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19837286-DS-5
| 19,837,286 | 27,831,679 |
DS
| 5 |
2118-06-04 00:00:00
|
2118-06-04 17:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old male with PMH of Craniopharyngioma
resected in ___ after presenting with repeated episodes of
confusion and brain imaging showing this intracranial tumor.
Since surgery he has was placed on keppra and for seizure ppx
recently discontinued (1 week ago) by Dr. ___ of his
persistent episodes of confusion even after surgery. On the day
PTA, he presented to his PCP's office where he had a witnessed
seizure; tonic per wife's description which lasted about three
minutes. He was taken to an OSH where he underwent CT scan of
brain which reportedly shows a fluid collection in the right
subdural space with air bubbles. He has had no previous seizure
episodes or any recurrent episodes since. He was subsequently
transferred to ___.
He has had no fevers/chills, headaches, vision changes, numbness
or tingling, cough, shortness of breath, chest pain, hemoptysis,
diarrhea, dyuria, hematuria, back/flank pain. He continues to
have episodes of confusion including visual hallucinations, per
his wife.
Recent medication changes include discontinuation of keppra and
downtitration of pramipexole.
In the ED:
His vital signs were at presentation: 0 97.5 104 117/76 18 100%
2L Nasal Cannula
Chemistry profile and CBC unremarkable
He was given 1gram of Keppra x 1 dose and his home medications
given.
Upon transfer to the floor his vitals were:98.5 100 101/64 16
96% RA
Past Medical History:
Craniopharyngioma
Parkinsons
Steroid induced hyperglycemia
HTN
hypothyroid
Diabetes Insipidus
Social History:
___
Family History:
NC
Physical Exam:
ADMIT:
VS:98.1 113/68 102 19 97%
GENERAL: Somnolent but arousable and oriented x 3. Confused but
easily re-oriented. NAD. Speech coherent.
HEENT: Right frontal parietotemporal surgical scar healing well.
EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares,
MMM, good dentition, nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Clear, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABD: Obese. nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXT: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. Strength ___ in upper and lower
extremities bilaterally. Negative pronator drift. proprioception
and sensation to touch intact. Gait is balanced. No dyskinesia
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE:
VS:Tm 97.8 temp 122/64 p97 rr20 96%RA bs 167, 362,243,330.
I/O 24Hour ___
GENERAL: Somnolent but arousable and oriented x 3. Confused but
easily re-oriented. NAD. Speech coherent.
HEENT: Right frontal parietotemporal surgical scar healing well.
EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares,
MMM, good dentition, nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Clear, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABD: Obese. nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXT: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. Strength ___ in upper and lower
extremities bilaterally. proprioception and sensation to touch
intact. No dyskinesia
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE:
Pertinent Results:
___ 12:20AM BLOOD WBC-4.1 RBC-3.29* Hgb-10.0* Hct-31.5*
MCV-96 MCH-30.5 MCHC-31.9 RDW-15.3 Plt ___
___ 12:20AM BLOOD Neuts-62.3 ___ Monos-4.8 Eos-3.2
Baso-0.7
___ 12:20AM BLOOD Glucose-140* UreaN-12 Creat-1.0 Na-144
K-3.8 Cl-106 HCO3-27 AnGap-15
___ 12:20AM BLOOD ALT-84* AST-28 AlkPhos-79 TotBili-0.4
___ 12:20AM BLOOD Calcium-9.6 Phos-4.4 Mg-2.0 Iron-47
___ 12:20AM BLOOD Osmolal-296
___ 07:25AM BLOOD FSH-1.1* LH-<1.0
___ 12:20AM BLOOD Free T4-0.50*
___ 07:25AM BLOOD Testost-<12 SHBG-10*
___ 08:42AM BLOOD Cortsol-0.9
URINE CULTURE (Final ___: NO GROWTH.
___ 6:15 pm BLOOD CULTURE x 2 (Pending):
CHEST XRAY PA & LAT ___
IMPRESSION:
No good evidence of pneumonia
EEG fellow prelim read:
This is an abnormal continuous ICU monitoring study because of
diffuse ___ Hz theta slowing with intermixed slower delta waves.
This is indicative of a mild encephalopathy, which is
nonspecific in etiology. There are no epileptiform features or
electrographic seizures.
DISCHARGE LABS:
___ 07:15AM BLOOD WBC-3.6* RBC-3.66* Hgb-10.8* Hct-35.0*
MCV-96 MCH-29.6 MCHC-30.9* RDW-15.7* Plt ___
___ 07:15AM BLOOD Glucose-153* UreaN-15 Creat-1.0 Na-142
K-3.8 Cl-106 HCO3-29 AnGap-11
*
Brief Hospital Course:
___ old male with PMH of craniopharyngioma, ___ and
hypothyroidism, who has been having confusion since discharge
from last hospitalization, presenting after a witnessed episode
of /seizure ___
# Encephalopathy/?Seizure: DDx include CNS infections,
especially HSV, tumor recurrence with mass effect/edema, trauma
with intracranial bleed. Had a CT scan at OSH with no reported
bleed. No fevers, neck pain/rigidity or other signs/symptoms to
suggest meningitis or encephalitis. No marked derangement on
chemistry profile such as profound hyponatremia. No evidence of
infection on blood, urine Cx and Chest xray. Unremarkable LFT's
with exception of elevated ALT makes hepatic encephalopathy
unlikely. Other considerations include polypharmacy as well as
endocrinopathies given recent surgery with subsequent
panhypopituitarism. He underwent an EEG with no evidence of
epileptiform activity but slowed theta waves indicative of a
mild encephalopathy. Outside CT imaging of head was reviewed
with no acute findings to explain presentation. His Keppra was
resumed. Medications were reviewed with the impression of
possibility of dopaminergic ___ meds contributing to his
subacute encephalopathy. His pramipexole and Sinemt doses were
reduced. Will follow up with neurology for continuous workup.
Stable at discharge.
# ___ disease: stable. Continued his home meds: Doses
decreased as above.
#Post-surgical hypopituitarism: Endocrine service was consulted.
Cortisol levels were remarkably low as well as free T4.
Appropriate urine osmolality so DDAVP continued at current home
doses. so doses of hydrocortisone and levothyroxine increased
respectively. Gonadotropin and testosterone levels also low and
endocrine aware. Will follow up outpatient.
# Hyperglycemia (steroid-induced): On hydrocortisone due to
panhypopituitarism and doses further increased during this
hospital stay. Managed on a sliding scale of insulin, regular.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Carbidopa-Levodopa (___) 2 TAB PO 4X/DAY
3. Citalopram 40 mg PO DAILY
4. Desmopressin Nasal 10 mcg NAS BID
5. Famotidine 20 mg PO BID
6. Hydrocortisone 5 mg PO QPM
7. Hydrocortisone 10 mg PO Q AM
8. Levothyroxine Sodium 25 mcg PO DAILY
9. pramipexole 0.25 mg oral 4 times a day
10. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Carbidopa-Levodopa (___) 1.5 TABS PO 4X/DAY
3. Citalopram 40 mg PO DAILY
4. ClonazePAM 1 mg PO QHS:PRN anxiety, insomnia
5. Desmopressin Nasal 10 mcg NAS BID
6. Famotidine 20 mg PO BID
7. Hydrocortisone 20 mg PO Q AM
RX *hydrocortisone 10 mg ___ tablet(s) by mouth twice daily Disp
#*40 Tablet Refills:*0
8. Hydrocortisone 10 mg PO QPM
9. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL 20 units SC at bedtime
Disp #*5 Vial Refills:*0
10. Levothyroxine Sodium 75 mcg PO DAILY
RX *levothyroxine 75 mcg 1 tablet(s) by mouth daily Disp #*60
Tablet Refills:*0
11. pramipexole 0.125 mg oral QID
12. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
- Seizure
- Acute encephalopathy
- Hyperglycemia
- Pan-hypopituitarism
Secondary Diagnoses:
- ___ disease
- Craniopharyngioma (status-post resection)
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent (with supervision).
Discharge Instructions:
Dear Mr. ___.,
You were admitted to ___ for evaluation of your recent seizure
and confusion. ___ hour EEG monitoring didn't show
further seizures after the initiation of the anti-seizure
medication (keppra). You will continue this medication at home.
You also had an evaluation for infection which was negative. You
had some adjustments of your hormone levels and will continue
these new medications and follow-up with endocrinology. Please
also keep your follow-up with Dr. ___ as we decreased some
of the ___ medications.
We wish you the best! HAPPY BIRTHDAY!
Your ___ Care Team
Followup Instructions:
___
|
19837618-DS-10
| 19,837,618 | 20,394,373 |
DS
| 10 |
2129-01-10 00:00:00
|
2129-01-10 15:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
nausea/vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Per PCP ___, "Home ___ called on behalf of the patient because
he has ongoing nausea/vomiting. He has not been able to eat. He
has had
persistently low blood glucoses, blood sugars in the ___
persistently over the past few days, currently it is 133. He has
been vomiting for the past 4 days, he had one good day on ___
but has otherwise been unable to eat/drink and vomits every time
he does take something PO... The patient reports that he feels
very weak. I asked the patient to please come into the ER."
.
Vitals in the ER: 98.9 95 144/63 22 95% RA. He received Zofran,
IV Morphine, Levoflozacin, Vancomycin, and 2L NS.
.
The patient states that he has had intermittant hypoglycemia
from the ___ associated with nausea, vomiting, but no
diaphoresis or shaking. He states that he has fatigue and has
taken Metformin and Glyburide without having eaten much food
secondary to fatigue and poor appetite. He also complains of
left-sided chest pain with vomiting and coughing associated with
the Pleur-X cath. He also has chronic right shoulder and right
foot pain, the latter after surgery on ___. He states that
Oxycodone is slightly effective but does not last long enough
nor does it stop baseline pain.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, photophobia. Denies
headache Denies chest pain or tightness, palpitations, lower
extremity edema. Denies wheezes, diarrhea, constipation,
abdominal pain, melena, hematemesis, hematochezia. Denies
dysuria, stool or urine incontinence. Denies rashes or skin
breakdown. All other systems negative.
.
Past Medical History:
PAST MEDICAL HISTORY (outside nonsmall cell lung cancer):
1. Hypertension;
2. Hyperlipidemia;
3. Type 2 diabetes mellitus;
4. Chronic shoulder pain, arthritis;
5. S/P right toe surgery for a bone cyst ___
6. S/P Pleur-X cath placement for malignant effusion
7. Admitted ___ for sepsis and pneumonia
8. Hypoxemia 88% RA on 2L home O2
9. Cervical stenosis with radiculopathy
.
ONCOLOGY HISTORY: Mr. ___ is a ___ year-old
___ man current smoker (50 pack-years) who
presented
to medical care in ___ with subacute worsening of
shortness of breath and cough productive of purulent sputum. He
also had low grade fever. He denied prior cardio-pulmonary
complaints or constitutional symptoms. At time of admission he
was quite hypoxic on room air and required supplemental
oxygenation.
.
He was admitted to ___ from ___ to ___ for
evaluation.
.
Imaging studies with CT chest from ___ disclosed a
consolidation of the lingula, bronchial narrowing, mediastinal
lymphadenopathy, liver hypodense lesions and a large loculated
left pleural effusion. A PET/CT Scan from ___ disclosed the
presence of extensive FDG-avid consolidative process in the
lingula, lymphangitic carcinomatosis, non-FDG avid pleural
effusion, FDG-avid lymphadenopathy involving the bilateral
supraclavicular regions, mediastinum, subcarinal stations,
hilar,
portacaval and retroperiotenal nodes. FDG-avid liver lesions and
FDG-avid osseous metastases. Head MRI from ___ did not
disclose evidence of lesions.
.
The patient was symptomatically treated with antibiotics
(completed a course of cefpodoxime - 14 days), supplemental
oxygen and a left-sided thoracentesis. The patient referred
significant improvement of his cardio-pulmonary function with
the
pleural drainage.
.
The malignant pleural fluid removed on ___ disclosed a
carcinoma. Immunohistochemical stains of the tumor cells were
positive for CK5/6, and CK7; and negative for CK20, p63, and
TTF-1. This immunoprofile is nonspecific but compatible with a
non-small-cell lung cancer not otherwise specified.
.
Since his inpatient discharge, the patient's condition has
slowly
deteriorated. His dyspnea with exertion has worsened over the
last 2 weeks and he requires intermittent oxygen. He has a ___
that visits once a week. His cough is present but he no longer
has sputum. He is not smoking much. He denies much in the way of
chest pain.
Social History:
___
Family History:
Father with a stroke; mother with cancer; sister
with diabetes, hypertension.
Physical Exam:
VS: T 98.5 bp 120/77 HR 79 RR 18 SaO2 100 2L NC Wt 160 lbs
GEN: NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP dry and
without lesion
NECK: Supple
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. Pleur-X cath in
place with clean dressings
ABD: Soft, NT, ND, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c, normal perfusion; right foot has bandage after
operation on foot ___, not taken down at time of admission
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, no focal deficits, intact
sensation to light touch
PSYCH: appropriate
.
Pertinent Results:
___ 06:35PM LACTATE-4.2*
___ 06:10PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 06:10PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 03:33PM LACTATE-5.7*
___ 03:25PM GLUCOSE-76 UREA N-27* CREAT-1.0 SODIUM-136
POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-21* ANION GAP-23*
___ 03:25PM ALT(SGPT)-137* AST(SGOT)-109* ALK PHOS-512*
TOT BILI-0.2
___ 03:25PM LIPASE-29
___ 03:25PM ALBUMIN-3.6
___ 03:25PM WBC-11.9*# RBC-4.12* HGB-10.9* HCT-34.3*
MCV-83 MCH-26.4* MCHC-31.8 RDW-15.1
___ 03:25PM NEUTS-86.5* LYMPHS-7.8* MONOS-4.7 EOS-0.8
BASOS-0.2
___ 03:25PM PLT COUNT-470*
___ 03:25PM ___ PTT-31.0 ___
.
___
5:30p CT Abd & Pelvis With Contrast -- Preliminary Result
Moderate left nonhemorrhagic pleural effusion with a Pleurx
catheter in place. Multiple liver hypodensities concerning for
metastases. Prominent cluster of periaortic nodes at the level
of the left renal artery.
.
___
3:39p CT Head W/O Contrast -- Full Report
No acute intracranial process. Note that the normal MRI from
___ more effectively exclude metastasis.
.
CXR:
FINDINGS: In comparison with the study of ___, there has been
removal of some pleural fluid from the left. No definite
pneumothorax. Some fissural is again seen.
The right lung is essentially clear
.
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY
.
___ 05:10AM BLOOD WBC-6.3 RBC-3.85* Hgb-9.9* Hct-31.4*
MCV-82 MCH-25.8* MCHC-31.6 RDW-15.0 Plt ___
___ 06:20AM BLOOD WBC-7.9 RBC-3.74* Hgb-9.9* Hct-30.4*
MCV-81* MCH-26.5* MCHC-32.6 RDW-15.8* Plt ___
___ 06:10AM BLOOD WBC-6.0 RBC-3.60* Hgb-9.3* Hct-29.4*
MCV-81* MCH-25.9* MCHC-31.8 RDW-15.9* Plt ___
___ 03:25PM BLOOD WBC-11.9*# RBC-4.12* Hgb-10.9* Hct-34.3*
MCV-83 MCH-26.4* MCHC-31.8 RDW-15.1 Plt ___
___ 03:25PM BLOOD Neuts-86.5* Lymphs-7.8* Monos-4.7 Eos-0.8
Baso-0.2
___ 03:25PM BLOOD ___ PTT-31.0 ___
___ 12:45PM BLOOD K-PND
___ 06:45AM BLOOD Glucose-106* UreaN-16 Creat-0.8 Na-135
K-5.5* Cl-100 HCO3-22 AnGap-19
___ 06:30AM BLOOD Na-136 K-4.6 Cl-99
___ 06:55AM BLOOD Glucose-82 UreaN-13 Creat-0.8 Na-135
K-4.7 Cl-100 HCO3-22 AnGap-18
___ 05:10AM BLOOD Glucose-75 UreaN-15 Creat-0.9 Na-134
K-4.9 Cl-97 HCO3-22 AnGap-20
___ 06:20AM BLOOD Glucose-66* UreaN-13 Creat-0.9 Na-135
K-4.9 Cl-99 HCO3-23 AnGap-18
___ 06:10AM BLOOD Glucose-47* UreaN-17 Creat-0.9 Na-137
K-5.3* Cl-103 HCO3-24 AnGap-15
___ 03:25PM BLOOD Glucose-76 UreaN-27* Creat-1.0 Na-136
K-5.0 Cl-97 HCO3-21* AnGap-23*
___ 05:10AM BLOOD CK(CPK)-283
___ 06:20AM BLOOD ALT-118* AST-105* AlkPhos-466*
TotBili-0.3
___ 06:10AM BLOOD LD(LDH)-457*
___ 03:25PM BLOOD ALT-137* AST-109* AlkPhos-512*
TotBili-0.2
___ 03:25PM BLOOD Lipase-29
___ 05:10AM BLOOD TSH-4.3*
___ 06:55AM BLOOD Free T4-1.2
___ 05:10AM BLOOD Cortsol-14.8
___ 05:47AM BLOOD Lactate-3.1*
___ 07:38AM BLOOD Lactate-3.2*
___ 06:35PM BLOOD Lactate-4.2*
___ 03:33PM BLOOD Lactate-5.7*
Brief Hospital Course:
Pt is a ___ y.o male with h.o metastatic NSCLC with malignant
pleural effusion who was admitted for hypoglycemia, found to
have acidosis.
.
#Hypoglycemia with associated nausea and vomiting - secondary to
taking oral hypoglycemics in the setting of moderate
malnutrition and poor PO intake. Resolved after stopping
metformin and glyburide. Pt was placed on an insulin sliding
scale with minimal requirements. He can continue this while at
rehab. If diet continues to improve, pt may need consideration
of longer acting insulin.
.
#Rib pain secondary to metastatic disease with scapular pain and
right foot pain after operation on toe. Added MSContin as
baseline analgesia and increased oxycodone to ___ Q4 prn.
Dc'd naproxen given poor po intake and concern for future ___.
.
#Anion Gap acidosis with Lactacemia secondary to volume
depletion in the setting of N/V and poor PO intake as well as
concurrent malignancy. Hemodynamics stable currently and on
presentation without fever do not suggest sepsis. Improved with
volume and increased PO intake.
.
#Malignant pleural effusion s/p Pleur-X cath. Drained every
other day during his stay. Last drained ___ for about
125cc. Continued 2L home O2. WOuld premedicate with oxycodone
prior to drainage.
.
#metastatic NSCLC-onc f/u scheduled later this month to
determine if palliative chemo is an option after genotype
studies return. PET concerning for lymphangitic carcinomatosis
with osseous involvement. Will need rehab to increase
performance status. Pt was started on mirtazipine and megace for
anorexia/nausea. Palliative care was involved during admission.
Pain controlled by starting oxycontin and increasing dose of
oxycodone. Pt was consulted who recommended rehab. ___ will be
following up with oncology later this month after genotype
studies return to discuss palliative chemotherapy options. See
appointment scheduled below. ___ was started on remeron and
megace for appetite with good effect and compazine and zofran
for nausea with good effect.
.
#prolapsed hemorrhoids-outpt f/u suggested. Pt ordered for ___
baths, bowel regimen and fiber. Pt should follow up with Dr.
___ ongoing care and evaluation as an outpatient. See
appointment below.
.
#deconditioning/Sinus tachycardia with ambulation/exertion-Pt
would benefit from rehab.
.
#hyperkalemia-unclear etiology. Not on any clear inciting meds.
Could have been due to Hep SC for DVT ppx. This improved with
kayexylate therapy. K 4.9 on the day of discharge. Would recheck
potassium on ___ to consider need for further kayexylate
therapy.
.
#DM2, contiued ___, started scale insulin. Stopped metformin and
glyburide, see above. DM diet, HISS.
.
#HTN, ___. CCB dose was decreased to 15mg QID of
diltiazem.
.
FEN: DM diet .
#PPx - SC heparin
.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Losartan Potassium 50 mg PO DAILY
4. Benzonatate 100 mg PO TID
5. Docusate Sodium 100 mg PO BID
6. urea *NF* 40 % Topical BID
Apply to affected areas of both feet
7. Simvastatin 10 mg PO DAILY
8. Sildenafil 50 mg PO DAILY:PRN sex
9. Naproxen 500 mg PO Q12H:PRN pain
Please take with food
10. MetFORMIN (Glucophage) 850 mg PO TID
11. GlyBURIDE 5 mg PO BID
12. Senna 1 TAB PO BID
13. Polyethylene Glycol 17 g PO DAILY
14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
.
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Benzonatate 100 mg PO TID
3. Sildenafil 50 mg PO DAILY:PRN sex
4. urea *NF* 40 % Topical BID
Apply to affected areas of both feet
5. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
6. Docusate Sodium 100 mg PO BID
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. OxycoDONE (Immediate Release) 5 mg PO DAILY:PRN prior to
pleurx drainage
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 1 TAB PO BID
11. Simvastatin 10 mg PO DAILY
12. Megestrol Acetate 80 mg PO TID
13. Mirtazapine 15 mg PO HS
14. Morphine SR (MS ___ 15 mg PO Q12H
15. Prochlorperazine 10 mg PO Q6H:PRN nausea
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. Diltiazem 15 mg PO QID
18. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q6H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic non-small cell lung cancer
Malignant left pleural effusion
hypoglycemia- medication-induced
prolapsed hemorrhoids
deconditioning
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with a low blood sugar. This
resolved after stopping yoru diabetes medications (metformin and
glyburide). You only needed small doses of insulin to control
your diabetes and this can be continued while at rehab. You were
also started medications to increase your appetite (megace and
mirtazipine) and treat your nausea (compazine, zofran). Fluid
from your lungs was removed throughout your stay. Fluid last
removed ___ ~125cc.
Please see below for your follow up appointments.
Followup Instructions:
___
|
19837618-DS-11
| 19,837,618 | 26,349,571 |
DS
| 11 |
2129-01-23 00:00:00
|
2129-01-23 12:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
S/p fall, PleurX catheter management
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a pleasant ___ year old male with metastatic NSCLC
presenting s/p unwitnessed fall at rehab. He was recently
discharged on ___ for an admission for nausea, vomiting and
anion-gap metabolic acidosis. The patient states he was sitting
on the edge of his bed with the urge to urinate and fell
reaching for the urinal. He landed directly onto his face. He
denies loss of consciousness. He complains of right sided head
pain and right shoulder pain. He also notes some difficulty
moving his right arm, but denies complete weakness numbness or
tingling. He complains of a chronic cough and shortness of
breath.
In the ED, initial VS were 99.6 110 123/75 12 97% 4L.
In the ED he received albuterol 0.083% Neb Soln, morphine
sulfate 4mg IV, ipratropium bromide neb 2.5mL, GlyBURIDE 5 mg
Tab, Benzonatate 100mg Capsule, Diltiazem Extended-Release 120
mg x2, Senna 1 Tablet, Guaifenesin 200 mg / 10 mL, Morphine SR
15mg Tab, Aspirin 81mg Tab and Levofloxacin 750mg IV.
Labs significant for anion gap metabolic acidosis (AG = 19) and
slightly elevated troponin (0.03->0.04). Imaging significant for
CT C-spine w/ no fractures and severe degenerative disease; CT
Head with small subgaleal hematoma, no intracranial hemorrhage
and non-displaced left nasal and right lamina papyracea
fractures. CT Chest with lingular mass with post-obstructive
pneumonitis, chronic effusions, innumerable nodal/liver/osseous
metastases and right middle lobe inflammation or early
infection. No fractures on shoulder x-rays.
Transfer VS 97.0 100 134/79 16 96%.
On arrival to the floor, the patient reports significant right
shoulder pain. He complains of shortness of breath which has not
significantly changed over the last 24 hours. He denies
productive cough, fevers and chills. He denies chest pain. He
has a mild headache which he only admitted to on direct
questioning. His right hand function is improving; he has no
other focal weakness.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, chest pain, abdominal pain, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. Type 2 diabetes mellitus
4. Chronic shoulder pain, arthritis
5. S/P right toe surgery for a bone cyst ___
6. S/P Pleur-X cath placement for malignant effusion
7. Admitted ___ for sepsis and pneumonia
8. Hypoxemia 88% RA, on 2L home O2
9. Cervical stenosis with radiculopathy
10. Non-small cell lung cancer
ONCOLOGY HISTORY: Mr. ___ is a ___ year-old ___
male former smoker (50 pack-years) who presented to medical care
in ___ with subacute worsening of shortness of
breath and cough productive of purulent sputum. He also had low
grade fevers. He denied prior cardio-pulmonary complaints or
constitutional symptoms. At the time of admission he was quite
hypoxemic on room air and required supplemental oxygenation. He
was admitted to ___ from ___ to ___ for evaluation.
Imaging studies with CT chest from ___ disclosed a
consolidation of the lingula, bronchial narrowing, mediastinal
lymphadenopathy, liver hypodense lesions and a large loculated
left pleural effusion. A PET/CT Scan from ___ disclosed the
presence of an extensive FDG-avid consolidative process in the
lingula, lymphangitic carcinomatosis, non-FDG avid pleural
effusion, FDG-avid lymphadenopathy involving the bilateral
supraclavicular regions, mediastinum, subcarinal stations, hilar
portacaval and retroperiotenal nodes. FDG-avid liver lesions and
FDG-avid osseous metastases. Head MRI from ___ did not
disclose evidence of lesions. The patient was symptomatically
treated with antibiotics (completed a course of cefpodoxime - 14
days), supplemental oxygen and a left-sided thoracentesis. The
patient reported significant improvement of his cardio-pulmonary
function with the pleural drainage. The malignant pleural fluid
removed on ___ disclosed a carcinoma. Immunohistochemical
stains of the tumor cells were positive for CK5/6, and CK7; and
negative for CK20, p63, and TTF-1. This immunoprofile is
nonspecific but compatible with a non-small-cell lung cancer not
otherwise specified. Since his inpatient discharge, the
patient's condition has slowly deteriorated. His dyspnea with
exertion has worsened since his diagnosis. His cough is present
but w/o significant sputum production. He is no longer smoking.
He denies much in the way of chest pain. A PleurX catheter was
recently placed to manage his chronic left pleural effusion.
Social History:
___
Family History:
Father with a stroke; mother with cancer; sister with diabetes,
hypertension.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.5 bp 123/78 HR 96 RR 20 ___ NC Wt 160 lbs
GEN: NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP dry and
without lesion
NECK: Supple
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTA on right,
decreased breath sounds on left w/ dullness to percussion,
Pleur-X cath in place with clean dressing
ABD: Soft, NT, ND, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c, normal perfusion; right foot has bandage after
operation on foot ___
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, ___ upper extremity
strength, ___ lower extremity strength, (right upper extremity
difficult to assess in detail due to recent injury and pain),
intact sensation to light touch throughout
PSYCH: appropriate
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
Admission labs:
___ 03:14AM BLOOD WBC-9.6# RBC-3.57* Hgb-9.2* Hct-28.8*
MCV-81* MCH-25.9* MCHC-32.1 RDW-16.1* Plt ___
___ 03:14AM BLOOD Neuts-81.6* Lymphs-10.8* Monos-6.4
Eos-1.1 Baso-0.2
___ 03:14AM BLOOD Glucose-165* UreaN-23* Creat-0.9 Na-135
K-4.6 Cl-96 HCO3-20* AnGap-24*
___ 03:14AM BLOOD cTropnT-0.03*
___ 09:15AM BLOOD cTropnT-0.04*
___ 03:14AM BLOOD Calcium-9.4 Phos-4.0 Mg-1.8
Discharge labs:
___ 06:05AM BLOOD WBC-12.0* RBC-3.44* Hgb-8.9* Hct-29.0*
MCV-85 MCH-26.0* MCHC-30.7* RDW-17.0* Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD UreaN-37* Creat-0.9 Na-133 K-6.2* Cl-98
HCO3-15* AnGap-26*
___ 09:20AM BLOOD UricAcd-9.2*
___ 06:05AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.2
___ 04:21PM BLOOD Lactate-6.6*
___ 04:21PM BLOOD ___ pH-7.39
CT SPINE ___
FINDINGS: There are no fractures or malalignments. Chronic
loss of height in the C3 through C6 vertebrae. Moderate loss of
disc height, bridging anterior osteophytes, and mild
uncovertebral/facet joint hypertrophy throughout the cervical
spine. Broad-based disc osteophyte complexes are mild at C2-3,
large at C3-4, and moderate at C4-5, C5-6, and C6-7. These
markedly efface the ventral thecal sac and obliterate the dorsal
CSF space. There is mild left neural foraminal narrowing at
C4-5 on the left, and moderate narrowing at C5-6 on the left.
Anterior osteophytes impinge on the esophagus. Visualized
posterior fossa demonstrates atrophy. Mastoid air cells, middle
ear cavities, and maxillary sinuses are clear. Note is made of
right palatine tonsillith. Retained secretions in the
oropharynx. Thyroid gland is heterogeneous. Calcifications of
the bilateral carotid artery bifurcations. No pathologically
enlarged cervical lymph nodes. Moderate
centrilobular/paraseptal emphysema and pleuroparenchymal
scarring at the lung apices. Chronic left pleural thickening
and effusion, better evaluated on accompanying chest CT.
IMPRESSION: No fractures. Severe degenerative disease with
thecal sac compression at all levels, particularly C3-4 and
C4-5.
CT HEAD ___
FINDINGS: No intracranial hemorrhage, edema, mass effect, or
vascular
territorial infarct. Ventricles and sulci are prominent,
compatible with
age-related involutional changes. Periventricular and
subcortical white
matter hypodensities reflect small vessel ischemic disease.
Calcifications in the cavernous carotid and basilar arteries.
No shift of the normally midline structures. Non-displaced nasal
bone fractures (___), with mild overlying soft tissue
swelling. There is also minimally displaced fracture of the
right lamina papyracea (3:10), with overlying focus of gas. 6
mm right frontal subgaleal hematoma and mild left frontal scalp
swelling. Mastoid air cells and middle ear cavities are clear.
IMPRESSION: 1. Small subgaleal hematoma. No intracranial
hemorrhage. 2. Non-displaced left nasal and right lamina
papyracea fractures. ATTENDING NOTE: The fractures described are
of undetermined age.
CT CHEST ___
IMPRESSION:
1. Lingular mass with post-obstructive pneumonitis,
peribronchovascular and possible lymphangitic spread.
2. Extensive left pleural and pericardial invasion, with chronic
effusions.
3. Innumerable nodal, liver, and osseous metastases.
4. Right middle lobe inflammation or early infection.
5. Innumerable osseous metastases, without pathologic fracture.
R SHOULDER XR ___
RIGHT SHOULDER, AP INTERNAL/EXTERNAL ROTATION, Y, AND AXILLARY
VIEWS: There is an oblique linear lucency along the
mid-to-distal medial humeral shaft, likely a nutrient foramen.
Mildly prominent deltoid tuberosity. No
dislocation. Mild glenohumeral joint space narrowing. Mild
cromioclavicular joint spurring. Right elbow joint is grossly
normal. The right lung apex is unremarkable. IMPRESSION: Mild
degenerative changes of the right shoulder.
BILATERAL HIP XR ___
There is no evidence of fracture. Moderate right and mild left
degenerative changes are seen with osteophytes, sclerosis of
joint surfaces, and decrease in the joint space. There are
vascular calcifications. There are surgical clips in the left
pelvis.
MR HEAD ___
FINDINGS: The study is compared with the recent NECT dated
___, and
(motion-degraded) enhanced MR examination dated ___.
There is
significant image distortion of the diffusion-weighted sequence,
particularly at the vertex and a second acquisition is even
further degraded, for unclear reasons (with no additional
notation by the MR technologist). Allowing for this artifactual
limitation, and comparing the two acquisitions, there is no
definite focus of slow diffusion to suggest acute ischemia. The
principal intracranial vascular flow voids, including those of
the dural venous sinuses are preserved, and these structures
enhance normally. Again demonstrated is both discrete and
confluent FLAIR-hyperintensity in bihemispheric, subcortical and
periventricular, as well as central pontine white matter, likely
the sequelae of chronic small vessel ischemic disease. There is
only mild bifrontal cortical atrophy, the midline structures are
in the midline, and there is no intra- or extra-axial
hemorrhage. There is no pathologic parenchymal, leptomeningeal
or dural focus of enhancement. There is no space-occupying
lesion, and the sella, parasellar region and remainder of the
skull base, and orbits are unremarkable. The mastoid air cells
and included paranasal sinuses are grossly clear. The regional
bone marrow signal is overall preserved, with no suspicious
osseous lesion. Incidentally noted is severe degenerative
disease involving the limited included upper cervical spine with
marked ventral canal narrowing at the C2-3 and C3-4 levels, and
frank compression and angulation of the cervical spinal cord at
the latter, as on the recent NECT of ___ this has likely
progressive since the MR examination of ___.
IMPRESSION:
1. The diffusion-weighted sequence is very limited, particularly
at the
cranial vertex, likely due to technical factors (unclear, at
present);
however, there is no definite large focus of slow diffusion to
suggest acute ischemia.
2. No pathologic focus of enhancement or cerebral edema to
suggest
intracranial metastatic disease.
3. Bifrontal cortical atrophy and moderately severe sequelae of
chronic small vessel ischemic disease.
4. Severe degenerative disease in the limited included upper
cervical spine, with significant compression and angulation of
the spinal cord at the C3-4 level.
Brief Hospital Course:
___ year old male with metastatic NSCLC presenting s/p
unwitnessed fall at rehab. He was recently discharged on
___ for an admission for nausea, vomiting and anion-gap
metabolic acidosis.
#FALL
Mr. ___ fell off the side of his bed after reaching for the
urinal. He recalls the entire event and denies any loss of
consciousness. He was advised by nursing to call for help if he
needed to use the urinal. He ignored this advice. The fall
appears to be mechanical, however the patient reported right
upper extremity weakness after the event. His weakness was
difficult to assess initially due to pain in his right shoulder,
grip strength was decreased to ___ on presentation. He sustained
a minor amount of head trauma. CT scan in the ED revealed a
small subgaleal hematoma, no intracranial hemorrhage and
non-displaced left nasal and right lamina papyracea fractures.
