per month
4. BuPROPion 150 mg PO BID
5. Fish Oil (Omega 3) 1000 mg PO BID
6. econazole 1 % topical BID
7. LORazepam 0.5 mg PO BID:PRN anxiety
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Cyanocobalamin 500 mcg PO DAILY
11. Escitalopram Oxalate 20 mg PO DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
13. Fluticasone Propionate NASAL 2 SPRY NU DAILY
14. Levothyroxine Sodium 50 mcg PO DAILY
15. Loratadine 10 mg PO DAILY
16. Omeprazole 20 mg PO BID
17. Pravastatin 20 mg PO QPM
18. Tamsulosin 0.4 mg PO QHS
19. TraZODone 100 mg PO QHS:PRN insomnia
20. Vitamin D 1000 UNIT PO DAILY
21. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
22. amLODIPine 10 mg PO DAILY
23. HydrALAZINE 25 mg PO BID
24. Furosemide 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
over the counter
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Ciprofloxacin HCl 500 mg PO Q12H
1st dose ___ evening, end date ___
4. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth twice a day Disp #*12
Tablet Refills:*0
5. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 10 mg 1 tablet(s) by mouth q6hr Disp #*120 Tablet
Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation
Please take if no bowel movement in 3 days especially on pain
medications
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
8. Aspirin 81 mg PO DAILY
9. BuPROPion 150 mg PO BID
10. econazole 1 % topical BID
11. Escitalopram Oxalate 20 mg PO DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
13. Fluticasone Propionate NASAL 2 SPRY NU DAILY
14. Furosemide 40 mg PO DAILY
Please take ___ tab when you have leg swelling
15. Levothyroxine Sodium 50 mcg PO DAILY
16. LORazepam 0.5 mg PO BID:PRN anxiety
RX *lorazepam 0.5 mg 1 po by mouth twice a day Disp #*14 Tablet
Refills:*0
17. MetFORMIN (Glucophage) 1000 mg PO BID
18. mometasone 0.1 % topical BID 2 weeks per month
19. Omeprazole 20 mg PO BID
20. Pravastatin 20 mg PO QPM
21. Tamsulosin 0.4 mg PO QHS
22. TraZODone 100 mg PO QHS:PRN insomnia
23. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until discussion with PCP
24. HELD- Cyanocobalamin 500 mcg PO DAILY This medication was
held. Do not restart Cyanocobalamin until discussion with PCP
25. HELD- Fish Oil (Omega 3) 1000 mg PO BID This medication was
held. Do not restart Fish Oil (Omega 3) until discussion with
PCP
26. HELD- HydrALAZINE 25 mg PO BID This medication was held. Do
not restart HydrALAZINE until discussion with PCP
27. HELD- Loratadine 10 mg PO DAILY This medication was held.
Do not restart Loratadine until discussion with PCP
28. HELD- Testosterone Cypionate 200 mg IM QWEEK This
medication was held. Do not restart Testosterone Cypionate until
discussion with PCP
29. HELD- Valsartan 320 mg PO DAILY This medication was held.
Do not restart Valsartan until discussion with PCP
30. HELD- Vitamin D 1000 UNIT PO DAILY This medication was
held. Do not restart Vitamin D until discussion with PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Severe Sepsis ___ urinary tract source
2. Metastatic Urothelilial Carcinoma
3. Stage II CKD
4. Deconditioning
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
It was our pleasure taking care of you during your
hospitalization. You came in very sick with an infection we
believe to be in your urine. You were treated with broad
antibiotics an started on a pill for of ciprofloxacin on
___. You are weak from being in the intensive care unit
and will need to take things slow at home with walking and
transferring. Please use your walker at home. We are also
working on setting up hospice at home and they will be arranging
care with you as well.
1. Please take ciprofloxacin 500 mg twice daily starting
tonight, ___ with food until complete on ___.
2. Please only take ___ tab or ___ tab of your Lasix 40 mg with
swelling in your legs.
3. Please hold all of your blood pressure medications
(Valsartan, Hydralazine, Amlodipine) until you follow up with
Dr. ___.
4. Please call Dr. ___ either ___ or ___ to
check in regardless of symptoms
5. Please continue psychiatric medications until further
discussions with psychiatrist
6. Please take ___ tab -1 tab daily of oxycodone every ___ hours
while in pain. This can cause constipation so make sure you take
Senna or over the counter Colace to continue to have bowel
movements every 3 days.
Followup Instructions:
___
|
19821816-DS-15
| 19,821,816 | 29,880,291 |
DS
| 15 |
2154-08-16 00:00:00
|
2154-08-18 12:09:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
___: Bronchioalveolar lavage
History of Present Illness:
In brief, this ___ is a ___ M current non-smoker w/ h/o
ILD(thought to be desquamative interstitial pneumonia (DIP) vs.
respiratory bronchiolitis interstitial lung disease (RB-ILD) vs.
hypersensitivity pneumonitis), and steroid induced hyperglycemia
(on Metformin, %HbA1c 8.9) who p/w hypoxemia to 80% on
ambulation and HR 136. This ___ was dx with ILD after wedge
resection/bx (___), at which time the pt was started on
azathioprine, steroids, and Bactrim (PCP ___. He has been
followed by Dr. ___ and has been considered for
a lung transplant by ___ but ultimately was not considered a
candidate as his lung disease was considered stable. Most recent
PFTs were (___): FVC 31% of predicted, FEV1 of 30% of
predicted, ratio 97%. 6 months ago, he stopped using home O2.
Because the pt was feeling well, 3 months ago he self-dc'ed his
Bactrim. However he started developing worsening SOB and
exertional dyspnea, however he did not seek medical attention
until he presented to his PCP and ___ clinic on ___ for
follow up appointments. In the clinic, he was visibly SOB with
ambulating from the waiting room to the exam room, and was found
to have SpO2 ~80s%, tachycardia 120s, HTN, and was sent to the
___ ED where he was found to have vitals: 97.9 ___ 18
98%RA(lowest 91%).
CXR showed chronic changes c/w ILD, but it was diffcult to
exclude subtle superimposed process. CTA was neg for PE or
aortic abnormality, but showed progression of ILD fibrosis and
increased tract bronchiectasis. No malignancy or overt
consolidation identified, though there was a sight opacification
of the RML/RUL on imaging. His lactate was elevated at 4.7, he
was given 1L IVF with improvement to 2.5, another 1L with
improvement to 2.3, and his metformin was d/c'ed for
hospitalization. Given high c/f ILD flair, pt was put on 500mg
BID solumedrol overnight and restarted on ppx Bactrim.
On arrival to the floor he denies dyspnea at rest. For the last
2 months he endorses only being able to walk ___ block, and in
the past week only being able to walk up ___ stairs without
pausing to catch his breath. He endorses a chronic cough with
minimal sputum for the past ___ years, which has increased only
minimally in the past few days. It is lightly yellow in color,
without blood. He received his influenza vaccine this year. He
has no sick contacts, and notes no fevers, rhinorrhea, nasal
congestion, pharyngitis, headaches or myalgias. He denies chest
pain, leg swelling, lightheadedness. No history of blood clots.
REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation,
hematochezia, dysuria, hematuria.
Past Medical History:
1. Interstitial lung disease - hypersensitivity pneumonitis dx
___
2. Steroid-induced hyperglycemia - on metformin
3. History of Herpes-Zoster
Social History:
Cigarettes: [ ] never [x] ex-smoker [ ] current
Pack-yrs:_10___
quit: _________
ETOH: [ ] No [X] Yes drinks/wk: ___, quit 4 mo ago
Drugs: None
Exposure: [ ] No [x ] Yes [ ] Radiation
[ ] Asbestos [x ] Other:rats, mice and
rabbits
Currently unemployed. Former ___, with exposure to rats.
Stopped working there ___ years ago.
Occupation: ___
Marital Status: [x ] Married [ ] Single
Lives: [ ] Alone [ x] w/ family [ ] Other:
Other pertinent social history: ___
Family History:
Mother: ~___ when passed away, unknown cause of death
Father: ___ passed away ?diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 97.5, BP 162/100, HR 106, R 32-36, SpO2 94%/RA, 77.9
kg, dyspnea ___, pain ___
GENERAL: Pleasant, well appearing, in no apparent distress
though ___ appears to be minimalizing severity of dyspnea
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear.
NECK: Neck Supple, No LAD, No thyromegaly. JVP not elevated.
CARDIAC: Tachycardic, regular. Normal S1, S2. No murmurs, rubs
or ___.
LUNGS: Bilateral upper lung fields without appreciable breath
sounds. Bilateral lower half of posterior lung fields with
coarse crackles. No wheezing.
ABDOMEN: NABS. Soft, non-tender. Abdomen appears somewhat
distended (though ___ reports baseline), with rigidity,
consistent with accessory respiratory muscle use
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis pulses
bilaterally
SKIN: Hypopigmented macules across upper chest and back
consistent with tinea versicolor
NEURO: A&Ox3. Appropriate. Face symmetric, tongue protrudes
midline, palate elevates midline. Preserved sensation
throughout. ___ strength throughout. Normal coordination. Gait
assessment deferred.
PSYCH: Listens and responds to questions appropriately,
pleasant
DISCHARGE PHYSICAL EXAM:
VITALS: Tm 98.1 Tc 98.1 P ___ HR 82(60-80)
RR ___ SpO2 >96%RA->2L
GENERAL: Pleasant, well appearing, cushingoid in appearance, in
no apparent distress after ambulating from bathroom
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear.