His most significant complaint after the fall was right shoulder
pain. XR in the ED demonstrated no fracture or pathology of the
___ joint. He received IV morphine with good effect. He used a
sling during the early part of his hospitalization. Pain control
was provided with morphine ___ and morhpine IV PRN. After he
was unable to swallow, he was placed on morphine oral
concentrate 5q3h standing and ___ PRN.
#RIGHT ARM WEAKNESS
Mr. ___ presented with right arm weakness which was initially
difficult to assess because of his right upper extremity pain
after the fall. On the second day of his hospitalization his
strength improved, however was clearly different from the left
upper extremity. His right upper extremity strength remained at
___ and he later developed right lower extremity strength. A
facial droop was noted by the pulmonary consult team, but was
felt to be facial asymmetry with preserved function of all
facial nerves and muscles by the medicine team. An MR head was
obtain on ___ which showed no evidence of stroke and evere
degenerative disease in the upper cervical spine, with
significant compression and angulation of the spinal cord at the
C3-4 level. This was thought to be the culprit lesion. Full
C-spine MR imaging was not obtained as the patient was
subsequent made CMO, therefore a compressive metastatic lesion
could not be totally excluded. The patient responded well to
dexamethasone 10mg IV x1 followed by 4mg IV Q6hrs. His extremity
strength improved to ___. It remained unclear whether the fall
and associated neck trauma precipitated further cord compression
or if the weakness was present before the fall. Dexamethasone
was discontinued when the patient became unable to swallow.
#FACIAL FRACTURES
Non-displaced left nasal and right lamina papyracea fractures.
Case discussed with ENT; non-operative, antibiotics recommended.
Patient was started on a 7 day course of amoxicillin, which was
later discontinued with initiation of post-obstructive pneumonia
treatment.
#SHORTNESS OF BREATH
Mr. ___ complained of shortness of breath since his discharge
on ___. He was admitted on 24hr nasal cannula oxygen. He
has a chronic cough which is unchanged. He denied sputum
production, worsening chest pain, fevers and chills on
presentation. His SOB is likely related to his primary lung
cancer and large, malignant effusion on the left. The patient
received a dose of levofloxacin in the ED, which was not
continued on the floor. Chest CT noted focal RML ___
opacities suggestive of inflammation or early infection. He had
no lower extremity swelling or other evidence of DVT. The
patient developed low grade temperatures on his ___ and ___
hospital days; treatment for post-obstuctive HCAP was started
with cefepime and vancomycin. His fevers resolved, however his
shortness of breath did not significantly change. His PlearX
catheter was drained as necessary. Output was quite poor
compared to his previous admission, <250mL per 2 days. The
patient was made CMO and his IV was not replaced. Cefepime and
vancomycin were changed to levofloxacin, but this was
discontinued when the patient became unable to swallow. He was
on morphine oral concentrate as above for dyspnea as well.
#METASTATIC NSCLC
Patient presented with dyspnea, cough and community acquired
pneumonia in ___. Imaging studies included CT chest on
___ which disclosed a consolidation of the lingula,
bronchial narrowing, mediastinal lymphadenopathy, liver
hypodense lesions and a large loculated left pleural effusion. A
PET/CT Scan from ___ disclosed the presence of an extensive
FDG-avid consolidative process in the lingula, lymphangitic
carcinomatosis, non-FDG avid pleural effusion, FDG-avid
lymphadenopathy involving the bilateral supraclavicular regions,
mediastinum, subcarinal stations, hilar portacaval and
retroperiotenal nodes. FDG-avid liver lesions and FDG-avid
osseous metastases. Pleural fluid removed on ___ disclosed
a carcinoma. Immunohistochemical stains of the tumor cells were
positive for CK5/6, and CK7; and negative for CK20, p63, and
TTF-1. This immunoprofile was nonspecific but compatible with a
non-small-cell lung cancer not otherwise specified. Extensive
discussions between family, patient and primary oncologist lead
to the decision for no further cancer directed therapies,
including palliative chemo, radiation or surgery.
#AG METABOLIC ACIDOSIS
Issue on previous admission, attributed to lactic acidosis from
malignancy, and metformin. Metformin discontinued on previous
admission. Lactate on ___ 6.6. Anion gap stable, no
improvement with IVFs.
#TYPE II DIABETES MELLITUS
Metformin and glyburide discontinued during previous
hospitalization due to reports of hypoglycemia and lactic
acidosis. Insulin sliding scale continued during hospitalization
in the setting of dexamethasone administration. Aspirin
discontinued after CMO decision was made.
#HYPERTENSION
Blood pressures well controlled this admission. Diltiazem 15 mg
PO/NG QID continued until CMO decision was made.
#PROLAPSED HEMORRHOIDS
Stable issue. Outpatient follow up suggested during prior
admission. Patient ordered for an aggressive bowel regimen.
TRANSITIONAL ISSUES
*******************
-PleurX catheter care, drainage PRN
-Continue concentrated morphine solution for dyspnea and pain,
may increase to 5mg q5min as needed
-Continue inhaler for shortness of breath
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Benzonatate 100 mg PO TID
3. Sildenafil 50 mg PO DAILY:PRN sex
4. urea *NF* 40 % Topical BID
Apply to affected areas of both feet
5. Insulin SC Sliding Scale Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
6. Docusate Sodium 100 mg PO BID
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. OxycoDONE (Immediate Release) 5 mg PO DAILY:PRN prior to
pleurx drainage
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 1 TAB PO BID
11. Simvastatin 10 mg PO DAILY
12. Megestrol Acetate 80 mg PO TID
13. Mirtazapine 15 mg PO HS
14. Morphine SR (MS ___ 15 mg PO Q12H
15. Prochlorperazine 10 mg PO Q6H:PRN nausea
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. Diltiazem 15 mg PO QID
18. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q6H
Discharge Medications:
1. urea *NF* 40 % Topical BID
Apply to affected areas of both feet
2. Tiotropium Bromide 1 CAP IH DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
5. Morphine Sulfate (Concentrated Oral Soln) 5 mg PO Q3H
pain/dsypnea/PleurX drainage
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 5 mg by mouth
every 3 hours Disp ___ Milliliter Refills:*0
6. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q2H:PRN
pain, dyspnea
concentration 20mg per mL
please dispense 30mL
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by
mouth every 2 hours Disp ___ Milliliter Refills:*0
7. Bisacodyl ___AILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Non-small cell lung cancer
Malignant pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Somnolent but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted after a fall at your rehab
facility and for management of you PlearX catheter. X-ray
studies and laboratory tests showed progression of your
non-small cell lung cancer. We discussed cancer treatment
options with your oncologist and family and do not believe you
would benefit from chemotherapy, radiation or additional chest
tubes. During a family meeting we discussed end of life goals
and collectively decided to focus on your comfort as there is no
cure for your cancer. You will be discharged with plenty of
morphine pills to take under your tongue for the pain.
If you have any further questions regarding your hospitalization
feel free to contact your ___ providers.
Please take your medications as prescribed.
Followup Instructions:
___
|
19837632-DS-12
| 19,837,632 | 21,556,883 |
DS
| 12 |
2148-10-11 00:00:00
|
2148-10-15 20:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
iodine-iodine containing contrast dye
Attending: ___
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
Ms. ___ is a ___ year-old right-handed with a past
medical history of arthritis, prior mastectomy for localized
breast CA and hypertension, who presents with a month long
history of intermittent headache with prior abnormal lumbar
puncture.
Beginning roughly 1 month ago, Mrs. ___ had sudden onset of
a
new severe headache. The headache is described as throbbing and
posterior in nature (high cervical and low occipital) that
radiates around the top of her head and then down again to her
eyes. It is associated with nausea. It can be worse on the
right or left side. It tends to improve when laying down, but
has woken her from sleep several times. The headache can come
and go throughout the day, with some days much better than
others.
For this, she initially presented to ___ on ___,
where she underwent abnormal LP (WBC 369, RBC 74, protein <6-
tube 4). Total protein <6.) Oepning pressure was not done, but
reportedly headache did not improve with Tap. She was admitted
and initially covered with Acyclovir and ceftriaxone. Acyclovir
was discontinued when HSV PCR returned negative. Ceftriaxone
was
also discontinued at around day 5 (when CSF lyme titers were
negative, though Serum positive). She was transitioned to
doxycycline and discharged after an 8 day hospital stay feeling
slightly better with plan to treat for acute lyme. Of note, the
lymphocytes from this lumbar puncture were felt to be
"atypical",
but reportedly read by a pathologist as "reactive".
Her headache remained stable and was slightly improved. She was
discharged from that initial hospitalization on a course of
doxycycline which was was converted to cefuroxime (due to nausea
on doxy) to complete the course.
Roughly a week after that first discharge, she was readmitted to
the hospital for overnight obs in the setting of worsened
headache (as above), which improved on antiemetics and opiates.
Following this discharge (roughly 1 week ago) she was once again
doing okay.
Most recently, she was doing "okay", until very early the
morning
of this presentation, when at around 1am, she awoke from sleep
suddenly with her typical headache. It was much more severe
than
it has been since her initial admission. Concerned, they
initially represented to OSH, where NCHCT was benign. She was
transferred for further management.
Of note, there is not (and has never been) sensitivity to light
or sound with this headache. There are no unilateral autonomic
symptoms. She has had intermittent chills during this past
month, but has not felt particularly ill. She lives in a rurual
area, and has recent tick exposure (found one on her skin) prior
to onset of this headache (but known no recent bites).
Multiple medications have been tried for this headache,
inclduing
tylenol, toradol, ibuprofen, oxycodone with only mild
improvement.
Lab evaluation has been extensive (and is well documented in
transferred records. In brief, she has had a negative CSF lyme,
Serum Lyme positive, previous serum ___ 1:160 in ___. on her
first admission CSF VZV, enterovirus, EBV, and HSV were
negative
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt reports intermittent chills
and questionable fevers. No night sweats or recent weight loss
or gain. Denies cough, shortness of breath. Denies chest pain
or
tightness, palpitations. Denies diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits.
Past Medical History:
- Arthritis
- Fibromyalgia
- Hypertension
- s/p Mastectomy for Breast cancer (local, no chemo or
radiation)
- Asthma
- Hypercholesterol
Social History:
___
Family History:
- Family history of celiacs diease. No significant family
history
of neurologic diease- no stroke, seizures, brain tumors, etc.
Physical Exam:
===================================
Admission Physical Exam:
====================================
Vitals: T 99.7, HR 121, BP 148/66, RR18, Satting 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM, no lesions noted in oropharynx
Neck: Supple. No nuchal rigidity, no pain with eye movements,
negative brudzinkis. Significant b/l paraspinal tenderness.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2,
Abdomen: soft, NT/ND, normoactive bowel sounds,
Extremities: WWP.
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:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, mildly tone throughout. Tone in upper
extremities significantly enhances with distraction tasks
(particularly at elbow). Mild right pronation, but no drift
bilaterally. Bilateral symmetric postural and action tremor
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2 2 3 3
R 2+ 2 2 3 3
Plantar response was down on left, equiv on right
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
============================
Discharge Physical Exam
===========================
VS: T 98.7, BP 142/45, HR 67, RR 18 100% on RA
General: well-appearing and pleasant, elderly female in NAD
Neck: supple, no nuchal rigidity
-Mental status: awake, alert and oriented X 3. Able to relate
history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors.
-Cranial nerves
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor
Delt Bic Tri WrE FE IP TA ___
L 5 4+ ___ 5 5 5
R 5 4+ ___ 5 5 5
-Sensory: light touch intact, proprioception intact.
-Coordination: small left-sided action tremor on FNF
===========================================================
DISCHARGE EXAM:
Notable for AAO, Pupils 3->2.5 ___, face symmetric, light touch
intact. Motor ___ (4+ on biceps, triceps, Fex, IP). ___
negative, postural tremor, significant paraspinal tenderness and
tighness. Sensory-proprioceptions/ LT intact; negative pronator
drift.
Pertinent Results:
=====================
LAB VALUES ADMISSION
=====================
___ 01:50PM BLOOD WBC-10.8* RBC-3.55* Hgb-10.0* Hct-30.5*
MCV-86 MCH-28.2 MCHC-32.8 RDW-14.4 RDWSD-44.7 Plt ___
___ 01:50PM BLOOD Neuts-75.8* Lymphs-15.7* Monos-7.8
Eos-0.0* Baso-0.3 Im ___ AbsNeut-8.21* AbsLymp-1.70
AbsMono-0.84* AbsEos-0.00* AbsBaso-0.03
___ 01:50PM BLOOD Plt ___
___ 01:50PM BLOOD Glucose-125* UreaN-17 Creat-1.0 Na-129*
K-5.0 Cl-94* HCO3-21* AnGap-19
___ 01:50PM BLOOD ALT-13 AST-39 AlkPhos-65 TotBili-0.3
___ 01:50PM BLOOD Albumin-4.2 Calcium-9.6 Phos-4.0 Mg-2.0
___ 05:00PM URINE Color-Straw Appear-Clear Sp ___
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 05:00PM URINE RBC-1 WBC-7* Bacteri-FEW Yeast-NONE Epi-3
TransE-<1
=====================
LAB VALUES DISCHARGE
=====================
___ 05:00AM BLOOD WBC-6.7 RBC-3.27* Hgb-9.3* Hct-28.5*
MCV-87 MCH-28.4 MCHC-32.6 RDW-14.2 RDWSD-44.9 Plt ___
___ 05:00AM BLOOD Plt ___
___ 10:00AM BLOOD Ret Aut-1.7 Abs Ret-0.06
___ 10:00AM BLOOD calTIBC-346 ___ Ferritn-15 TRF-266
___ 10:00AM BLOOD LD(LDH)-167
___ 05:00AM BLOOD Glucose-91 UreaN-14 Creat-0.8 Na-136
K-4.4 Cl-103 HCO3-23 AnGap-14
___ 05:00AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.2
PENDING LABS AT DISCHARGE:
Send Outs
___ 10:48 ANAPLASMA PHAGOCYTOPHILUM (HUMAN GRANULOCYTIC
EHRLICHIA AGENT) IGG/IGM
___ 10:00 BABESIA ANTIBODIES, IGG AND IGM
___ 17:00 REFRIGERATE AND HOLD (NEOGENOMICS) (other body
fluid)
___ 16:18 VARICELLA DNA (PCR) (cerebrospinal fluid (csf))
___ 16:18 HERPES SIMPLEX VIRUS PCR (cerebrospinal fluid
(csf))
___ 16:18 BORRELIA BURGDORFERI ANTIBODY INDEX FOR CNS
INFECTION (cerebrospinal fluid (csf))
Microbiology
___ 10:48 SEROLOGY/BLOOD LYME SEROLOGY
___ 17:43 CSF;SPINAL FLUID FLUID CULTURE
___ 14:01 BLOOD CULTURE Blood Culture, Routine
Diagnostic Reports
___ Tissue: immunophenotyping - CSF
===================
CSF
===================
___ 04:18PM CEREBROSPINAL FLUID (CSF) WBC-20 RBC-3* Polys-0
___ ___ 04:18PM CEREBROSPINAL FLUID (CSF) WBC-11 RBC-8* Polys-0
___ Macroph-2
___ 04:18PM CEREBROSPINAL FLUID (CSF) TotProt-39 Glucose-55
==================
MICROBIOLOGY
==================
___ 7:33 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 4:18 pm CSF;SPINAL FLUID Source: LP TUBE#3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
___: CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS. Lymphocytes
and macrophages.
=================
IMAGING
=================
MRI/MRA ___
1. Findings of small vessel ischemic changes. Otherwise,
unremarkable MRI of
the brain.
2. Arteriosclerotic disease demonstrated by MRA of the head,
more significant
in the middle cerebral arteries as described above, with no
aneurysm greater
than 4 mm.
3. Nonspecific bilateral mastoid fluid opacification.
MRI C-SPINE W/ AND W/OUT CONTRAST ___
1. Multilevel multifactorial degenerative disease of the
cervical spine, worst at C4-C5 with moderate bilateral neural
foramen narrowing and moderate to severe spinal canal stenosis.
2. No focal cord signal abnormality or enhancing lesion is seen.
CXR ___
IMPRESSION:
The patient carries a right-sided PICC line. The course of the
line is unremarkable, the tip of the line projects over the mid
SVC. No evidence of complications, notably no pneumothorax.
Brief Hospital Course:
Ms. ___ is a ___ year-old right-handed female with a
past medical history of arthritis, prior mastectomy for
localized breast CA and hypertension, who presents with a month
long history of intermittent headache with prior abnormal lumbar
puncture.
# Headache: pt was transferred from OSH for further w/u. NCHCT
at OSH was benign. Upon arrival to the floor, the pt was given
acetaminophen and lorazapem. The next morning, the pt's headache
had substantially subsided from ___ to about 0-1/10. MRI/MRA
was overall benign, except for minor vascular ischemic changes.
Throughout the hospitalization, her headache was episodic
ranging from no headache to a ___ headache. ID was consulted
and recommended treating her for Lyme, given positive IgM from
OSH. Lyme titers and LP (WBC 20 RBC 3 Protein 39 Glucose 55) was
repeated here. PICC was placed. Pt was started on 28-day course
of cextriaxone 2mg. Day 1 on ___ Stop Date ___. ID
outpatient ___ was established with weekly labs. Recommended ___
with home neurologist ___ in ___, ___.
# Hyponatremia: pt was hyponatremia at Na 129, but resolved upon
administration of NS.
# Normocytic anemia: pt discharge H/H 9.3/28.5, MCV 87. Iron
studies approaching iron deficiency. Patient declined ferrous
sulfate due to nausea. Recommended PCP ___ and up to date
colonscopy screening.
#Transitional Issues:
- Cervical Canal Stenosis/ Degenerative Disc Disease in Cervical
Spine: Hot packs recommended. Should have close neurology follow
up for any change in exam that may require surgical intervention
- Weekly Labs to be sent to ID OPAT
- ID follow up
- patient would like a short stay in snf, and may be
advantageous for patient to transition from snf to home with iv
antibitoic services rather than remaining in snf for entire iv
antibiotic ___ode status: full
# Contact: pt cell ___, home ___
# Patient's son, ___ cell ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Vitamin D Dose is Unknown PO DAILY
3. Aspirin 81 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Pravastatin 20 mg PO QPM
6. OxycoDONE (Immediate Release) 5 mg PO PRN headache
7. Lorazepam 0.5 mg PO PRN headache
8. Ondansetron 4 mg PO PRN nausea
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Lisinopril 5 mg PO DAILY
4. Lorazepam 0.5 mg PO PRN headache
5. Ondansetron 4 mg PO PRN nausea
6. Pravastatin 20 mg PO QPM
7. Vitamin D 1000 UNIT PO DAILY
8. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 G Iv Daily
Disp #*27 Intravenous Bag Refills:*0
9. OxycoDONE (Immediate Release) 5 mg PO PRN headache
10. Outpatient Lab Work
Please draw weekly Cbc with differential, bun, cr, ast, alt, tb,
Alk phos
All lab results should be sent to:
Attention ___ ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lyme Meningitis.
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 headache in the setting of a partially
treated lyme infection. You brain imaging was normal. Your
lumbar puncture where we examined your spinal fluid had signs of
inflammation. Given your positive lyme within the past month and
the partial treatment of lyme, infectious disease was consulted
and recommended a 28 day course of IV antibiotics for treatment
of lyme meningitis. You should have weekly blood work and follow
up with infectious disease. You should also follow up with your
outpatient neurologist.
During this hospitalization, we also found that you were anemic
(low red blood cell levels), and your iron levels were on the
low side of normal. Please follow up with your PCP and make sure
you are up to date on your colonscopy screening.
Your medication changes include:
START Ceftriaxone 2 G daily for 28 days (stop date of
antibiotics ___
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19837636-DS-12
| 19,837,636 | 27,651,495 |
DS
| 12 |
2175-11-05 00:00:00
|
2175-11-13 12:25:00
|
Name: ___ ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nexium
Attending: ___.
Chief Complaint:
cough, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of CLL on Ibrutinib (since ___, c/b
microscopic colitis on prednisone taper (currently on 30mg
prednisone a day from 80mg) who presents to the ED with with
fever, cough. Pt reports that on ___ he started having dry,
non-productive cough. This morning, temp is 100.6. He doesn't
feel unwell and his wife (a pediatrician) said his lungs sound
clear. He receives monthly IVIG, last was ___. Planning to
fly to ___ at 2pm tomorrow. He was admitted for evaluation and
infectious workup and check of immunoglobulins as may require
IVIG.
In the ED, initial vitals: 98.7 HR 113 147/73 20 98% RA. Blood,
urine cultures were drawn.
- ED Exam notable for: Pt A&Ox3, calm and cooperative. Pt taking
non-labored breaths with equal chest rise. Lungs clear
bilaterally. Denies CP. ST in 110s, pt reports he is typical in
the ___. Denies N/V/D/C. pt currently afebrile.
- Labs were notable for: lactate 2.3, CMP wnl, H/H and WBC wnl,
platelets 66, UA not suspicious for infection
- Imaging: CXR ___: ___ comparison. The lung volumes are
normal. Borderline size of the cardiac silhouette. ___ pulmonary
edema. ___ pleural effusions. ___ pneumonia.
- Patient was given: IVF (volume NR)
- Decision was made to admit to ___ for work up of his fever.
- Vitals prior to transfer were: 98.0 93 118/68 15 96% RA
On arrival to the floor, pt reports feeling well other than the
cough. Denies fever, chills, headache, CP, dyspnea, abdominal
pain, nausea, vomiting, diarrhea, rash, or dysuria.
A 10-point was performed with pertinent findings noted in HPI.
Past Medical History:
CLL - diagnosed ___ by labs; stable and was followed until ___
when he developed increased WBC, LAD, anemia, fatigue
-FR x 6 cycles, from ___, with good response, but
c/b autoimmune hemolytic anemia; followed by Rituximab
maintenance
-___ x 6 cycles, ___ - with good response;
recurrence of autoimmune hemolytic anemia with increased LAD
-treated with Rituximab and high dose steroids ___ with
resolution of anemia and improvement in LAD
PMH:
CLL, as above - ___
Urinary Hesitancy - ___
Low back pain - ___
Erectile Dysfunction - ___lock - ___
Migraines - ___
Osteoarthritis, spine - ___
Sciatica - ___
Low testosterone - ___
Automimmune hemolytic anemia - ___
GERD - ___
Carpal tunnel syndrome, left - ___
HSV - ___
Pneumonia - ___
PSH:
Discectomy, cervical, C5-C6, for disc herniation and mild cord
compression - ___
Social History:
___
Family History:
His mother with essential thrombocythemia and reports she
tranformed into a leukemia. Father was a non___ but died from
lung cancer, adenocarcinoma
1 older and ___ younger Brother - ___ esoph, sleep
apnea and bipolar, younger with "fibromyalgia" 1
sister-migraines; otherwise in good health
Physical Exam:
ADMISSION/DISCHARGE PHYSICAL EXAM:
Vitals: 98.1, 125/71 89 18 97 Ra
Gen: lying in bed, legs crossed, appears comfortable
HEENT: ___ conjunctival pallor. ___ icterus. MMM. OP clear.
NECK: ___ lymphadenopathy, supple
CV: Normocardic, regular. Normal S1,S2. ___ MRG.
LUNGS: Mild rhonchi at bases, ___ wheeze or crackles. ___ cough.
ABD: NT, ND, normal BS, ___ organomegaly
EXT: WWP. ___ edema.
SKIN: ___ rash
NEURO: A&Ox3.
LINES: PIV
Pertinent Results:
___ 08:47PM OTHER BODY FLUID FluAPCR-POSITIVE *
FluBPCR-NEGATIVE
___ 02:01PM COMMENTS-GREEN TOP
___ 02:01PM LACTATE-2.2*
___ 11:49AM URINE HOURS-RANDOM
___ 11:49AM URINE UHOLD-HOLD
___ 11:49AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:49AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 11:23AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 10:51AM ___ COMMENTS-GREEN TOP
___ 10:51AM LACTATE-2.3*
___ 10:26AM GLUCOSE-101* UREA N-16 CREAT-1.1 SODIUM-136
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-24 ANION GAP-18
___ 10:26AM estGFR-Using this
___ 10:26AM CALCIUM-9.6 PHOSPHATE-2.6* MAGNESIUM-1.8
___ 10:26AM CALCIUM-9.6 PHOSPHATE-2.6* MAGNESIUM-1.8
___ 10:26AM IgG-489* IgA-9* IgM-<5*
___ 10:26AM WBC-8.6 RBC-4.41* HGB-15.0 HCT-42.1 MCV-96
MCH-34.0* MCHC-35.6 RDW-14.4 RDWSD-49.9*
___ 10:26AM NEUTS-82* BANDS-4 LYMPHS-4* MONOS-7 EOS-1
BASOS-1 ___ METAS-1* MYELOS-0 AbsNeut-7.40* AbsLymp-0.34*
AbsMono-0.60 AbsEos-0.09 AbsBaso-0.09*
___ 10:26AM HOS-DONE
___ 10:26AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 10:26AM PLT SMR-VERY LOW PLT COUNT-66*
IMAGING:
==============
CXR pa/lat ___:
IMPRESSION:
___ comparison. The lung volumes are normal. Borderline size of
the cardiac
silhouette. ___ pulmonary edema. ___ pleural effusions. ___
pneumonia.
MICRO:
==============
___ 20:47
VIRAL, MOLECULAR
Influenza A by PCRPOSITIVE *
Influenza B by PCR NEGATIVE
Brief Hospital Course:
___ with a history of CLL on Ibrutinib (since ___, c/b
microscopic colitis on prednisone taper (currently on 30mg
prednisone a day from 80mg) who presents to the ED with fever
with dry cough, admitted for evaluation and infectious workup
with check of immunoglobulins as possible IVIG.
#Cough, fever: 24 hours duration without associated sxs. Pt not
neutropenic. Afebrile since presentation to ED. Tachy on
presentation but improved with IV fluids. Likely viral
respiratory infection but given immunosuppression, workup and
observation warranted. Given his hx of decompensation with viral
illnesses and IgG <500, he received 1 dose IVIG. Flu was
initially negative but on repeat was positive so started on
Tamiflu for at least 14 day course, may need up to 28 days.
# CLL: Dx in ___. On trial drug idelalisib from ___ until ~2
months ago when it was discontinued ___ colitis and difficult to
manage diarrhea. He was also started on prednisone 80mg for
control of the colitis but is now tapering down by 10mg q5 days,
current dose of 30mg. He initiated ibrutinib in ___. His
diarrhea is improved and he reports ___ drug side effects. He has
a hx of infections requiring hospitalization including
parainfluenza ___ yr ago and receives IVIG on a monthly basis.
SPEP from ED showed IgG 489.
-cont ibrutinib 420 mg daily
-PPX: Bactrim, Valtrex
-Immune: Prednisone 30mg daily
-cont pepto for diarrhea
#Thrombocytopenia: plts consistently low but 126 one month ago,
now 66. Possibly ___ viral infection or ___ ibrutinib as
thrombocytopenia documented side effect.
-f/u labs were this admission were Hgb 13.8 and plt 64.
#Hx Zoster: T7 dermatome, resolved.
-On Valtrex for suppression.
TRANSITIONAL ISSUES:
=======================
- initiated on Tamiflu on ___, written for 14 day course, will
defer to outpatient team if 28 treatment is warranted given
immunoduppresion
-maintained on home meds including ibrutinib
-f/u next week for platelet check (___)
-f/u with oncologist as planned or sooner if concerned (see
appts above)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO BID
2. PredniSONE 30 mg PO DAILY
3. ibrutinib 420 mg oral daily
4. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
5. ValACYclovir 1000 mg PO Q24H
6. ZOLMitriptan 5 mg oral prn
7. Bismuth Subsalicylate 15 mL PO TID:PRN diarrhea
Discharge Medications:
1. OSELTAMivir 75 mg PO Q12H
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth twice a
day Disp #*28 Capsule Refills:*0
2. Bismuth Subsalicylate 15 mL PO TID:PRN diarrhea
3. ibrutinib 420 mg oral daily
4. PredniSONE 30 mg PO DAILY
5. Ranitidine 150 mg PO BID
6. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
7. ValACYclovir 1000 mg PO Q24H
8. ZOLMitriptan 5 mg oral prn
Discharge Disposition:
Home
Discharge Diagnosis:
influenza A
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ were admitted to ___ for cough and fever. Given your state
of immunosuppression secondary to CLL and current steroid use,
___ warranted observation overnight for what is likely a viral
respiratory infection. It turned out to be the flu.
Your IgG was found to be below 500 so ___ were given IVIG. We
kept ___ on your home medications while ___ were here.
Please follow-up with your outpatient oncologist if your
symptoms do not resolve or ___ have concerns or questions.
It was a pleasure to meet ___ and we wish ___ the best,
The ___ Care Team
Followup Instructions:
___
|
19837674-DS-21
| 19,837,674 | 23,931,665 |
DS
| 21 |
2171-05-13 00:00:00
|
2171-05-14 18:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / ampicillin
Attending: ___
___ Complaint:
fever
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Dr. ___ is a pleasant ___ w/ IgG MM dx ___, s/p Auto HSCT
___, previously on lenalidominde and bortezomib, now on
___ Carfilzomib/Dexamethasone and pomalidomide, who presents
from ___ with a fever.
History is limited as patient was understandingly exhausted.
In short, she spent the past two weeks mainly in ___ where
she met the ___ and attending lecture. She spent a short
period of time outside of ___. She stated she was advised
by her doctor NOT to take ___.
Over the past week, she had low grade temperatures of 99-100 and
developed a non-productive cough. She denied any headache,
retro-orbital pain, neck pain. Denied any N/V or abdominal pain,
but admits to diarrhea (one loose stool per day x 2 weeks which
she states is normal for her). She denied any dysuria,
hematuria. Denied any rashes or joint pain, but admitted to
myalgias. She admits to many sick contacts - states many
individuals on her trip had similar symptoms. She did not take
any antibiotics apart from her daily clarithromycin.
Yesterday, she developed a fever of ___ and presented to the ED
just after arrival from ___. Apart from the temperature
spike, she largely feels better and notes her cough is
improving.
In ED, Tmax 102.7F. BP 120/67. HR 81-92. She received 2 gm
Cefepime, 1 gm Vancomycin, 750 Levofloxacin, Ibuprofen, KCL
40mEq, 1 gm APAP.
REVIEW OF SYSTEMS:
10 point ROS reviewed in detail and negative except for what is
mentioned above in HPI
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
A ___ woman with multiple myeloma status post
treatment on protocol number ___: Blockade of PD-1 in
conjunction with the dendritic cell/myeloma vaccines following
stem cell transplantation (vaccine and ___ after her
autologous stem cell transplant on ___, with noted
recurrent disease.
ONCOLOGIC HISTORY:
- ___, diagnosed with IGG multiple myeloma.
- Pulse Decadron starting in ___ with the addition of
thalidomide in ___ which was continued until ___.
- Subsequent rise in IgG monoclonal protein off therapy with
initiation of Velcade on ___ and completed 6 cycles of
therapy as of ___ with a good response to her monoclonal
protein.
- Received 4 weeks of maintenance Velcade completing on
___ and has been observed off therapy.
- Started Revlimid therapy C1 @ 5mg for 21 days on ___.
C2 @ 10 mg for 21 days on ___. C3 @ 15 mg for 21 days on
___. C4 @ 15 mg for 21 days on ___. C5 @ 15mg for
21 days on ___. C6 @ 15mg for 21 days started on
___.
C7 @ 15mg for 21 days on ___. C8 delayed until ___
@
15mg for 21 days. C9 @ 15mg for 21 days on ___.
- Followed for a prolonged period of time on treatment with
Curcumin and fish oil.
- Presented for usual visit on ___ with marked
progression of her myeloma with total protein of 12.4 and total
IgG 7429 with monoclonal IgG kappa of 42% or 5210 mg/dl of the
total protein. Initiated on treatment with Velcade/Decadron on
___ as she has responded to this in the past. First 2
cycles given with Decadron 20 mg on Day of Velcade and day after
Velcade.
- Cycle 3 with D 1 Velcade only with Decadron 20 mg on
___ then Decadron for 3 more doses as she was travelling
for the ___.
- Cycle 4 on ___ and Cycle 5 on ___, Velcade with
Decadron 20 mg on day of Velcade only
- Cycle 6 Velcade with Decadron 20 mg on day of Velcade. Only
D1 given as then had to travel for family medical issues.
- Cycle 7 on ___ and Cycle 8 on ___ with Velcade and
Decadron 20 mg on day of Velcade only.
- ___, switched to maintenance therapy with Velcade
1.3mg/m2 and Decadron 10 mg on day of Velcade given 4 weeks on,
2
weeks off. Received 3 weeks only as had to deal with family
issues, last treated ___.
- Returned for follow up in ___ with noted progression of
her
myeloma with IgG > 6 grams. Restarted Velcade SQ/Decadron on
weekly basis, 4 weeks on and 1 week off on ___.
- ___ Another cycle of Velcade SQ/Decadron. Received D1,
D8, (missed D 15).
- ___ Started another cycle of Velcade SQ/Decadron given
D1, D4, D8.
- ___ Velcade SQ/Decadron given on D1, D4, D8, D11.
- Went on vacation and developed pneumonia. Off treatment and
noted progression of myeloma with IgG > 7 grams.
- ___ Velcade SQ/Decadron given on D1, D4, D8, D11 with
plan to add in Revlimid for next cycle.
- ___ Velcade SQ given on D1, D8, D15 with Decadron 10 mg
on day of and day following Velcade and Revlimid on D 1 - 14.
- ___ to ___ Velcade, Decadron and Revlimid
continues.
- ___ Another opinion at ___.
- Increasing to stable myeloma parameters. Interested in
moving forward with autologous transplant but needs further
cytoreduction.
- ___ and signed consent for Protocol
___: Blockade of PD-1 in Conjunction With the Dendritic
Cell/Myeloma Vaccines Following Stem Cell Transplantation
- Bone marrow biopsy on ___ showed plasma cells are 39% of
aspirate differential and include several cytologically atypical
and anaplastic forms. By CD138 immunostaining, they are 50-60%
of the core biopsy and kappa restricted by kappa and lambda
immunostaining. Multiple cytogenetic abnormalities.
- ___ Velcade 1.3mg/m2 with Decadron.
- ___ Treatment switched to Cytoxan 300 mg/m2 on D 1, 8,
15, 22 with Velcade 1.3 mg/m2 on D 1, 4, 8, 11. Decadron 20 mg
on day of and day after Velcade.
- ___ cycle of Cytoxan, Velcade and Decadron but
received D1 only as myeloma parameters increased somewhat.
- ___ Received Cytoxan 1200 mg/m2
- ___ Admitted for DPACE in hopes of augmenting response
as had continued slow response but with IGG of ~ 4 gms. Issues
with parasomnias and pulling line out. Treatment switched to
Cytoxan, etoposide and cisplatin in order to avoid steroids and
anthracyclines. Required transfusion support with minimal
response to chemotherapy.
- ___ Dendritic cells harvested in order to make vaccines
for post autologous transplant vaccinations on Protocol ___.
- ___ Cycle 1 Carfilzomib and Decadron
- ___ Cycle 2 Carfilzomib and Decadron
- ___ Bone marrow biopsy with persistent involvement with
myeloma with noted plasma cells comprising 10% of aspirate
differential and approximately ___ by CD138 immunostaining of
the core biopsy. Persistent cytogenetic abnormalities.
- ___ cycle of Carfilzomib to further cytoreduce
myeloma before proceeding with autologous transplant.
- ___ Admission for high dose Cytoxan for stem cell
mobilization with unfortunately unsuccessful attempt at
collections.
- ___ to ___, stem cell collections with Plerixifor
and Neupogen
- ___, Admitted for autologous stem cell transplant with
high dose Melphalan. D0 = ___
- ___, BM biopsy with CD138 highlighting plasma cells,
present singly and in small clusters, comprising an estimated
___ of the overall cellularity.
- Fusion Vaccine #1 on ___ on Protocol ___: Blockade
of PD-1 in Conjunction With the Dendritic Cell/Myeloma Vaccines
Following Stem Cell Transplantation.
- Delay of ___ due to illness; given on ___.
- Fusion Vaccine #2 on ___.
- ___ infusion #2 on ___.
- Fusion Vaccine #3 on ___.
- ___ infusion #3 on ___.
- ___, Month 1 follow up with progression of disease. BM
with 70-80% plasma cells by CD 138 staining.
- ___, Restarted treatment with Carfilzomib and
Pomalidomide(only took 7 days of Pomalidomide) with Decadron.
- ___ cycle Pomalidomide 4 mg daily for 21 days.
- ___ cycle Carfilzomib.
- ___ cycle Carfilzomib, Decadron with Pomalidomide
- ___ cycle Carfilzomib, Decadron with Pomalidomide
- Continuing on treatment with Carfilzomib, Decadron and Pom.
PAST MEDICAL HISTORY (per OMR):
1. Myeloma as outlined.
2. Hypertension.
3. Anxiety.
4. Parasomnias.
Social History:
___
Family History:
Father had diabetes and died in ___ after long illness. She
has one sister who has a thyroid condition, and is HLA ___
compatible. She has another half-sister. There are no
lymphomas, myelomas, or other malignancies in her family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: ___ 100/64 64 18 95% RA
General: sleeping in bed comfortably, in NAD, arousable
HEENT: MMD, no OP lesions, no cervical adenopathy, neck is
supple, no obvious photophobia, sclera anicteric
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, + crackles left base, no wheezing, No respiratory
distress
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: Grossly normal
DISCHARGE PHYSICAL EXAM:
Vitals: 98.2 (Tmax 99.1 noon ___, 80, 112/78, 18, 98%RA
Gen: Pleasant, calm
HEENT: OP clear
NECK: JVP not visualized
LYMPH: No cervical or supraclav LAD
CV: RRR, nl S1 S2, no murmurs/rubs/gallops
LUNGS: rales in b/l bases, coughing with deep breathing
ABD: NABS, Soft, nontender, nondistended, no HSM
EXT: WWP, no ___ edema
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3
Pertinent Results:
ADMISSION LABS:
___ 05:15PM BLOOD WBC-0.3*# RBC-2.15* Hgb-8.2* Hct-24.2*
MCV-113* MCH-38.1* MCHC-33.9 RDW-13.4 RDWSD-55.1* Plt Ct-54*
___ 05:15PM BLOOD Neuts-54 Bands-0 ___ Monos-8 Eos-0
Baso-0 Atyps-2* ___ Myelos-0 Other-0 AbsNeut-0.16*
AbsLymp-0.11* AbsMono-0.02* AbsEos-0.00* AbsBaso-0.00*
___ 05:15PM BLOOD Glucose-126* UreaN-14 Creat-1.2* Na-126*
K-3.2* Cl-96 HCO3-22 AnGap-11
___ 05:15PM BLOOD ALT-12 AST-18 LD(LDH)-374* CK(CPK)-284*
AlkPhos-40 TotBili-0.4
___ 05:15PM BLOOD Albumin-3.6 Calcium-7.8* Phos-2.9 Mg-1.7
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-9.0# RBC-2.23* Hgb-8.3* Hct-24.4*
MCV-109* MCH-37.2* MCHC-34.0 RDW-13.1 RDWSD-52.1* Plt Ct-63*
___ 06:45AM BLOOD Neuts-71 Bands-5 Lymphs-3* Monos-20*
Eos-1 Baso-0 ___ Myelos-0 NRBC-1* AbsNeut-6.84*
AbsLymp-0.27* AbsMono-1.80* AbsEos-0.09 AbsBaso-0.00*
___ 06:45AM BLOOD Glucose-83 UreaN-7 Creat-0.8 Na-134 K-3.5
Cl-104 HCO3-24 AnGap-10
___ 06:45AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.7
___ 11:15AM BLOOD FreeKap-6950* FreeLam-1.9* Fr K/L-GREATER
TH
___ 06:05AM BLOOD IgG-___*
IMAGING/STUDIES
CXR ___ Subtle lingular opacity is suspicious for
pneumonia.
CT CHEST ___
Diffuse predominantly peripheral opacities most severe in the
lower lobes. Differential includes organizing pneumonia, NSIP or
eosinophilic pneumonia; infection is thought less likely but
parasitic infection should be considered given provided
clinical history. Tissue diagnosis is recommended for
confirmation.
MICROBIOLOGY:
___ 5:15 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ ___
21:50.
___ BLOOD CULTURE PENDING
___ BLOOD CULTURE PENDING
___ BLOOD CULTURE PENDING
___ BLOOD FUNGAL CULTURE PENDING
___ 8:00 am Blood (Malaria)
Malaria Antigen Test (Final ___:
Negative for Plasmodium antigen.
___ 11:33 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
___ 2:00 am SPUTUM Site: EXPECTORATED
Source: Expectorated.
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
___ CMV VIRAL LOAD PENDING
Brief Hospital Course:
Dr. ___ is a ___ w/ IgG MM dx ___, s/p Auto HSCT ___,
previously on lenalidominde and bortezomib, now on ___
Carfilzomib/Dexamethasone and pomalidomide, who presents from
___ with an improving cough, persistent fevers in context of
severe neutropenia, ___, found to have influenza B.
# Neutropenic Fever: Pt presented with fever to 102 in ED after
recent travel to ___. Found to be positive for influenza B.
She was started on vancomycin, cefepime, levofloxacin and
ostletamivir. CXR on admission showed lingular opacity
concerning for possible pneumonia. Further evaluation with CT
Chest showed b/l lower lobe opacities, thought to be an
organizing pneumonia. The patient was found to have ___ blood
cultures positive for GPCs, thought to be a contaminant. Stool
studies and malarial antigen were negative. The patient was
evaluated by infectious disease who recommended a 21 day course
of ostletamivir (through ___ given immunocompromised state.
She was covered on vancomycin, cefepime, and levofloxacin from
___. The patient was also started on neupogen with
improvement in her counts, which was stopped on ___.
# Acute Kidney Injury: The patient presented with Cr 1.2,
thought to be pre-renal in origin as Cr trended down with IVF.
# Multiple Myeloma: The patient has a history of IgG MM, s/p
AutoSCT in ___, now on carfilzomib, dexamethasone and
pomalidomide. The patient's clarithromycin was held on admission
as she was started on levofloxacin as above. The patients
pomalidomide and carfilzomib were held in the setting of her
acute illness. She should f/u with oncology after discharge to
determine further course of treatment.
# Thrombocytopenia: thought to be secondary to chemotherapy and
underlying disease. The patient's aspirin was held.
# Anemia: In setting of neoplastic disease and antineoplastic
therapy. The patient did not require a blood transfusion during
her hospitalization.
# Hyponatremia: Na 126 on admission, likely hypovolemic,
improved to 134 with IVF.
Transitional Issues
- Continue ostletamivir x 28days (through ___
- ASA held due to thrombocytopenia, discuss when to restart
- Consider restarting clarithromycin when stopping levofloxacin
- Patient will discuss with outpatient oncologist whether
patient should be taking Bactrim PPX as patient has not been
taking it recently.
# CODE STATUS: Full code, presumed
# HCP: ___, husband, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Nortriptyline 85 mg PO HS
4. Vitamin D 1000 UNIT PO DAILY
5. Pomalyst (pomalidomide) 4 mg oral other
6. Clarithromycin 500 mg PO DAILY
Discharge Medications:
1. OSELTAMivir 75 mg PO Q12H
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth Twice a
day Disp #*48 Capsule Refills:*0
2. Atenolol 25 mg PO DAILY
3. Nortriptyline 85 mg PO HS
4. Vitamin D 1000 UNIT PO DAILY
5. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
6. Aspirin 81 mg PO DAILY
7. Clarithromycin 500 mg PO DAILY
8. Pomalyst (pomalidomide) 4 mg oral other
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs IH every 4
hours Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Influenza B pneumonia, gram positive cocci bacteremia,
acute kidney injury, hyponatremia
Secondary: multiple myeloma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital because of your fevers. You
were found to have low blood counts. You were found to have
influenza B. We treated you with ostletamivir, which you should
keep taking, with your last dose on ___. You were found
to have some findings on your chest imaging that were suggestive
of pneumonia. We treated you with antibiotics.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19837674-DS-22
| 19,837,674 | 20,523,071 |
DS
| 22 |
2171-06-10 00:00:00
|
2171-06-10 18:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / ampicillin
Attending: ___
___ Complaint:
Fevers, dysuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with IgG MM s/p auto-HSCT in ___,
Rev/Velcade, 18 cycles of carfilzomib/dex/pomalidomide, recently
admitted for febrile neutropenia found to be flu positive on
Tamiflu through ___, started on Daratumamab ___ presents
with one episode of chills and temp at home to 100.5. She took
Tylenol and no fever since. She states that for the past three
days she has actually been having some dysuria, though mild,
which resolved when she drank more fluids. She does not
otherwise
feel dehydrated and has been keeping up with PO intake however
notes ___ episodes of watery diarrhea (nonbloody) in the past
several days since starting daratumumab. No nausea/vomiting. no
cough or dyspnea. No headache or visual disturbances. No abd
pain
or flank pain or melena/BRBPR.
Note that she was recently admitted ___ with fever and
___ after a trip to ___, found to be flu B positive. Started
on
vanc/cefepime/levoflox/oseltamavir with CT chest showing
bilateral Lower lobe opacities and she has ___ blood cultures
with GPCs ultimatey deemed a contaimant. Stool studies/malarial
ag neg. ID recommended 21 d course of oseltamavir through ___.
OTher antibiotics stopped ___. neupogen given with improvement
in counts (DCd ___.
Regarding her multiple myeloma, the patient has a history of IgG
MM, s/p AutoSCT in ___, most recently on carfilzomib,
dexamethasone and pomalidomide, however with progressive
disease,
therefore she was started on daratumumab ___.
In the ED she has been afebrile. T 97.5 HR 97 BP 161/94 -->
116/74. RR 18 100% RA. Labs with neutropenia (ANC 1,660) Hct
26.6 Plts 65. She received 2g IV cefepime, 1g IV vanc, 75mg po
oseltamavir. CXR unremarkable. Urine with pos nitr, sm leuks, 11
wbc, few bact, 0 epis. Labs significant for lactate 2.1, Na 131,
BUN/cr ___, LFTs unremarkable. She was given vanc/cefepime
and
restarted on oseltamivir.
On arrival to the floor she is alert and oriented and
comfortable
and conversant. She endorses occasional dysuria as above and
watery stools as above but no other abnormal symptoms in the
past
several days. No mouth sores or pain.
- ___, diagnosed with IGG multiple myeloma.
- Pulse Decadron starting in ___ with the addition of
thalidomide in ___ which was continued until ___.
- Subsequent rise in IgG monoclonal protein off therapy with
initiation of Velcade on ___ and completed 6 cycles of
therapy as of ___ with a good response to her monoclonal
protein.
- Received 4 weeks of maintenance Velcade completing on
___ and has been observed off therapy.
- Started Revlimid therapy C1 @ 5mg for 21 days on ___.
C2 @ 10 mg for 21 days on ___. C3 @ 15 mg for 21 days on
___. C4 @ 15 mg for 21 days on ___. C5 @ 15mg for
21 days on ___. C6 @ 15mg for 21 days started on
___.
C7 @ 15mg for 21 days on ___. C8 delayed until ___
@
15mg for 21 days. C9 @ 15mg for 21 days on ___.
- Followed for a prolonged period of time on treatment with
Curcumin and fish oil.
- Presented for usual visit on ___ with marked
progression of her myeloma with total protein of 12.4 and total
IgG 7429 with monoclonal IgG kappa of 42% or 5210 mg/dl of the
total protein. Initiated on treatment with Velcade/Decadron on
___ as she has responded to this in the past. First 2
cycles given with Decadron 20 mg on Day of Velcade and day after
Velcade.
- Cycle 3 with D 1 Velcade only with Decadron 20 mg on
___ then Decadron for 3 more doses as she was travelling
for the ___.
- Cycle 4 on ___ and Cycle 5 on ___, Velcade with
Decadron 20 mg on day of Velcade only
- Cycle 6 Velcade with Decadron 20 mg on day of Velcade. Only
D1 given as then had to travel for family medical issues.
- Cycle 7 on ___ and Cycle 8 on ___ with Velcade and
Decadron 20 mg on day of Velcade only.
- ___, switched to maintenance therapy with Velcade
1.3mg/m2 and Decadron 10 mg on day of Velcade given 4 weeks on,
2
weeks off. Received 3 weeks only as had to deal with family
issues, last treated ___.
- Returned for follow up in ___ with noted progression of
her
myeloma with IgG > 6 grams. Restarted Velcade SQ/Decadron on
weekly basis, 4 weeks on and 1 week off on ___.
- ___ Another cycle of Velcade SQ/Decadron. Received D1,
D8, (missed D 15).
- ___ Started another cycle of Velcade SQ/Decadron given
D1, D4, D8.
- ___ Velcade SQ/Decadron given on D1, D4, D8, D11.
- Went on vacation and developed pneumonia. Off treatment and
noted progression of myeloma with IgG > 7 grams.
- ___ Velcade SQ/Decadron given on D1, D4, D8, D11 with
plan to add in Revlimid for next cycle.
- ___ Velcade SQ given on D1, D8, D15 with Decadron 10 mg
on day of and day following Velcade and Revlimid on D ___ - ___.
- ___ to ___ Velcade, Decadron and Revlimid
continues.
- ___ Another opinion at ___.
- Increasing to stable myeloma parameters. Interested in
moving forward with autologous transplant but needs further
cytoreduction.
- ___ and signed consent for Protocol
___: Blockade of PD-1 in Conjunction With the Dendritic
Cell/Myeloma Vaccines Following Stem Cell Transplantation
- Bone marrow biopsy on ___ showed plasma cells are 39% of
aspirate differential and include several cytologically atypical
and anaplastic forms. By CD138 immunostaining, they are 50-60%
of the core biopsy and kappa restricted by kappa and lambda
immunostaining. Multiple cytogenetic abnormalities.
- ___ Velcade 1.3mg/m2 with Decadron.
- ___ Treatment switched to Cytoxan 300 mg/m2 on D 1, 8,
15, 22 with Velcade 1.3 mg/m2 on D 1, 4, 8, 11. Decadron 20 mg
on day of and day after Velcade.
- ___ cycle of Cytoxan, Velcade and Decadron but
received D1 only as myeloma parameters increased somewhat.
- ___ Received Cytoxan 1200 mg/m2
- ___ Admitted for DPACE in hopes of augmenting response
as had continued slow response but with IGG of ~ 4 gms. Issues
with parasomnias and pulling line out. Treatment switched to
Cytoxan, etoposide and cisplatin in order to avoid steroids and
anthracyclines. Required transfusion support with minimal
response to chemotherapy.
- ___ Dendritic cells harvested in order to make vaccines
for post autologous transplant vaccinations on Protocol ___.
- ___ Cycle 1 Carfilzomib and Decadron
- ___ Cycle 2 Carfilzomib and Decadron
- ___ Bone marrow biopsy with persistent involvement with
myeloma with noted plasma cells comprising 10% of aspirate
differential and approximately ___ by ___ immunostaining of
the core biopsy. Persistent cytogenetic abnormalities.
- ___ cycle of Carfilzomib to further cytoreduce
myeloma before proceeding with autologous transplant.
- ___ Admission for high dose Cytoxan for stem cell
mobilization with unfortunately unsuccessful attempt at
collections.
- ___ to ___, stem cell collections with Plerixifor
and Neupogen
- ___, Admitted for autologous stem cell transplant with
high dose Melphalan. D0 = ___
- ___, BM biopsy with CD138 highlighting plasma cells,
present singly and in small clusters, comprising an estimated
___ of the overall cellularity.
- Fusion Vaccine #1 on ___ on Protocol ___: Blockade
of PD-1 in Conjunction With the Dendritic Cell/Myeloma Vaccines
Following Stem Cell Transplantation.
- Delay of ___ due to illness; given on ___.
- Fusion Vaccine #2 on ___.
- ___ infusion #2 on ___.
- Fusion Vaccine #3 on ___.
- ___ infusion #3 on ___.
- ___, Month 1 follow up with progression of disease. BM
with 70-80% plasma cells by CD 138 staining.
- ___, Restarted treatment with Carfilzomib and
Pomalidomide(only took 7 days of Pomalidomide) with Decadron.
- ___ cycle Pomalidomide 4 mg daily for 21 days.
- ___ cycle Carfilzomib.
- ___ cycle Carfilzomib, Decadron with Pomalidomide
- ___ cycle Carfilzomib, Decadron with Pomalidomide
started Daratumamab ___
PAST MEDICAL HISTORY (per OMR):
1. Myeloma as outlined.
2. Hypertension.
3. Anxiety.
4. Parasomnias.
Past Medical History:
- ___, diagnosed with IGG multiple myeloma.
- Pulse Decadron starting in ___ with the addition of
thalidomide in ___ which was continued until ___.
- Subsequent rise in IgG monoclonal protein off therapy with
initiation of Velcade on ___ and completed 6 cycles of
therapy as of ___ with a good response to her monoclonal
protein.
- Received 4 weeks of maintenance Velcade completing on
___ and has been observed off therapy.
- Started Revlimid therapy C1 @ 5mg for 21 days on ___.
C2 @ 10 mg for 21 days on ___. C3 @ 15 mg for 21 days on
___. C4 @ 15 mg for 21 days on ___. C5 @ 15mg for
21 days on ___. C6 @ 15mg for 21 days started on
___.
C7 @ 15mg for 21 days on ___. C8 delayed until ___
@
15mg for 21 days. C9 @ 15mg for 21 days on ___.
- Followed for a prolonged period of time on treatment with
Curcumin and fish oil.
- Presented for usual visit on ___ with marked
progression of her myeloma with total protein of 12.4 and total
IgG 7429 with monoclonal IgG kappa of 42% or 5210 mg/dl of the
total protein. Initiated on treatment with Velcade/Decadron on
___ as she has responded to this in the past. First 2
cycles given with Decadron 20 mg on Day of Velcade and day after
Velcade.
- Cycle 3 with D 1 Velcade only with Decadron 20 mg on
___ then Decadron for 3 more doses as she was travelling
for the ___.
- Cycle 4 on ___ and Cycle 5 on ___, Velcade with
Decadron 20 mg on day of Velcade only
- Cycle 6 Velcade with Decadron 20 mg on day of Velcade. Only
D1 given as then had to travel for family medical issues.
- Cycle 7 on ___ and Cycle 8 on ___ with Velcade and
Decadron 20 mg on day of Velcade only.
- ___, switched to maintenance therapy with Velcade
1.3mg/m2 and Decadron 10 mg on day of Velcade given 4 weeks on,
2
weeks off. Received 3 weeks only as had to deal with family
issues, last treated ___.
- Returned for follow up in ___ with noted progression of
her
myeloma with IgG > 6 grams. Restarted Velcade SQ/Decadron on
weekly basis, 4 weeks on and 1 week off on ___.
- ___ Another cycle of Velcade SQ/Decadron. Received D1,
D8, (missed D 15).
- ___ Started another cycle of Velcade SQ/Decadron given
D1, D4, D8.
- ___ Velcade SQ/Decadron given on D1, D4, D8, D11.
- Went on vacation and developed pneumonia. Off treatment and
noted progression of myeloma with IgG > 7 grams.
- ___ Velcade SQ/Decadron given on D1, D4, D8, D11 with
plan to add in Revlimid for next cycle.
- ___ Velcade SQ given on D1, D8, D15 with Decadron 10 mg
on day of and day following Velcade and Revlimid on D 1 - 14.
- ___ to ___ Velcade, Decadron and Revlimid
continues.
- ___ Another opinion at ___.
- Increasing to stable myeloma parameters. Interested in
moving forward with autologous transplant but needs further
cytoreduction.
- ___ and signed consent for Protocol
___: Blockade of PD-1 in Conjunction With the Dendritic
Cell/Myeloma Vaccines Following Stem Cell Transplantation
- Bone marrow biopsy on ___ showed plasma cells are 39% of
aspirate differential and include several cytologically atypical
and anaplastic forms. By CD138 immunostaining, they are 50-60%
of the core biopsy and kappa restricted by kappa and lambda
immunostaining. Multiple cytogenetic abnormalities.
- ___ Velcade 1.3mg/m2 with Decadron.
- ___ Treatment switched to Cytoxan 300 mg/m2 on D 1, 8,
15, 22 with Velcade 1.3 mg/m2 on D 1, 4, 8, 11. Decadron 20 mg
on day of and day after Velcade.
- ___ cycle of Cytoxan, Velcade and Decadron but
received D1 only as myeloma parameters increased somewhat.
- ___ Received Cytoxan 1200 mg/m2
- ___ Admitted for DPACE in hopes of augmenting response
as had continued slow response but with IGG of ~ 4 gms. Issues
with parasomnias and pulling line out. Treatment switched to
Cytoxan, etoposide and cisplatin in order to avoid steroids and
anthracyclines. Required transfusion support with minimal
response to chemotherapy.
- ___ Dendritic cells harvested in order to make vaccines
for post autologous transplant vaccinations on Protocol ___.
- ___ Cycle 1 Carfilzomib and Decadron
- ___ Cycle 2 Carfilzomib and Decadron
- ___ Bone marrow biopsy with persistent involvement with
myeloma with noted plasma cells comprising 10% of aspirate
differential and approximately ___ by CD138 immunostaining of
the core biopsy. Persistent cytogenetic abnormalities.
- ___ cycle of Carfilzomib to further cytoreduce
myeloma before proceeding with autologous transplant.
- ___ Admission for high dose Cytoxan for stem cell
mobilization with unfortunately unsuccessful attempt at
collections.
- ___ to ___, stem cell collections with Plerixifor
and Neupogen
- ___, Admitted for autologous stem cell transplant with
high dose Melphalan. D0 = ___
- ___, BM biopsy with CD138 highlighting plasma cells,
present singly and in small clusters, comprising an estimated
___ of the overall cellularity.
- Fusion Vaccine #1 on ___ on Protocol ___: Blockade
of PD-1 in Conjunction With the Dendritic Cell/Myeloma Vaccines
Following Stem Cell Transplantation.
- Delay of ___ due to illness; given on ___.
- Fusion Vaccine #2 on ___.
- ___ infusion #2 on ___.
- Fusion Vaccine #3 on ___.
- ___ infusion #3 on ___.
- ___, Month 1 follow up with progression of disease. BM
with 70-80% plasma cells by CD 138 staining.
- ___, Restarted treatment with Carfilzomib and
Pomalidomide(only took 7 days of Pomalidomide) with Decadron.
- ___ cycle Pomalidomide 4 mg daily for 21 days.
- ___ cycle Carfilzomib.
- ___ cycle Carfilzomib, Decadron with Pomalidomide
- ___ cycle Carfilzomib, Decadron with Pomalidomide
started Daratumamab ___
PAST MEDICAL HISTORY (per OMR):
1. Myeloma as outlined.
2. Hypertension.
3. Anxiety.
4. Parasomnias.
Social History:
___
Family History:
Father had diabetes and died in ___ after long illness. She
has one sister who has a thyroid condition, and is HLA ___
compatible. She has another half-sister. There are no
lymphomas, myelomas, or other malignancies in her family.
Physical Exam:
*ADMISSION PHYSICAL EXAM*
General: NAD
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
GI: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown, does have small bruises over
shins bilaterally
NEURO: Oriented x3. Cranial nerves II-XII are within normal
limits excluding visual acuity which was not assessed, no
nystagmus; strength is ___ of the proximal and distal upper and
lower extremities; reflexes are 2+ of the biceps, triceps,
patellar, and Achilles tendons, toes are down bilaterally; gait
is normal, coordination is intact.
*DISCHARGE PHYSICAL EXAM*
VS: 98.1 ___ 85 18 98%ra
General: NAD
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
GI: BS+, soft, mild LUQ discomfort to deep palpation
LIMBS: No peripheral Edema
NEURO: alert, oriented, no focal deficits
Pertinent Results:
*ADMISSION LABS*
___ 06:21PM BLOOD WBC-1.8* RBC-2.66* Hgb-9.2* Hct-26.6*
MCV-100* MCH-34.6* MCHC-34.6 RDW-16.7* RDWSD-60.2* Plt Ct-65*
___ 06:21PM BLOOD Neuts-92* Bands-0 Lymphs-7* Monos-1*
Eos-0 Baso-0 ___ Myelos-0 NRBC-1* AbsNeut-1.66
AbsLymp-0.13* AbsMono-0.02* AbsEos-0.00* AbsBaso-0.00*
___ 06:21PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
___ 06:21PM BLOOD Plt Smr-VERY LOW Plt Ct-65*
___ 06:21PM BLOOD Glucose-140* UreaN-11 Creat-1.5* Na-131*
K-3.5 Cl-100 HCO3-21* AnGap-14
___ 06:21PM BLOOD ALT-13 AST-20 LD(LDH)-313* AlkPhos-37
TotBili-0.3
___ 06:21PM BLOOD Albumin-3.5 UricAcd-3.4
___ 06:21PM BLOOD Osmolal-286
___ 06:21PM BLOOD LtGrnHD-HOLD
___ 06:25PM BLOOD Lactate-2.1*
*DISCHARGE LABS*
___ 07:50AM BLOOD WBC-1.2* RBC-2.66* Hgb-9.2* Hct-27.0*
MCV-102* MCH-34.6* MCHC-34.1 RDW-16.6* RDWSD-61.1* Plt Ct-49*
___ 07:50AM BLOOD Neuts-80* Bands-1 Lymphs-10* Monos-6
Eos-2 Baso-1 ___ Myelos-0 AbsNeut-0.97*
AbsLymp-0.12* AbsMono-0.07* AbsEos-0.02* AbsBaso-0.01
___ 07:50AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Tear
___
___ 07:50AM BLOOD Plt Smr-VERY LOW Plt Ct-49*
___ 07:50AM BLOOD Glucose-91 UreaN-10 Creat-1.3* Na-134
K-3.8 Cl-105 HCO3-23 AnGap-10
___ 07:50AM BLOOD ALT-15 AST-22 LD(LDH)-342* AlkPhos-34*
TotBili-0.4
___ 07:50AM BLOOD TotProt-10.0* Albumin-3.2* Globuln-6.8*
Calcium-8.7 Phos-3.6 Mg-2.0
___ 07:50AM BLOOD FreeKap-PND FreeLam-PND IgG-4718*
*MICROBIOLOGY*
___ Blood Culture - PENDING
___ Blood Culture - PENDING
___ Urine Culture - ESCHERICHIA COLI. >100,000
ORGANISMS/ML..
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ RVP - 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.
*IMAGING*
___ CXR PA/Lateral
No focal consolidation is seen. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are unremarkable. Previously seen lingular opacity has
essentially resolved in the interval.
Brief Hospital Course:
___ with multiple myeloma s/p autoSCT with refractory disease
and now on daratumumab C1D1 ___ presents with fevers to
101 at home and transient dysuria.
# Urinary Tract Infection/Fevers: Dysuria resolved prior to
admission and she had no other localizing symptoms. She was
started on empiric vancomycin and cefepime. Urine cultures were
positive for e. coli, with sensitivities pending on discharge.
She was discharged on a 10 day course of ciprofloxacin and will
follow-up in clinic on ___.
# Multiple Myeloma s/p autoSCT: she has refractory disease. IgG
level is 4718. She is currently on daratumumab C1D1 ___
will resume this pending discussion with her primary oncologist.
TRANSITIONAL ISSUES:
- Start ciprofloxacin 500mg PO q12h x 10 days (___)
- Sensitivities pending. In-patient and out-patient teams should
follow.
- f/u in ___ clinic on ___
CODE: FULL CODE
CONTACT: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OSELTAMivir 75 mg PO Q12H
2. Atenolol 25 mg PO DAILY
3. Nortriptyline 85 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
6. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
2. Atenolol 25 mg PO DAILY
3. Nortriptyline 85 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
6. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Urinary Tract Infection
SECONDARY DIAGNOSIS
Multiple Myeloma
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 fevers and burning with
urination. We treated you with fluids and IV antibiotics. Your
urine tests showed an e. coli bacteria infection.
Important instructions:
- Please take ciprofloxacin 500mg every 12 hours for 10 days
(___)
- Please attend all follow-up appointments
- Please take all medications as prescribed
- Please stay well hydrated
It was a pleasure caring for you. We wish you the best!
Sincerely,
Your ___ care team
Followup Instructions:
___
|
19837674-DS-23
| 19,837,674 | 28,433,990 |
DS
| 23 |
2171-06-16 00:00:00
|
2171-06-16 11:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / ampicillin
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo female with a history of multiple myeloma on treatment
with
daratumumab who is admitted with a fever. The patient states she
first noticed the fever earlier today. She also has had fatigue
and muscle aches. She otherwise feels well and denies any sore
throat, cough, shortness of breath, nausea, diarrhea, rash, or
dysuria. She was recently admitted with a fever between her ___
and 2nd dose of daratumumab and treated for a UTI.
REVIEW OF SYSTEMS:
- All reviewed and negative except as noted in the HPI.
Past Medical History:
- ___, diagnosed with IGG multiple myeloma.
- Pulse Decadron starting in ___ with the addition of
thalidomide in ___ which was continued until ___.
- Subsequent rise in IgG monoclonal protein off therapy with
initiation of Velcade on ___ and completed 6 cycles of
therapy as of ___ with a good response to her monoclonal
protein.
- Received 4 weeks of maintenance Velcade completing on
___ and has been observed off therapy.
- Started Revlimid therapy C1 @ 5mg for 21 days on ___.
C2 @ 10 mg for 21 days on ___. C3 @ 15 mg for 21 days on
___. C4 @ 15 mg for 21 days on ___. C5 @ 15mg for
21 days on ___. C6 @ 15mg for 21 days started on
___.
C7 @ 15mg for 21 days on ___. C8 delayed until ___
@
15mg for 21 days. C9 @ 15mg for 21 days on ___.
- Followed for a prolonged period of time on treatment with
Curcumin and fish oil.
- Presented for usual visit on ___ with marked
progression of her myeloma with total protein of 12.4 and total
IgG 7429 with monoclonal IgG kappa of 42% or 5210 mg/dl of the
total protein. Initiated on treatment with Velcade/Decadron on
___ as she has responded to this in the past. First 2
cycles given with Decadron 20 mg on Day of Velcade and day after
Velcade.
- Cycle 3 with D 1 Velcade only with Decadron 20 mg on
___ then Decadron for 3 more doses as she was travelling
for the ___.
- Cycle 4 on ___ and Cycle 5 on ___, Velcade with
Decadron 20 mg on day of Velcade only
- Cycle 6 Velcade with Decadron 20 mg on day of Velcade. Only
D1 given as then had to travel for family medical issues.
- Cycle 7 on ___ and Cycle 8 on ___ with Velcade and
Decadron 20 mg on day of Velcade only.
- ___, switched to maintenance therapy with Velcade
1.3mg/m2 and Decadron 10 mg on day of Velcade given 4 weeks on,
2
weeks off. Received 3 weeks only as had to deal with family
issues, last treated ___.
- Returned for follow up in ___ with noted progression of
her
myeloma with IgG > 6 grams. Restarted Velcade SQ/Decadron on
weekly basis, 4 weeks on and 1 week off on ___.
- ___ Another cycle of Velcade SQ/Decadron. Received D1,
D8, (missed D 15).
- ___ Started another cycle of Velcade SQ/Decadron given
D1, D4, D8.
- ___ Velcade SQ/Decadron given on D1, D4, D8, D11.
- Went on vacation and developed pneumonia. Off treatment and
noted progression of myeloma with IgG > 7 grams.
- ___ Velcade SQ/Decadron given on D1, D4, D8, D11 with
plan to add in Revlimid for next cycle.