NECK: Neck Supple, No LAD, No thyromegaly. JVP not elevated.
CARDIAC: Regular. Normal S1, S2. No murmurs, rubs or ___.
LUNGS: Bilateral upper L lung without appreciable breath
sounds. RUL CTA. Bilateral lower half of posterior lung fields
with coarse crackles. No wheezing.
ABDOMEN: +BS. Non-tender. Abdomen appears somewhat distended
(though ___ reports baseline), with rigidity, consistent
with accessory respiratory muscle use
EXTREMITIES: trace pitting edema, 2+ dorsalis pedis pulses
bilaterally
SKIN: Hypopigmented macules across upper chest and back
consistent with tinea versicolor
NEURO: A&Ox3. Appropriate. CN II-XII intact. ___ strength
throughout. FNF normal. Gait assessment deferred.
PSYCH: Listens and responds to questions appropriately,
pleasant A&Ox3, CNs II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
___ 03:20PM BLOOD WBC-15.6* RBC-5.20 Hgb-15.3 Hct-46.2
MCV-89 MCH-29.4 MCHC-33.1 RDW-14.6 RDWSD-47.5* Plt ___
___ 03:20PM BLOOD Neuts-84* Bands-6* Lymphs-3* Monos-6
Eos-0 Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-14.04*
AbsLymp-0.62* AbsMono-0.94* AbsEos-0.00* AbsBaso-0.00*
___ 03:20PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL
Polychr-NORMAL Schisto-OCCASIONAL Tear Dr-OCCASIONAL
___ 03:20PM BLOOD Plt Smr-NORMAL Plt ___
___ 03:20PM BLOOD Glucose-187* UreaN-24* Creat-0.8 Na-138
K-5.3* Cl-102 HCO3-20* AnGap-21*
___ 09:53PM BLOOD %HbA1c-8.9* eAG-209*
___ 03:33PM BLOOD Lactate-4.7* K-5.3*
DISCHARGE LABS:
___ 10:30AM BLOOD WBC-16.9* RBC-4.41* Hgb-13.2* Hct-40.4
MCV-92 MCH-29.9 MCHC-32.7 RDW-15.2 RDWSD-51.0* Plt ___
___ 10:30AM BLOOD Glucose-267* UreaN-25* Creat-0.8 Na-139
K-4.1 Cl-103 HCO3-24 AnGap-16
___ 10:30AM BLOOD Calcium-9.3 Phos-2.5* Mg-2.1
___ 10:47AM BLOOD Lactate-2.3*
LFTs:
___ 06:57AM BLOOD ALT-28 AST-14 LD(LDH)-436* AlkPhos-104
TotBili-0.2
HEMOLYSIS LABS:
___ 06:57AM BLOOD Hapto-221*
___ 06:57AM BLOOD Ret Aut-1.7 Abs Ret-0.07
DIABETES:
___ 09:53PM BLOOD %HbA1c-8.9* eAG-209*
RHEUM/INFLAMMATORY:
___ 06:57AM BLOOD ANCA-PND
___ 06:57AM BLOOD ___ dsDNA-PND
___ 06:57AM BLOOD RheuFac-10
___ 06:57AM BLOOD SCLERODERMA (SCL-70) ANTIBODY- <1.0 Neg
___ 06:57AM BLOOD RO & LA (SS-A)- <1.0 Neg
___ 06:57AM BLOOD RO & LA (SS-B)- <1.0 Neg
___ 06:57AM BLOOD CYCLIC CITRULLINATED PEPTIDE (CCP)
ANTIBODY, IGG-PND
___ 06:57AM BLOOD ANTI-JO1 ANTIBODY- <1.0 Neg
___ 06:57AM BLOOD ALDOLASE-PND
INFECTIOUS:
___ 06:44AM BLOOD B-GLUCAN-Indeterminate
Results Reference Ranges
------- ----------------
74 pg/mL Negative Less than 60 pg/mL
Indeterminate 60 - 79 pg/mL
Positive Greater than or equal to
80 pg/mL
MICROBIOLOGY:
___ 8:55 am Rapid Respiratory Viral Screen & Culture
BRONCHIAL LAVAGE, GIVE TO MICRO ___ .
Respiratory Viral Culture (Pending):
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.
___ 8:55 am BRONCHOALVEOLAR LAVAGE
BRONCHIAL LAVAGE, GIVE TO MICRO ___ .
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Preliminary):
LEGIONELLA CULTURE (Preliminary):
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Preliminary):
FUNGAL CULTURE (Preliminary):
NOCARDIA CULTURE (Preliminary):
ACID FAST SMEAR (Preliminary):
ACID FAST CULTURE (Preliminary):
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD)
(Pending):
___ 9:43 am SPUTUM Source: Induced.
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH OROPHARYNGEAL FLORA.
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Preliminary):
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___:
SPECIMEN NOT PROCESSED DUE TO: QUANTITY NOT SUFFICIENT.
Less than 2 ml received.
PLEASE SUBMIT ANOTHER SPECIMEN.
TEST CANCELLED, ___ CREDITED.
Reported to and read back by ___ ___ (___) AT 1540
___.
FUNGAL CULTURE (Preliminary):
___ 1:19 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
PFTs (___):
Pre-Observed Pre-%Predicted Predicted
-FVC(L): 1.32 31 4.30
-FEV1(L): 0.99 30 3.34
-FEV1/FVC(%): 75 97 78
-FEF max (L/sec): 4.74 54 8.72
-tE: 7.39
IMAGING:
- ___ ECHO: The left atrium is normal in size. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. The estimated right
atrial pressure is ___ mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: No ASD or PFO seen. Normal global and regional
biventricular systolic function.
- ___ CTA: No evidence of pulmonary embolism or aortic
abnormality. Extensive fibrotic lung changes involving both
lungs has progressed from ___ with considerable tracts
bronchiectasis also increased from the prior examination.
- ___ CXR: Similar pattern of perihilar ground-glass opacity
likely reflects known hypersensitivity pneumonitis. Difficult to
exclude a subtle superimposed process.
- ___ EKG: normal sinus rhythm
PATHOLOGY:
R LOBE WEDGE RESECTION BX x3 (___):
A similar process appears to involve all three lung wedge
resections, though to varying degrees. The dominant finding is
that of single and cohesive clusters of pulmonary macrophages
(many fine pigment laden) filling the alveolar spaces and small
airways. There is also an associated mild to moderate uniform
interstitial fibrosis, though without evidence of architectural
distortion or honeycomb change (most severe in part 3). Multiple
foci of squamous metaplasia and bronchiolar metaplasia are
observed around the small airways, and patchy lymphocytic
aggregates are present. Abundant carbon pigment deposition is
present along areas of lymphatic drainage.
The interstitial fibrosis is relatively uniform in character,
and no fibroblastic foci are identified. There are no granulomas
or areas of organizing pneumonia identified. Eosinophils are not
present in any
significant numbers. There is no evidence of a vasculitis or
capillaritis. Polarizable silicates are scant. There is no
evidence of an acute infectious process (also see associated
microbiologic culture results, ___ ___ ___, and no
malignancy is identified.
In total, the findings are consistent with desquamative
interstitial pneumonia (DIP) / respiratory bronchiolitis
interstitial lung disease (RB-ILD). There are no findings to
suggest a hypersensitivity
pneumonitis. Clinical and radiologic correlation is advised.
This case was shown and discussed at ___ Pulmonary
Medicine-Thoracic Imaging conference on ___ by Dr. ___
___.
Brief Hospital Course:
# Hypoxia: Likely ILD progression. Pt w/ history f ILD ___ years,
biopsy from ___ showing likely desquamative interstitial
pneumonia (DIP) vs. respiratory bronchiolitis interstitial lung
disease (RB-ILD). Both pathologies usually resolve with smoking
cessation though, and the pt endorses quitting Tob ___ years ago.
Urine cotinine pending. Pt presented to follow up pulmonology
and PCP ___ ___ with hypoxemia (91% on RA) and
tachycardic to 136 that was responsive to IVF. TTE + bubble
study (___) were neg for cardiac pathology or shunting. CXR was
equivocal for pneumonia vs. atelectasis in addition to
underlying ILD. CTA revealed no evidence of PE, but was
consistent with progression of ILD. There was no overt evidence
of pneumonia on sputum neg (___), and pt had baseline
leukocytosis with Neutrophilic predominance, but is on chronic
steroids and received a large pulse in the ED (___). Pulmonology
was consulted. Elevated lactate (4.7) and slight worsening of
cough with minor sputum production gives mild c/f PJP PNA i/s/o
immunosuppression (on Azathioprine) and discontinuation of
Bactrim (has not been taking for 3 months prior to
presentation). BAL was performed ___ (viral Ag labs neg,
other infectious labs pending). Without any positive infectious
work up, clinical progression of sx and imaging was thought to
be more representative of interval worsening of his underlying
ILD, and pt was continued on home prednisone, azathioprine.
Restarted on Bactrim prophylaxis. Pulmonology also started an
extensive rheumatologic and infectious work up for the ___
to follow up with as an outpatient. On d/c RF, SS-A, SS-B,
SCL-70, ___ Ab Neg. The ___ could also follow up with
a swallow eval as outpatient as chronic aspiration may be
contributing to his hypoxemia given history of choking while
eating. The ___ was discharged on home oxygen after
desaturating to SpO2 85% on room air with ambulation, however
the pt did not feel significantly short of breath during
hospitalization, denied chest pain, and denied worsening of his
baseline cough. Hypoxemia is mild at rest with SpO2 >94% on 2L.