- ___ Velcade SQ given on D1, D8, D15 with Decadron 10 mg
on day of and day following Velcade and Revlimid on D 1 - 14.
- ___ to ___ Velcade, Decadron and Revlimid
continues.
- ___ Another opinion at ___.
- Increasing to stable myeloma parameters. Interested in
moving forward with autologous transplant but needs further
cytoreduction.
- ___ and signed consent for Protocol
___: Blockade of PD-1 in Conjunction With the Dendritic
Cell/Myeloma Vaccines Following Stem Cell Transplantation
- Bone marrow biopsy on ___ showed plasma cells are 39% of
aspirate differential and include several cytologically atypical
and anaplastic forms. By CD___ immunostaining, they are 50-60%
of the core biopsy and kappa restricted by kappa and lambda
immunostaining. Multiple cytogenetic abnormalities.
- ___ Velcade 1.3mg/m2 with Decadron.
- ___ Treatment switched to Cytoxan 300 mg/m2 on D 1, 8,
15, 22 with Velcade 1.3 mg/m2 on D 1, 4, 8, 11. Decadron 20 mg
on day of and day after Velcade.
- ___ cycle of Cytoxan, Velcade and Decadron but
received D1 only as myeloma parameters increased somewhat.
- ___ Received Cytoxan 1200 mg/m2
- ___ Admitted for DPACE in hopes of augmenting response
as had continued slow response but with IGG of ~ 4 gms. Issues
with parasomnias and pulling line out. Treatment switched to
Cytoxan, etoposide and cisplatin in order to avoid steroids and
anthracyclines. Required transfusion support with minimal
response to chemotherapy.
- ___ Dendritic cells harvested in order to make vaccines
for post autologous transplant vaccinations on Protocol ___.
- ___ Cycle 1 Carfilzomib and Decadron
- ___ Cycle 2 Carfilzomib and Decadron
- ___ Bone marrow biopsy with persistent involvement with
myeloma with noted plasma cells comprising 10% of aspirate
differential and approximately ___ by CD___ immunostaining of
the core biopsy. Persistent cytogenetic abnormalities.
- ___ cycle of Carfilzomib to further cytoreduce
myeloma before proceeding with autologous transplant.
- ___ Admission for high dose Cytoxan for stem cell
mobilization with unfortunately unsuccessful attempt at
collections.
- ___ to ___, stem cell collections with Plerixifor
and Neupogen
- ___, Admitted for autologous stem cell transplant with
high dose Melphalan. D0 = ___
- ___, BM biopsy with CD138 highlighting plasma cells,
present singly and in small clusters, comprising an estimated
___ of the overall cellularity.
- Fusion Vaccine #1 on ___ on Protocol ___: Blockade
of PD-1 in Conjunction With the Dendritic Cell/Myeloma Vaccines
Following Stem Cell Transplantation.
- Delay of ___ due to illness; given on ___.
- Fusion Vaccine #2 on ___.
- ___ infusion #2 on ___.
- Fusion Vaccine #3 on ___.
- ___ infusion #3 on ___.
- ___, Month 1 follow up with progression of disease. BM
with 70-80% plasma cells by CD 138 staining.
- ___, Restarted treatment with Carfilzomib and
Pomalidomide(only took 7 days of Pomalidomide) with Decadron.
- ___ cycle Pomalidomide 4 mg daily for 21 days.
- ___ cycle Carfilzomib.
- ___ cycle Carfilzomib, Decadron with Pomalidomide
- ___ cycle Carfilzomib, Decadron with Pomalidomide
started Daratumamab ___
PAST MEDICAL HISTORY (per OMR):
1. Myeloma as outlined.
2. Hypertension.
3. Anxiety.
4. Parasomnias.
Social History:
___
Family History:
Father had diabetes and died in ___ after long illness. She
has one sister who has a thyroid condition, and is HLA ___
compatible. She has another half-sister. There are no
lymphomas, myelomas, or other malignancies in her family.
Physical Exam:
# ADMISSION EXAM
General: NAD
VITAL SIGNS: T 99.9 BP 138/80 HR 95 RR 16 O2 95%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.
# DISCHARGE EXAM
Unchanged. Afebrile
Pertinent Results:
ADMISSION LABS
___ 06:50PM BLOOD WBC-1.3* RBC-2.45* Hgb-8.5* Hct-24.3*
MCV-99* MCH-34.7* MCHC-35.0 RDW-16.3* RDWSD-58.5* Plt Ct-43*
___ 06:50PM BLOOD Neuts-88* Bands-1 Lymphs-5* Monos-5 Eos-0
Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-1.16* AbsLymp-0.08*
AbsMono-0.07* AbsEos-0.00* AbsBaso-0.00*
___ 06:50PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
___ 06:50PM BLOOD Plt Smr-VERY LOW Plt Ct-43*
___ 06:50PM BLOOD ___ PTT-25.4 ___
___ 06:50PM BLOOD Glucose-93 UreaN-10 Creat-1.1 Na-129*
K-3.4 Cl-99 HCO3-23 AnGap-10
___ 06:50PM BLOOD ALT-22 AST-28 AlkPhos-35 TotBili-0.3
___ 06:50PM BLOOD Albumin-3.5 Calcium-8.3* Phos-3.2 Mg-1.6
___ 06:58PM BLOOD Lactate-1.8
DISCHARGE LABS
___ 06:05AM BLOOD WBC-1.0* RBC-2.29* Hgb-7.8* Hct-22.8*
MCV-100* MCH-34.1* MCHC-34.2 RDW-15.9* RDWSD-57.7* Plt Ct-34*
___ 06:05AM BLOOD Neuts-84* Bands-0 Lymphs-10* Monos-4*
Eos-0 Baso-2* ___ Myelos-0 AbsNeut-0.84*
AbsLymp-0.10* AbsMono-0.04* AbsEos-0.00* AbsBaso-0.02
___ 06:05AM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-2+ Microcy-1+ Polychr-NORMAL Tear
Dr-OCCASIONAL
___ 06:05AM BLOOD Plt Smr-VERY LOW Plt Ct-34*
___ 06:05AM BLOOD Glucose-92 UreaN-7 Creat-1.0 Na-133 K-3.7
Cl-109* HCO3-20* AnGap-8
___ 06:05AM BLOOD Calcium-7.9* Mg-3.2*
MICROBIOLOGY
Urine culture pending
Blood culture pending
PERTINENT STUDIES
CXR ___
IMPRESSION:
No acute cardiopulmonary abnormality.
Brief Hospital Course:
___ yo female with a history of multiple myeloma on treatment
with daratumumab who is admitted with a fever.
# ACTIVE ISSUES
The etiology the fever was unclear. Patient received one dose
of Cefepime in the ED. She had non-focal exam and ROS.
Infectious workup was obtained, including CXR, blood and urine
culture, and no evidence of bacterial infection was noted during
this admission. Of note this occurred after her prior infusion
of daratumumab. She was given 1 neupogen injection for ANC of
800 and ANC was up to 2800 at the time of discharge, at which
point she was afebrile without infectious symptoms.
# CHRONIC
Multiple Myelmoma
- S/p C2 Daratumumab ___.
Anxiety
- Continued home nortriptyline, clonazepam, and lorazepam.
HTN
- Continued home atenolol.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Nortriptyline 85 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Lorazepam 0.5-1 mg PO QHS:PRN Anxiety
5. ClonazePAM 0.5-1 mg PO QHS:PRN Insomnia
6. Cephalexin 250 mg PO Q8H
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. ClonazePAM 0.5-1 mg PO QHS:PRN Insomnia
3. Lorazepam 0.5-1 mg PO QHS:PRN Anxiety
4. Nortriptyline 85 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
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 ___ for fever after your chemotherapy. You
were treated with antibiotics in the emergency room. We have
not found any evidence of infectious illness. Your fever has
resolved. Although we do not have a clear explanation for your
fever, we felt you are safe to return home.
Followup Instructions:
___
|
19837705-DS-24
| 19,837,705 | 24,097,910 |
DS
| 24 |
2192-02-13 00:00:00
|
2192-02-16 16:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Celebrex / ceftriaxone
Attending: ___
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
Cardioversion
History of Present Illness:
___ with PMH significant for Afib s/p PVI on coumadin, COPD,
LBBB, s/p AVR and MVR for rheumatic valve disease,
cardiomyopathy of unknown etiology with (EF 35-40%) who
presented to OSH with palpitations.
His daughter noted his heart rate was fast and mildly irregular.
He noticed palpitations but had no other symptoms (including
chest pain, sob, lightheadedness).
He was evaluated at ___ where he was first noted to
be in a 2:1 atrial tachycardia with a ventricular rate of around
150bpm. He was given a dose of adenosine, metoprolol, and
magnesium without any effect. TroponinI was mildly elevated
(0.06). Transferred to ___ for further management.
In the ED initial vitals were: 97.7 150 133/86 18 95% RA.
-EKG showed atrial flutter with mostly 2:1 conduction.
- Labs/studies notable for: INR 2.8, Cr 1.4 (baseline 1.2), HCO3
18, BNP 5185, TropT <0.01.
-The patient was given metoprolol 5mg IV without effect. The
patient underwent DCCV and cardioverted to NSR in the ___. 20
minutes later, he convereted back to Afib with RVR in the 170s.
He then converted back to NSR on his own. The patient was loaded
with amiodarone and started on a drip.
-Vitals prior to transfer were: 91 134/91 19 94% RA.
Upon arrival to the floor, pt confirms the above history. He
reports he has been short of breath for weeks, attributed to
COPD. He becomes short of breath with speaking. He becomes short
of breath with walking short distances (ie from car to house).
No orthopnea, paroxysmal nocturnal dyspnea, lower extremity
edema.
ROS: Denies cough, fevers, diarrhea, abdominal pain, nausea,
vomiting. otherwise as per HPI
Past Medical History:
- Atrial fibrillation s/p PVI ___, recurrence ___ placed on
flecainide, later d/c'd due to depressed EF and prolonged QRS.
On coumadin.
- LBBB
- S/p mechanical AVR and MVR in ___ for rheumatic valve disease
and AI
- Cardiomyopathy, unknown etiology (EF 35-40%)
- COPD
- Glucose intolerance
- Ventral hernia
- Gout
Social History:
___
Family History:
No family hx of arrhythmia or premature CAD.
Physical Exam:
ADMISSION EXAM
VS: 97.9 130/83 90 20 94% on RA 108.2kg (standing)
GENERAL: obese pleasant middle-aged gentleman in no distress.
HEENT: NCAT. Sclera anicteric. EOMI.
NECK: Supple with JVP not elevated
CARDIAC: Normal rate, Mechanical heart sounds, ___ systolic
murmur.
LUNGS: Tachypneic - pauses mid-sentence to take a deep breath.
CTAB
ABDOMEN: Soft, nontender. Abdominal binder in place. Large
midline scar and ventral hernia.
EXTREMITIES: No c/c/e. 2+ pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE EXAM
VS: T=98.4 BP=99-124/71-89 ___ O2 sat=92-97% RA
I/O: 1120/1700 24H, ___ 8H
Wt: 104.9 kg (from 105.4, 108.0, 108.2 on admission)
GENERAL: WDWN Caucasian Male in NAD. Alert. Oriented x3. Mood,
affect appropriate.
HEENT: Sclera anicteric. MMM. Oopharynx without lesion or
exudate
NECK: Supple with JVP not elevated.
CARDIAC: RRR, mechanical S1 and S2. ___ holosystolic murmur best
heard at apex.
LUNGS: CTA bilaterally, no wheezes
ABDOMEN: Obese, NTND. No hepatomegaly. +BS
EXTREMITIES: no edema, warm and well perfused. No cyanosis
SKIN: No rashes or lesions
NEURO: No gross focal neurologic deficits
Pertinent Results:
LABS ON ADMISSION
___ 04:14PM BLOOD WBC-9.6 RBC-4.47* Hgb-14.5 Hct-43.4
MCV-97 MCH-32.4* MCHC-33.4 RDW-13.8 RDWSD-48.7* Plt ___
___ 04:14PM BLOOD Glucose-116* UreaN-32* Creat-1.4* Na-142
K-4.1 Cl-108 HCO3-18* AnGap-20
___ 05:00AM BLOOD ALT-33 AST-42* AlkPhos-62 TotBili-4.1*
DirBili-0.3 IndBili-3.8
___ 04:14PM BLOOD CK(CPK)-94
___ 04:14PM BLOOD CK-MB-3 cTropnT-0.01 proBNP-5185*
___ 04:14PM BLOOD Calcium-8.8 Phos-3.0 Mg-1.9
___ 04:55AM BLOOD Hapto-24*
___ 05:00AM BLOOD TSH-1.8
LABS ON DISCHARGE
___ 07:25AM BLOOD WBC-6.1 RBC-3.77* Hgb-12.0* Hct-37.9*
MCV-101* MCH-31.8 MCHC-31.7* RDW-13.9 RDWSD-50.5* Plt ___
___ 07:25AM BLOOD Glucose-94 UreaN-28* Creat-1.3* Na-140
K-4.0 Cl-105 HCO3-19* AnGap-20
___ 07:25AM BLOOD ALT-23 AST-27 AlkPhos-66 TotBili-3.7*
DirBili-0.4* IndBili-3.3
___ 07:25AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.8
REPORTS
TTE (___):
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is mildly dilated.
There is severe global left ventricular hypokinesis (LVEF = 20 -
25 %). No masses or thrombi are seen in the left ventricle. The
right ventricular cavity is mildly dilated with moderate global
free wall hypokinesis. Tricuspid annular plane systolic
excursion is depressed (1.4 cm) consistent with right
ventricular systolic dysfunction. The ascending aorta is mildly
dilated. A bileaflet aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. A bioprosthetic
mitral valve prosthesis is present. The mitral prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular gradients. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Severe globally depressed
LV dysfunction. Well seated mitral and aortic mechanical
bioprostheses. Mild to moderate RV systolic dysfunction in
setting of mild RV dilation.
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, if not previously known or
a change, a follow-up echocardiogram is suggested in ___ year; if
previously known and stable, a follow-up echocardiogram is
suggested in ___ years.
Compared with the prior study (images reviewed) of ___, the
LV systolic function is mildly less significant. The RV is
further depressed but was slightly depressed before.
CXR (___):
Severe cardiomegaly is stable. The lungs are clear. There is
no pneumothorax or enlarging pleural effusions. The patient is
status post aortic and mitral valve repair. Sternal wires are
aligned.
___ (___):
1. Echogenic liver consistent with steatosis. Other forms of
liver disease including hepatic fibrosis or cirrhosis or
steatohepatitis cannot be excluded on the basis of this
examination.
2. Stable nonobstructive stone in the left kidney.
Brief Hospital Course:
___ with PMH significant for Afib s/p PVI on coumadin, LBBB,
AVR and MVR for rheumatic valve disease, cardiomyopathy of
unknown etiology (EF 35-40%) who presented with palpitations and
2:1 atrial flutter. Unsuccessfully cardioverted in ED, then
auto-converted back to sinus, and was started started on
amiodarone. TTE this admission showing decrease in EF now to
___ (from 35-40%).
ACTIVE ISSUES
# History of Atrial fibrillation; New Atrial flutter: History of
A-Fib, on coumadin and Carvedilol 12.5 BID. Pt presented in 2:1
atrial flutter. As he was therapeutically anticoagulated for his
AVR/MVR, he was cardioverted in the ED. He then went back into
flutter, and later auto-converted back to sinus. He was started
on amiodarone gtt, then transitioned to PO Amiodarone. Remained
in sinus for the rest of the admission. Cause for episode
uncertain, no evidence of infection, trop negative. BNP 5000.
Baseline LFT's and TSH were checked, with indirect bilirubinemia
but no transaminitis, TSH normal. He was discharged onamiodarone
400mg po BID for 2 weeks, and will then transition to 200mg BID.
He was also set up with ___ of hearts monitor. Rate control
was continued with Carvedilol 12.5mg BID. For discussion of
anticoagulation, see below.
# S/p mechanical AVR and MVR in ___ for rheumatic valve disease
and AI: INR's therapeutic on admission. Goal INR 2.5-3.5.
Coumadin dosage was decreased given initation of Amiodarone and
known DDI b/w Amio and Warfarin. INR 2.2 ___, 1.6 ___. He was
bridged with Lovenox given mechanical valves, and was discharged
home on lovenox, which he has used before. Per pharmacy, the DDI
between Amio and Warfarin will take days to weeks to kick in, so
OK to keep at lowered dose of coumadin for now. He follows with
his PCP for INR/Coumadin management, and will continue to do
this after discharge.
# sCHF exacerbation: EF 35-40% in ___, etiology unclear, this
admission down to ___ with global hypokinesis. DDx for
decrease in EF includes progression of primary cardiomyopathy,
vs. transient decrease secondary to tachycardia/arrythmia; new
ischemic event less likely given no CAD history, no CP.
Initially dyspneic and appeared volume overloaded on exam.
Physical exam and dyspnea much improved after diuresis with
Lasix 20mg IV x2 on ___. CXR ___ without evidence of vasc
congestion. He was started on PO Lasix 40mg daily and Lisinopril
5mg daily. He was continued on Atorvastatin and Carvedilol 12.5
mg BID. Given reduced EF and bundle branch block, may warrant
consideration of CRT as outpatient, as well as ICD placement,
and he will f/u with EP regarding this.
# Indirect bilirubinemia: Most likely due to hemolysis with
valves. Downtrending, and hemoglobin stable. With normal
transaminases and Alk Phos, hepatic pathology is less
concerning, but he does have macrocytosis and borderline-low
platelets. ___ consistent with fatty liver. LDH/hapto
consistent with mild hemolysis. Hepatitis serologies were
pending at time of dicharge.
CHRONIC PROBLEMS
# COPD: ___ also be contributing to his presenting dyspnea, in
addition to his sCHF and arrythmia. He was continued on home
advair 250/50 1 puff BID, and given ipratropium nebs PRN
# Ventral hernia: cont w/ abdominal binder
# Gout: continue allopurinol ___ po BID
TRANSITIONAL ISSUES
- Because of drug-drug interactions between Warfarin and
Amiodarone, his dosage of Warfarin was reduced to 2 mg daily,
and then his INR's fell out of the therapeutic range. Thus, he
will be sent home with lovenox to bridge until his INR is
therapeutic, and he will continue to follow with his PCP for
anticoagulation management. Next INR to be drawn on ___
- Was not on any diuretic prior to discharge but started on
lasix 40 mg daily; patient to have repeat lytes drawn on ___
- Patient provided with ___ of Hearts monitor prior to
discharge. Patient instructed to call the cardiac monitor lab at
___ to receive further instructions.
- Patient to be on amiodarone 400 mg BID until ___ will start
200 mg BID thereafter
- Please follow-up hepatitis serologies
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Warfarin 3.5 mg PO DAILY16
5. Atorvastatin 20 mg PO QPM
6. Vitamin D 5000 UNIT PO DAILY
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Carvedilol 12.5 mg PO BID
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Warfarin 2 mg PO DAILY16
RX *warfarin 2 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Amiodarone 400 mg PO BID
Please take 400 mg BID up until ___. On ___, start taking 200
mg BID.
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*23
Tablet Refills:*0
7. Enoxaparin Sodium 100 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 100 mg/mL 100 mg SC twice a day Disp #*14 Syringe
Refills:*0
8. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
11. Vitamin D 5000 UNIT PO DAILY
12. Amiodarone 200 mg PO BID
Please start taking on ___.
RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
13. Outpatient Lab Work
ICD-9 427.31. Please check CBC, Chem 10, ___. Please
forward results to: Dr. ___, Phone:
___, Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Atrial flutter
Acute exacerbation of systolic congestive heart failure
Mechanical aortic valve
Mechanical mitral valve
Secondary diagnoses:
Chronic obstructive pulmonary disease
Ventral hernia
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital because of
palpitations. You were found to be in an abnormal electrical
rhythm called atrial flutter. You underwent electrical
cardioversion and you were started on an antiarrhythmic
medication called amiodarone. You have been in a normal
electrical rhythm since. We also found that your heart is not
pumping as well as it should; this is a condition called heart
failure. You were very congested and had too much fluid in your
system so you were started on a medication called furosemide
(Lasix) which you will need to take every day. You will need to
really watch your salt intake because of your heart failure.
The heart failure is a progressive disease so if you do not
watch your diet or take your medications as prescribed, it will
only get worse.
Because you will be on the amiodarone, it will interact with
your coumadin levels. We have decreased your coumadin dose for
now, because eventually the amiodarone will cause your coumadin
levels to rise. For now, you will use Lovenox shots to cover
until your coumadin levels return to normal. It will be
important to get your coumadin levels checked every week, and to
follow up with your primary care doctor regarding dose
adjustments.
We provided you with ___ of Hearts monitor to monitor for any
further arrhythmia. Please call the cardiac monitor lab at
___ on ___ for instructions regarding your ___
of Hearts monitor.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Once again, it was a pleasure participating in your care. We
wish you all the best.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
19838167-DS-12
| 19,838,167 | 23,930,640 |
DS
| 12 |
2155-06-28 00:00:00
|
2155-06-29 13:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / Augmentin
Attending: ___.
Chief Complaint:
Transaminitis, nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of Crohn's disease s/p partial colectomy and
recent additional partial colectomy for bowel perforation after
colonoscopy who presents with transaminitis. The patient was
admitted to ___ ___ after OSH surveillance colonoscopy
revealing small polyps and severe proctitis was complicated by
bowel perforation. She was taken emergently to the OR and
underwent exploratory laparoscopy, which revealed perforation in
the transverse colon and underwent segmental transverse
colectomy and end to end anastomosis of the transverse colon.
She had an uncomplicated postop course and was discharged on
___. She presented again on ___ complaining of abdominal
pain. CT abdomen revealed large pneumoperitoneum and she was
brought back to the OR for exlap. Anastomotic leak was confirmed
intraoperatively and anastomotic segment was resected. Again her
postop course was relatively uncomplicated and she was
discharged to home with a 7 day course of Augmentin for
significant intraperitoneal fecal load from leak. She completed
the 7 day course on ___ and saw her surgeon as an outpatient at
which time she was diagnosed with a wound infection. Prednisone
was stopped and wound vac was applied.
The patient developed nausea on ___ and presented to urgent
care where LFTs were checked. LFT trend below:
___ - ___ - ___
AP - ___
T.Bili - 2.0 - 2.8
AST ___
ALT: ___
She was seen by GI at ___ who felt this could be a medication
effect, especially from Augmentin and/or fluconazole which she
had been taking for oral candidiasis. She was advised to stop
all medications and underwent CT abdomen at ___ on ___ which
showed no abscess or other explanation for the patient's lab
abnormalities. She presented to ___ urgent care on morning of
admission with worsening nausea and poor PO intake. ___
contacted ___ GI fellow on call who recommended labs and ED
transfer if not improving. She was referred to the ___ ED. She
denies abdominal pain, vomiting, fever, chills, CP, SOB. She
endorses watery non-bloody diarrhea starting the morning of
admission. She endorses travel to ___ in ___, to ___ in
___. No travel to ___, ___. ___. ___.
She denies exposure to wild mushrooms. She reports taking ___
Tylenol per day of unknown dosage and perhaps one additional
Tylenol #3 during the day as well. She has no h/o viral
hepatitis or IVDU and is not a ___. She denies
jaundice or confusion.
In the ED, initial VS: 97.2 81 124/52 14 100% RA. Labs showed UA
with trace leuks, 7 WBC, few bacteria, Hct 35, INR 1.2, AST 459,
ALT 690, AP 955, lipase 221, Tbili 2.8, Dbili 2.0, albumin 4.2.
RUQ U/S showed normal CBD diameter, increased liver echogenicity
without focal lesions c/w fatty liver. She was given 2L NS.
Hepatology was consulted and recommended admission to medicine,
they will follow. Colorectal surgery was made aware of the
patient. VS at transfer: 98.4 85 116/57 18 98% RA.
Currently, she has no complaints. Denies nausea or abdominal
pain, concerned about significance of LFT abnormalities.
Past Medical History:
Vitamin D Deficiency
COLONIC POLYP
ROSACEA
OSTEOPOROSIS, UNSPEC
CROHN'S DISEASE
ANEMIA
NEVUS, ATYPICAL
HEADACHE, MIGRAINE
s/p partial laparoscopic colectomy 1990s
s/p Ex lap, segmental resection transverse colon ___
s/p Ex lap, resection anastamosis ___ for anastomatic leak,
c/b wound infection requiring wound vac
Social History:
___
Family History:
Uncle ___ ___ years. Brother s/p colectomy for multifocal
dysplasia in setting of IBD. Nephew and niece with Crohn's.
Negative for: liver disease, GERD, PUD, stomach cancer, celiac
sprue, IBS, colon polyps and HNPCC associated malignancies
Physical Exam:
VS - Temp 98.3F, BP 118/66, HR 67, R 18, O2-sat 100% RA
GENERAL - chronically ill appearing female in NAD, somewhat
cachectic, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
no frenular jaundice
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, II/VI holosystolic murmur
loudest at LLSB, nl S1-S2
ABDOMEN - NABS, soft, mildly tender in RUQ, non-distended, no
masses or HSM, no rebound/guarding, wound vac in place c/d/i
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions, no jaundice or spider angiomata
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, moving all extremities
Pertinent Results:
LFTs:
___ ALT-482* AST-245* AlkPhos-832* TotBili-1.2
___ ALT-596* AST-312* CK(CPK)-27* AlkPhos-875* TotBili-2.0*
___ ALT-690* AST-459* AlkPhos-955* TotBili-2.8*
DirBili-2.0* IndBili-0.8
___ GGT-289*
Hepatitis Work-up:
___ HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV
Ab-NEGATIVE IgM HBc-NEGATIVE0
___ 08:20AM BLOOD HCV Ab-PND
___ HCV Viral load - PND
___ 08:20AM BLOOD CERULOPLASMIN-PND
___ calTIBC-270 Ferritn-690* TRF-208
___ 08:20AM BLOOD PEP-NO SPECIFI IgG-1007 IgA-318
___ 09:30PM BLOOD Acetmnp-NEG
___ 08:20AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 08:20AM BLOOD ___
___ 08:20AM BLOOD tTG-IgA-5
Imagaing:
Right upper quadrant ultrasound - The main portal vein has
normal hepatopetal flow Echogenic liver, consistent with fatty
infiltration. However, other forms of liver disease including
advanced liver disease and cirrhosis not excluded. No intra- or
extra-hepatic biliary dilatation.
Brief Hospital Course:
Primary Reason for Hospitalization:
___ with a history of Crohn's disease s/p partial colectomy and
recent additional partial colectomy for bowel perforation after
colonoscopy who presented with transaminitis and nausea was
found to have likely drug-induced hepatitis.
Active Diagnoses:
#Hepatitis, Likely drug induced:
Mrs. ___ was admitted with elevated LFTs. Her LFTs trended
down while in the hospital as follows:
___ ALT-690* AST-459* AlkPhos-955* TotBili-2.8*
DirBili-2.0* IndBili-0.8
___ ALT-596* AST-312* CK(CPK)-27* AlkPhos-875* TotBili-2.0*
___ ALT-482* AST-245* AlkPhos-832* TotBili-1.2
She also improved clinically and was able to tolerate PO fluids.
The Liver service was consulted who felt this was a case of
augmentin induced hepatitis. Given the clnincal improvement and
the trend of the LFTs further monitoring and testing was
deferred to the outpatient setting. In addition if in ___ weeks
there has been no normalization of the LFTs then MRCP and liver
biopsy should be considered. Below is a list of pending lab
tests at time of discharge.
Chronic Diagnoses:
#CROHN'S DISEASE
Doccumented history of this condition. The patient was admitted
and maintained on her home doswe of Mesalamine. There were no
flairs while in hospital.
#s/p Ex lap, resection anastamosis ___ for anastomatic
leak, c/b wound infection requiring wound vac. Patient arrived
with wound vac in place and the dressing clean, dry and intact.
She was maintained on the wound vac while in the hospital and
had her dessing changed on the day of discharge as scheduled by
the surgery team.
Transitional Issues:
Tests pending at time of discharge:
___ 08:20AM BLOOD CERULOPLASMIN-PND
___ HCV Viral load
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Mesalamine 1200 mg PO QID
2. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
3. Hydrocortisone Acetate Suppository 1 SUPP PR QHS
4. Lorazepam 0.5 mg PO HS:PRN insomnia, anxiety
5. Acetaminophen Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Mesalamine 1200 mg PO QID
2. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
3. Hydrocortisone Acetate Suppository 1 SUPP PR QHS
4. Lorazepam 0.5 mg PO HS:PRN insomnia, anxiety
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hepatitis. Likely a drug reaction to the antibiotic Augmentin.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because tests for liver injury were higher
than normal. While you were in the hospital we investigated a
cause for why there was liver injury. To date your tests were
negative and your liver function tests are coming back down. The
current thought is that the liver injury was from the antibiotic
Augmentin (amoxicillin/clavulanate)
Please do not take the antibiotic Augmentin
(amoxicillin/clavulanate).
Please follow up with your outpatient gastoenterologist Dr.
___ follow up labs in 2 weeks with labs.
Followup Instructions:
___
|
19838518-DS-7
| 19,838,518 | 20,657,697 |
DS
| 7 |
2165-04-22 00:00:00
|
2165-04-22 22:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers, right-sided back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with a history of CKD on the transplant list,
latent TB on isoniazid, and H. pylori (receiving treatment) who
presents with recurrent fevers, myalgias, and right-sided back
pain.
The patient was seen at the ___ ED a week ago with similar
symptoms including fever, myalagias, and mild headache which
resolved. A viral illness was thought likely, and the patient
was discharged with follow up. She started feeling better over
the week and consequently cancelled a clinic appointment, but
then started experiencing a return of the symptoms. A new
symptom, however, is right, posterior thorax pain which is
constant but worse with inspiration. She denies rash, neck
stiffness, difficulty concentration. Her husband denies
confusion. She has tried Tylenol for her symptoms with only a
little improvement.
In the ED she was tachycardic and had a temperature of 100.2.
She is not hypoxemic. A mild, neutrophilic-predominate
leukocytosis was present. Chemistries and hepatic panel WNL with
her renal function at its recent baseline. D-dimer was 1270.
Influenza PCR was negative. Lactate WNL. She received IVF and
dilaudid.
She spends most of her time inside and is unaware of any obvious
risk for tick exposure. She has not travelled outside of
___ in over ___ years.
Past Medical History:
HYPERTENSION
CHRONIC KIDNEY DISEASE
HYPOTHYROIDISM
FIBROID UTERUS
Social History:
___
Family History:
No known malignancies, autoimmune conditions
Physical Exam:
ADMISSION EXAM:
GENERAL: Appears uncomfortable
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. ___
and ___ signs absent.
CV: Heart regular but tachycardic. no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
MSK: Reports bilateral knee and hip pain without knee warmth or
effusion. Moves all extremities, strength grossly full and
symmetric bilaterally in all limbs
SKIN: No splinter hemorrhages, ___ lesions
NEURO: Alert, oriented, face symmetric, speech fluent, moves all
limbs, sensation to light touch grossly intact throughout
PSYCH: Appropriate affect
DISCHARGE EXAM:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
MMMs
CV: RRR no m/r/g
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, mild tenderness throughout
abdomen without guarding, worst in lower abdomen. Bowel sounds
present
MSK: legs TTP (improving)
SKIN: No rashes or ulcerations noted
EXTR: wwp, bilateral edema present (compression socks in place)
NEURO: Alert, interactive, face symmetric, gaze conjugate with
EOMI, speech fluent, motor function grossly intact/symmetric
PSYCH: pleasant, appropriate affect
Pertinent Results:
=====
LABS:
=====
WBC 11.7 (___) ---> 33 (___) ----> 11.4 (___)
Hgb 9.5 (___) ----> 7.0 (___) ---> 9.7 (___)
Plt 274 (___) ----> 592 (___) --> 423 (___)
INR 2.3 (___) ----> 1.1 (___)
Cre/BUN ___ --> 6.0/47 (___) --> 3.6/109 (___) -->
___
Bicarb mostly ___, as low as 12, as high as 23
K 4.0 (___) ----> 6.3 (___) ----> 5.0 (___)
ALT mostly wnl until ___, at which point went 86->99->110->89
AST mostly wnl, did not rise with ALT
Alk phos mostly wnl, but briefly elevated around ___, with peak
at 195
CK 351---->13
Tbili <0.2-0.5
Phos peak 9.1 (___)
Albumin 4.0-> 2.9 (___)
Iron 19, TIBC ___
Ferritin 1100s--->1900s (___) ---> 1100s
TSH 3.4-5.8
PTH 78-139
Cortisol 15
Vitamin D 45
Hep B sAb +, cAb-, sAg -
Hep A Ab +
Hep C neg
HIV neg
CRP >300 ---> 14
___ + 1:40
RF neg
dsDNA neg
Quant Igs wnl
SPEP neg
C3 74 (LLN 90)
C4 28 (wnl)
Stool O&P neg
Anti RNP neg
Hantavirus neg
Antihistone neg
Qfever IgM neg, IgG +
Dengue IgM neg, IgG +
Erlichia neg
Chikungunya neg
Brucella neg
Anaplasma neg
Beta glucan neg
Aspergillus neg
Bartonella neg
CMV IGM neg IgG+
Cryptococcal Ag neg
RPR neg
Lyme neg
Parasite smear neg x4
Parvo neg
Strongy neg
Schisto neg
Flu neg
Toxo neg
EBV neg
Mycolytic culture pnd
Blood and urine cultures neg
===============
IMAGING/STUDIES:
===============
PET: 1. No evidence of occult infection or malignancy. 2.
Diffusely
increased marrow and spleen uptake of FDG consistent with marrow
activation. 3.
Right upper and middle lobe pulmonary nodules measuring up to 5
mm. Recommend
follow-up per ___ criteria.
Pelvic US:
1. Limited study due to patient discomfort demonstrate uterine
fibroids
measuring up to 3.4 cm.
2. 2 nonvascular endometrial echogenic foci, nonspecific.
3. Limited views of the adnexa without visualization of the
ovaries.
CT Chest ___
No evidence of current acute pneumonia.
Small 5 mm solid nodule. Follow-up is recommended below.
Atelectasis with indwelling traction bronchiectasis and
calcified granulomas in the left upper lobe, likely sequela from
prior granulomatous infection.
CT Abd ___. No evidence of intra-abdominal infection-within limitations
of a
noncontrast-enhanced scan.
2. Atrophic kidneys consistent with chronic kidney disease.
3. No significant change in the known left renal mass better,
evaluated on
prior MRI dated ___.
TTE: Suboptimal image quality. Normal LV systolic function. No
valvular pathology or
pathologic flow identified. Normal estimated pulmonary artery
systolic pressure.
V/Q:Low likelihood ratio for recent pulmonary embolism.
CT A/P ___. No evidence of intra-abdominal infection within the
limitations of a noncontrast study.
2. Unchanged atrophic kidneys consistent with chronic renal
disease. No significant interval change in a known left renal
mass, better evaluated on the MRI dated ___.
3. No splenomegaly or lymphadenopathy.
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of
CKD4/5 (on the transplant list), latent TB (on isoniazid), and
H. pylori (receiving treatment) who presents with recurrent
fevers, myalgias, and diffuse pain, ultimately started on
treatment for suspected Still's disease.
# Fever, arthralgias, myalgias
# Adult Stills Disease
Patient underwent extensive work-up for potential infectious or
malignant sources of her symptoms (see last section of report).
No definite etiology was identified. TB felt to be extremely
unlikely since she had no concerning findings and was well into
her LTBI treatment course. Did not improve on doxycycline and
flagyl (H pylori therapy). Her labs showed evidence of
progressively worsening inflammation during the first week of
her hospital course. Despite a lack of overwhelming evidence
(borderline of meeting criteria), there was a reasonable concern
for Still's and so per strong preference of patient and her
husband she was ___ on high dose steroids. Her symptoms and
many of her lab finding (CK elevation, ferritin, anemia,
leukocytosis) improved on therapy. Patient discharged on 60 mg
prednisone daily with plan for rheum follow-up. On atovaquone
for PCP ppx given hyperkalemia, vitamin D, calcium, PPI.
# ___ on CKD stage 5
# Hyperkalemia
# Metabolic acidosis
# Hyperphosphatemia
# Hyponatremia
Patient developed ___ during admission with creatinine up to 6,
improved to ~4 by discharge. Uncertain
etiology of CKD but possibly from NSAIDs or other medications
given in ___. She is followed by renal transplant and
considering peritoneal dialysis while awaiting transplant.
Toward the end of the admission her hyperkalemia worsened, which
prompted avoidance of potentially contributing meds, and
aggressive bowel regimen. This was successful in improving
hyperkalemia, but also worsened acidosis. Bicarb increased, and
bowel regimen reduced slightly, which appeared to achieve
appropriate balance. BMP checked afternoon of discharge to
ensure hyponatremia not worsening, and noted to have bump in
creatinine from 3.6 to 4.3. However in discussion with renal,
felt this was not contraindication to discharge given low
clinical suspicion that this reflected a new acute process but
rather a dramatic instance of baseline fluctuation. Patient will
have labs 2 days and 5 days post-discharge, which will be sent
to Dr. ___. Patient also started on phoslo and her
torsemide was continued at 10 mg. Instructed to maintain healthy
bowel regimen.
#Worsening abdominal pain ___ - suspected fibroid pain
#Menstrual bleeding
Patient developed worsening abdominal pain on ___, and
subsequently developed menstrual bleeding. She stated that this
was similar to prior fibroid pain, which had improved 2 months
ago with initiation of depoprovera by her gynecologist.
Gynecology consulted, but at this point no hormonal therapies
were recommended. She was treated supportively with tylenol and
tramadol with mild improvement. She will follow-up in
gynecology.
#ALT elevation
New ALT elevation noted on ___, without AST elevation. Peaked
at 110 and started to downtrend by discharge. Likely drug
related. Would follow-up as outpatient. holding statin for now
# HTN
BPs mostly 120s-150s on torsemide alone. Telmisartan held due to
hyperkalemia. Patient takes hydralazine PRN at home.
# Lower extremity edema
Probably multifactorial including albumin and steroids. Using
compression stockings and torsemide with mild improvement.
# Latent TB.
Per discussion with ID, held INH until she follows up as
outpatient.
# H. pylori gastritis
Completed quadruple therapy with bismuth, doxycycline
substituted for tetracycline, metronidazole and omeprazole.
# Hypothyroidism
Continued levothyroxine. TSH borderline elevated, free T4 wnl,
would recheck as outpatient.
# Anemia of CKD, inflammation +/- iron deficiency:
Would consider restarting iron when constipation not problem
====================
Transitional issues:
====================
- Patient has follow-up in renal, ID, rheum, and primary care
clinics
- Please ensure patient has refills of meds when appropriate
(given 1 month worth of most meds)
- CBC, BMP, and LFTs to be checked ___ and ___ and sent to
Dr. ___ need close monitoring of potassium and
bicarb)
- recheck thyroid studies in follow-up
- restart statin if LFTs stable/improved in follow-up
- consider further titration of BP regimen
- Continue to titrate bowel regimen
- Will need surveillance imaging for renal lesions
- Right upper and middle lobe pulmonary nodules measuring up to
5 mm. Per ___ criteria these likely do not require
follow-up imaging as she is low risk
====================
====================
> 30 minutes in patient care and coordination of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sodium Bicarbonate 650 mg PO TID
2. Lactulose 15 mL PO DAILY
3. telmisartan 80 mg oral DAILY
4. Bismuth Subsalicylate Chewable 524 mg PO QID
5. MetroNIDAZOLE 500 mg PO TID
6. Isoniazid ___ mg PO DAILY
7. HydrALAZINE 10 mg PO DAILY:PRN HTN
8. Rosuvastatin Calcium 5 mg PO QPM
9. Torsemide 10 mg PO DAILY
10. MedroxyPROGESTERone Acetate 150 mg IM EVERY 12 WEEKS
11. Omeprazole 20 mg PO BID
12. Calcium Carbonate 1500 mg PO DAILY
13. Vitamin D3 (cholecalciferol (vitamin D3)) 400 unit oral
DAILY
14. Doxycycline Hyclate 100 mg PO Q12H
15. Levothyroxine Sodium 50 mcg PO DAILY
16. Nephro-Vite (B complex-vitamin C-folic acid) 0.8 mg oral
DAILY
17. Calcitriol 0.25 mcg PO THREE TIMES A WEEK
18. Pyridoxine 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg ___ tablet(s) by mouth up to three
times daily Disp #*120 Tablet Refills:*0
2. Atovaquone Suspension 1500 mg PO DAILY PJP ppx given steroid
use
RX *atovaquone 750 mg/5 mL 1500 mg by mouth daily Disp #*420
Milliliter Milliliter Refills:*3
3. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
RX *bisacodyl 10 mg 1 suppository(s) rectally daily as needed
Disp #*30 Suppository Refills:*0
4. Calcium Acetate 667 mg PO TID W/MEALS
RX *calcium acetate [Eliphos] 667 mg 1 tablet(s) by mouth three
times daily with meals Disp #*90 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO TID
RX *polyethylene glycol 3350 [Miralax] 17 gram 17 grams by mouth
three times daily Disp #*90 Packet Refills:*0
7. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 60 mg by mouth once daily Disp #*90 Tablet
Refills:*0
8. Senna 8.6 mg PO DAILY
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp
#*60 Tablet Refills:*0
9. Simethicone 40-80 mg PO QID:PRN indigestion or cramps
RX *simethicone [Gas Relief] 80 mg ___ tablet by mouth up to
three times daily as needed Disp #*60 Tablet Refills:*0
10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *tramadol 50 mg ___ tablet(s) by mouth up to twice daily as
needed Disp #*20 Tablet Refills:*0
11. Lactulose 30 mL PO BID
RX *lactulose 10 gram/15 mL (15 mL) ___ ml by mouth twice
daily Disp #*1 Bottle Refills:*0
12. Sodium Bicarbonate 1300 mg PO TID
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth three times
daily Disp #*180 Tablet Refills:*0
13. Calcitriol 0.25 mcg PO THREE TIMES A WEEK
14. Calcium Carbonate 1500 mg PO DAILY
15. HydrALAZINE 10 mg PO DAILY:PRN HTN
16. Levothyroxine Sodium 50 mcg PO DAILY
17. MedroxyPROGESTERone Acetate 150 mg IM EVERY 12 WEEKS
18. Nephro-Vite (B complex-vitamin C-folic acid) 0.8 mg oral
DAILY
19. Omeprazole 20 mg PO BID
20. Torsemide 10 mg PO DAILY
21. Vitamin D3 (cholecalciferol (vitamin D3)) 400 unit oral
DAILY
22. HELD- Isoniazid ___ mg PO DAILY This medication was held.
Do not restart Isoniazid until Dr. ___ you to do so
23. HELD- Pyridoxine 50 mg PO DAILY This medication was held.
Do not restart Pyridoxine until Dr. ___ you to do so
24. HELD- Rosuvastatin Calcium 5 mg PO QPM This medication was
held. Do not restart Rosuvastatin Calcium until instructed by
your primary care doctor
25. HELD- telmisartan 80 mg oral DAILY This medication was
held. Do not restart telmisartan until instructed by Dr.
___
___ Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Still's disease
CKD IV
Hyperkalemia
Metabolic acidosis
Latent TB
HTN
ALT elevation
Fibroids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ for fevers. You had a extensive
workup to find a cause including looking for an infection, a
cancer or blood disorder, or an autoimmune disorder. After a
thorough work up, we feel that you have likely Adult Still's
disease and you were started on steroid therapy, which gave you
a lot of relief. You were also started on a medication to
prevent infection while on steroids. And your treatment for
latent tuberculosis was paused. You have follow-up appointments
with infectious disease, rheumatology, and your primary care
doctor.
A few notes about your discharge plan:
(1) for now you will continue 60 mg of prednisone daily, which
will likely be reduced to a lower dose when you see the
rheumatology team
(2) atovaquone is an important medication for reducing the
chance of a rare type of pneumonia (pneumocystis) while on the
steroids
(3) we have prescribed a number of medications for constipation.
The goal is to have ___ soft bowel movements today. If you are
having more bowel movements than that or they are watery, then
you will need to reduce the dose. If you are having constipation
again then you may need the dose increased and should discuss
with your doctor
(___) you will have your blood work checked by ___ nurses on
___ and ___, and the results will be sent to Dr. ___
(5) It is important to eat a diet low in phosphorus and
potassium
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19838619-DS-19
| 19,838,619 | 25,486,439 |
DS
| 19 |
2134-08-21 00:00:00
|
2134-08-21 22:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a complicated PMHx of chronic
epigastric pain, nausea, and cyclical vomiting of unclear
etiology who presents with abdominal pain.
In brief, she currently lives in ___, but has seen Dr.
___ in GI clinic at ___ as a second opinion for
evaluation of her ongoing abdominal pain. She has also been
seen in ___ as well as at the ___. Per Dr.
___ note in ___, her symptoms began in ___.
She developed crampy abdominal pain and bilious emesis. Initial
CT imaging and labs were all unremarkable. She had a HIDA scan
that "only showed 17%" so she underwent a CCY. She continued to
have a ongoing vomiting and apparently was presenting to the ED
multiple times a month for ___ months. Hot showers reportedly
helped during her episodes of acute emesis. She also developed
anxiety due to her GI symptoms. She was placed on probiotics,
peppermint oil, buspirone, and tramadol for her cramps with
limited symptomatic improvement. She was then seen at the ___
___ where she underwent swallow study, gastric emptying
study, tilt table testing, esophageal manometry, and MRE; all of
these studies were negative. They subsequently recommended her
going to a pain rehabilitation program. The patient declined.
Of note, over this period of time, she also has experienced
unintentional 30 pound weight gain from 141 pounds to 107
pounds. Per Dr. ___, her abdominal pain could be
related to "cyclic vomiting syndrome, sludge, abdominal
migraines".
Her additional testing at ___ thus far has included wnl
EGD/colonoscopy. There was some evidence of very mild
gastritis. Her esophageal brushing did return positive for
___ for which she completed a 2 week course in ___.
She returned to ___ this week for scheduled MRE at ___.
She reported sudden onset of intestinal pain which she states is
characteristic of her typical abdominal migraines and therefore
presented to the ED. She states she has been having BMs about
every other day. In the ED, initial VS were wnl. Labs showed
wnl chem7, wnl LFTs and Tbili, WBFC 13.2, Hgb 14.2, Plt 346,
negative UA, negative UCG, and lactate 1.8. Prelim read of her
MRE showed stool burden in the colon but no evidence of
impaction or obstruction; no other acute pathology was noted.
She was given multiple doses of 0.5 mg IV dilaudid, phenergan,
Benadryl, and reglan prior to transfer to the floor.
Upon arrival to the floor, the patient asks me to give her a
very large dose of dilaudid which she states her "home ER" in
___ normally gives her. She explains that the treatment
of her abdominal migraines is to "stun [her] brain so her body
will respond" to pain medication. We had a prolonged discussion
regarding appropriate use of narcotic pain medication.
Of note, she is scheduled for a GI motility study on ___. The
patient is supposed to be leaving for ___ on ___.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
s/p CCY
abdominal pain, cyclic vomiting, nausea of unclear etiology
anxiety
Social History:
___
Family History:
Mother adopted. Patient reports family history of colon cancer.
Physical Exam:
Vitals- 98.6 137 / 83 83 18 95 Ra
GENERAL: anxious, agitated, tearful young female crouched over
face down in bed
HEENT: MMM, NCAT, EOMI, anicteric sclera
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: CTAB, unlabored respirations
ABDOMEN: soft, nondistended, diffuse TTP with deep palpation,
no rebound/guarding, + bowel sounds
EXTREMITIES: wwp, no pitting edema of BLE
NEUROLOGIC: AOx3, grossly nonfocal, wnl gait.
Pertinent Results:
___ 08:10PM URINE UCG-NEGATIVE
___ 08:10PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-NEG
___ 08:10PM URINE RBC-0 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-3
___ 08:10PM URINE MUCOUS-OCC
___ 06:29PM LACTATE-1.8
___ 06:20PM GLUCOSE-85 UREA N-10 CREAT-0.9 SODIUM-136
POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-21* ANION GAP-21*
___ 06:20PM ALT(SGPT)-16 AST(SGOT)-38 ALK PHOS-28* TOT
BILI-0.8
___ 06:20PM LIPASE-27
___ 06:20PM ALBUMIN-4.8
___ 06:20PM WBC-13.2*# RBC-4.69 HGB-14.2 HCT-41.4 MCV-88
MCH-30.3 MCHC-34.3 RDW-12.9 RDWSD-41.6
___ 06:20PM NEUTS-79.2* LYMPHS-13.9* MONOS-5.3 EOS-0.2*
BASOS-0.9 IM ___ AbsNeut-10.44*# AbsLymp-1.84 AbsMono-0.70
AbsEos-0.03* AbsBaso-0.12*
___ 06:20PM PLT COUNT-346
MRE:
IMPRESSION:
1. Limited examination due to inadequate distention of small
bowel
demonstrates no evidence for obstruction, mass, or inflammatory
bowel disease.
2. Large stool burden in the colon.
Brief Hospital Course:
Ms. ___ is a ___ with a complicated PMHx of chronic
epigastric pain, nausea, and cyclical vomiting of unclear
etiology who presents with abdominal pain.
# Abdominal pain
Patient with complicated constellation of GI symptoms with
extensive work-up, felt to potentially have cyclic vomiting
syndrome and abdominal migraines. She presents with symptoms
reportedly typical of her abdominal migraines. Labs and verbal
prelim read of MRE shows no acute pathology to explain her GI
symptoms. She does intermittent problems with constipation,
although unclear if her constipation could be contributing to
her current acute presentation. She underwent motility study
without complication. She did have an attack of her pain
treated successfully with IV ativan, toradol, tramadol. Her
remeron was increased to 30mg qHS on discharge and close follow
up was recommended
- GI will call patient with results of these tests.
# Anxiety
- Continue home buspirone
- Continue home Xanax prn
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.25 mg PO BID:PRN anxiety
2. BusPIRone 10 mg PO BID
3. Mirtazapine 15 mg PO QHS
4. Omeprazole 20 mg PO DAILY
5. TraMADol 50 mg PO Q12H:PRN Pain - Moderate
6. Morphine Sulfate ___ 15 mg PO Q12H:PRN Pain - Moderate
7. Ondansetron ODT 4 mg PO Q6H:PRN n/v
8. coenzyme Q10 200 mg oral BID
9. LevoCARNitine 1000 mg PO BID
10. Milk of Magnesia 30 mL PO QHS:PRN constipation
11. peppermint oil 0.2 ml oral DAILY
Discharge Medications:
1. Mirtazapine 30 mg PO QHS
RX *mirtazapine 30 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
2. ALPRAZolam 0.25 mg PO BID:PRN anxiety
3. BusPIRone 10 mg PO BID
4. coenzyme Q10 200 mg oral BID
5. LevoCARNitine 1000 mg PO BID
6. Milk of Magnesia 30 mL PO QHS:PRN constipation
7. Omeprazole 20 mg PO DAILY
8. Ondansetron ODT 4 mg PO Q6H:PRN n/v
9. peppermint oil 0.2 ml oral DAILY
10. TraMADol 50 mg PO Q12H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation of your abdominal pain. The
gastroenterologists will review the MRI and motility study and
contact you with the results. They recommended that you
increase your Remeron dose, prescribed below.
Followup Instructions:
___
|
19838860-DS-17
| 19,838,860 | 20,662,769 |
DS
| 17 |
2151-01-27 00:00:00
|
2151-01-29 16:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide / oxcarbazepine / lorazepam
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Thoracentesis ___
History of Present Illness:
Mr. ___ is an ___ y/o m with HOCM, afib on xarelto, CHB s/p
PPM, HFrEF who presents with dyspnea on exertion worsening over
the last three months, sent in by his PCP for evaluation of a
pleural effusion.
He reports that for the last year, he has had a chronic cough
with intermittent hemoptysis. He has also had worsening dyspnea
on exertion for the past year. He denies orthopnea, PND, rest
angina, weight gain.
He has no acute symptoms. He was diagnosed with a right pleural
effusion almost 3 weeks ago. He visited an outside
pulmonologist, where a CT chest demonstrated the pleural
effusion. He was going to have a thoracentesis, but he reports
that the procedure was canceled due to "technical difficulty."
He then switched his PCP to ___ new PCP, who recommended he come
to the ED for emergent evaluation, admission, and thoracentesis.
In the ED, initial vital signs were: T 97.4, HR 87, BP 130/86,
RR 18, O2 98% RA.
- Exam notable for: clear lungs to auscultation, 1+ ___ edema
- Labs were notable for: Hgb 12.8 (baseline), WBC 5.1, Cr 1.8
(baseline 1.1), MB 4 and Trop 0.10->0.09, D-Dimer 916, proBNP
4753
- Studies performed include: CXR which showed a moderate right
pleural effusion and atelectasis; ___ which was negative
for DVT
- Patient was given his home medications on schedule
- Vitals on transfer: 98.2, 73, 125/64, 17, 100% RA
Upon arrival to the floor, the patient request to leave AMA. He
did not feel it was necessary to stay in the hospital for a
thoracentesis when he felt otherwise well, and he asked to do
the procedure as an outaptient. After discussion with the son
and patient, it was decided that the patient would stay for
workup of his ___ and dyspnea.
Review of Systems: as per HPI
Past Medical History:
CVA ___
Afib with 3rd degree heart block
Hypertrophic cardiomyopathy
Seizures
TIA ___
Gout
COPD
Prostatectomy
Pacemaker Insertion
Social History:
___
Family History:
Significant for hypertension, heart failure and
stroke.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 97.3, 131/78, 76, 18, 97% RA
GENERAL: Well appearing male, lying in bed
HEENT: MMM, normal dentition
CARDIAC: Regular rate, no murmurs/rubs/gallops
LUNGS: Clear to auscultation bilaterally, diminished breath
sounds at right base
ABDOMEN: Soft, nontender, nondistended, no organomegaly palpable
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
NEUROLOGIC: CN2-12 intact. ___ strength throughout
DISCHARGE PHYSICAL EXAM:
Vitals- 97.8 PO 146 / 83 81 18 95 Ra
GENERAL: Well-appearing male, lying in bed
HEENT: MMM, oropharynx clear
CARDIAC: Regular rate, no murmurs/rubs/gallops
LUNGS: Clear throughout lung fields, diminished breath sounds at
r base.
ABDOMEN: Soft, nontender, nondistended, no organomegaly
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
NEUROLOGIC: CN2-12 intact. ___ strength throughout
Pertinent Results:
ADMISSION LABS:
---------------
___ 06:50PM BLOOD WBC-5.1 RBC-3.95* Hgb-12.8* Hct-39.4*
MCV-100*# MCH-32.4* MCHC-32.5 RDW-14.9 RDWSD-55.0* Plt ___
___ 06:50PM BLOOD Neuts-70.9 Lymphs-15.1* Monos-11.0
Eos-2.0 Baso-0.8 Im ___ AbsNeut-3.62 AbsLymp-0.77*
AbsMono-0.56 AbsEos-0.10 AbsBaso-0.04
___ 06:39AM BLOOD Glucose-79 UreaN-39* Creat-1.6* Na-138
K-4.0 Cl-104 HCO3-24 AnGap-14
___ 09:10PM BLOOD Glucose-90 UreaN-43* Creat-1.8* Na-137
K-4.4 Cl-101 HCO3-24 AnGap-16
___ 09:10PM BLOOD CK(CPK)-80
___ 02:40AM BLOOD cTropnT-0.09*
___ 09:10PM BLOOD CK-MB-4 cTropnT-0.10* proBNP-4753*
___ 06:50PM BLOOD D-Dimer-916*
URINALYSIS:
----------------
___ 10:20PM URINE Color-Straw Appear-Clear Sp ___
___ 10:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
MICROBIOLOGY:
-------------
___ 10:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ PLEURAL FLUID CULTURE
___ 10:48 am PLEURAL FLUID PLEURAL.
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 (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
PLEURAL FLUID ANALYSIS:
___ 10:48AM PLEURAL TNC-327* RBC-292* Polys-7* Lymphs-55*
___ Meso-4* Macro-20* Other-14*
___ 10:48AM PLEURAL TotProt-2.4 Glucose-109 LD(LDH)-77
Albumin-39 Cholest-21 Triglyc-<9 Misc-BODY FLUID
IMAGING:
--------
EKG: HR 75, QTc 570, v-paced
CXR ___:
Moderate right pleural effusion and atelectasis. No pulmonary
edema.
___ ___:
No evidence of deep venous thrombosis in the left lower
extremity veins.
DISCHARGE & PERTINENT LABS:
___ 07:48AM BLOOD WBC-4.5 RBC-3.91* Hgb-12.9* Hct-38.8*
MCV-99* MCH-33.0* MCHC-33.2 RDW-15.0 RDWSD-54.5* Plt ___
___ 07:48AM BLOOD ___ PTT-31.5 ___
___ 07:48AM BLOOD Glucose-88 UreaN-34* Creat-1.5* Na-140
K-4.1 Cl-104 HCO3-23 AnGap-17
___ 07:48AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.1
Brief Hospital Course:
Mr. ___ is an ___ y/o m with HOCM, afib on xarelto, CHB s/p
PPM, HFrEF who presents with dyspnea on exertion worsening over
the last three months, sent in by his PCP for evaluation of a
pleural effusion
# Pleural effusion:
# Dyspnea on exertion: Endorses progressive dyspnea on exertion
for the past several months, which may be due to HOCM vs right
pleural effusion vs worsening heart failure (less likely as no
signs of volume overload aside from elevated proBNP). Unlikely
PE despite mildly positive age adjusted d-dimer as he has no new
symptoms, is on rivaroxaban, and no other risk factors; however
CTA to completely rule PE out could not be performed secondary
to his ___. He underwent uncomplicated thoracentesis on ___
and elected to have his results followed up outpatient. He was
discharged after being transitioned back to a decreased dose of
Xarelto in the setting of CKD.
# Acute kidney injury on CKD: Baseline Cr unknown but in ___
was 1.3. Admission cr 1.8 with BUN/Cr ratio > 20. No signs of
infection and no hypotension in ED. We ordered urine lytes and
encouraged PO hydration. His renal function improved to 1.5
prior to discharge, which may be a new baseline for him.
# Paroxsymal atrial fibrillation: Rates stable on home
metoprolol succ 25 mg daily. On home xarelto 20 daily. Held
xarelto with heparin bridge until thoracentesis. Xarelto
restarted post-procedure at a reduced dose as above.
# Hypertrophic cardiomyopathy: ___ be causing his dyspnea on
exertion. He is on Lasix 40 mg PO daily at home. proBNP elevated
to 4700, but chronically elevated to 5000+ in ___. Held Lasix
on admission due to ___ (per notes diuresis recently increased
secondary to effusion). Restarted upon discharge.
# CHB s/p dual chamber PPM: Placed on ___ for CHB. Set to DDR
60-130, recently interrogated in ___
# HLD: Continued home atorva 20 mg daily
# Gout: Held home allopurinol due to ___. Resumed on discharge.
# Presumed COPD: Continued home albuterol prn and spiriva
# Hx of CVA
# Hx of focal seizures
-------------------
TRANSITIONAL ISSUES
-------------------
[] Rivaroxaban dose was decreased to 15 mg daily in the setting
of acute kidney injury. Please resume 20 mg daily dosing once
___ has resolved.
[] Patient underwent thoracentesis on ___. Pleural fluid
studies pending at time of discharge and will be followed up by
Pulmonology.
[] Concern for pulmonary embolism on admission, however lower
extremity ultrasound without deep vein thrombosis, patient on
anticoagulation, normal vital signs, and no acute change in SOB.
If still concerned for pulmonary embolism, please consider
outpatient CTA once renal function normalizes.
[] Please check renal function at next PCP ___.
Discharge Cr 1.5.
#Contact: ___ (Wife, HCP) ___, Son ___
___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 20 mg PO QPM
2. Rivaroxaban 20 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Furosemide 40 mg PO DAILY leg swelling
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
7. quercetin dihydrate (bulk) 100 % miscellaneous DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Rivaroxaban 15 mg PO DINNER
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
3. Allopurinol ___ mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Furosemide 40 mg PO DAILY leg swelling
6. Metoprolol Succinate XL 25 mg PO DAILY
7. quercetin dihydrate (bulk) 100 % miscellaneous DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
-----------------
Right pleural effusion
shortness of breath
acute renal injury
SECONDARY DIAGNOSIS
-------------------
chronic kidney disease
chronic diastolic heart failure
Gout
hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you!
Why you were admitted:
- You had shortness of breath and cough.
- A chest x-ray showed fluid in your right lung that has been
there for many weeks.
What we did for you:
- Ultrasounds of your legs did not show any clot.
- We drained the fluid from your right chest and set it for
testing.
What you should do after discharge:
- please follow up with your primary care doctor and the
interventional pulmonologist to go over the results of the lab
tests we ran on the fluid in your lungs.
Best,
Your ___ Care Team
Followup Instructions:
___
|
19839174-DS-9
| 19,839,174 | 22,018,600 |
DS
| 9 |
2168-04-26 00:00:00
|
2168-04-27 15:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ healthy female with recent history of right ankle
fracture and worsening right leg pain presented to the ED with
shortness of breath and found to have PEs.
The patient fractured her right ankle on ___ and has had a full
cast on until recently when it was changed to a walking boot.
Four days prior to admission, the patient developed new
shortness of breath. She noted that she was more fatigued and
out of breath with usual activities. She developed palpitations
on ___ while in the shower. Presented to her PCP who was
concerned for DVT/PE and sent her to the ED. Review of systems
negative for fevers, chills, chest pain, pleuritic cheset pain,
cough, nausea, vomiting, diarrhea, dysuria, hematuria, or
headaches.
In the ED, initial vitals were: ___ 99 136/99 18 99%
ra
- Labs were significant for proBNP 749 but otherwise normal
chem10 and cbc.
- Imaging was significant for CTA showing pulmonary emboli in
the distal right and left main pulmonary arteries extending into
the segmental and subsegmental branches bilaterally, unable to
exclude small pulmonary infarction in left lung base.
- Patient was given: 2tab Oxycodone-Acetaminophen (5mg-325mg)
Vitals prior to transfer were:
Today 16:00 0 98 126/86 12 97% RA
On the floor, initial vitals were:T 97.9 BP 121/84 HR 76 RR 18
O2 98RA. The patient feels well. She does have some mild chest
tightness which is new today. She denies SOB at rest or
pleuritic chest pain. She has mild right leg pain currently.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough. 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:
Right ankle fracture
Chronic back pain
Depression
Acne
Social History:
___
Family History:
Aunt with several DVTs in her ___. No other family members with
history of DVT/PE
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.9 BP 121/84 HR 76 RR 18 O2 98RA
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, ___ systolic murmur
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: right leg in walking boot. left leg warm, well perfused, 2+
pulses, no clubbing, cyanosis or edema
DISCHARGE PHYSICAL EXAM
VS: T 98.4 BP 115/70 (110-120s) HR 74 (70s) RR 18 O2 95RA
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, ___ systolic murmur
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: right leg in walking boot. left leg warm, well perfused, 2+
pulses, no clubbing, cyanosis or edema
Pertinent Results:
ADMISSION LABS:
___ 10:45AM BLOOD WBC-9.9 RBC-4.47 Hgb-13.4 Hct-37.4
MCV-84# MCH-30.0 MCHC-35.9* RDW-12.7 Plt ___
___ 10:45AM BLOOD Neuts-72.1* ___ Monos-4.1 Eos-1.8
Baso-0.3
___ 10:45AM BLOOD ___ PTT-24.9* ___
___ 10:45AM BLOOD Glucose-109* UreaN-14 Creat-0.8 Na-140
K-4.0 Cl-108 HCO3-20* AnGap-16
___ 10:45AM BLOOD cTropnT-<0.01 proBNP-749*
DISCHARGE LABS:
___ 07:45AM BLOOD WBC-5.7 RBC-4.42 Hgb-13.2 Hct-37.3 MCV-84
MCH-29.8 MCHC-35.3* RDW-13.2 Plt ___
___ 07:45AM BLOOD ___ PTT-33.2 ___
___ 07:45AM BLOOD Glucose-80 UreaN-12 Creat-0.8 Na-137
K-4.1 Cl-105 HCO3-22 AnGap-14
___ 07:45AM BLOOD Calcium-9.2 Phos-5.0* Mg-2.0
IMAGING:
___ CXR:
Normal chest x-ray.
___ CTA:
Pulmonary emboli in the distal right and left main pulmonary
arteries extending into the segmental and subsegmental branches
bilaterally, most significantly at affecting the lower lobes. A
small opacity at the left lung base may represent atelectasis,
however a small pulmonary infarction is possible. No evidence
of right heart strain.
EKG: NSR without evidence of right heart strain or ST changes
Brief Hospital Course:
___ with recent history of immobilization secondary to right
ankle fracture, obesity, and on OCPs admitted with SOB found to
have new PEs. Pt remained hemodynamically stable and was
saturating high ___ on RA. She was started on lovenox on
admission and transitioned to rivaroxaban for anticoagulation.
Her OCP was discontinued as she is not currently sexually
active. She will discuss alternative methods of contraception
with her PCP and consider seeing an ___ about the option of
paraguard IUD.
# Pulmonary Embolism: provoked in the setting of being
immobilized with right ankle fracture and on OCPs.
Hemodynamically stable and saturating well on RA. Started on
lovenox in the ED which was continued on the floor. BMI ~35 so
appropriate dosing 1mg/kg Q12. Patient was transitioned to
rivaroxaban for at least 3 months.
# Right ankle fracture: continued walking boot. Pain controlled
with percocet prn. Discontinued ibuprofen in the setting of
anticoagulation
# Depression: Continued home bupropion
# Acne: Continued home spironolactone
# CODE: Full (confirmed)
# CONTACT: Mother ___ (___)
TRANSITIONAL ISSUES:
- pt with provoked DVT started on rivaroxaban for 3 months - she
should take 15mg twice daily with food for 21 days and then
transition to 20mg once daily WITH food
- OCP discontinued as patient not sexually active and estrogen
containing OCPs put her at risk of clots. Please discuss
alternative methods of contraception such as paraguard IUD.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Loryna (28) (drospirenone-ethinyl estradiol) ___ mg oral
DAILY
2. Ibuprofen 800 mg PO Q8H:PRN pain
3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
4. BuPROPion (Sustained Release) 450 mg PO QAM
5. Spironolactone 100 mg PO DAILY
6. ALPRAZolam 0.5 mg PO BID:PRN anxiety
Discharge Medications:
1. ALPRAZolam 0.5 mg PO BID:PRN anxiety
2. BuPROPion (Sustained Release) 450 mg PO QAM
3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every 4 hours Disp #*21 Tablet Refills:*0
4. Spironolactone 100 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*60 Capsule Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
7. Rivaroxaban 15 mg PO BID
RX *rivaroxaban [___] 15 mg (42)- 20 mg (9) 1 tablets(s) by
mouth twice a day Disp #*1 Dose Pack Refills:*0
8. Rivaroxaban 20 mg PO DAILY Duration: 2 Months
Please start after completing first month of prescribed
rivaroxaban
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp
#*28 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Pulmonary embolism
Secondary: Ankle fracture, depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted with a pulmonary embolism,
which is a clot in your lungs. This clot likely occured in your
leg due to you being less mobile with your fracture as well as
having the risk factors of being overweight and taking oral
contraceptives. For the clot in your lungs, you are being
treated with a medication to thin your blood called rivaroxaban,
also known as xarelto. You will take 15mg twice daily for 21
days and then 20mg once daily for 3 months total. It is very
important that you take this medication as prescribed and do not
miss doses. Always take this medication with food. Not taking
your blood thinner will put you at risk of more clots in your
lungs which could be life-threatening. While taking this
medication, you should try to avoid NSAIDs such as aspirin and
ibuprofen which put you at risk for bleeding. Since you are not
currently sexually active, you should stop taking your oral
contraceptive as this increases your risk of developing clots.