Pt was seen by ___ Transplant team ___ and rejected from lung
transplant list. F/u appointment with ___ Transplant team on
___, 10AM.
# Leukocytosis: likely secondary to chronic prednisone use and
large solumedrol pulse on ___ of 500mg x2, epecially given lack
of fever or localizing infectious symptoms.
# Steroid-induced hyperglycemia: on metformin 850mg at home,
though ___. ISS during hospitalization. %Hgb A1C 5.7 in
___. %Hgb A1c now 8.9 (___).
# Transient anemia: Normocytic. H/H 12.___.2. Etiology unknown
but may be ACD. Labs were negative for hemolysis. Consider iron
labs as outpatient.
# Hypertensive urgency: BP in clinic yesterday 162/90, however
in ED, markedly elevated to 188/129. No intervention given. BP
downtrended to 141/108 prior to transfer to floor. On arrival to
floor, BP 162/100. Labetalol 200 mg PO TID started. Placed on
telemetery. BP controlled and normotensive at discharge.
# elevated lactate: presented with lactate elevated to 4.7 on
admission, which downtrended to 2.3 after IVF on discharge. No
hypotension (rather, hypertensive urgency, as above).
TRANSITIONAL ISSUES:
- F/u appointment with ___ Transplant team on ___, 10AM
- F/u pending rheumatologic and infectious work up
- Consider swallow eval as chronic aspiration may be
contributing given history of choking with eating
- F/u DLCO and spirometry as outpatient with Dr. ___
- ___ discharged on home O2
- Elevated BG in the setting of steroids managed with ISS while
in hospital, please follow up as an outpatient
- Started and discharged on labetalol TID given SBP to 190s on
admission, re-evaluate as outpatient need for medication, SBP
110-130
- Restarted on PCP ppx
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 40 mg PO DAILY
2. MetFORMIN (Glucophage) 850 mg PO BID
3. Azathioprine 100 mg PO DAILY
Discharge Medications:
1. Azathioprine 100 mg PO DAILY
2. PredniSONE 40 mg PO DAILY
3. MetFORMIN (Glucophage) 850 mg PO BID
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
5. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
6. Labetalol 200 mg PO TID
RX *labetalol 200 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Interstitial lung disease progression
-Anemia of chronic disease
-Hypertension
- steroid-induced hyperglycemia
Discharge Condition:
SpO2 >94% on 2L at rest, does not complain of shortness of
breath/chest pain/cough
Desaturates to SpO2 ~85% on room air with ambulation.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were not getting
enough oxygen, your heat rate and blood pressure were elevated.
We initially gave you some antibiotics to treat what we thought
might be a lung infection, but we stopped these during your
hospitalization since we had a low suspicion for this. Imaging
of your lungs was performed and showed progression of your
pre-existing lung disease, and no clear sign of a lung
infection. We also took a sample of the mucous from deep in your
lungs (bronchioalveolar lavage). We have been unable to isolate
any kind of infection prior to your discharge, but there are
some labs that are pending. We therefore thought your increased
difficulty breathing was more likely due to worsening of your
pre-existing lung disease. You were given steroids,
azathioprine, as well as an antibiotic (Bactrim) to help prevent
a fungal infection of your lungs. You should continue these
medications when you leave the hospital. You will be seen by the
___ Transplant team for re-evaluation in ___.
Followup Instructions:
___
|
19822093-DS-22
| 19,822,093 | 27,103,693 |
DS
| 22 |
2145-11-05 00:00:00
|
2145-11-05 18:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Weakness and confusion
Major Surgical or Invasive Procedure:
___- Debridment of the left plantar footby podiatry
History of Present Illness:
___ hx of poorly controled DM, CAD s/p stenting, Osteo L foot s/p
6 week course of cipro and ctx, GBS bacteremia ___ ___ presented
with confusion and gait unsteadiness earlier today. Earlier
today his friend called EMS because he was unsteady on his feet
an unable to walk 20 feet and had cold sweets. He had a headache
for three though but it has improved and had no neck pain or
light sensititivy. Pt reports feeling worsening weakness and
tiredness over the past week with associated occasional cold
sweats. On the day of admission he was walking with his friend
when he became unsteady and confused and had cold sweats. His
friend called EMS. He denied any chest pain or shortness of
breath. Of note patient just completed a 6 week course of cipro
and ctx on ___. during that admisison he was followed by
Podiatry who found a polymicrobial wound and there was concern
for osteo however no bone biopsy was performed.
Initial Vitals were 97.8 99 113/51 18 99%. EKG was notable for
Rate of 97 ___ sinus with LAD and poor RV progresssion, unchanged
from prior. Chem 7 showed Cr 1.8 from baseline of 1.4
(___). LFT's were normal with no acute process on CXR. UA
not suggestive of UTI. Tpn < 0.01. Leukocytosis at 14 with left
shift (18% neutrophils and no bands). ___ the ED received 1.5L
IVF and BP improved to 130s systolic from 95, HR ___ the ___.
Blood cultures were drawn. ___ 230's and repeat was ___ 150s, no
insulin was administered. He is admitted to the medical team for
further workup of likely infection of no known source. Pt was
not given any antibiotics ___ the ED as no clear source was
apparent.
Past Medical History:
IDDM (Diagnosed ___ ___
-CAD
-CKD
-hyperlipidemia
-3-vessel CABG? ___
-?MYOCARDIAL INFARCT, UNSPEC SITE & CARE
-PVD (peripheral vascular disease) due to DM
-Left ___ metatarsal partial amputation and left ___ matatarsal
amputation ___
-Right foot amputation at tarsal/metatarsal junction ___
-Cyst removal from chin ___ years ago)
-Depression
-Presumed osteomyelitis of left foot ___, polymicrobial wound
infection Strep, serratia, Enterobacter, enterococcus, C
septicum, coag negatiev staph. No biospy was performed. TTE
performed with no obvious vegetations. Received full 6 wk course
of Cipro and Ceftriaxone followed by the ___ clinic and
completed on ___.
Social History:
___
Family History:
No diabetes mellitus.
Physical Exam:
Admission Physical Exam
GEN Alert, oriented, irritable because doesn't like the dinner
HEENT large beard, mmm, no visible orpharynx lesions
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR no MRG appreciated ABD soft NT ND normoactive bowel
sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
LABS: reviewed, see below
Gait- steady with a cane ___ right hand
DIscharge Physical Exam
98.1, 124/80, 63, 18, 98RA Wt 96.1kg
Gen: aaox3, NAD. lying ___ bed ___ NAD,pleasant
HEENT: PEERLA, MMM, no oral lesions
Cardiac: RRR, no MRG
Lungs: CTAB
Abd: Sfot, nontender nondistended normoactive bowel sounds
Extremities: No peripheral edema. When foot was unwrapped
plantar incision has some dried blood around it and is well
approximated and no surrounding erythema or warmth
Pertinent Results:
Admission labs:
___ 01:55PM BLOOD WBC-14.1* RBC-4.73 Hgb-14.1 Hct-42.0
MCV-89 MCH-29.8 MCHC-33.6 RDW-13.0 Plt ___
___ 01:55PM BLOOD Neuts-81.0* Lymphs-10.6* Monos-6.2
Eos-2.0 Baso-0.3
___ 06:15AM BLOOD ___ PTT-28.2 ___
___ 01:55PM BLOOD ESR-55*
___ 01:55PM BLOOD Glucose-251* UreaN-40* Creat-1.8* Na-138
K-4.3 Cl-103 HCO3-21* AnGap-18
___ 01:55PM BLOOD ALT-20 AST-16 AlkPhos-87 TotBili-0.7
___ 01:55PM BLOOD CRP-13.6*
Urine studies
___ 05:29PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:29PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 05:29PM URINE RBC-<1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
___ 05:29PM URINE CastHy-7*
Discharge Labs:
Microbiology:
Blood cultures ___ and ___- NEGATIVE
___ 7:57 am SWAB Source: left foot ulcer.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture..
STAPH AUREUS COAG +. MODERATE GROWTH.
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 .
LINEZOLID AND Daptomycin Sensitivity testing per ___.
___
___ ___. SENSITIVE TO Daptomycin (0.75
MCG/ML).
Daptomycin Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
DAPTOMYCIN------------ S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 11:02 am SWAB LEFT FOOT WOUND.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ENTEROBACTER CLOACAE COMPLEX. RARE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Piperacillin/Tazobactam Sensitivity testing per ___.
___
___ ___.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
AMIKACIN-------------- <=2 S
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
___ 05:38AM BLOOD WBC-6.1 RBC-4.19* Hgb-12.2* Hct-36.4*
MCV-87 MCH-29.1 MCHC-33.5 RDW-12.7 Plt ___
___ 06:02AM BLOOD Glucose-163* UreaN-25* Creat-1.2 Na-144
K-3.7 Cl-110* HCO3-27 AnGap-11
Brief Hospital Course:
Mr. ___ is a ___ with PMH poorly controlled DM-2, PVD, CKD
stage III, CAD s/p stent, and recent osteomyelitis of the lef
foot s/p 6 week course of abx here with MRSA and enterobacter
cellulitis of the left foot and s/p debridement on ___ and
prerenal azotemia that responded to IV fluids.
# Left foot MRSA cellulititis- pt w/ PMH of osteo who completed
a 6 week course of treatment for a polymicrobial presumed
osteomyelitis ___ this area on ___ with cipro/ceftriaxone.
On presentation he felt weak and was hypotensive (partially
dehydrated). He had an elevated WBC that trended down without
antibiotics and his weakness and hypotension resolved with
minimal fluids. On admission he was noted to have some erythema
of his left foot and podiatry was consulted. Initial cultures
from drainage on ___ grew out MRSA and the pt was started on
vancomycin. Podiatry performed an excisional debridement ___ the
OR and they found that the infection did NOT track to bone.
Cultures from this debridement ultimately grew out resistant
enterobacter and the patient was started on ertapenem. His
outpatient ID physicians were consulted and recommended a course
of MRSA coverage +Ertapenem as an outpatient x ___ with
follow-up with them ___ clinic.
-pt needs f/u with podiatry (Dr. ___ and ___ need
stitches removed ___ 3 weeks from discharge
-Vancomycin and Ertapenem on discharge
-pt will need weekly CBC, CMP and Vanc trough drawn and sent to
the ___ clinic
-pt has f/u with Dr. ___ ID on ___ to discuss need for
continuation of treatment.
# Acute on chronic kidney disease: Likely secondary to being
intravascularly depleted as he had hyaline casts ___ his urine
and it responded back to baseline with IV hydration. His
medications were renally dosed and his creatinine was trended
while he was here and remained stable.
# CAD- patient had no chest pain during his admission.
-his metoprolol succinate was decreased to 25mg po qday instead
of 50 gievn his hypotension on admission, and his BPs remained
within normal limits while here.
# DM: He remained having elevated BS ___ the 200-300s during his
hospitalization and did not adhere to a diabetic diet while
inhouse. He was continued on his home regimen of Insulin/lispro
while here and is discharged on the same regimen
# Depression:
- continue home CITALOPRAM 20 mg daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
hold for sbp<100 or hr<60
3. Humalog ___ 40 Units Breakfast
Humalog ___ 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Atorvastatin 80 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. FoLIC Acid ___ mcg PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. FoLIC Acid ___ mcg PO DAILY
6. Humalog ___ 40 Units Breakfast
Humalog ___ 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Vancomycin 1000 mg IV Q 12H
anticipated duration 4 weeks
8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
9. ertapenem *NF* 1 gram Injection daily
anticipated duration is 4 weeks
10. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
MRSA Cellulitis
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 you were here at
___.
You were admitted to the hospital with an infection of your left
foot. While you were here you were seen by podiatry who took you
to the OR to drain and debride some of the infected tissues. As
the infection was resistant to many antibiotics we had to place
a PICC Line to give you IV antibiotics which you will need to
continue for 4 weeks. As you were unable to bear weight on the
infected site while it heals ___ recommended that you go to
rehab.
-You will need to have blood tests done weekly while taking
these antibiotics.
Followup Instructions:
___
|
19822093-DS-24
| 19,822,093 | 27,612,946 |
DS
| 24 |
2148-07-18 00:00:00
|
2148-07-26 16:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / vancomycin
Attending: ___.
Chief Complaint:
Left foot pain and nausea
Major Surgical or Invasive Procedure:
___: L ___ and ___ ray amputations with VAC placement
___: R PICC placement
History of Present Illness:
___ yo M with a history of poorly controlled type II diabetes on
insulin, CAD c/b MI s/p stents who presents with one day of
nausea and vomiting. He also notes worsening left foot pain. He
reports that his ___ noted a foot wound and that was the first
time he noticed it might be infected. He was then referred to
the ED.
Per review of his Atrius records, Mr. ___ was reported to have
increased confusion, fatigue and difficulty with ambulation for
the past few weeks. There were no complaints of chest pain, SOB,
DOE, dizziness, or lightheadedness.
___ the ED, initial vitals were: 100 110/70 18 97% RA.
- Labs were significant for WBC 13.3 with 86.2% PMNs, H&H
12.4/37.6, plts 484. BUN/Cr ___.
- Imaging revealed resorption of the fifth metatarsal and
residual fourth proximal phalanx with soft tissue gas consistent
with osteomyelitis.
- The patient was given 1LNS, clindamycin and levofloxacin.
- He was evaluated by podiatry who attempted a bedside I&D.
However, they could not fully debride the area so he was taken
to the OR.
- ___ the OR, he received general anaesthesia and underwent open
left fourth and fifth ray amputation with VAC placement. He
required neo intra-op but was weaned ___ the PACU. Gram stain
returned with GPC ___ pairs and clusters and GNRs.
Past Medical History:
-type II DM, on insulin
-CAD
-CKD, stage III
-hyperlipidemia
-3-vessel CABG? ___
-?MYOCARDIAL INFARCT, UNSPEC SITE & CARE
-PVD (peripheral vascular disease) due to DM
-Left ___ metatarsal partial amputation and left ___ matatarsal
amputation ___
-Right foot amputation at tarsal/metatarsal junction ___
-Cyst removal from chin ___ years ago)
-Depression
-Presumed osteomyelitis of left foot ___, polymicrobial wound
infection Strep, serratia, Enterobacter, enterococcus, C
septicum, coag negatiev staph. No biospy was performed. TTE
performed with no obvious vegetations. Received full 6 wk course
of Cipro and Ceftriaxone followed by the ___ clinic and
completed on ___.
Social History:
___
Family History:
No diabetes mellitus.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 98.3 118/81 89 20 97%RA
General: Alert, oriented, intermittently tearful and yelling
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: 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, left foot with wound vac ___ place
draining minimal amounts of red blood, right foot with past
amputations
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 98.7 97.6 154/97 (140-150s/80-90s) 67 (60-70s) 18 100%RA
FSBG 141-312
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, EOMI, PERRL
Neck: Supple
CV: RRR, distant heart sounds, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, non-tender, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Left foot with past ___ metatarsal amputation, new ___ and
___ metatarsal amputation with dressing ___ place, soiled/d/i and
VAC ___ place. Right foot with past tarsal/metatarsal amputation.
Bilateral feet warm, well-perfused, capillary refill ___
seconds.
Neuro: CNII-XII intact, MAEE.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:25PM WBC-13.3* RBC-4.27*# HGB-12.4*# HCT-37.6*#
MCV-88 MCH-29.0 MCHC-33.0 RDW-12.3 RDWSD-39.8
NEUTS-86.2* LYMPHS-5.5* MONOS-7.5 EOS-0.1* BASOS-0.2 IM ___
AbsNeut-11.47* AbsLymp-0.73* AbsMono-1.00* AbsEos-0.01*
AbsBaso-0.03
PLT COUNT-484*
GLUCOSE-93 UREA N-25* CREAT-1.5* SODIUM-134 POTASSIUM-4.0
CHLORIDE-99 TOTAL CO2-23 ANION GAP-16
ALT(SGPT)-17 AST(SGOT)-23 ALK PHOS-87 TOT BILI-0.6
LIPASE-20
ALBUMIN-3.1*
___ PTT-33.1 ___
LACTATE-1.8
RELEVANT LABS:
==============
___ 04:55AM BLOOD WBC-10.6* RBC-3.97* Hgb-11.4* Hct-35.4*
MCV-89 MCH-28.7 MCHC-32.2 RDW-12.4 RDWSD-40.2 Plt ___
___ 04:39AM BLOOD WBC-5.7 RBC-3.63* Hgb-10.3* Hct-32.7*
MCV-90 MCH-28.4 MCHC-31.5* RDW-12.4 RDWSD-41.1 Plt ___
CK(CPK)-22*
___ 04:55AM BLOOD CRP-133.9*
DISCHARGE LABS:
===============
___ 06:47AM BLOOD WBC-6.6 RBC-3.95* Hgb-11.2* Hct-35.4*
MCV-90 MCH-28.4 MCHC-31.6* RDW-12.1 RDWSD-39.6 Plt ___
Glucose-252* UreaN-23* Creat-1.0 Na-132* K-4.5 Cl-100 HCO3-25
AnGap-12
Calcium-8.7 Phos-2.3* Mg-1.9
IMAGING / STUDIES:
==================
___ FOOT X-RAY
Resorption of the fifth metatarsal head and residual fourth
proximal phalanx, with adjacent soft tissue gas, consistent with
osteomyelitis.
___ FOOT X-RAY
___ comparison with the study of ___, there has been further
resection of phalanges and a portion of the metatarsals of the
fourth and fifth digits. Otherwise little change.
___ CXR
No acute cardiopulmonary process
MICROBIOLOGY:
==============
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:55 pm SWAB Source: L foot.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
ANAEROBIC CULTURE (Final ___:
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. Bacterial growth was screened for
the presence
of B.fragilis, C.perfringenes, and C.septicum. None of
these species
was found.
___ 11:57 pm TISSUE Site: BONE LEFT FOOT.
GRAM STAIN (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0315.
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
TISSUE (Final ___:
WORK UP PER ___ ___ (___).
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
PROTEUS VULGARIS. MODERATE GROWTH.
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
MORGANELLA ___. SPARSE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PROTEUS VULGARIS
| ___
| |
STAPHYLOCOCCUS, COAGULASE N
| | |
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- 2 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S 1 S
CLINDAMYCIN----------- <=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S <=1 S <=0.5 S
LEVOFLOXACIN---------- 0.25 S
MEROPENEM-------------<=0.25 S <=0.25 S
OXACILLIN------------- <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final ___:
MIXED BACTERIAL FLORA.
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. The presence of B.fragilis,
C.perfringens,
and C.septicum is being ruled out.