Please discuss starting an alternative method of contraception
with your primary care physician or an ___.
We wish you the best!
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
19840128-DS-26
| 19,840,128 | 28,067,057 |
DS
| 26 |
2160-02-17 00:00:00
|
2160-02-18 15:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ yo female with PMH notable for reactivation
TB on therapy, HTN, NIDDM now presenting with subacute right
back and chest pain. Patient reports that she has had burning
pain in her side for at least the last 2 weeks. She is unable to
provide a clear timeline and becomes somewhat distressed when
pressed for how long this has been going on. The pain is
somewhat "eased" by taking Motrin 800mg every 6 hours. She
reports that the pain is worse with "straining" as when she
lifts an object or twists. It is also worse with deep breaths.
The pain became worse today and patient presented to the ED.
In the ED, VS were 97.6 62 135/104 18 99%RA. Labs were
unremarkable. Patient had CXR and CTA performed which showed
healing bilateral rib fractures. She received 500cc NS and
Morphine 4mg IV. VS on transfer were 97.6 72 ___ 100%RA.
On arrival to the floor, patient was continuing to complain of
right-sided pain.
ROS: She denies fevers, chills, CP, abdominal pain,
nausea/vomiting, dysuria. She reports SOB with exertion that is
at her baseline. She reports dry intermittent cough. She reports
a previous history of weight loss prior to diagnosis of TB - she
reports that she is now starting to regain some weight. Last BM
was yesterday morning.
Past Medical History:
Hypertension
Hyperlipidemia
Hypothyroidism
Non-insulin dependent Diabetes Mellitus
Stress neg (___)
Arthritis - s/p bilateral knee replacement ___
4-cm subcarinal mass, inseparable from the esophageal wall, with
enlarged mediastinal lymph nodes- LN path c/w granulomatous
lymphadenitis (found on CTA during ___
AVNRT/Paroxysmal Afib
Reactivation of TB
Social History:
___
Family History:
No family history of any malignancy; her mother died of heart
disease. All 5 children are healthy.
Physical Exam:
Admission Exam:
VS: 98.0 150/72 80 18 93%RA ___ 178
Gen: awake, alert, appears somewhat uncomfortable but NAD
HEENT: MMM, 8mm papule on hard palate (patient reports it has
been present for decades)
CV: RRR, no m/r/g
Lungs: CTAB
Chest: tenderness to palpation in the right midclavicular line
just under the right breast. no tenderness to palpation over the
right back. No tenderness to palpation on the left chest
wall/back. Skin is unremarkable (scattered seborrheic
keratoses).
Abd: +BS, soft, NT/ND
Ext: WWP, no edema
Neuro: ___ strength bilateral upper extremities
Discharge Exam:
Gen: awake, alert, appears somewhat uncomfortable but NAD
CV: RRR, no m/r/g
Lungs: CTAB
Chest: no tenderness to palpation on the right chest this AM. no
tenderness to palpation over the right back. No tenderness to
palpation on the left chest wall/back. Skin is unremarkable
(scattered seborrheic keratoses).
Abd: +BS, soft, NT/ND
Ext: WWP, no edema
Pertinent Results:
Admission Labs:
___ 04:30AM BLOOD WBC-6.3# RBC-3.05* Hgb-7.5* Hct-26.7*
MCV-88 MCH-24.5* MCHC-27.9* RDW-19.1* Plt ___
___ 04:30AM BLOOD Neuts-35* Bands-0 Lymphs-63* Monos-2
Eos-0 Baso-0 ___ Myelos-0
___ 04:30AM BLOOD ___ PTT-29.3 ___
___ 04:30AM BLOOD Glucose-166* UreaN-27* Creat-0.8 Na-138
K-5.0 Cl-106 HCO3-23 AnGap-14
___ 04:30AM BLOOD ALT-17 AST-94* AlkPhos-79 TotBili-0.4
___ 04:30AM BLOOD Lipase-64*
___ 04:30AM BLOOD TotProt-6.0* Albumin-4.3 Globuln-1.7*
___ 05:10AM BLOOD Lactate-1.0
Discharge Labs:
___ 07:15AM BLOOD Glucose-109* UreaN-23* Creat-0.8 Na-141
K-4.0 Cl-107 HCO3-26 AnGap-12
___ 07:15AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.7
SPEP:
___ 04:30AM BLOOD PEP-NO SPECIFIC ABNORMALITIES
SEEN;INTERPRETED BY ___, MD
Urine:
___ 07:49AM URINE Color-Yellow Appear-Clear Sp ___
___ 07:49AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
___ 07:49AM URINE RBC-1 WBC-8* Bacteri-NONE Yeast-NONE
Epi-<1
___ 07:49AM URINE CastHy-8*
___ 07:49AM URINE Mucous-RARE
___ 07:49AM URINE Hours-RANDOM Creat-31 TotProt-227
Prot/Cr-7.3*
___ 07:49AM URINE U-PEP-ABNORMAL B IFE-MONOCLONAL
EKG ___: Sinus rhythm with atrial premature beats. Left axis
deviation. RSR' pattern in lead V1. Since the previous tracing
of ___ precordial voltage is now more prominent. T waves are
improved and there is a single premature beat of uncertain
etiology, quite different from the atrial premature beats.
Clinical correlation is suggested.
CXR ___: IMPRESSION: Bibasilar atelectasis and mild pulmonary
edema. Refer to chest CT performed subsequently for further
information.
CTA Chest ___: IMPRESSION: 1. Increasing pulmonary nodules,
and decreased size of central lymph nodes consistent with
diagnosis of tuberculosis. 2. Bilateral rib fractures. 3. Mild
pulmonary edema.
Brief Hospital Course:
The patient is a ___ yo female with PMH notable for reactivation
TB on therapy, HTN, NIDDM now presenting with subacute right
back and chest pain.
Active issues:
# Right-sided pain: Given the history this is most likely pain
from rib fractures vs musculoskeletal pain. No evidence for INH
neuropathy as this typically presents as a peripheral
neuropathy. Given history and exam, no evidence for cardiac
process. Pain was reproducible on initial exam but not on repeat
later - etiology is unclear. Patient was maintained on Tylenol
___ TID standing and Tramadol 50mg PO q6hrs PRN with good
effect.
# Rib fractures: Possible cause of pain (see above). As rib
fractures were of unclear etiology (no clear history of trauma
but patient is poor historian), patient was started on calcium
and Vitamin D. Patient may benefit from bisphosphanate to be
started as an outpatient. She was found to have an abnormal UPEP
raising the possiblity of a hematologic process. This will need
to be evaluated further as an outpatient.
Chronic issues:
# TB: On active treatment. Continued isoniazid, rifampin,
pyridoxine
# Hypothyroidism: Stable. Continue levothyroxine
# HTN: Combo med non-formulary - maintained on Losartin and HCTZ
as indiviual pills (home reg). Continued ASA 81mg, metoprolol.
Patient reported outpatient PCP instructed her to hold
atorvastatin so held during this admission.
Transitional issues:
- ___ benefit from bisphosphanate as outpatient
- CT scan showed worsening pulmonary nodules but unclear if this
is actually improved since starting TB treatment (comparison CT
predated treatment start). Will need further follow-up as
outpatient.
- Continue TB treatment and follow-up with already established
ID provider.
- f/u abnormal UPEP result
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Levothyroxine Sodium 100 mcg PO DAYS (___)
2. Isoniazid ___ mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Pyridoxine 50 mg PO DAILY
5. Rifampin 600 mg PO Q24H
6. GlyBURIDE 5 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Acetaminophen ___ mg PO Q8H:PRN pain
9. losartan-hydrochlorothiazide *NF* 100-25 mg Oral ___ tablet
daily
10. Atorvastatin 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Isoniazid ___ mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAYS (___)
5. Metoprolol Tartrate 25 mg PO BID
6. Pyridoxine 50 mg PO DAILY
7. Rifampin 600 mg PO Q24H
8. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth twice a day Disp #*60 Tablet Refills:*0
9. Lidocaine 5% Patch 1 PTCH TD DAILY
apply to ribs
RX *lidocaine 5 % (700 mg/patch) Apply 1 patch daily Disp #*30
Unit Refills:*0
10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*40
Tablet Refills:*0
11. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
12. Atorvastatin 10 mg PO DAILY
13. GlyBURIDE 5 mg PO BID
14. losartan-hydrochlorothiazide *NF* 100-25 mg Oral ___ tablet
daily
Discharge Disposition:
Home
Discharge Diagnosis:
Rib fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted with pain in your side and back. There was no
evidence that this pain was related to your heart or lungs. You
were found to have healing fractures in your ribs which are
likely contributing to your pain. We controlled your pain with
medications and started you on vitamins to help prevent future
broken bones.
Followup Instructions:
___
|
19840128-DS-27
| 19,840,128 | 29,535,939 |
DS
| 27 |
2160-04-05 00:00:00
|
2160-04-05 12:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is ___ with history of DM, hypothyroidism, recent TB
diagnosis 6 months ago, who p/w one-month history of worsening
bilateral lower back pain radiating to her buttocks. The
patient was brought into her PCP's office by her family with
radiation of this back pain into her left buttock with radiation
down to her lower leg. At this time, the patient denied having
any urinary or fecal incontinence.
As for her pain control, the patient had been taking Vicodin
BID, tramadol BID, and lidocaine patches daily. Of note, the
patient had a rib fracture and was discharged ___.
She reports that her pain is worse with walking, and she has
been avoiding walking due to pain.
In the ED, the patient denies any weakness or numbness in her
legs, no urinary retention, no incontinence, no saddle
anesthesia. Exam notable for nonfocal neurologic exam. The
patient was seen in the ED by Neurosugery, who said that there
was no indication for surgical intervention at this time. They
recommended admission to medicine for pain control and possible
rehab placement, as well as TLSO brace as needed for comfort.
ROS: no chest pain, cough, shortness of breath, night sweats,
abdominal pain, incontinence, numbness, nausea, vomiting or
diarrhea
Past Medical History:
Hypertension
Hyperlipidemia
Hypothyroidism
Non-insulin dependent Diabetes Mellitus
Stress neg (___)
Arthritis - s/p bilateral knee replacement ___
4-cm subcarinal mass, inseparable from the esophageal wall, with
enlarged mediastinal lymph nodes- LN path c/w granulomatous
lymphadenitis (found on CTA during ___
AVNRT/Paroxysmal Afib
Reactivation of ___
Social History:
___
Family History:
No family history of any malignancy; her mother died of heart
disease. All 5 children are healthy.
Physical Exam:
ADMISSION:
VS: afebrile 98.4 153/54 HR 65 sat 95% on RA
General: well appearing, anxious and tearful woman, in NAD when
laying in bed
HEENT: EOMI, PERRL
CV: NR, RR, no murmur
lungs: clear to auscultation b/l
abdomen: soft, nontender, nondistended
extremities: warm, well perfused, no ___ edema, 2+ DP pulses
rectal: normal rectal tone
MSK: no tenderness to spinal palpation down entirety of spine,
no tenderness to palpation of her buttock b/l
Neuro: ___ strength bilaterally with leg raising while supine,
___ dorsiflexion and plantarflexion of feet b/l, ___ knee
flexion b/l, CN ___ intact, mental status normal
psych: tearful with repeat questioning
ON DISCHARGE:
Pertinent Results:
___ 03:10PM BLOOD WBC-5.6 RBC-2.93* Hgb-7.6* Hct-26.0*
MCV-89 MCH-25.9* MCHC-29.3* RDW-18.9* Plt ___
___ 03:10PM BLOOD Glucose-172* UreaN-17 Creat-0.8 Na-142
K-4.1 Cl-106 HCO3-23 AnGap-17
___ 03:10PM BLOOD CK(CPK)-56
___ 03:10PM BLOOD Calcium-9.3 Phos-2.9 Mg-1.7
___ 03:10PM BLOOD TSH-9.1*
___ 12:45PM BLOOD b2micro-PND IgG-464* IgA-51* IgM-10*
Thoracolumbar Spine AP/Lat Xray ___: FINDINGS: There is
mild upper thoracic levoconvex scoliosis with S-shaped
thoracolumbar scoliosis. Increased density of a mid thoracic
intervertebral disc may be due to degenerative change and
appears similar compared to prior
CT. Right lateral subluxation of L3 seen on L4. There is new
compression
deformity of an upper-mid thoracic vertebral body without
detected
retropulsion on these views. IMPRESSION: New upper-mid thoracic
vertebral body compression deformity without retropulsion.
MRI LUMBAR SPINE ___:
There is levoscoliosis of the lumbar spine with right lateral
listhesis of L2on L3. The alignment is otherwise maintained.
The vertebral body heights are within normal limits. The bone
marrow signal is normal with foci of focal fat at the L4
vertebral body. The conus medullaris terminates at T12-L1 and
appears normal.
A T2 bright lesion is visualized in the left sacral ala likely
representing a bone cyst. The paraspinal soft tissues are
unremarkable.
At T10-T11, there is a tiny disc protrusion superimposed on a
mild diffuse
disc bulge without significant spinal canal or neural foraminal
narrowing.
At T11-T12, there is a diffuse disc bulge with a central disc
protrusion
without significant spinal canal or neural foraminal narrowing.
At T12-L1, there is a diffuse disc bulge with a superimposed
left paracentral disc protrusion and deforming the thecal sac
and resulting in mild to moderate left neural foraminal
narrowing. There is no spinal canal or right neural foraminal
narrowing.
At L1-L2, there is a diffuse disc bulge with superimposed
bilateral foraminal protrusions which in conjunction with facet
joint arthropathy results in mild-to-moderate right and severe
left neural foraminal narrowing. The spinal canal is not
narrowed.
At L2-L3, there is a diffuse disc bulge and significant facet
joint
arthropathy resulting in moderate to severe narrowing of the
subarticular
zones, right worse than left, moderate to severe spinal canal
narrowing, as
well as moderate bilateral neural foraminal narrowing.
At L3-L4, there is a diffuse disc bulge, facet joint arthropathy
and
ligamentum flavum thickening resulting in moderate to severe
narrowing of the right subarticular zone and moderate to severe
spinal canal narrowing, as well as moderate to severe right and
mild left neural foraminal narrowing.
At L4-L5, there is a diffuse disc bulge, ligamentum flavum
thickening, and
facet joint arthropathy resulting in moderate spinal canal
narrowing with
severe right and moderate left subarticular zone narrowing.
There is moderate right and mild left neural foraminal
narrowing.
At L5-S1, there is a mild diffuse disc bulge and facet joint
arthropathy
without significant spinal canal or neural foraminal narrowing.
IMPRESSION: Multilevel spondylosis of the lumbar spine with
associated levoscoliosis as described, most severe at L2-L3.
Skeletal Survey ___
IMPRESSION: 75% compression fracture involving an upper thoracic
vertebrae - approximately T5 vertebra. The approximate level
cannot be determined on the current radiograph. This likely
represent source of patient's pain.
Notable Labs
___ 12:45PM BLOOD b2micro-PND IgG-464* IgA-51* IgM-10*
___ 03:10PM BLOOD TSH-9.1*
___ 12:45PM BLOOD FREE KAPPA AND LAMBDA, WITH K/L RATIO-PND
Labs on Discharge
___ 05:10AM BLOOD WBC-4.6 RBC-3.16* Hgb-8.0* Hct-27.4*
MCV-87 MCH-25.3* MCHC-29.2* RDW-18.6* Plt ___
___ 05:10AM BLOOD Glucose-116* UreaN-17 Creat-0.8 Na-137
K-3.9 Cl-100 HCO3-27 AnGap-14
___ 05:10AM BLOOD Calcium-9.0 Phos-4.6* Mg-1.8
Brief Hospital Course:
Ms. ___ is ___ with history of DM, hypothyroidism, recent TB
diagnosis 6 months ago on treatment, who p/w one-month history
of progessive bilateral lower back pain radiating to her
buttocks, with subluxation of L3 on L4 on Xray, and iliopsoas
weakness bilaterally, which is most consistent with structural
problem.
# Back pain/weakness:On admission, the patient was found to have
upper T-spine compression fracture, but this was not in
distribution of her pain or weakness. Subluxation of L3/L4 on
MRI could be causing nerve root impingement, but her tenderness
was localized mostly to her butocks. MRI L spine did not show
evidence of Pott's Disease with no concern for cord compression.
Iliopsoas strength on exam was markedly decreased, and was
difficult to tell if limited by pain, effort or weakness. Given
uncertainty after MRI L spine, MRI pelvis may be performed as
outpatient. She will follow up as outpatient with Orthopedics.
# Tuberculosis: Treatment started ___ to end ___. Pott's Disease ruled out by MRI. Will cont treatment with
INH, Rifampin, and pyridoxine. Has ID follow-up as outpatient.
# Positive UPEP: No lytic lesions on plain film or skeeltal
survey. Oncology consulted- Low likelihood of myeloma given no
renal dysfunction, negative SPEP and no lytic lesions of
skeletal survey. Also no Bone marrow involvement detected on MRI
L spine. Likely positive UPEP from MGUS. Patient also has
decreased immunoglobulin levels. Other Onc labs pending (see
below). She has outpatient follow-up with Onc ___.
# Hypothyroidism: TSH 9.1 on ___ with baseline less than
0.5, likely due to TB drugs, and could be contributing to
weakness. Levothyroxine was continued in house.
# DM:
-holding home Glyburide 5 mg BID
-Humalog ISS
# HTN:
Losartan, HCTZ, and metoprolol were continued.
# HLD:
-Statin is being held while patient is treated for TB.
# Psych: Tearful affect on admission, and seemed to be having
trouble coping with her new disability. Social work was
consulted and family meeting was arranged ___. Patient and
family comfortable with work-up and diagnoses thus far.
Transitional Issues
-Patient may have MRI as outpatient and follow-up with
Orthopedics
-Patient has beta 2 microglobulin, urine immunofixation, and
serum light chains pending, has onc follow-up appointment
-She will continue TB treatment through ___ with ID
follow-up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fentanyl Patch 12 mcg/h TP Q72H
2. GlyBURIDE 5 mg PO BID
3. Ibuprofen 600 mg PO Q8H
4. Isoniazid ___ mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
except ___
6. Lidocaine 5% Patch 1 PTCH TD DAILY
7. Losartan Potassium 50 mg PO DAILY
please hold for SBP<100, HR <60
8. Hydrochlorothiazide 12.5 mg PO DAILY
please hold for SBP<100
9. Metoprolol Tartrate 25 mg PO BID
please hold for SBP<100, HR<60
10. Rifampin 600 mg PO Q24H
11. TraMADOL (Ultram) 50 mg PO BID
12. Aspirin 81 mg PO DAILY
13. Calcium Carbonate 1250 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Pyridoxine 50 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 1250 mg PO DAILY
3. Fentanyl Patch 12 mcg/h TP Q72H
4. Hydrochlorothiazide 12.5 mg PO DAILY
please hold for SBP<100
5. Levothyroxine Sodium 100 mcg PO DAILY
except ___
6. Lidocaine 5% Patch 1 PTCH TD DAILY
7. Isoniazid ___ mg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
please hold for SBP<100, HR <60
9. Metoprolol Tartrate 25 mg PO BID
please hold for SBP<100, HR<60
10. Pyridoxine 50 mg PO DAILY
11. Rifampin 600 mg PO Q24H
12. Vitamin D 1000 UNIT PO DAILY
13. Acetaminophen 500 mg PO Q8H
14. Gabapentin 100 mg PO HS
15. GlyBURIDE 5 mg PO BID
16. TraMADOL (Ultram) 50 mg PO BID
17. Bisacodyl 10 mg PO DAILY
18. Docusate Sodium 100 mg PO BID
19. Senna 1 TAB PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Thoracic vertebral fracture
Treated Tuberculosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You came to the hospital with back pain. You were found to have
a fracture in your spine. For this, we have given you a large
brace to improve your comfort.
You also have pain in your lower back and pelvis. We are not
sure why you have this pain. To further evaluate this, you may
have an MRI done as an outpatient. You should also follow-up
with your Orthopedist as an outpatient.
Blood tests show you have extra protein in your blood. Sometimes
this is caused by a cancer called multiple myeloma. This seems
very unlikely in your case, but we would like you to still see
an Oncologist as an outpatient.
Please see changes to your medications below.
Please see follow-up appointments below.
It was a pleasure taking care of you, Ms ___.
Followup Instructions:
___
|
19840215-DS-4
| 19,840,215 | 20,610,761 |
DS
| 4 |
2158-05-05 00:00:00
|
2158-05-05 13:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
pneumoperitoneum
Major Surgical or Invasive Procedure:
revision of ileocolonic anastomosis/ileocolonic resection
History of Present Illness:
Ms. ___ is a ___ with history of cecal volvulus s/p right
hemicolectomy in ___ at ___, presents with a CT scans showing
pneumoperitoneum and pneumotosis intestinalis. Patient has had
chronic abdominal pain since her surgery and describes acute
post prandial episodes. On ___ she developed acute onset of
abdominal pain after dinner. She then had an episode of diarrhea
which improved her pain. She has been tolerating a diet since
but repots not having a bowel movement since her pain. She had
another episode of pain this morning but was not as bad. Patient
saw PCP today who referred her in for CT scan showing
pneumoperitoneum and pneumatosis intestinalis at the surgical
anastomosis site concerning for bowel perforation. Patient
otherwise denies any fevers, chills, nausea, vomiting, chest
pain, shortness of breath, urinary symptoms. Of note, she has
not had a period in 6 months.
Past Medical History:
PMH: Cecal volvulus
PSH: Hemicolectomy ___
Social History:
___
Family History:
Noncontributory
Physical Exam:
Discharge Physical Exam:
VS: 98.9, 107/55, 51, 16, 98%/RA
GEN: NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, No JVD
PULM: normal excursion, no respiratory distress
ABD: soft, NT, ND, no mass, no hernia, midline incision well
approximated with dermabond- c/d/i
EXT: WWP, no CCE, 2+ B/L radial
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
Pertinent Results:
___ 01:05PM BLOOD WBC-15.4* RBC-3.65* Hgb-11.5 Hct-34.6
MCV-95 MCH-31.5 MCHC-33.2 RDW-13.2 RDWSD-45.2 Plt ___
___ 07:45PM BLOOD WBC-7.0 RBC-4.12 Hgb-12.8 Hct-38.6 MCV-94
MCH-31.1 MCHC-33.2 RDW-12.9 RDWSD-44.3 Plt ___
___ 07:45PM BLOOD Neuts-57.9 ___ Monos-10.1 Eos-1.3
Baso-0.4 Im ___ AbsNeut-4.05 AbsLymp-2.12 AbsMono-0.71
AbsEos-0.09 AbsBaso-0.03
___ 01:05PM BLOOD Plt ___
___ 07:45PM BLOOD ___ PTT-32.0 ___
___ 07:45PM BLOOD Plt ___
___ 01:05PM BLOOD Glucose-145* UreaN-10 Creat-0.7 Na-140
K-4.1 Cl-106 HCO3-23 AnGap-11
___ 07:45PM BLOOD Glucose-80 UreaN-16 Creat-0.9 Na-142
K-4.4 Cl-106 HCO3-24 AnGap-12
___ 07:45PM BLOOD ALT-25 AST-22 AlkPhos-63 TotBili-0.2
___ 01:05PM BLOOD Calcium-8.1* Phos-4.2 Mg-1.9
___ 07:45PM BLOOD Albumin-4.6
___ 07:45PM BLOOD Lactate-0.8
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 2:29 ___
IMPRESSION:
Pneumatosis intestinalis involving the right colon extending
from the level of the enterocolonic anastomosis in the right mid
abdomen through the mid transverse colon, with associated tiny
volume pneumoperitoneum. The differential for pneumatosis
intestinalis includes bowel ischemia though given patient age,
consider alternative etiologies such as inflammatory bowel
disease, medication induced pneumatosis or connective tissue
disorders.
Brief Hospital Course:
Ms. ___ was sent to the emergency department at ___ on
___ with CT scan significant for pneumoperitoneum and
pneumatosis intestinalis. She was taken to the operating room on
___ for an open right colectomy with side-to-side ileocolonic
anastomosis. She tolerated the procedure well without
complications (Please see operative note for further details).
After a brief and uneventful stay in the PACU, the patient was
transferred to the floor for further post-operative management.
Neuro: Pain was well controlled on Tylenol and tramadol for
breakthrough pain.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulm: The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored. She had good
pulmonary toileting, as early ambulation and incentive
spirometry were encouraged throughout hospitalization.
GI: The patient was initially kept NPO after the procedure. The
patient was advanced to and tolerated a regular diet. Patient's
intake and output were closely monitored. Although she was
passing gas, the patient was unable to have a bowel movement
post surgery and was given milk of magnesia, miralax, and a
glycerin suppository. Despite these medications, the patient was
still unable to have a bowel movement. She was given two fleet
enemas and began to have bowel movements. She is being
discharged home with daily miralax.
GU: The patient had a Foley catheter that was removed prior to
discharge. At time of discharge, the patient was voiding without
difficulty. Urine output was monitored as indicated.
ID: The patient was closely monitored for signs and symptoms of
infection and fever, of which there was none.
Heme: The patient received subcutaneous heparin and ___ dyne
boots during this stay. She was encouraged to get up and
ambulate as early as possible.
On ___, the patient was discharged to home. At discharge,she
was tolerating a regular diet, passing flatus, voiding, and
ambulating independently. She will follow-up in the clinic in
___ weeks. This information was communicated to the patient
directly prior to discharge.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] Constipation
[ ] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehab hospital disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
dispo
[x] No social factors contributing in delay of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Discharge Disposition:
Home
Discharge Diagnosis:
Cecal volvulus here with pneumoperitoneum and pneumotosis
instestinalis of unclear origin
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 after a revision of
ileocolonic anastomosis/ileocolonic resection for surgical
management of your pneumatosis intestinalis of unclear origin.
You have recovered from this procedure and you are now ready to
return home.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to discharge which is
acceptable; however it is important that you have a bowel
movement in the next ___ days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but you should not have prolonged constipation. However, you may
have loose stool and passing of small amounts of dark, old
appearing blood. If you notice that you are passing bright red
blood with bowel movements or having large amounts of loose
stool without improvement please call the office or go to the
emergency room. While taking narcotic pain medications you are
at risk for constipation, please take an over the counter stool
softener such as Colace.
You have a long vertical surgical incisions on your abdomen. It
is important that you monitor these areas for signs and symptoms
of infection including: increasing redness of the incision
lines, white/green/yellow/foul smelling drainage, increased pain
at the incision, increased warmth of the skin at the incision,
or swelling of the area.
Pain is expected after surgery. This will gradually improve over
the first week or so you are home. You should continue to take
2 Extra Strength Tylenol (___) for pain every 8 hours around
the clock. Please do not take more than 3000mg of Tylenol in 24
hours or any other medications that contain Tylenol such as cold
medication. Do not drink alcohol while taking Tylenol. You may
also take Advil (Ibuprofen) 600mg every 8 hours for 7 days.
Please take Advil with food. If these medications are not
controlling your pain to a point where you can ambulate and
perform minor tasks, you should take a dose of the narcotic pain
medication tramadol. Please do not take sedating medications,
drink alcohol, or drive while taking the narcotic pain
medication.
You may feel weak or "washed out" for up to 6 weeks after
surgery. Do not lift greater than a gallon of milk for 3 weeks.
At your post op appointment, your surgical team will clear you
for heavier exercise. In the meantime, you may climb stairs and
go outside and walk. Please avoid traveling long distances
until you speak with your surgical team at your post-op visit.
Thank you for allowing us to participate in your care, we wish
you all the best!
Followup Instructions:
___
|
19840300-DS-21
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| 21 |
2180-05-24 00:00:00
|
2180-05-24 15:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
INITIAL LABS
============
___ 08:25AM BLOOD WBC-0.2* RBC-2.29* Hgb-7.3* Hct-22.0*
MCV-96 MCH-31.9 MCHC-33.2 RDW-15.1 RDWSD-50.6* Plt Ct-<5*
___ 08:25AM BLOOD Neuts-1* Lymphs-99* Monos-0* Eos-0*
Baso-0 AbsNeut-0.00* AbsLymp-0.20* AbsMono-0.00* AbsEos-0.00*
AbsBaso-0.00*
___ 08:25AM BLOOD UreaN-20 Creat-0.9 Na-143 K-3.6 Cl-103
HCO3-27 AnGap-13
___ 08:25AM BLOOD ALT-23 AST-15 LD(LDH)-550* AlkPhos-82
TotBili-0.7 DirBili-<0.2 IndBili-0.7
___ 08:25AM BLOOD TotProt-5.4* Albumin-2.9* Globuln-2.5
Calcium-8.0* Phos-2.1* Mg-1.7 UricAcd-4.3
___ 04:04AM BLOOD Lactate-1.9
___ 03:40AM URINE Color-Straw Appear-Clear Sp ___
___ 03:40AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 03:40AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 08:02AM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
MICROBIOLOGY
============
___ 3:40 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 3:45 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:45 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:02 am 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
=======
CXR (___):
No evidence of pneumonia
CT CHEST W/O CONTRAST (___):
Slight decrease in mediastinal nodes. Small new right-sided
pleural effusion. New patchy bronchovascular opacities in the
superior segment of the left lower lobe, suggesting infectious
or inflammatory process, perhaps minor aspiration. Correlation
with clinical circumstances is recommended.
BILAT LOWER EXT VEINS (___):
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
TTE (___):
The left atrium is not well seen. The interatrial septum is
aneurysmal. There is no evidence for an atrial septal defect by
2D/color Doppler. The estimated right atrial pressure is ___
mmHg. Due to the focused nature of the study, regional left
ventricular function cannot be fully assessed. Overall left
ventricular systolic function is hyperdynamic. The visually
estimated left ventricular ejection fraction is >=75%. No
ventricular septal defect is seen. Normal right ventricular
cavity size with normal free wall motion. The aortic valve is
not well seen. There is no aortic regurgitation. The mitral
valve leaflets are mildly thickened with no mitral valve
prolapse. There is trivial mitral regurgitation. The pulmonic
valve leaflets are not well seen. The tricuspid valve is not
well seen. The pulmonary artery systolic pressure could not be
estimated. There is no pericardial effusion.
IMPRESSION: Focused study. No pericardial effusion present.
Normal left ventricular wall thickness, biventricular cavity
sizes, and hyperdynamic regional/global biventricular systolic
function.
OTHER RESULTS
=============
___ 12:00AM BLOOD proBNP-326
DISCHARGE LABS
==============
___ 12:00AM BLOOD WBC-2.2* RBC-2.82* Hgb-8.4* Hct-26.1*
MCV-93 MCH-29.8 MCHC-32.2 RDW-19.0* RDWSD-62.8* Plt Ct-31*
___ 12:00AM BLOOD Neuts-65 ___ Monos-4* Eos-0* Baso-0
Atyps-1* AbsNeut-1.43* AbsLymp-0.68* AbsMono-0.09* AbsEos-0.00*
AbsBaso-0.00*
___ 12:00AM BLOOD Glucose-83 UreaN-20 Creat-1.2 Na-142
K-4.1 Cl-100 HCO3-27 AnGap-15
___:00AM BLOOD ALT-11 AST-6 LD(LDH)-316* AlkPhos-98
TotBili-0.2
___ 12:00AM BLOOD Albumin-3.2* Calcium-8.5 Phos-3.1 Mg-1.9
Brief Hospital Course:
PATIENT SUMMARY
=================
Mr. ___ is a ___ year old man with history of relapsed mantel
cell lymphoma after recent CHOP (___) and rituximab (___)
who presented with neutropenic fever.
ACUTE ISSUES
=============
# Neutropenic fever
Mr. ___ presented with ___ fever to 100.4. He was
empirically started on vancomycin and cefepime and given
neulasta on ___. BCx/UCx (___) did not grow pathologic
bacteria. CXR and CT CHEST were unremarkable. Ultimately, the
source was attributed to possible URI or infected skin lesion.
His neutropenia resolved on ___ and he was discharged on oral
bactrim and levofloxacin with last scheduled dose at ___.
CHRONIC ISSUES
===============
# Relapsed mantle cell lymphoma - His ibrutinib was held during
this hospitalization in preparation for CAR-T therapy. His
allopurinol was continued.
# External hemorrhoids - He presented with painful external
hemorrhoids that were leading to constipation. His symptoms were
treated with laxatives, ___ bath, and which ___.
# HTN - He was continued on his home losartan,
hydrochlorothiazide, and diltiazem.
# GERD - He was continued on his home omeprazole.
TRANSITIONAL ISSUES
====================
[ ] LOWER EXTREMITY EDEMA: please evaluate need for maintenance
diuretic
[ ] ELECTROLYTE ABNORMALITIES: repeat BMP on ___ to check
on creatinine trend after stopping furosemide
[ ] THROMBOCYTOPENIA: repeat CBC on ___ to trend
platelets, transfuse to Plt >10
[ ] MANTLE CELL LYMPHOMA: follow up in ___ clinic to
discuss resumption of ibturinib and plan for CAR-T therapy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Durezol (difluprednate) 0.05 % ophthalmic (eye) BID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Prolensa (bromfenac) 0.07 % ophthalmic (eye) BID
9. Loratadine 10 mg PO DAILY:PRN allergies
10. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. LevoFLOXacin 750 mg PO DAILY Duration: 6 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Duration: 6 Days
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth once a day Disp #*4 Tablet Refills:*0
3. Acyclovir 400 mg PO Q12H
4. Allopurinol ___ mg PO DAILY
5. Diltiazem Extended-Release 240 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Durezol (difluprednate) 0.05 % ophthalmic (eye) BID
8. Hydrochlorothiazide 25 mg PO DAILY
9. Loratadine 10 mg PO DAILY:PRN allergies
10. Losartan Potassium 100 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Prolensa (bromfenac) 0.07 % ophthalmic (eye) BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
======================
- Neutropenic fever
SECONDARY DIAGNOSIS
======================
Mantle cell lymphoma
External hemorrhoids
- Hypertension
Gastroesophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had a fever while your white blood cells (infection
fighting cells) were very low.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given antibiotics to treat the possible infection
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Call your doctor if you develop another infection, a
productive cough, worsening rash, or bleeding with your bowel
movements.