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
___ 2:29 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).
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
___ yo M with a history of Asperger's syndrome, poorly controlled
type II diabetes on insulin c/b neuropathy, CAD and MI s/p
stents, PVD, s/p right TMA and left ___ and ___ toe amputations
___ non-healing diabetic ulcers, h/o osteomyelitis, and CKD
(stage III), who presented with left foot pain, found to have
deep soft tissue infection and osteomyelitis, now s/p amputation
of left ___ and ___ rays and on IV ceftriaxone and PO flagyl.
ACUTE ISSUES:
=============
# Osteomyelitis/SSTI of left foot: Likely ___ diabetic ulcer
over ___ submetatarsal region and ___ the setting of poorly
controlled T2DM and PVD. Went to OR for emergent left ___ and
___ ray amputations. Tissue culture grew Proteus, Morganella
___, coag-negative staph, viridans strep, and Bacteroides
fragilis. Blood cultures were negative. Initial antibiotics for
broad coverage were clindamycin, levofloxacin, and
metronidazole. These were transitioned to daptomycin and
meropenem given history of prior presumed osteomyelitis with MDR
enterobacter and MRSA. Given final culture results, per ID
recommendations, antibiotics were ultimately transitioned to
ceftriaxone 1g IV q24h and PO flagyl (see antibiotic chart
below). Right PICC was placed ___. Per podiatry, there was no
indication for further surgical debridement at this point; they
had recommended left TMA for definitive management, but this can
be delayed. Patient will be discharged to rehab for IV
antibiotics and wound care. He will follow up with podiatry at
___ as well as his regular podiatrist at ___.
Abx course:
- Clindamycin 600mg IV q8hr, day 1 = ___ - ___
- Levofloxacin 750mg IV daily, day ___ - ___
- Metronidazole 500mg IV q8hr, day ___ - ___
- Daptomycin 550 mg IV Q24H, day 1 = ___ - ___
- Meropenem 500 mg IV Q6H, day 1 = ___ - ___
- Ceftriaxone 1g IV Q24H = ___ - now
- Metronidazole 500 mg PO/NG Q8H - ___ - now
# Nausea: Likely due to acute illness from osteomyelitis/SSTI,
resolved after first few days of hospitalization after surgery
and initiation of antibiotics. Lipase normal, LFTs normal.
Abdominal exam benign.
# Failure to thrive: Social work spoke at length with patient,
brother, ___ services, and health care proxy. There were
significant concerns about cleanliness of apartment and
patient's ability to care for himself at home. ___ services were
concerned for their own safety and expressed unwillingness to
work with patient ___ the future. Social work has recommended
increased home services upon discharge, possibly through Elder
Services.
# Fatigue/Altered Mental Status: Patient did not report fatigue
during hospitalization and was alert and oriented x3 on exam.
His fatigue was likely due to acute illness from
osteomyelitis/SSTI. UA bland and urine culture negative
(although collected after several days of antibiotics).
CHRONIC ISSUES:
===============
# Diabetes: Most recent A1c 8.9%. He was continued on home
glargine (40U at breakfast and, increased from 37U to 40U
bedtime) and humalog (15U at breakfast and dinner) and insulin
sliding scale. FSBG were well-controlled on this regimen, with
some bumps likely due to dietary indiscretion.
# Hypertension: Home metoprolol 50mg qd continued during
hospitalization. BPs were initially well-controlled but
uptrended to 140-180s systolic on ___. Hydralazine PO 20mg TID
was started on ___. Patient had high BP overnight. Hydralazine
was stopped and losartan 25mg qd was started on ___. BPs stable
___ 150s systolic.
# CAD: Per At___ cardiology records, Mr. ___ had a
pharmacologic stress test which was consistent with at least 2VD
and a mildly reduced EF to 40-45%. Given his diabetes, there was
concern for multi-vessel disease. ___ ___, this was discussed
with the patient who opted to defer making a decision about next
steps including additional stents vs coronary revascularization.
It was recommended he undergo diagnostic cardiac
catheterization, which was deferred by the patient. Patient was
concerned that he had to go to hospital for his foot infection
rather than to the ___ clinic to see his cardiologist. He had
no signs or symptoms of an acute cardiac event during this
hospitalization. His home aspirin, atorvastatin, and metoprolol
were continued. He is scheduled to follow up with his
cardiologist at ___.
# Depression: Home citalopram continued.
TRANSITIONAL ISSUES:
===============================
-Patient will require VAC changes every other day.
-Infectious disease ___ clinic follow-up being arranged at time
of discharge. Infectious disease team will contact rehab
facility to coordinate these appointments.
-Will need weekly labs checked while on ceftriaxone: CBC, BUN,
creatinine, ALT, AST, Alk phos, total bilirubin, CRP, ESR.
Please fax results to ___ Infectious Disease ___ clinic at
___
-Patient will require ceftriaxone 1g Q24H IV and metronidazole
500mg PO Q8H for total antibiotic course of 6 weeks, final day
of antibiotics ___
-Patient will follow up with podiatrist at ___, Dr. ___
on ___ at 1:00PM. He will follow up with podiatrist at
___ on ___ at 10:00AM.
-per Atrius cardiology records, he had an pharmacologic stress
test which was consistent with at least 2VD and a mildly reduced
EF to 40-45%. Given his diabetes, there was concern for
multi-vessel disease. ___ ___, this was discussed with the
patient who opted to defer making a decision about next steps
including additional stents vs coronary revascularization. It
was recommended he undergo diagnostic cardiac catheterization,
which was deferred by the patient.
Patient will follow up with cardiologist at ___. He has
appointments to see NP on ___ at 11:10AM and MD on ___ on 11:00AM.
-Patient will need to have an appointment set up to see his PCP
___ on discharge from rehab.
-Patient was started on losartan 25mg qd for high blood
pressures during hospitalization.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Humalog 30 Units Breakfast
Humalog 30 Units Dinner
detemir 40 Units Breakfast
detemir 37 Units Bedtime
2. Atorvastatin 80 mg PO QPM
3. Citalopram 20 mg PO DAILY
4. FoLIC Acid ___ mcg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Aspirin 81 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Citalopram 20 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Losartan Potassium 25 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth Q4H:PRN Disp #*30
Capsule Refills:*0
8. FoLIC Acid ___ mcg PO DAILY
9. Glargine 40 Units Breakfast
Glargine 40 Units Bedtime
Humalog 15 Units Breakfast
Humalog 15 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
10. CeftriaXONE 1 gm IV Q24H
final day ___
11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
final day ___
12. Acetaminophen 1000 mg PO Q8H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
==================
Osteomyelitis and deep soft tissue infection of left ___ and ___
metatarsals
Secondary diagnoses:
====================
Diabetes mellitus, type II
CAD
CKD stage III
PVD
L ___ metatarsal partial amputation and ___ metatarsal
amputation ___
R tarsal/metatarsal amputation ___
Asperger's syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___
because you had an infection ___ your left foot and you were
nauseous. You had x-rays that showed the infection had spread to
your bone. You had a surgery that removed the infected bone. You
were then started on treatment with IV antibiotics and another
antibiotic that you can take orally to treat any remaining
infection.
___ terms of your nausea, we think that it was most likely due to
the infection. It improved when the infection was controlled and
while you were taking the antibiotics.
You will be going to rehab to complete a course of IV
antibiotics. The VAC dressing will stay on your foot and will be
changed every other day at the rehab center. If you put weight
on your left foot, please try to only put weight on your heel.
You will have an appointment with your foot surgeon on ___
at 1:00PM. When you are preparing to leave rehab, you should ask
the staff to help set up an appointment for you with your PCP,
___. You will also follow up with your podiatrist at
___ on ___.
As we discussed during your stay, it will also be important for
you to follow up with your cardiologist. You have an appointment
to see Ms. ___, NP, at ___ on ___ at 11:10
AM. You have an appointment with Dr. ___ at ___ on ___ at 11:00 AM.
Thank you for letting us take part ___ your care!
Sincerely,
The ___ Team
Followup Instructions:
___
|
19822093-DS-25
| 19,822,093 | 24,395,472 |
DS
| 25 |
2148-08-16 00:00:00
|
2148-08-16 17:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / vancomycin
Attending: ___.
Chief Complaint:
Agitation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old man with a history of IDDM s/p L foot
ulcer debridement who presented from ___ (___)
___ by ambulance after he had been noted to be
agitated towards the stuff and other patients, and is now being
admitted to the medicine floor for management of osteomyelitis.
Most of the history was obtained from prior charts as the
patient was too somnolent to give an adequate history on
admission to the floor.
Reportedly, the patient had been in his usual state of health at
___ when he got into an argument with the center staff. Per the
patient, he asked the staff to turn down his neighbor's TV which
was loud at 5 in the morning. After he became agitated towards
the neighbor and other patients, he was brought in for for
aggression.
In the ED, his vitals were: T 98.4 HR 112 BP 92/62 RR 18 SpO2
100% on RA. His labs were notable for a WBC of 6.2 and H/H=
11.9/37.5, Platelets =235 and ESR= 47. Urine tox screen was
negative and he was adamant about returning to ___. Psychiatry
was consulted and they deemed that, while the patient did not
meet section 12a criteria, he lacked capacity to manage his
antibiotics and PICC line which he needs to treat his ongoing
osteomyelitis. The patient however expressed to psychiatry that
he would be willing to go back to ___ should a bed become
available, upon which ___ ED Case management was involved.
He received ___ haldol/diphenhydramine for agitation and
psychiatry recommended continuation of all psych meds. Prior to
transfer to the floor, ___ staff informed ___ ED Case
management that a bed may become available on ___.
The patient was thus admitted for lack of capacity and for
management of osteomyelitis.
Past Medical History:
-type II DM, on insulin
-CAD
-CKD, stage III
-hyperlipidemia
-3-vessel CABG? ___
-?MYOCARDIAL INFARCT, UNSPEC SITE & CARE
-PVD (peripheral vascular disease) due to DM
-Left ___ metatarsal partial amputation and left ___ matatarsal
amputation ___
-Right foot amputation at tarsal/metatarsal junction ___
-Cyst removal from chin ___ years ago)
-Depression
-Presumed osteomyelitis of left foot ___, polymicrobial wound
infection Strep, serratia, Enterobacter, enterococcus, C
septicum, coag negatiev staph. No biospy was performed. TTE
performed with no obvious vegetations. Received full 6 wk course
of Cipro and Ceftriaxone followed by the ___ clinic and
completed on ___.
- osteomyelitis (___), treated with ceftriaxone and flagyl via
___
Social History:
___
Family History:
No diabetes mellitus.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
Vitals: 98.6 159/99 108 18 99%RA
General: Very somnolent but arousable and responsive to loud
stimuli, however in NAD
HEENT: Sclera anicteric with pink conjunctiva.
Neck: Supple
Lungs: CTAB, no w/r/r
CV: RRR, normal S1 and S2, no m/g/r
Abdomen: Soft,non-distended and non-tender. Liver edgee not
palpable below the costal margin.
GU: no foley
Ext: Notable for a well-healed R transverse tarsal amputation. L
well-wrapped in dry nonexudative bandage. No edema
Neuro: Squeezes hands when asked to.
DISCHARGE PHYSICAL EXAM:
=======================
Vitals: 97.9 84 120s- 160s/60s-90s 18 100%RA
General: alert, oriented, sitting in bed and tearful about "I
had a nightmare that my life was insignificant".Otherwise not in
acute distress.
HEENT: Sclera anicteric with pink conjunctiva.
Neck: Supple with no LAD
Lungs: CTAB, no w/r/r
CV: RRR, normal S1 and S2, no m/g/r
Abdomen: Soft,non-distended and non-tender. Liver edge not
palpable below the costal margin.
GU: no foley
Ext: s/p R transverse me-tarsal amputation, which is well
healed. L foot wrapped in dry nonexudative bandage, no visible
pus or exudate. No edema or cyanosis
Neuro: Grossly intact to observation, AOX3
Pertinent Results:
ADMISSION LABS:
==============
___ 10:30AM BLOOD WBC-6.2 RBC-4.09* Hgb-11.9* Hct-37.5*
MCV-92 MCH-29.1 MCHC-31.7* RDW-15.0 RDWSD-50.7* Plt ___
___ 10:30AM BLOOD Glucose-326* UreaN-19 Creat-1.4* Na-131*
K-4.6 Cl-99 HCO3-20* AnGap-17
DISCHARGE LABS:
===============
___ 06:18AM BLOOD WBC-5.3 RBC-4.00* Hgb-11.6* Hct-36.4*
MCV-91 MCH-29.0 MCHC-31.9* RDW-14.7 RDWSD-49.4* Plt ___
___ 06:18AM BLOOD Plt ___
___ 06:18AM BLOOD Glucose-79 UreaN-16 Creat-0.9 Na-135
K-4.0 Cl-101 HCO3-26 AnGap-12
___ 06:18AM BLOOD Calcium-9.4 Phos-3.4 Mg-1.9
URINE STUDIES:
==============
___ 10:19AM URINE Hours-RANDOM UreaN-591 Creat-97 Na-109
K-44 Cl-88
MICROBIOLOGY:
============
none
IMAGING:
=======
___ CXR: A right-sided PICC terminates in the mid SVC,
unchanged in position compared the prior study done on ___,
prior to admission.
PROCEDURES:
==========
none
Brief Hospital Course:
Patient will require rehab for less than 30 days.
===
Mr. ___ is a ___ year old man w/ history of IDDM c/b
osteomyelitis s/p L foot ulcer debridement currently on
ceftriaxone and flagyl, who presented with agitation and deemed
to lack decision-making capacity by psychiatry, and susequently
admitted for osteomyelitis antibiosis and now being discharged
to rehabilitation.
#AGITATION: Pt presented from rehab with severe agitation
(verbal only, non-combative)towards staff and other pts
regarding loud TV noise early in the AM in his neighbor's room.
Per negative tox screen, agitation was unlikely drug-induced.
Initially received ___ Haldol/diphenhydramine in the ED, with
improvement in agitation. He did not receive any addition
antii-agitation drugs during his course. Also, per psych
recommendations, his Celexa for depression was continued.
#OSTEOMYELITIS: The patient had recently undergone debridement
of ___ and ___ metatarsal for osteomyelitis on ___ by Dr,
___ without any complications. He was admitted with a PICC
line for which he was getting IV flagyl 500mg Q8H and 1gm
Ceftriaxone Q24H. Following confirmation of correct PICC
placement, we resumed his antibotics and he was also seen by
wound care specialists who felt the skin graft was intact and
recommended regular cgentle leaning with wound cleanser and dry
patting. They also recommended adaptic - nonadherent dressing
followed by dry gauze and ABD pad, secure with kerlix to be
changed daily.
At discharge, the falgyl was converted to PO administration at
the same dose.
___: Patient p/w creatinine of 1.4 up from a baseline of ~1.1.
Given return to baseline with 1L LR infusion, ___ was likely
pre-renal i/s/o poor PO intake.
#IDDM: Given that patient is an insulin-dependent diabetic, both
his basal and prandial glucose regimens were continued. He
takes 40U of glargine twice daily and is on a Humalog sliding
scale for prandial dosing. His blood sugars were well-controlled
during his course here.
TRANSITIONAL ISSUES:
====================
1) Pt has a history of Asperger's and paranoid/schizotypal
personality which sometimes limits his way of interacting. The
best way to discuss any issues with him is to limit time spent
with patient and to focus on immediate needs, mostly of a
practical nature during interactions.
2) Because of item 1 above, in general, try to communicate
concrete and concise information about the treatment plan (eg
how many days of abx, how long anticipated
rehab stay) which will ultimately limit opportunities to create
disagreements among
staff.
3) For his osteomyelitis and foot ulcer, please clean wound
GENTLY with wound cleanser then pat dry. Do not pull on graft or
wipe aggressively with gauze and
cover wound with adaptic - nonadherent dressing followed by dry
gauze and ABD pad. Then secure with kerlix and change the
dressing daily.
4) Infectious disease ___ clinic follow-up appointment is
___ at 9:00 AM with ___, MD ___
located in ___ Building (___ Basement.
5) For his antibiotics, he will need weekly labs checked while
on ceftriaxone: CBC, BUN, creatinine, ALT, AST, Alk phos, total
bilirubin, CRP, ESR. Please fax results to ___ Infectious
Disease ___ clinic at ___. Patient will require
ceftriaxone 1g Q24H IV and metronidazole 500mg PO Q8H for total
antibiotic course of 6 weeks, final day of antibiotics ___.
6) Patient will follow up with podiatrist at ___, Dr.
___
on ___ at 1:00PM in the ___ ___)
___ Floor.
7) Patient will need to have an appointment set up to see his
PCP ___ on discharge from rehab. Patient was started on
losartan 25mg qd for high blood
pressures during his prior hopitalization ending on ___.
8) Vital signs to be collected per routine.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CeftriaXONE 1 gm IV Q24H
2. Glargine 40 Units Breakfast
Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Citalopram 20 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Losartan Potassium 25 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. CeftriaXONE 1 gm IV Q24H
4. Citalopram 20 mg PO DAILY
5. Glargine 40 Units Breakfast
Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. FoLIC Acid 1 mg PO DAILY
7. Losartan Potassium 25 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
- Osteomyelitis
- Agitation
- ___
SECONDARY DIAGNOSES:
===================
- Type II diabetes
- Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you while you were in the
hospital. You were admitted to ___ on
___ for agitation after you had fallen into a
misundertanding with the staff at ___
(___). Since you were quite agitated when you initially
arrived, you were seen by our psychiatry team in the emergency
room who recommended that we admit you to help you manage your
antibiotics for the infection on your left foot (osteomyelitis).
Our psychiatry team recommended medicine that helped calmed you
down, and the agitation had resolved by the time we met you on
the floor.
Since we primarly admitted you to manage your antibiotics, the
first thing we did was confirm with the aid of a chest X-ray
that your PICC line (the IV in your arm) was correctly placed.
After that we continued to give you the antibiotics you had been
taking at ___ (ceftriaxone and Flagyl). The last day of your
antibiotics is ___ and as we discussed, it is important
to finish taking all your antibiotics and follow-up with both
our infectious diseases specialists and yuour podiatrist, Dr.
___ as indicated below. Doping so will make sure that your
infection does not worsen.
During your time here, you were concerned about weight-bearing
so we reached out to Dr. ___ expressed that
weight-bearing on the heel would be OK until he sees you on the
___. You should plan to follow-up with him as highlighted in
the appointment below.
Also, because your blood tests showed abnormalities in your
kidney function (Acute kidney injury) when you first arrived, we
gave you some additional body fluids via IV, which helped
resolve the kidney malfunction within the first day of your
admission. We believe the abnormalities in your kidneys were
caused by low fluids in your blood, so when you leave the
hospital, you should try drinking water regularly.