We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19840732-DS-4
| 19,840,732 | 21,400,650 |
DS
| 4 |
2189-07-23 00:00:00
|
2189-07-23 17:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Transfer for septic shock
Respiratory Failure, Septic Shock
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ reported history of CVAs c/b quadriplegia transferred with
respiratory failure and septic shock to ___ ___, adm FICU after
___ conversation for continued care.
___ records, the patient received ceftriaxone and
azithromycin for several days at her nursing home prior to
admission. She developed 103.6 while at rehab, so was
transferred to ___. She was noted to be tachypnic and
hypotensive, a CVL was placed, she was given fluids (total 2.5L)
and subsequently developed pulmonary edema. Due to continual
hypotension, she was placed on Levophed. She received vanc and
cefepime for empiric HCAP treatment. Because she was DNI, she
was placed on BiPAP. During her course, she developed atrial
flutter with rate of 150, she was given digoxin, CCBs and BBs
were avoided due to hypotension of 90/70, no cardioversion due
to DNR status.
___ labs were: Na 153, K 3.96, Cl 108, Co2 23, Bun 116,
Creatinine 3.9, Glucose 187, Ca 8.3. BNP 6813. WBC 20, HCT 36,
PLT 129. UA was reported as negative. CXR with mild CHF w/ L
pleural effusion, left base atelectasis. ALT 337, AP 135, T Bili
1.5.
In the ___, initial vitals: 98.1 155 122/64 30 95 BIpap% bipap.
Initial labs here were notable for: WBC 18.1, H/H 10.6/33.8, PLT
141. UA negative. UTox, STox negative. Initial BUN/Cr 115/3.8.
proBNP 5438. Trop 0.29. Lipase was 102. Overnight labs off green
top: 7.3/47/44/24(?venous), Na 151, K 3.6, Cl 114, Bicarb 23,
Glucose 151, freeCa 1.06, Lactate 1.5, Hgb 11.2.
___ CXR showed: IMPRESSION:
Right upper lobe opacity could reflect pneumonia in the
appropriate clinical situation, however, pulmonary mass cannot
be excluded. Close interval follow-up after treatment for
resolution and/or Chest CT could be performed to further
evaluate.
___ EKG showed AFib with RVR.
___ discussion was had with sons by ___ (one who is the HCP and
lives nearby, two further away who are MDs):
-son here/HCP agrees with palliative approach/making pt
comfortable, other 2 sons do NOT want palliative care at this
time, want full medical treatment
-currently all sons agree on con't full medical treatment
despite severity and very poor prognosis
AM Labs on ___: Na 156, K 4.2, Cl 115, Bicarb 17, BUN 120, Cr
4.1, Glucose 211. Ca 8.1, Mg 2.9, P 6.8. ALT 249, AST 55, AP
117, TBili 1.1, Alb 2.5. Trop 0.18, proBNP 4555. VBG:
7.35/41/38. Lactate 1.6. WBC down to 14.9, H/H stable.
___ left voicemail for son at 0822 re: renal failure, told to
call back to discuss.
___ CXR: IMPRESSION:
1. Right upper lobe pneumonia.
2. Persistent bibasilar airspace opacities which may reflect
atelectasis but infection cannot be excluded. Small left
pleural effusion unchanged.
3. Mild pulmonary vascular congestion, similar to the previous
study.
Interventions:
___ 23:50 IV DRIP Norepinephrine Started 0.18 mcg/kg/min
___ 00:24 IV MetRONIDAZOLE (FLagyl) 500 mg
___ 04:30 IV DRIP Norepinephrine Rate 0.09 mcg/kg/min
___ 06:56 IV CefePIME 2 g
On transfer, vitals were: 97.5 ___ 38 93% on 5L NC
On arrival to the MICU, the patient is non-verbal so is unable
to answer ROS.
Past Medical History:
-Two hemorrhagic strokes
-Quadriplegia
-Non-verbal
-Epilepsy
-COPD
-Sjogrens
-HTN
Social History:
___
Family History:
Ms. ___ has six brothers and sisters. One brother has a
mental illness that is undiagnosed. He has delusional beliefs,
but continues to work and function independently.
The maternal grandfather, aunt, and two of Ms. ___
children
have bipolar disorder. Another son has depression. There is no
family history of stroke/ CNS bleed/ CNS tumors/ avm, seizure,
or
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals: Reviewed in Metavision
GENERAL: Patient appears chronically ill, non-verbal
HEENT: Eyes deviated to the right, no tracking,
NECK: supple, right cvl in place, unable to appreciate JVP due
to body habitus
LUNGS: Bronchial breath sounds at right superior aspect of lower
lobe, otherwise CTAB. Pt is tachypnic
CV: irregularly irregular rate and rhythm, no murmurs, rubs, or
gallops
ABD: soft, distended, PEG tube in place with dressing, + BS.
Patient does not wince on exam but difficult to assess given
mental status
EXT: Trace edema at ankles bilaterally. Otherwise warm, well
perfused, 2+ pulses, no clubbing or cyanosis
SKIN: No rashes or bruising noted
NEURO: Non-verbal at baseline. Eyes are deviated to the right
and do not track. PERRL. Quadriplegic so no voluntary extremity
movement. Patient is noted to have occasional myoclonic-type
jerks and is rigid to passive movement of the ext. Opens mouth
to command when son asks ___ speaking only)
DISCHARGE PHYSICAL EXAM
VS: 98.6 155/89 98 18 100% on RA
Gen - supine in bed, comfortable appearing, does not track with
eyes, blinks spontaneously
Eyes - does not track, PERRL
ENT - non-compliant with OP exam
Heart - irreg irreg no mrg
Lungs - CTA bilaterally, no crackles, intermittently
___ breathing
Abd - soft nontender, normoactive bowel sounds, PEG c/d/i
Ext - trace edema to mid-shin
Skin - small stage 3 at coccyx, healing stage 2 at L ankle
Vasc - 2+ DP/radial pulses
Neuro - opens eyes to voice, does not track with eyes, does not
follow to commands
Psych - unable to evaluate given neurologic status
Pertinent Results:
ADMISSION LABS:
===============
___ 11:54PM BLOOD WBC-18.1* RBC-3.11* Hgb-10.6* Hct-33.8*
MCV-109* MCH-34.1* MCHC-31.4* RDW-15.0 RDWSD-60.0* Plt ___
___ 11:54PM BLOOD ___ PTT-26.5 ___
___ 11:54PM BLOOD UreaN-115* Creat-3.8*
___ 10:30AM BLOOD ALT-249* AST-55* AlkPhos-117* TotBili-1.1
___ 11:54PM BLOOD Lipase-102*
___ 11:54PM BLOOD cTropnT-0.29*
___ 11:54PM BLOOD proBNP-5438*
___ 06:15AM BLOOD Calcium-8.1* Phos-6.5* Mg-2.9*
PERTINENT LABS:
===============
___ 11:54PM BLOOD ___
___ 11:54PM BLOOD cTropnT-0.29*
___ 10:30AM BLOOD cTropnT-0.18*
___ 11:54PM BLOOD proBNP-5438*
___ 10:30AM BLOOD proBNP-4555*
___ 11:59PM BLOOD Glucose-151* Lactate-1.5 Na-151* K-3.6
Cl-114* calHCO3-23
___ 06:20AM BLOOD Lactate-1.8 K-4.1
___ 10:35AM BLOOD Lactate-1.6
Imaging:
========
___ CXR
IMPRESSION:
Right upper lobe opacity could reflect pneumonia in the
appropriate clinical
situation, however, pulmonary mass cannot be excluded. Close
interval
follow-up after treatment for resolution and/or Chest CT could
be performed to
further evaluate.
___ EEG
This was a highly abnormal continuous video EEG study due to
the
presence of frequent multifocal epileptiform discharges (right
centroparietal,
right frontal, right central) embedded in a background of
continuous
suppression and rare bursts of diffuse delta activity. These
findings are
consistent with diffuse cortical irritability and an underlying
severe
encephalopathy. There were no electrographic seizures or
pushbutton
activations. Note was made of an irregularly irregular heart
rate on EKG
___ CT head:
IMPRESSION:
Interval increase in size of the ventricles and extensive
periventricular
hypodensity, likely representing transependymal flow of CSF
superimposed on
chronic small vessel ischemic changes, with increased effacement
of the sulci,
findings likely represent developing hydrocephalus.
___ unilateral upper ext US
IMPRESSION:
No evidence of deep vein thrombosis in the right upper
extremity. Please note
that the right cephalic vein was not visualized and the right
internal jugular
vein was obscured by overlying bandages.
___ renal US
Normal appearance of the kidneys bilaterally with no
hydronephrosis.
___ TTE
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF =
80%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The right
ventricular free wall is hypertrophied. Right ventricular
chamber size is normal with normal free wall contractility. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion. There
is an anterior space which most likely represents a prominent
fat pad.
CXR ___
In comparison with the study of ___, there is little
change in the
appearance of the cardiomediastinal silhouette. The elevation
of pulmonary
venous pressure has its decreased. Opacification at the right
base has
substantially cleared. On the left, however, there is still
retrocardiac
opacification with poor definition of the hemidiaphragm,
consistent with a
combination of volume loss in the left lower lobe and left
pleural effusion.
Brief Hospital Course:
___ reported history of CVAs c/b quadriplegia transferred with
respiratory failure and septic shock to ___ ___, adm FICU after
___ conversation for continued care. Admitted ___ with
acute hypoxic respiratory failure and septic shock secondary to
acute bacterial pneumonia, course complicated by acute on
chronic diastolic CHF, new atrial fibrillation, acute kidney
injury, now clinically improving. Course also complicated by
tachypnea which improved with diuresis and pain control, but
also noted to have ___ breathing pattern.
# Respiratory failure, Hypoxemic: Patient presented with
respiratory failure from ___. Was reportedly symptomatic
and treated for PNA at ___ home before presenting. Likely
secondary to pulmonary edema and pneumonia. Patient was admitted
to the ICU where she was started on antibiotics and
intermittently required BiPAP. There was concern that her
respiratory status would require intubation as her oxygenation
requirements and work of breathing worsened. However, patient
was diuresed aggressively with improvement in her respiratory
status. The patient was made DNI after discussions of ___ with
family.
# Tachypnea. Most likely ___ breathing given
respiratory pattern, but other ddx is volume overload, PE is
less likely, no hypoxia, and central process causing tachypnea
is unlikely, would more commonly cause hyponea. VBG shows
respiratory compensation and normal lactate, and in fact, has
slightly elevated PCO2, making constant tachypnea unlikely. Does
not appear grossly volume overloaded, but does have small left
pleural effusions. She received 80mg IV furosemide for several
days, as well as pain control with standing acetaminophen, with
improved tachypnea, but ongoing ___ breathing.
# Healthcare-associated pneumonia with septic shock: Patient
presented with increased O2 requirement, suggestive CXR findings
of PNA, and hypotension requiring levophed. She was started on
broad spectrum antibiotics (vanc/cefepime) on admission.
Patient was able to be weaned off pressors and maintained MAPs
in the ___. WBC count now uptrending despite treatment. Of
note, cefepime was converted to ceftriaxone for low concern for
pseudomonal infection and concern for neurotoxic effects of
cefepime.
# Hydrocephalus: Noted to have e/o developing hydrocephalus on
CT non-con on ___, vs chronic brain injury. Per son, at
baseline patient only tracks with eyes. Unknown etiology,
unclear if there is even an acute process going on at this
point. neurosurgery consulted, recommended ophtho consult.
Ophtho feels no papilledema and has signed off; unlikely
surgical intervention given lack of papilledema. Neurology
recommends MRI CSF study to r/o obstructive hydrocephalus, and
if negative, LP with studies. However, not in keeping with goals
of care per family so will not pursue at this time.
# Goals of Care: Discussion held with brothers. Will still
pursue therapy at present, would like to have her be able to
leave the hospital. However, have made her DNR/DNI.
# Atrial fibrillation: During her course at the OSH, she
developed atrial fibrillation with RVR requiring 0.25 mg IV
Digoxin; BBs and CCBs were avoided given hypotension. No prior
history of atrial fibrillation that we know of. On arrival to
the ICU, the patient is in multifocal atrial tachycardia. Is
still in afib. Started on digoxin and metoprolol, with
improvement in rate to ___. CHADS2 at least 3. New-onset
afib which could have been induced by hypoxia or catecholamine
excess in the setting of sepsis. CHADS2-vasc score is high, but
per my discussion during goals of care conversation with family,
anticoagulation is not within goals of care, also confirmed in
ICU.
# ___: Creatinine 4.1 on admission; baseline 0.8 in ___. Nephrology was consulted for poor UOP and failure of
creatinine to improve. Likely ischemic ATN in setting of
hypotension. Not ___ candidate for RRT. Improving by the time of
discharge.
# Epilepsy: Patient with hx of epilepsy on keppra at home. The
patient was noted to have rightward gaze without tracking on
presentation which the son says is new. Improved with Ativan
administration, however this morning on exam her rightward gaze
has returned. EEG with epileptiform discharges but no overt
seizure activity. CT head non-con on ___ negative for acute
stroke/hemorrhage.
# Anion gap Acidosis: On admission, AG of 16, bicarb of 16.
Normal lactate, no e/o ketoacidosis. Given her albumin of 2.5,
her effective anion gap is 11, so her bicarb would be 31 at
baseline. Delta/Delta ratio is 2.2, indicating an AGMA and
concurrent metabolic alkalosis. Given her COPD, she likely has
some element of chronic CO2 retention with metabolic
compensation. Likely secondary to uremia.
# Transaminitis: Hepatocellular pattern with ALT predominance.
Improving today. Likely from hypotension in the setting of
shock. Downtrending
# Thrombocytopenia: At ___ was reportedly 125. Platelets
now recovering.
# Troponemia: Troponin elevated to 0.29 upon admission, has
downtrended to 0.18. Possibly secondary to demand ischemia in
setting of hypotension and Afib w/ RVR. Her acute renal failure
could contribute to decreased troponin clearance. EKG negative,
trops downtrended.
# Acute Severe Protein Calorie Malnutrition - suspect secondary
to infection; Alb 2.4. Continued tube feeds, change to nepro.
TRANSITIONS OF CARE
-------------------
# Follow-up: patient will follow up with her doctor at her
nursing home.
# Code status: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. HydrALAzine 10 mg PO Q8H
3. Acetaminophen (Liquid) 650 mg PO TID
4. Amlodipine 10 mg PO DAILY
5. famotidine 40 mg/5 mL oral DAILY
6. Furosemide 10 mg PO DAILY
7. Mupirocin Ointment 2% 1 Appl TP DAILY
8. Lisinopril 20 mg PO DAILY
9. LeVETiracetam Oral Solution 500 mg PO BID
10. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN sob
11. Docusate Sodium (Liquid) 100 mg PO DAILY
12. Senna 17.2 mg PO QHS
13. Bisacodyl ___AILY:PRN constipation
14. Milk of Magnesia 30 mL PO QHS
15. Fleet Enema ___AILY:PRN constipation
16. Acetaminophen 650 mg PO Q4H:PRN pain
17. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q4H:PRN GI
upset
18. Polyethylene Glycol 17 g PO DAILY
19. Guaifenesin-Dextromethorphan 10 mL PO Q4H:PRN cough
20. Artificial Tears 2 DROP BOTH EYES BID
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO TID
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q4H:PRN GI
upset
4. Artificial Tears 2 DROP BOTH EYES BID
5. Docusate Sodium (Liquid) 100 mg PO DAILY
6. famotidine 40 mg/5 mL oral DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN sob
8. LeVETiracetam Oral Solution 750 mg PO BID
9. Mupirocin Ointment 2% 1 Appl TP DAILY
10. Polyethylene Glycol 17 g PO DAILY
11. Senna 17.2 mg PO QHS
12. Furosemide 10 mg PO DAILY
13. Amlodipine 10 mg PO DAILY
14. Bisacodyl ___AILY:PRN constipation
15. Acetaminophen 650 mg PO Q4H:PRN pain
16. Guaifenesin-Dextromethorphan 10 mL PO Q4H:PRN cough
17. Milk of Magnesia 30 mL PO QHS
18. Metoprolol Tartrate 12.5 mg PO Q6H
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Acute Hypoxic Respiratory Failure
Acute on Chronic Diastolic congestive heart failure
Acute Bacterial Pneumonia
Acute kidney injury
Hypernatremia
New onset atrial fibrillation
Acute Severe Protein Calorie Malnutrition
Type 2 NSTEMI
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 at ___! You were
admitted for trouble breathing and low oxygen to the ICU, where
you were found to have a pneumonia, which we treated you for.
You also had acute kidney injury, which is resolving. You had
extra fluid in your body, which we removed with diuretics.
You are now returning to your nursing home. It is important
that you follow up with your doctor at the nursing home and take
all medications as prescribed.
Good luck!
Followup Instructions:
___
|
19840732-DS-5
| 19,840,732 | 23,801,481 |
DS
| 5 |
2189-08-09 00:00:00
|
2189-08-10 10:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abnormal labs (hypernatremia, hypokalemia) in outpatient setting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman who is nonverbal and quadriplegic at baseline
secondary to two large prior strokes, HTN, epilepsy, COPD, and
sjogens who was brought to the ED from her nursing home with
abnormal labs. Per her family members, she has been acting like
her usual self, and these labs were just routine labs. Her labs
showed Na 154, K 3.1, Alk phos 137, Cr 1.4. WBC23.6, hgb 11.6,
Pllt 329, 85%N. She had a recent admission (___)
for respiratory failure and septic shock. During that admission,
she was made DNR/DNI. She has reportedly been doing well since
her discharge.
In the ED, initial VS were: 98.5 116 113/68 18 95% RA. Her labs
were significant for: lactate 1.8, K 2.7 Na 153 Cre 1.4 WBC
20.7, UA with small leuk, nitr neg, She had a chest xray without
acute process. She received 60 cc free water. She did not
receive any potassium prior to transfer. VS prior to transfer:
98.6 99 115/64 16 99% RA
On arrival to the floor, patient opens eyes to voice, otherwise
nonverbal or interactive.
REVIEW OF SYSTEMS: Unable to obtain
Past Medical History:
-Two hemorrhagic strokes
-Quadriplegia
-Non-verbal
-Epilepsy
-COPD
-Sjogrens
-HTN
-Septic shock ___ pneumonia ___
Social History:
___
Family History:
Ms. ___ has six brothers and sisters. One brother has a
mental illness that is undiagnosed. He has delusional beliefs,
but continues to work and function independently. The maternal
grandfather, aunt, and two of Ms. ___ children have
bipolar disorder. Another son has depression. There is no
family history of stroke/ CNS bleed/ CNS tumors/ avm, seizure,
or
cancer.
Physical Exam:
Admission exam:
VS - T 97.6 BP 125/84 HR 98 RR 18 100% RA
GENERAL: NAD, opens eyes to voice
HEENT: anicteric sclera, clear oropharynx, dry MM
CARDIAC:irregular, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, anteriorly, without use of accessory muscles
ABDOMEN: Hyperactive BS, appears nontender
EXTREMITIES: no cyanosis, clubbing or edema, small healed
ulcers L lateral malleolus, R ___ metatarsal
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, small erythema on posterior
Discharge exam:
VS - T 97.8 BP 150/98 HR 105 (90s-100s) RR 28 98% RA
Gen: Older female in NAD, nonverbal, not following commands
HEENT: anicteric sclera, clear oropharynx, dry MM
CARDIAC: irreg irreg, no murmur or rub
LUNG: CTAB, anteriorly, without use of accessory muscles
ABDOMEN: Hyperactive BS, appears nontender without guarding, non
distended
EXTREMITIES: no cyanosis, clubbing or edema, small healed ulcers
L lateral malleolus, R ___ metatarsal
PULSES: 2+ DP pulses bilaterally
GU: foley in place
SKIN: warm and well perfused, small erythema on posterior
Neuro: not moving extremities spontaneously. Flexion
contractures noted of extremities
Pertinent Results:
ADMISSION LABS:
===============
___ 01:20AM WBC-20.7* RBC-3.18*# HGB-11.0*# HCT-34.6#
MCV-109* MCH-34.6* MCHC-31.8* RDW-16.4* RDWSD-66.1*
___ 01:20AM NEUTS-81.9* LYMPHS-11.4* MONOS-5.6 EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-16.97* AbsLymp-2.36 AbsMono-1.17*
AbsEos-0.02* AbsBaso-0.07
___ 01:20AM ___ PTT-28.0 ___
___ 01:20AM LIPASE-88*
___ 01:20AM estGFR-Using this
___ 01:20AM GLUCOSE-125* UREA N-64* CREAT-1.4*
SODIUM-153* POTASSIUM-2.7* CHLORIDE-111* TOTAL CO2-27 ANION
GAP-18
___ 01:24AM LACTATE-1.8
___ 03:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-SM
___ 03:45AM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-0
___ 07:00AM TSH-2.1
___ 07:00AM CALCIUM-9.8 PHOSPHATE-4.0 MAGNESIUM-2.8*
DISCHARGE LABS
==============
___ 12:42PM BLOOD WBC-13.8* RBC-2.92* Hgb-10.0* Hct-31.2*
MCV-107* MCH-34.2* MCHC-32.1 RDW-15.1 RDWSD-59.7* Plt ___
___ 07:05AM BLOOD Glucose-108* UreaN-31* Creat-0.8 Na-140
K-4.3 Cl-105 HCO3-28 AnGap-11
___ 07:10AM BLOOD ALT-45* AST-34 AlkPhos-130* TotBili-0.3
___ 07:05AM BLOOD Calcium-9.4 Phos-2.7 Mg-2.3
IMAGING
=======
CXR ___
FINDINGS: The cardiomediastinal silhouette is stable. The
aorta is moderately tortuous. The patient status post median
sternotomy with wires intact. Previously seen opacities in the
right upper and right lower lobes are almost completely
resolved. IMPRESSION: Previously seen opacities in the right
upper and right lower lobes are almost completely resolved.
MICROBIOLOGY
============
URINE CULTURE (Final ___: NO GROWTH.
C. difficile DNA amplification assay ___: NEGATIVE
Blood cultures ___: pending
Brief Hospital Course:
Ms. ___ is a ___ woman who is nonverbal and
quadriplegic at baseline secondary to two large prior strokes,
h/o HTN, epilepsy, COPD, and Sjogens (not on anti-inflammatory
regimen) who was brought to the ED from her nursing home with
abnormal labs, namely hypernatremia, hypokalemia, and
leukocytosis, after a recent admission for pneumonia complicated
by septic shock (___).
#Hypernatremia/hypokalemia: Patient presented with Na+ 153 and
K+ 2.7. Most likely due to decreased tube feeds and possibly
insensible losses with resolving PNA. Hypokalemia likely related
to appropriate aldosterone release. Her TBW deficit on admission
was 3.2L, which was corrected with free water flushes via G tube
over 2 days. Hypokalemia improved with po supplementation, and
she did not have EKG changes.
#Leukocytosis: Patient also presented with leukocytosis with WBC
20K. This was felt to be due to resolving PNA with an element of
hemoconcentration. After free water flushes, her WBC improved to
14 at discharge. CXR showed resolving PNA from prior CXR during
admission for PNA (___). Urine cultures were negative,
and blood cultures were pending at time of discharge. CDiff was
sent due to loose stool on admission but was negative.
#Atrial fibrillation: Hospital course was complicated by afib
with RVR, which improved with increased home metoprolol po to 50
mg q6h and with IV metoprolol pushes during RVR episodes. Of
note, patient has a high CHADS-VASC score, but per OMR during
recent goals of care discussion, anticoagulation is not within
family's goals of care and was felt to be too high risk in this
patient with prior hemorrhagic stroke.
#H/o prior hemorrhagic CVAs: non-verbal, quadriplegic at
baseline. Patient seen by wound team for recommendations (see
worksheet for recommendation).
___: Patient's creatinine on admission was 1.4, which is higher
than a baseline around 1 but improved from a discharge
creatinine of 1.9 from last admission. Her new baseline is
unclear currently, as she was thought to have possible ATN in
setting of septic shock during prior admission.
CHRONIC ISSUES:
#CAD complicated by recent type 2 NSTEMI: started aspirin and
statin this admission for secondary prevention
#Epilepsy: continued home keppra.
#COPD: continued home ipratropium nebs
#HTN: held home amlodipine throughout admission and at discharge
due to BPs around 140 and because metoprolol dose was increased.
Amlodipine may be restarted if indicated.
#H/o constipation: continued home docusate, bisacodyl, milk of
magnesia, polyethylene glycol
#NSTEMI on prior admission: EKG this admission without ST
changes. Continued metoprolol as above, and started aspirin 81
mg this admission as well.
TRANSITIONAL ISSUES:
- Please ensure adequate free water flushes, as hypovolemia is
the most likely explanation for abnormal labs; we recommend
250ml H20 q4h
- Check chem7 within 1 week of discharge
- Home amlodipine discontinued during admission and on discharge
given BPs in 140s
- Home Lasix held throughout admission and at discharge given
hypovolemia. However, would recommend this be restarted at rehab
approximately 1 week after discharge if concern for volume
overload and recommend follow up BMP accordingly.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen (Liquid) 650 mg PO TID
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q4H:PRN GI
upset
4. Artificial Tears 2 DROP BOTH EYES BID
5. Docusate Sodium (Liquid) 100 mg PO DAILY
6. famotidine 40 mg/5 mL ORAL DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN sob
8. LeVETiracetam Oral Solution 750 mg PO BID
9. Mupirocin Ointment 2% 1 Appl TP DAILY
10. Polyethylene Glycol 17 g PO DAILY
11. Senna 17.2 mg PO QHS
12. Furosemide 10 mg PO DAILY
13. Amlodipine 10 mg PO DAILY
14. Bisacodyl ___AILY:PRN constipation
15. Acetaminophen 650 mg PO Q4H:PRN pain
16. Guaifenesin-Dextromethorphan 10 mL PO Q4H:PRN cough
17. Milk of Magnesia 30 mL PO QHS
18. Metoprolol Tartrate 12.5 mg PO Q6H
19. Ascorbic Acid (Liquid) 500 mg PO DAILY
20. Zinc Sulfate 220 mg PO DAILY
21. Silver Sulfadiazine 1% Cream 1 Appl TP BID
22. CeftriaXONE 1 gm IV Q24H
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO TID
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q4H:PRN GI
upset
4. Artificial Tears 2 DROP BOTH EYES BID
5. Ascorbic Acid (Liquid) 500 mg PO DAILY
6. Bisacodyl ___AILY:PRN constipation
7. Docusate Sodium (Liquid) 100 mg PO DAILY
8. famotidine 40 mg/5 mL ORAL DAILY
9. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN sob
10. LeVETiracetam Oral Solution 750 mg PO BID
11. Metoprolol Tartrate 50 mg PO Q6H
12. Milk of Magnesia 30 mL PO QHS
13. Mupirocin Ointment 2% 1 Appl TP DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. Senna 17.2 mg PO QHS
16. Zinc Sulfate 220 mg PO DAILY
17. Aspirin 81 mg PO DAILY
18. Multivitamins W/minerals 1 TAB PO DAILY
19. Silver Sulfadiazine 1% Cream 1 Appl TP BID
20. Guaifenesin-Dextromethorphan 10 mL PO Q4H:PRN cough
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary:
Hypernatremia
Hypokalemia
Atrial fibrillation with rapid ventricular response
Secondary:
Epilepsy
History of hemorrhagic stroke c/b quadriplegia
Chronic obstructive pulmonary disease
Hypertension
Coronary artery disease with prior Non-ST elevation myocardial
infarction
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ due to
abnormal labs that were seen at your rehabilitation facility.
Specifically, you were found to have low potassium and high
sodium. These were felt to be due to dehydration. We gave you
some water flushes through your G tube and your sodium improved.
We also gave you potassium supplementation, which helped your
potassium levels.
During your hospital stay, you had fast heart rates, which are
related to your atrial fibrillation (a-fib). For this, we
increased your metoprolol, which helped your heart rates
improve.
While you were here, we repeated your chest xray given your
recent pneumonia; this was improving on the repeat xray.
It was a pleasure taking care of you at ___.
Please take all medications as prescribed and please follow up
with your appointments.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
19840743-DS-11
| 19,840,743 | 26,168,320 |
DS
| 11 |
2120-10-11 00:00:00
|
2120-10-11 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:
Chronic Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a past medical history of chondroscarcoma s/p L AKA and
chemotherapy with gemcitabine and taxotere c/b neuropathy , who
presents today for evaluation of multiple abdominal complaints.
For full history please see full GI note ___. In brief his
symotms first began in ___ and have been waxing and waning
since that time. He described severe band like pain over his
abdomen
complicated by severe constipation then followed by diarrhea.
His symptoms improve with bowel movements. He has been seen by
several gastroenterologists and has tried multiple different
therapies including fiber, FOODMAP diet, Reglan, domperidone,
Linzess, Trulance, Bentyl, Rifaximin and VSL3. He has also tried
multiple laxatives including lactulose, mag citrate, and
MiraLAX.
For the last ___ year he feels like symptoms have been much worse.
He also now describes attacks where he has chest pain, shortness
of breath and high blood pressure. During these episodes he
states that he feels like he is blacked out and doesn't remember
what is happening although per his family he is awake. He has
been hospitalized several times for this. All cardiac workup has
been negative and he has been diagnosed with severe anxiety. For
this anxiety he has been prescribed Ativan 1 mg q6hrs. He states
although he tries to take only 4 a day he often takes more esp
when he feels his physical symptoms are at their worst.
He was seen by GI who recommended direct admit for further care.
He declined this initially. Yesterday he felt he was going to
pass out which prompted him to come to the Ed.
He states his family would like him admitted for a month until
he is completely better. His ongoing medical issues have
stressed them to the point that they feel they cannot care for
him.
In the ED vitals were T 98.8, HR 102, BP 184/102, RR14, O2Sat
96% RA. He underwent a CT abdomen without any abnormality seen.
Labs were drawn and showed normal troponin, normal LFTs, normal
CBC. He was given Ativan, dicyclomine, rifaximine. He was
admitted to medicine for GI and psychiatric care.
On arrival to the floor he is very tangential. He states he has
not had a bowel movement for three days. His pain is stable. He
feels his anxiety is likely out of control and agrees this is
likely connected in some way to his symptoms. He becomes more
anxious as we talk and states he feels like he is going to have
an abdominal attack. He is anxious to see GI.
.
Review of Systems: A 10-point review of systems was performed
and negative in detail except as noted in the HPI.
Past Medical History:
1. Chondrosarcoma s/o amputation and chemo with gemcitabine and
taxotere
2. Peripheral neuropathy
3. Hypertension
4. IBS
5. Gastroparesis
6. Anxiety/depression
Past Surgical History:
1. Left AKA
2. Hiatal hernia repair
Social History:
___
Family History:
No family history of any IBD, GI cancers
Physical Exam:
ADMISSION EXAM:
VS: ___ 0733 Temp: 98.1 PO BP: 105/59 R Lying HR: 72 RR: 18
O2 sat: 96% O2 delivery: Ra
___ Appearance: very anxious appearing, laying covered by
many blankets
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions, no supraclavicular or cervical lymphadenopathy, no JVD,
no carotid bruits, no thyromegaly or palpable thyroid nodules
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, mildly distended
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization.
GU: no catheter in place
DISCHARGE EXAM:
VS: 24 HR Data (last updated ___ @ 1113)
Temp: 97.9 (Tm 98.2), BP: 122/82 (107-138/69-93), HR: 73
(65-96), RR: 18, O2 sat: 95% (95-98), O2 delivery: Ra
4 BM's recorded yesterday
GEN: Alert, NAD
CV: RRR no m/r/g
RESP: CTA B, breathing appears comfortably
GI: soft NT/ND +BS no rebound or guarding. surgical scar noted
NEURO: Nonfocal
PSYCH: Calm, appropriate today
Pertinent Results:
ADMISSION LABS:
___ 12:07AM BLOOD WBC-8.8 RBC-4.82 Hgb-14.2 Hct-39.9*
MCV-83 MCH-29.5 MCHC-35.6 RDW-12.6 RDWSD-38.0 Plt ___
___ 12:07AM BLOOD Neuts-74.1* Lymphs-17.6* Monos-7.3
Eos-0.3* Baso-0.6 Im ___ AbsNeut-6.53* AbsLymp-1.55
AbsMono-0.64 AbsEos-0.03* AbsBaso-0.05
___ 12:07AM BLOOD Glucose-115* UreaN-4* Creat-0.6 Na-139
K-4.0 Cl-97 HCO3-27 AnGap-15
___ 12:07AM BLOOD ALT-10 AST-12 AlkPhos-88 TotBili-0.5
___ 12:07AM BLOOD Lipase-15
___ 12:07AM BLOOD cTropnT-<0.01
___ 12:07AM BLOOD Albumin-4.4
___ 12:40AM URINE Color-Straw Appear-Clear Sp ___
___ 12:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
CT A/P -
IMPRESSION:
No acute abnormality within the imaged abdomen and pelvis.
Brief Hospital Course:
Mr. ___ is a ___ with a past medical history of
chondroscarcoma s/p L AKA and chemotherapy with gemcitabine and
taxotere c/b neuropathy, who presents for evaluation of acute on
chronic GI dysfunction (constipation) with severe anxiety
#Chronic Abdominal Pain
#Constipation
#Bloating
#IBS
Ongoing for several years at this time, most likely IBS with
constipation. Had a CT scan which did not show any
abnormalities. In past, he states on colonoscopy he had a
tortuous colon, and has reportedly had extensive work up in the
past, including an emptying study at ___. His GI
dysfunction is likely made worse by his significant anxiety and
compulsions, with significant fear of constipation, abnormal
BMs, and ___ "fear of not waking up.". During admission,
stool softeners, enema, and sleep were optimized, and this
seemingly helped. He was continued on dicyclomine and
rifaximin. He will complete 10 day course of rifaximin on ___.