For your diabetes and depression, we maintained you on the same
medications you usually take at home, and there were no issues
in managing both these conditions.
Thank you for allowing us to be part of your care.
Your ___ team!
Followup Instructions:
___
|
19822093-DS-26
| 19,822,093 | 20,203,079 |
DS
| 26 |
2148-12-26 00:00:00
|
2148-12-27 19:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / vancomycin
Attending: ___
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
___ Left transmetatarsal amputation and tendo-
Achilles lengthening.
___ Transesophageal echocardiogram
History of Present Illness:
___ gentleman with past medical history significant for
poorly controlled diabetes (insulin-dependent), CKD, CAD (DES to
LAD and LCx in ___, HLD, and prior osteomyelitis of his
left foot who presented to the ___ ED with altered mental
status.
Per initial notes, the patient had been seen by his by HCP 4
days prior to admission, and reportedly in normal state of
health. The morning of admission he was found laying under a
pool table. Per report initial FSBG in 400s for EMS. Upon
arrival to the ED the patient stated he hasn't eaten for 2 days
due to vomiting. His mental status was AOx2, with unclear
baseline.
In the ___ ED, initial vitals: 96.1 112 119/82 20 98% RA,
with FSBG >500.
Initial labs were notable for:
WBC 18.6 Hbg/Hct 16.9/52.6 Plt 324
Neuts 89.9
142 / 95 / 132
---------------< 703
5.___ / 3.8
Ca ___ Mg 3.9 Phos 8.2
ALT 13 AST 12 AP 135 Tbili 1.2 Lipase 69
Trop <0.01
VBG with ___lood, ketones, glucose, but otherwise not
concerning for infection.
In the ED, the patient was started on IV insulin, and received
2L of NS with a 3rd liter started prior to transfer. He had a CT
head and chest xray that were without acute abnormality. An xray
of the left foot did not show evidence of osteomyelitis.
On transfer, vitals were: 97.9 107 138/67 16 99% RA, with
fingerstick glucose recorded as 474. Repeat VBG with 7.35/38/39.
On arrival to the MICU, the patient is alert and oriented to
self and place (but not year). He is able to follow simple
1-step commands.
He is complaining of thirst and requesting ginger ale. He denies
any pain, denies nausea or recent vomiting. He cannot provide
any specific historical details other than that he lives alone
and that his healthcare proxy is ___ (as listed in
our OMR).
Review of systems:
Patient denies all review of systems questions, stating that he
is only thirsty.
Past Medical History:
-type II DM, on insulin
-CAD (NSTEMI in ___ with DES to LAD and LCx; LVEF estimated
at 40% on perfusion stress test ___
-CKD, stage III
-hyperlipidemia
-PVD (peripheral vascular disease) due to DM
-Left ___ metatarsal partial amputation and left ___ matatarsal
amputation ___
-Right foot amputation at tarsal/metatarsal junction ___
-Cyst removal from chin ___ years ago)
-Depression
-Presumed osteomyelitis of left foot ___, polymicrobial wound
infection Strep, serratia, Enterobacter, enterococcus, C
septicum, coag negatiev staph. No biospy was performed. TTE
performed with no obvious vegetations. Received full 6 wk course
of Cipro and Ceftriaxone followed by the ___ clinic and
completed on ___.
- osteomyelitis (___), biopsy proven and cultures grew
coag-negative staph and corynobacterium, treated with
ceftriaxone and flagyl.
Social History:
___
Family History:
- no family history of DM.
- mother with lung cancer
Physical Exam:
ADMISSION
=========
Vitals: 97.9 107 136/72 99% on room air
GENERAL: Alert, oriented to self (name and ___, not to
year. In no distress.
HEENT: Sclera anicteric, very dry mucous membranes, no oral
lesions, dentition poor.
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes. Patient
takes short shallow breaths on command.
CV: Regular rhythm with rate of 100, normal S1 S2, no murmurs,
rubs, gallops.
ABD: BS+. Soft, non-distended. He reports "it hurts a little"
with palpation of epigastrum and umbilical region, no rebound
tenderness or guarding, no organomegaly appreciated.
EXT: He has complete transverse metarsal amputation of all toes
on the right lower extremity, no edema or wounds. The left lower
extremity has amputation of the ___, and ___ digits. The
___ digit has a scab and surrounding erythema but no warmth or
drainage. Prior wound site on lateral aspect of the left ___ toe
is healed and crusted but no sign of infection. No edema in
either ___. Extremities are cool.
healed.
SKIN: He has recent superficial scabs of both upper extremities.
No other skin breakdown or wounds.
NEURO: AOx2. CN2-12 grossly intact. Moving all extremities on
command and without focal deficits.
DISCHARGE PHYSICAL EXAM
========================
Vitals: 98.1, 115/58, 108, 16, 97% on RA
Output: no BMs o/n
GENERAL: NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear, very poor
dentition
NECK: supple, JVP not elevated, no LAD
LUNGS: CTAB
CV: RRR, no m/r/g
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: extremities slightly cool, s/p right TMA, left foot in
podiatry dressing c/d/I with drain in place. bilateral palpable
dp/pt pulses. bilateral waffle boots in place.
SKIN: No rashes
RECTAL: normal rectal tone
NEURO: Awake, alert, flat affect. AOx3.
ACCESS: ___ in RUE, LUE PIV
Pertinent Results:
ADMISSION
=========
___ 11:15AM BLOOD WBC-18.6*# RBC-5.73# Hgb-16.9# Hct-52.6*#
MCV-92 MCH-29.5 MCHC-32.1 RDW-12.4 RDWSD-41.5 Plt ___
___ 11:15AM BLOOD Neuts-89.9* Lymphs-1.9* Monos-7.5
Eos-0.0* Baso-0.2 Im ___ AbsNeut-16.74*# AbsLymp-0.36*
AbsMono-1.39* AbsEos-0.00* AbsBaso-0.03
___ 11:15AM BLOOD ___ PTT-22.5* ___
___ 11:15AM BLOOD Glucose-703* UreaN-132* Creat-3.8*#
Na-142 K-5.9* Cl-95* HCO3-16* AnGap-37*
___ 11:15AM BLOOD ALT-13 AST-12 CK(CPK)-225 AlkPhos-135*
TotBili-1.2
___ 11:15AM BLOOD Lipase-69*
___ 11:15AM BLOOD cTropnT-<0.01
___ 11:15AM BLOOD Albumin-4.2 Calcium-11.0* Phos-8.2*#
Mg-3.9*
___ 11:15AM BLOOD %HbA1c-10.6* eAG-258*
___ 05:00PM BLOOD ASA-NEG Ethanol-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 11:15AM BLOOD ___ pO2-39* pCO2-38 pH-7.29*
calTCO2-19* Base XS--8
___ 11:15AM BLOOD Lactate-3.6* K-5.9*
___ 01:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:30PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 01:30PM URINE RBC-4* WBC-3 Bacteri-NONE Yeast-NONE
Epi-0
___ 01:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
PERTINENT
=========
___ 12:05AM BLOOD ___ PTT-64.1* ___
___ 04:47AM BLOOD CK(CPK)-326*
___ 03:40PM BLOOD CK(CPK)-486*
___ 07:48PM BLOOD cTropnT-<0.01
___ 04:47AM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:40PM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:32AM BLOOD Albumin-2.2* Calcium-7.6* Phos-1.6*
Mg-2.1
___ 04:47AM BLOOD CRP-264.1*
___ 05:10AM BLOOD SED RATE- 80 (H)
DISCHARGE LABS
==============
___ 06:30AM BLOOD WBC-12.9*# RBC-2.62* Hgb-7.9* Hct-24.0*
MCV-92 MCH-30.2 MCHC-32.9 RDW-14.9 RDWSD-48.7* Plt ___
___ 06:30AM BLOOD Glucose-154* UreaN-12 Creat-1.4* Na-140
K-3.4 Cl-107 HCO3-24 AnGap-12
___ 06:30AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.8
MICROBIOLOGY
============
___ 6:09 pm SPUTUM Source: Expectorated.
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.
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
___ 4:48 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:16 pm BLOOD CULTURE
Source: Line-white port central line 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:32 am BLOOD CULTURE Source: Line-LIJ TLC.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:47 am BLOOD CULTURE Source: Line-cvl.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES PERFORMED ON CULTURE # ___,
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
___ 3:21 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
___ 1:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 11:15 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by ___, ___ @ 02:25AM
(___).
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
___ 1:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # ___ FROM
___.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by ___, ___ @ 04:07AM
(___).
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
STUDIES
=======
___ LEFT FOOT X-RAY
No definite radiographic evidence for osteomyelitis.
___ RIGHT KNEE X-RAY
No acute fracture or dislocation.
___ CXR
No acute cardiopulmonary abnormality.
___ CT HEAD
1. No acute intracranial abnormalities.
2. Chronic infarcts with encephalomalacia in the right frontal,
parietal, and occipital lobes.
___ CXR
Compared to prior radiograph from earlier the same date, a left
internal
jugular catheter has been placed, terminating in the mid
superior vena cava, with no pneumothorax. Exam is otherwise
similar to the recent study except for improving linear
bibasilar atelectasis.
___ ECHO
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. There is mild to
moderate global left ventricular hypokinesis (LVEF = 35-40 %).
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (?#) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. No masses or
vegetations are seen on the tricuspid valve, but cannot be fully
excluded due to suboptimal image quality. The pulmonary artery
systolic pressure could not be determined. No masses or
vegetations are seen on the pulmonic valve, but cannot be fully
excluded due to suboptimal image quality. There is an anterior
space which most likely represents a prominent fat pad.
Suboptimal image quality. No echocardiographic evidence of
pathologic flow. Compared with the prior study (images reviewed)
of ___, left ventricular function appears less vigorous.
___ CTA ABDOMEN/PELVIS
1. No intraluminal IV contrast extravasation into the large or
small bowel. No abdominopelvic hematoma.
2. Sigmoid and descending colonic diverticulosis.
3. Heterogeneous micronodular consolidation at the right lung
base may
represent sequela of aspiration or pneumonia.
4. Intraluminal filling defect at the aortic bifurcation
associated with
calcified atherosclerotic plaque, extending into the origin of
the left common iliac artery, has the appearance of noncalcified
atheroma. This results in moderate to severe narrowing of the
luminal diameter of the infrarenal abdominal aorta as well as
the origin of the left common iliac artery.
5. Intraluminal filling defect of the right profunda femoral
artery extending into its branches, associated with calcified
plaque, also likely representing arterial atheroma. This
results in moderate to severe narrowing of the arterial lumen.
___ LEFT FOOT X-RAY (POST-AMPUTATIONS)
Status post transmetatarsal amputation of all digits of the left
foot. There are sharp surgical margins. An overlying surgical
drain is noted. There is soft tissue swelling and air.
___ TEE
Dynamic interatrial septum. No atrial septal defect is seen by
2D or color Doppler. Right ventricular chamber size and free
wall motion are normal. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 35 cm from the incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Trivial mitral regurgitation is seen. There is
no pericardial effusion.
IMPRESSION: No evidence of valvular vegetation, abscess or
significant regurgitation. Normal biventricular systolic
function.
___ EGD
Findings:
Esophagus: Normal esophagus.
Stomach: Mucosa: Erythema of the mucosa was noted in the
antrum. Cold forceps biopsies were performed for histology to
evaluate for H.pylori.
Excavated Lesions A 4mm clean based ulcer was seen in the
pylorus.
Duodenum: Excavated Lesions Multiple clean based ulcers ranging
in size from 4 mm to 8 mm were found in the second part of the
duodenum.
Impression: Ulcer in the pylorus
Ulcers in the duodenum
Erythema in the antrum (biopsy)
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ gentleman with past medical history significant for
poorly controlled diabetes, CKD, CAD (NSTEMI with DES to LAD and
LCx in ___, HLD, and ongoing osteomyelitis of his left foot
who presented to the ___ ED with altered mental status and
diabetic ketoacidosis, subsequently found to have acute blood
loss anemia from GI bleed.
========================
ACTIVE ISSUES:
========================
#) Acute blood loss anemia: The patient was initially admitted
to the ___ ICU. He was then transferred to a ___
general medicine floor in preparation for TMA for osteomyelitis
as below. However on the morning of transfer, he was noted to
have a large maroon colored stool, estimated to be 500-1000cc in
volume associated with an 8-point drop in hematocrit and
hypotension to the SBP ___. He was subsequently transferred to
the MICU. He was transfused 6 units pRBCs and 1 unit FFP. NG
lavage was negative. He then began to have hematemesis; it was
unclear whether this was due to upper GI bleed or trauma related
to the NG lavage. The patient continued to pass clots per
rectum, but he remained hemodynamically stable. He was evaluated
by Gastroenterology, who recommended upper and lower endoscopy.
The patient underwent EGD which showed ulcers of the pylorus and
duodenum. Colonoscopy was attempted but bowel prep was poor.
However, GI felt that the most likely source of his bleed were
the ulcers seen on EGD. He will require repeat EGD in 8 weeks
post-discharge; GI clinic at ___ to coordinate. H. pylori
biopsies pending.
#) Diabetic ketoacidosis: Patient presented with serum glucose
of >700, anion gap of 31, and venous blood gas with pH of 7.29.
Ketones present in the urine. Precipitant likely a GI source
given vomiting in the days preceding admission and mild
abdominal tenderness on initial exam. Urine and CXR without sign
of infection, LFTs unremarkable, and initial troponin negative.
DKA resolved with insulin and IVF, and patient was restarted on
Lantus w/ ___. Precipitant likely infection. Patient
discharged on Lantus 18u BID.
#) Osteomyelitis: WBC of 18k on admission, with 90% neutrophils.
Blood cultures grew back MSSA. Most likely related to
osteomyelitis in foot. History of osteomyelitis of the left
foot, with initial ___ admission from ___. Patient
treated with nafcillin, and is scheduled to go to the OR for
amputation of his foot. Additionally, there was concern for
aspiration based on patient's symptoms and bibasilar opacities
on CXR; patient was evaluated by speech and swallow, and made
NPO to prevent further aspiration events. TTE and TEE
demonstrated no valvular vegetations.
#) Altered mental status: Resolved. atient noted to be altered
on day of admission, and was AOx2 on arrival to the ___. CT
head in ED was negative for acute changes. Altered status is
likely due to toxic-metabolic derangement in the setting of DKA,
vs changes related to infection.
#) Acute on chronic kidney disease: Serum creatinine was 0.9-1.1
as recent as ___ but then 1.4 in ___ as outpatient. Cr
elevated at 3.8 on presentation, likely due to hypovolemia in
the setting of DKA (with history of recent vomiting, Hbg/Hct
also with hemoconcentration). Creatinine improved with fluid
rescuscitation, suggesting prerenal etiology.
#) Nutrition. Patient noted to have significant dysphagia while
in ICU. Patient was evaluated by S&S multiple times and
ultimately liberalized to thin liquids/ground solids diet at
diet.
#) Atrial fibrillation: seen on EKG. Likely precipitant is acute
infection.
========================
CHRONIC ISSUES:
========================
#) Asperger's and paranoid/schizotypal personality: per prior
admission notes. Has at times limited his way of interacting
with hospital and rehab staff. Has required chemical restraints
in the past. Intermittently refused medications and treatments
while in hospital.
#) HTN: was started on losartan during hospitalization in
___. Held during this this admission given recent bleeding.
#) CAD: history of likely NSTEMI in ___ with DES to LAD and
LCx. Followed by Cardiology at ___. Per their notes, plan is
for likely repeat cardiac cath at some point due to suspicion of
multivessel disease (suspicion based on perfusion stress testing
___. Held home metoprolol succinate 50mg daily and losartan
25mg daily until stabilized clinically, then restarted.
Continued ASA 81mg daily and atorvastatin 80mg daily.
========================
TRANSITIONAL ISSUES:
========================
- Patient to have outpatient f/u with Podiatry.
- Patient needs weekly CBC/diff, BUN/Creatinine, AST, ALT, Alk
Phos and Tbili checked while on nafcillin.
- Last day of nafcillin on ___
- Patient to have repeat EGD in 8 weeks post-discharge; GI
Clinic at ___ to arrange f/u
- Patient discharged on 18u Lantus BID
- F/u H. pylori antigen
- F/u final margins on bone tissue biopsy
- Should monitor patient's PO intake; diet liberalized to thin
liquids and ground solids by S&S at discharge.
- Home losartan held given recent GI Bleed. ___ need to be
restarted if more hypertensive
- Patient with new fecal incontinence; rectal tone normal on
exam at discharge
- Communication: HCP: ___ (friend) ___
___
- Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. insulin detemir 40 u subcutaneous BID
2. Losartan Potassium 25 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. insulin aspart 30 u subcutaneous BID
5. Atorvastatin 80 mg PO QPM
6. Citalopram 20 mg PO DAILY
7. Fluocinolone Acetonide 0.025% Ointment 1 Appl TP BID
8. FoLIC Acid ___ mcg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Aspirin 81 mg PO DAILY
The Preadmission Medication list is accurate and complete.
1. insulin detemir 40 u subcutaneous BID
2. Losartan Potassium 25 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. insulin aspart 30 u subcutaneous BID
5. Atorvastatin 80 mg PO QPM
6. Citalopram 20 mg PO DAILY
7. Fluocinolone Acetonide 0.025% Ointment 1 Appl TP BID
8. FoLIC Acid ___ mcg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Citalopram 20 mg PO DAILY
4. FoLIC Acid ___ mcg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Glargine 18 Units Breakfast
Glargine 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Nafcillin 2 g IV Q4H
8. Pantoprazole 40 mg PO Q12H
9. Fluocinolone Acetonide 0.025% Ointment 1 Appl TP BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
MSSA bacteremia
diabetic ketoacidosis
gastrointestinal bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
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. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital because your
blood sugars were very high. You were admitted to the intensive
care unit to help control your blood sugars. We also found that
you had a serious bacterial blood stream infection for which you
will need IV antibiotics. We felt that your blood stream
infection was from wound on your left foot. You were evaluated
by Podiatry who performed a partial amputation of your L foot to
limit infection. You also had an ultrasound on your heart
called an echocardiogram which showed no infection of your heart
valves. While you were in the hospital, you had a very large
gastrointestinal bleed. The GI doctors performed ___ upper
endoscopy and found that you had large ulcers in your stomach
and small intestine. You required significant blood
transfusions but your blood counts have been stable.
Please follow-up with your outpatient providers as instructed
below.
Thank you for allowing us to participate in your care. All best
wishes for your recovery.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
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