Hospitalist met with him and his primary gastroenterologist to
review his clinical course and determine a plan going forward:
- medications as above
- GI follow up for anorectal manometry
- trial of sleep medication and recommendation for sleep study
- psychiatry follow up
- control over daily laxatives, trial and error
#Anxiety:
#OCD:
These are likely drivers of his exacerbated symptoms. He does
follow up with a therapist but does not follow with a
psychiatrist regularly. Psychiatry was consulted here and he
was initiated on Risperdal in addition to his Ativan. We
discussed in detail the importance of psychiatry referral for
ongoing care. He will f/u with his PCP regarding this.
#Hypertension:
- Continued home lisinopril, HCTZ
#Neuropathy:
- No report of symptoms currently
TRANSITIONAL ISSUES:
- Pt will complete 10 day course of rifaximin on ___. Please
refer to d/c med list for rest of patient's discharge
medications.
- Pt will need close f/u with GI
- Pt will need outpt anorectal manometry (GI to order).
- Pt was started on ___ as above, he will need psych
referral.
- Pt would benefit from outpt sleep study given signifcant
reports of insomnia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DICYCLOMine 10 mg PO QID
2. Rifaximin 550 mg PO TID
3. LORazepam 1 mg PO Q6H:PRN anxiety
4. Linzess (linaCLOtide) 145 mcg oral DAILY
5. Lisinopril 20 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Simethicone 40-80 mg PO QID:PRN bloating
8. Excedrin Migraine (aspirin-acetaminophen-caffeine) 250-250-65
mg oral Q8H:PRN
9. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Bisacodyl ___AILY:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally daily as needed
Disp #*50 Suppository Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Ramelteon 8 mg PO QHS:PRN insomnia
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at night as
needed Disp #*30 Tablet Refills:*0
4. RisperiDONE 0.5 mg PO BID
RX *risperidone 0.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. DICYCLOMine 10 mg PO QID
RX *dicyclomine 10 mg 1 capsule(s) by mouth four times a day
Disp #*120 Capsule Refills:*0
6. Excedrin Migraine (aspirin-acetaminophen-caffeine) unknown
oral Q8H:PRN headache
7. Hydrochlorothiazide 25 mg PO DAILY
8. Linzess (linaCLOtide) 145 mcg oral DAILY
9. Lisinopril 20 mg PO DAILY
10. LORazepam 1 mg PO Q6H:PRN anxiety
11. Polyethylene Glycol 17 g PO DAILY
12. Rifaximin 550 mg PO TID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth three times
a day Disp #*14 Tablet Refills:*0
13. Simethicone 40-80 mg PO QID:PRN bloating
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic constipation
IBS
Neuropathy
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation of your ongoing GI symptoms and
constipation. You were seen by your gastroenterologist here and
the psychiatry team. Your symptoms are likely a result of poor
motility of your GI tract in addition to significant anxiety and
fear of abnormal bowel movements. You also do not sleep well
and a sleep evaluation will be a good idea after you leave the
hospital. We have started you on new medications which may help
with your symptoms, both GI and anxiety related symptoms.
Please follow up closely with your GI doctor and PCP. Please
see your therapist. We also recommend follow up again with a
psychiatrist and see a sleep specialist for further care
Followup Instructions:
___
|
19840910-DS-20
| 19,840,910 | 20,016,768 |
DS
| 20 |
2124-01-15 00:00:00
|
2124-01-16 10:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RLE cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w PMH prostate cancer, hyperparathyroidism, and chronic back
pain who presents to the ED with 1 day of right foot pain,
swelling and redness. Patient denied any trauma/falls. Says he
had been feeling feverish and had measured his own temperature
for several days prior and had intermittent fevers up to 104
since ___. His right foot then became red and painful on
___ night. Patient unable to ambulate yesterday morning due
to pain. Patient tried using eczema cream on the foot with no
improvement. Patient has mild baseline swelling of the bilateral
feet but denies any heart issues. He was seen 6 months ago by a
podiatrist for right heel pain that was presumed plantar
fasciitis. Patient denies any other concurrent infectious
symptoms.
In the ED, initial vitals:
T98.7, HR 81, BP 117/60, RR 16, 96% RA (intermittently febrile
in
ED with Tmax 102.5)
- Exam notable for:
Vitals: Afebrile, HR 88
Gen: NAD, ___ speaking
CV: RRR
Ext: Right foot, ankle, and up to mid calf erythematous and
swollen compared to L. Baseline swelling of left leg w/o
pitting.
Sensation and movement intact. Strength 5- bilaterially. Signs
of
slight skin opening and likely fungal infection between R toes
___. No drainage from skin, toes are shiny but pt states that it
is Vaseline.
- Labs notable for:
WBC 8.6
BMP WNL, Lactate 0.9-->1.5
- Imaging notable for:
Doppler of RLE: No evidence of deep venous thrombosis in the
right lower extremity veins.
CXR: Linear opacity in the left base likely represents
atelectasis. No convincing evidence for pneumonia.
- Patient was given:
IV Vanc x1, ibuprofen/Tylenol,
Doxy PO 100mg Q12
- Consults:
___
- Vitals prior to transfer:
T98.5, BP 109/58, 48, 20, 97% RA
On arrival to the floor, pt denied having significant pain and
says his intermittent fevers and the RLE swelling/erythema are
his only active symptoms.
Past Medical History:
Iron deficiency anemia
Polyps and hemorrhoids on colonoscopy, pathology = no
abnormality
Hyperlipidemia
Hyperparathyroidism
Multinodular goiter, diagnosed using thyroid uptake scan ___
Carotid stenosis s/p endarterectomy
Hypoglycemia
s/p hernia repair
s/p Appendectomy
Social History:
___
Family History:
Father died of old age. Mother had cardiac disease, but later in
life and died at age ___. Denies any cancer, other heart disease,
diabetes history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T98.5, BP 109/58, 48, 20, 97% RA
GENERAL: Pleasant, lying in bed comfortably
HEENT: Face symmetric, no ptosis
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused. Right foot, ankle, and up to mid calf
erythematous and swollen compared to L (See OMR for pictures).
Baseline swelling of left leg w/o pitting. Sensation and
movement
intact. Strength ___ bilaterally. Signs of slight skin opening
and likely fungal infection between R toes. Toes are shiny; no
drainage noted.
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
DISCHARGE PHYSICAL EXAM:
GENERAL: Afebrile, Pleasant, lying in bed comfortably
HEENT: Face symmetric, no ptosis
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused. Right foot, ankle, and up to mid calf
erythematous and swollen compared to L (See OMR for pictures on
admission).
Baseline swelling of left leg w/o pitting. Sensation and
movement
intact. Strength ___ bilaterally. Signs of slight skin opening
and likely fungal infection between R toes. No drainage noted.
Additionally, an area of blanchable erythema in R groin that has
also been demarcated- improving on day 2 with less erythema.
Blanching, less tender to touch but not warm. No raised lesions.
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
Pertinent Results:
ADMISSION LABS:
___ 12:20PM BLOOD WBC-8.6 RBC-3.53* Hgb-11.5* Hct-34.4*
MCV-98 MCH-32.6* MCHC-33.4 RDW-13.8 RDWSD-50.1* Plt ___
___ 12:20PM BLOOD Neuts-83.6* Lymphs-9.2* Monos-6.5
Eos-0.3* Baso-0.2 Im ___ AbsNeut-7.17* AbsLymp-0.79*
AbsMono-0.56 AbsEos-0.03* AbsBaso-0.02
___ 12:20PM BLOOD Glucose-121* UreaN-28* Creat-0.9 Na-138
K-4.3 Cl-105 HCO3-23 AnGap-10
___ 04:45AM BLOOD Calcium-9.6 Phos-2.5* Mg-2.1
___ 12:25PM BLOOD Lactate-0.9
DISCHARGE LABS:
___ 06:36AM BLOOD WBC-8.9 RBC-3.53* Hgb-11.4* Hct-34.4*
MCV-98 MCH-32.3* MCHC-33.1 RDW-13.6 RDWSD-48.6* Plt ___
___ 06:36AM BLOOD Glucose-165* UreaN-23* Creat-0.9 Na-145
K-4.6 Cl-111* HCO3-20* AnGap-14
___ 06:36AM BLOOD Calcium-10.1 Phos-3.0 Mg-2.0
Imaging:
CXR: IMPRESSION: PICC line terminating in the superior vena
cava.
___ Doppler RLE: IMPRESSION: No evidence of deep venous
thrombosis in the right lower extremity veins.
Micro:
Blood Cxs: No growth to date
Brief Hospital Course:
___ yo man with history of prostate cancer, b/l mild ___ edema and
hyperparathyroidism p/w fevers and RLE erythema/edema found to
be cellulitis of right foot who was admitted for IV antibiotics.
Will
dispo home on IV Vanc course with PICC.
ACUTE ISSUES:
=============
#Right lower extremity cellulitis- Patient initially febrile on
___ and then had
pain, erythema, swelling on R foot. No history of diabetes but
has mild venous status at baseline with no heart failure. Has
slight opening between toes and a possible fungal infection. No
leukocytosis on presentation. US was negative for DVT on RLE.
Was given a dose of IV Vanc in the ED and then transitioned to
PO Doxycycline. On the floor, he was switched to Cephalexin
given low suspicion for MRSA cellulitis. Due to continued
intermittent fevers to 102 and spreading of the cellulitis
despite Cephalexin, IV Vanc was restarted with improvement of
cellulitis. He will continue IV Vancomycin at home until ___
for a full 10 day course. He had a PICC line placed prior to
discharge for home antibiotics.
CHRONIC ISSUES:
===============
#Bradycardia:
HR stayed in the ___ during his admission. ECG showed sinus
bradycardia. Remained asymptomatic and normotensive.
TRANSITIONAL ISSUES:
====================
[] Please draw BMP at first follow up to ensure no
nephrotoxicity secondary to Vancomycin
[] Monitor for improvement of RLE cellulitis (picture in OMR on
admission)
[] No medications were held. Only vancomycin was started with an
anticipated course of 10 days (___). Ensure PICC line is
removed after course of IV antibiotics has finished.
[] Please consider discontinuing ASA 325mg PO daily: No CAD so
would be primary prevention. Risk would likely outweigh benefit
even for low dose aspirin, but certainly would for full dose
ASA.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
2. Aspirin 325 mg PO DAILY
3. Cyanocobalamin 500 mcg PO DAILY
4. Ferrous GLUCONATE 324 mg PO DAILY
5. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
6. Miconazole 2% Cream 1 Appl TP BID:PRN fungal infection
7. Betamethasone Dipro 0.05% Oint 1 Appl TP BID eczema
Discharge Medications:
1. Vancomycin 1000 mg IV Q 24H
RX *vancomycin 1 gram 1000 mg IV daily Disp #*7 Vial Refills:*0
2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
3. Aspirin 325 mg PO DAILY
4. Betamethasone Dipro 0.05% Oint 1 Appl TP BID eczema
5. Cyanocobalamin 500 mcg PO DAILY
6. Ferrous GLUCONATE 324 mg PO DAILY
7. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
8. Miconazole 2% Cream 1 Appl TP BID:PRN fungal infection
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
Cellulitis of the right lower extremity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for an infection of the soft tissue in your
right leg.
What was done for me while I was in the hospital?
- You were started on IV antibiotics and treated for your
infection symptomatically.
What should I do when I leave the hospital?
- Ensure you continue the full course of antibiotics at home.
- Take the rest of your medications as prescribed on your
discharge paperwork.
- Continue monitoring the daily progress of your infection. You
can take pictures of it if you notice it significantly
worsening.
- Attend follow-up appointments with your primary care
physician.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19840941-DS-13
| 19,840,941 | 24,372,277 |
DS
| 13 |
2158-12-21 00:00:00
|
2158-12-25 20:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall down stairs while intoxicated
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p fall down stairs while intoxicated with Grade 3 liver
lac, perinephric hematoma, R ___ rib fx, R humerus close fx
(s/p reduction)
Past Medical History:
PMH: Hypertension, depression
PSH: None
Social History:
___
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 98.2 HR: 80 BP: 118/80 Resp: 16 O(2)Sat: 98
Constitutional: uncomofortable
HEENT: PERRL
c spine non-tender
Chest: BS B, R chest wall ttp
Cardiovascular: regular
Abdominal: firm, diffusely tender
Extr/Back: TLS non-tender, no stepoffs, RUE with significant
deformity, 2+ raidal
Skin: Warm and dry
Neuro: GCS 15
Physical exam upon discharge:
vital signs: 97.3, hr=82, bp 114/74 rr=18, 95 % room air
CV: ns1, s2, no murmurs
LUNGS: clear
ABDOMEN: hypoactive BS, soft, non-tender
EXT: + radial pulse bil., increased tenderness and swelling
right elbow, limited ROM right wrist and elbow
NEURO: ___ speaking, flat affect, follows simple commands
Pertinent Results:
___ 08:30AM BLOOD WBC-7.9 RBC-3.61* Hgb-10.6* Hct-33.3*
MCV-92 MCH-29.4 MCHC-31.8* RDW-15.1 RDWSD-50.8* Plt ___
___ 12:10PM BLOOD WBC-10.7* RBC-3.63* Hgb-10.9* Hct-33.1*
MCV-91 MCH-30.0 MCHC-32.9 RDW-15.1 RDWSD-50.4* Plt ___
___ 07:15AM BLOOD WBC-8.1 RBC-3.56* Hgb-10.8* Hct-33.0*
MCV-93 MCH-30.3 MCHC-32.7 RDW-15.1 RDWSD-51.7* Plt ___
___ 08:30AM BLOOD Plt ___
___ 02:21AM BLOOD ___ PTT-23.4* ___
___ 08:30AM BLOOD Glucose-79 UreaN-11 Creat-0.6 Na-137
K-3.8 Cl-102 HCO3-24 AnGap-15
___ 12:10PM BLOOD Glucose-92 UreaN-12 Creat-0.7 Na-134
K-3.9 Cl-99 HCO3-22 AnGap-17
___ 12:10PM BLOOD ALT-43* AST-39 AlkPhos-106* TotBili-0.8
___ 07:49PM BLOOD ALT-229* AST-449* LD(LDH)-552*
CK(CPK)-2440* AlkPhos-75 TotBili-0.6
___ 08:30AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.1
___ 03:45AM BLOOD ASA-NEG Ethanol-84* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:54AM BLOOD Lactate-2.0
___ 02:54AM BLOOD freeCa-1.22
___: chest x-ray:
Right seventh and eighth rib fractures.
___: humerus x-ray:
Status post reduction of distal humeral shaft fracture with
improved
alignment
___: right humerus:
Status post reduction of distal humeral shaft fracture with
improved
alignment
___: chest x-ray:
There are persistent low lung volumes. Small right pleural
effusion is
stable. Right lower lobe atelectasis are unchanged.
Retro-cardiac opacities have increased. There is no
pneumothorax or pleural effusion. Right rib fractures are again
noted.
___ 11:54 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ year old female admitted to Acute Care Surgery Service after
a fall down stairs while intoxicated resulting in a Grade 3
liver laceration, perinephric hematoma, right ___ rib fx,
right humerus close fx (s/p reduction). Upon admission, the
patient was made NPO, given intravenous fluids, and underwent
imaging.
Serial hematocrits were monitored for the liver laceration and
were stable at low ___. The patient's lactate and CK were also
trended and were coming down. Because of the patient's injuries,
the Orthopedic service was consulted and the patient underwent
a closed right humerus s/p reduction. Her activity orders
include: NWB, ROMAT at elbow + shoulder in ___. The
patient also sustained ___ right rib fractures. Her pain has
been controlled with oral analgesia.
During the patient's hospitalization, she experienced difficulty
voiding and had a foley catheter replaced twice for urinary
retention. She was started on a course of Flomax and a second
attempt at foley removal was successful. She has been voiding
without difficulty. She was started on a 7 day course of
ciprofloxacin for a klebsiella UTI. The patient was evaluated
by the Psychiatry service for depression and recommendations
were made for admission to an in-patient psychiatric facility to
further manage her depressive symptoms and
psychosis.
The patient has been medically cleared for discharge to an
inpatient psychiatric facility
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prazosin 1 mg PO QHS
2. lisinopril-hydrochlorothiazide ___ mg oral DAILY
3. LamoTRIgine 100 mg PO BID
4. OLANZapine 20 mg PO QHS
5. Temazepam 30 mg PO QHS
6. DiphenhydrAMINE 50 mg PO QHS
7. Propranolol 60 mg PO BID
8. amLODIPine 10 mg PO DAILY
9. Spironolactone 50 mg PO DAILY
10. ChlorproMAZINE 25 mg PO QHS
11. Sertraline 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
last dose
4. Docusate Sodium 100 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 8.6 mg PO BID:PRN constipation
10. Tamsulosin 0.4 mg PO QHS
may discontinue in 1 week
11. amLODIPine 10 mg PO DAILY
12. ChlorproMAZINE 25 mg PO QHS
13. DiphenhydrAMINE 50 mg PO QHS
14. LamoTRIgine 100 mg PO BID
15. lisinopril-hydrochlorothiazide ___ mg oral DAILY
16. OLANZapine 20 mg PO QHS
17. Prazosin 1 mg PO QHS
18. Propranolol 60 mg PO BID
19. Sertraline 100 mg PO DAILY
20. Spironolactone 50 mg PO DAILY
21. Temazepam 30 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Grade 3 liver laceration
Perinephric hematoma
Right ___ rib fractures
Right humerus close fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
___ with no significant PMHx admitted to Acute Care Surgery
Service after fall down stairs with Grade 3 liver laceration,
perinephric hematoma, Right ___ rib fx, R humerus close fx
(s/p reduction). Serial Hct were monitored for the liver
laceration and were stable at low ___. Patient's lactate and CK
were also trended and were coming down. Patient was unable to
void and so had Foley replaced twice fr urinary retention, she
was started on Flomax. She will be discharged with Foley, trial
of void at rehab. Her Tertiary Trauma Survey demonstrated no new
injuries.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
19840960-DS-21
| 19,840,960 | 23,267,597 |
DS
| 21 |
2157-07-03 00:00:00
|
2157-07-03 18:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Alcohol
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization ___
cardiac catheterization ___
History of Present Illness:
___ year old male with past medical history including diabetes,
hypertension, hyperlipidemia, CAD status post MI ___ and CABG
on ___ (LIMA-LAD, SVG-OM, radial artery-PDA), DES (endeavor)
x2 to the D1 in ___, balloon-only angioplasty of distal LCx and
proximal D1 in ___, chronic angina who complains of chest
pain w/ onset 3 days prior. Since his discharge in ___, he has
felt overall well but then 3 days ago started having
intermittent episodes of chest pain. He says it's very typical
of when he had angina in the past, prior to when he had his CABG
and when he's had catheterizations. Pain starts in R hand and
arm, radiates to chest substernal and to jaw. Assocated with
shortness of breath, nausea. Lasts about 30 minutes and improves
with SLNG x 3. Has recurred ___ for the last 3 days. Also
has been having dyspnea on minimal exertion. No lower extremity
edema or calf pain, no abdominal pain, no focal numbness
tingling or weakness, no dysuria, no vomiting, blood in stool,
black stools.
.
Notably, pt had nuclear stress test during admission for
hematochezia on ___ due to chest pain during admission, which
demonstrated stable severe, fixed defect of the inferior wall w/
no area of reversible ischemia; however, it is not known how
reliable nuclear stress testing is in this patient due to the
fact that in ___, testing failed to reveal areas of reversible
ischemia despite the fact that on cardiac cath in ___ distal
circumflex and proximal D1 demonstrated significant stenosis
(90% of LCx, extent of D1 not noted).
.
In the ED, initial vitals were ___ 74 196/104 18 99%
RA. Pt reports pain similar to when had an MI. Pt given aspirin
325, SLN for pain, morphine for pain, zofran for nausea. Pt
reported pain ___, slight relief with nitro, asa, IV
morphine 4mg and zofran 4mg. EKG showed no changes from
previous. Trop negative x1. BNP insignificant at 233. CXR with
no acute proceses. Pt experienced ___ chest pain prior to
transfer to floor from ED so in ED he was started on heparin gtt
and nitroglycerin gtt with some improvement in chest pain. Heme
negative on rectal exam.
.
Currently pt endorses ___ chest pain but otherwise feels well.
Denies shortness of breath, nausea. He is concerned about BP;
was 210 systolic when he checked at home prior to arrival and
currently 173/95, notes that it is usually 120s/80s (similar to
BPs noted in OMR from clinic). Denies any headache, numbness,
weakness, or other complaints.
.
On review of systems, he denies any prior history of stroke,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. he denies recent fevers, chills or rigors.
he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Cardiac Risk Factors: + Diabetes, + Dyslipidemia, +
Hypertension,
+OSA
Cardiac History:
CABG: in ___ anatomy as follows - LIMA-LAD, Radial-PDA, SVG-OM
Percutaneous coronary intervention: ___ anatomy as
follows: Two Endeavor study stents to the first diagonal with
moderate in-stent restenosis. LAD with mild disease proximally,
occluded after first diag. LCx with mild irregularities and
occluded OM1 branch. RCA with diffuse disease and mid 70%
stenosis, occluded
PDA
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father with CHF, brothers with HTN, father with
stroke, mother with h/o blood clot
Physical Exam:
admission exam
VS: 97.8 173/95 68 99% RA
GENERAL: obese M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of <10 cm.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
.
discharge exam:
98.3 119/98 73 18 98% RA
GENERAL: obese M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple without JVD
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
.
Pertinent Results:
admission labs
___ 06:59PM BLOOD WBC-7.7 RBC-4.25* Hgb-11.9* Hct-35.8*
MCV-84 MCH-28.1 MCHC-33.3 RDW-14.5 Plt ___
___ 06:59PM BLOOD Neuts-70.9* ___ Monos-5.0 Eos-1.8
Baso-0.5
___ 06:59PM BLOOD ___ PTT-32.0 ___
___ 06:59PM BLOOD Glucose-132* UreaN-19 Creat-1.0 Na-139
K-4.1 Cl-107 HCO3-23 AnGap-13
___ 06:59PM BLOOD proBNP-233*
___ 06:56PM BLOOD Lactate-1.5
.
cardiac enzymes
___ 06:59PM BLOOD cTropnT-<0.01
___ 01:40AM BLOOD CK-MB-5 cTropnT-<0.01
___ 08:55AM BLOOD CK-MB-4 cTropnT-<0.01
___ 05:32PM BLOOD CK-MB-5
___ 06:35AM BLOOD CK-MB-12* MB Indx-9.5*
___ 11:00PM BLOOD CK-MB-13*
___ 06:50AM BLOOD CK-MB-18*
.
admission ECG NSR 69, Q in II, III, aVF, no ST changes compared
to prior in ___
.
CXR ___ No acute intrathoracic process. Post-CABG changes.
.
Cardiac cath ___ (prelim read)
1. Selective native coronary angiography of this right dominant
system
demonstrated 3 vessel coronary artery disease. The LMCA had
minimal
diffuse coronary artery disease. The LAD was totally occluded
at its
mid portion, and had diffuse non-obstructive disease in the
diagnoal.
The LCX had a total occlusion of the OM1/ramus branch. The RCA
had
diffuse disease, up to 60%, throughout its course.
2. Selective venous conduit angiography demonstrated a 90%
lesion at the
distal anastomosis between the SVG and OM1.
3. Selective arterial conduit angiography demonstrated patent
LIMA to
LAD and radial to PDA grafts.
4. Limited resting hemodynamics revealed mild systemic arterial
hypertension with a central aortic blood pressure of 152/85.
5. Unsuccessful attempt at PCI of the SVG-OM anastomosis (see
___
comments).
6. Successful RFA AngioSeal.
FINAL DIAGNOSIS:
1. Three vessel native coronary artery disease.
2. 90% lesion in the SVG to OM1 graft.
3. Patent LIMA to LAD and radial to PDA grafts.
4. Mild systemic arterial hypertension.
5. Unsuccessful attempt at PCI of the SVG-OM.
6. Successful RFA AngioSeal.
.
Cardiac cath ___ (prelim read)
COMMENTS:
1. Successful PCI to the 80% SVG to the OM lesion with a
3.0x12mm
Integrity BMS and 2.25x8mm Mini Vision BMS.
2. Residual moderate 40% stenosis remains in the proximal
segement of
the SVG to OM, however this will be medically managed.
3. No complications.
4. Perclose to the left CFA.
FINAL DIAGNOSIS:
1. Successful PCI to the SVG to OM with Integrity and Mini
Vision BMS.
2. Perclose to the left CFA site.
3. Patient is to remain on aspirin indefinitely and clopidogrel
for at
least 9 months, uninterrupted, given ACS.
4. No complications.
.
ECHO ___
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with
inferior hypokinesis. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. The right
ventricular cavity is moderately dilated with borderline normal
free wall function. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
Discharge labs:
___ 06:50AM BLOOD WBC-8.2 RBC-3.77* Hgb-10.7* Hct-32.3*
MCV-86 MCH-28.3 MCHC-33.0 RDW-14.2 Plt ___
___ 06:50AM BLOOD Glucose-304* UreaN-23* Creat-1.0 Na-137
K-4.3 Cl-101 HCO3-29 AnGap-11
___ 06:50AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.0
Brief Hospital Course:
Primary Reason for Hospitalization:
___ yo M with hx of CAD s/p 3V CABG (LIMA-LAD, SVG-OM, radial
artery-PDA), DES x2 to the D1 in ___, balloon-only angioplasty
of distal LCx and proximal D1 in ___, HTN, HLD, DM, who
presented with Unstable Angina
.
ACTIVE ISSUES:
===============
# Unstable Angina: Patient with known 3VD s/p CABG presented
with symptoms of unstable angina. ECG showed no new ischemic
changes and CE negative x 3. Patient had recent ETT on Gervino
protocol which was suboptimal given RPP ___. Initially
patient was placed on heparin and nitro gtt. TIMI score is 5 for
age ___, at least 3 risk factors, prior CAD, 2 anginal episodes
in prior 24 hrs, ASA in prior 7 days. Nitro gtt was weaned off
and patient was chest pain free. He underwent cardiac
catheterization on ___, however, given tortuosity of vessel,
attempts at intervention were unsuccessful. On ___, after
review of prior coronary imaging, patient underwent repeat
cardiac catheterization and 2 BMS were placed in his SVG-OM.
There was resolution of patient's chest pain. Patient was
continued on his ASA and plavix. His carvedilol was uptitrated
to 25 mg twice daily and his simvastatin was changed to
atorvastatin in the setting of ACS. He was also continued on his
home quinapril. Patient did not have any apparent complications
from his procedure. He remained chest pain free for the rest of
his admission.
.
# Chronic Diastolic Heart Failure (EF 50-55% ___: Echo on
this admission showed mild regional left ventricular systolic
dysfunction with inferior hypokinesis and mild pulmonary artery
hypertension. He was continued on his quinapril and carvedilol.
.
# GERD: Patient had difficult time distinguishing his reflux
symptoms from his anginal pains at times. He will continue on
previous home dose of ranitidine 150mg qhs for now. However he
may benefit from increasing the dose or switching to a PPI. This
should be discussed at ___ with PCP.
.
# Hyperlipidemia: He was continued on niacin, omega-3 fatty
acids, fenofibrate. His simvastatin was changed to atorvastatin
80mg in the setting of unstable angina.
.
# DM: held glipizide and metformin while in hospital. His blood
sugars were controlled with sliding scale insulin. He will
resume previous home meds.
# HTN: Patient was normotensive on arrival to the floor with
nitro gtt. However, when nitro gtt weaned off patient was
hypertensive. He was continued on quinapril. His carvedilol was
uptitrated to 25 mg po BID. He also was started on amlodipine 10
mg daily. His imdur was decreased to 60mg daily because of
improvement in angina following revascularization. Patient's BP
was well controlled prior to discharge. Of note, patient had
been on amlodipine in the past and it had been discontinued ___ because of BPs on the low side. Therefore patient will need
close PCP and cardiology ___. Patient was given
prescription for home BP cuff and instructed to call his doctor
if values less than 90 systolic.
.
CHRONIC ISSUES:
===============
# Anemia: likely ___ rectal ulcer seen on colonoscopy in ___,
Hct is stable compared to last discharge in ___, pt denied
recent blood in stool or black stool and rectal exam in ED heme
negative. Patient's HCT remained stable.
.
# Anxiety: cont PRN lorazepam, citalopram
.
# Allergies: cont fluticasone
.
Transitional Issues:
====================
- Patient's cardiologist can consider stopping Imdur if no
longer needed for anginal symptoms or BP control
Medications on Admission:
BUPROPION HCL - 150 mg Tablet Extended Release - 1 Tablet(s) by
mouth twice a day
CARVEDILOL - 12.5 mg Tablet - one Tablet(s) by mouth twice a day
CITALOPRAM - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth daily
CROMOLYN - 4 % Drops - 1 to 2 qtt topically to both eyes 4 - 6
times daily as needed for allergic conjuctivitis
DISULFIRAM - 250 mg daily
FENOFIBRATE - 160 mg Tablet - 1 Tablet(s) by mouth once a day
FLUTICASONE - 50 mcg Spray, Suspension - 1 (One) spray(s)
nasally
one spray each nostril twice daily as needed for congestion
GLIPIZIDE - 10 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by
mouth twice a day
ISOSORBIDE MONONITRATE - 120 mg Tablet Extended Release 24 hr -
one Tablet(s) by mouth daily
LORAZEPAM - 2 mg Tablet - ___ Tablet(s) by mouth at bedtime as
needed for PRN sleep - No Substitution
METFORMIN - (Prescribed by Other Provider) - Dosage uncertain
NIACIN [NIASPAN EXTENDED-RELEASE] - (Prescribed by Other
Provider: Dr. ___ - 500 mg Tablet Extended Release 24
hr
- 1 Tablet(s) by mouth at bedtime
NITROGLYCERIN [NITROSTAT] - 0.4 mg Tablet, Sublingual - 1
Tablet(s) sublingually as instructed for chest discomfort. Disp
1
pkg of 4 bottles 25 tabs each
OMEGA-3 ACID ETHYL ESTERS [LOVAZA] - (Prescribed by Other
Provider: PCP) - 1 gram Capsule - 2 Capsule(s) by mouth twice a
day
QUINAPRIL - 40 mg Tablet - 1 (One) Tablet(s) by mouth once a day
in evening
RANITIDINE HCL - (Prescribed by Other Provider: Dr. ___
- 150 mg Tablet - 1 Tablet(s) by mouth once a day
SIMVASTATIN - 40 mg Tablet - one Tablet(s) by mouth once a day
ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth daily
BLOOD SUGAR DIAGNOSTIC [CONTOUR TEST STRIPS] - Strip - test
blood sugars 4 times a day
GERIATRIC MULTIVIT W/IRON-MIN [___] - (OTC) -
Tablet - Tablet(s) by mouth
IBUPROFEN - (OTC) - 200 mg Tablet - 2 Tablet(s) by mouth three
times a day as needed for pain
PSYLLIUM [METAMUCIL] - (OTC) - Powder - 1 tsp(s) by mouth
daily as needed for constipation
Discharge Medications:
1. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. cromolyn 4 % Drops Sig: ___ drops topically to both eyes
Ophthalmic ___ times daily as needed for allergic
conjunctivitis.
5. disulfiram 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. fenofibrate 160 mg Tablet Sig: One (1) Tablet PO daily ().
7. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal BID (2 times a day).
8. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO twice a day.
9. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
10. metformin Oral
11. niacin 500 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO daily ().
12. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed: Take one tablet at the onset of chest
pain. If pain continues after 5 minutes you may take a ___ pill.
If pain continues after 10 minutes you should take a third pill
and call ___.
.
13. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
17. quinapril 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
19. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
20. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. psyllium Packet Sig: One (1) Packet PO once a day as
needed for constipation.
22. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
23. Blood Pressure Cuff for Home
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
- unstable angina
- coronary artery disease
- hypertension
Secondaray
- hyperlipidemia
- type 2 diabetes
- hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you while you were in the hospital.
You were admitted because you were having chest pain due to
narrowing in your coronary arteries. You underwent a cardiac
catheterization which showed narrowing in one of your coronary
arteries which was opened with stents. It is very important that
you continue to take Aspirin and Plavix (Clopidogrel) every day
as these medications keep your stent open. Do NOT stop taking
these medications without talking to your cardiologist first.
Your blood pressures were also high while you were in the
hospital. High blood pressure can increase the risk of having a
heart attack therefore we made some changes to your blood
pressure medications as described below. You should check your
blood pressure at home and write down the results to bring to
your doctors ___. You were also switched to
atorvastatin from simvastatin because it is stronger and helps
prevent heart attacks.
The following changes were made to your medication regimen.
Please START Atorvastatin 80mg daily at bedtime
Please STOP Simvastatin
Please INCREASE carvedilol to 25 mg twice daily
Please START Amlodipine 10mg daily
Please DECREASE Imdur (Isosorbide Mononitrate) to 60mg daily
Please take the rest of your medications you were previously and
follow up with your doctors as ___.
Followup Instructions:
___
|
19841464-DS-9
| 19,841,464 | 21,232,930 |
DS
| 9 |
2171-11-07 00:00:00
|
2171-11-06 10:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain and leg weakness
Major Surgical or Invasive Procedure:
1. Anterior cervical diskectomy and arthrodesis: C5-C6 and
C6-C7.
2. Application of interbody cage: C5-C6, C6-C7.
3. Left iliac crest bone graft harvest, morselized,
minimally invasive.
4. Application of anterior instrumentation: C5-C6, C6-C7.
History of Present Illness:
___ presents for back pain and leg weakness after his doctor
told him to come in follow an abnormal MRI. 1 month ago he
developed sharp pain in the left upper back and lower back that
resolved with ibuprofen. No hx of trauma. 2 weeks ago the pain
returned. He has sharp nonradiating pain in the left upper back
near the scapula only after walking for about 5 minutes. He has
constant sharp, nonradiating pain in the lower back, worst in
the left lower back and worse with walking. He has associated
numbness from just below his umbilicus down through the sides of
both hips. He has severe burning, worse with palpation over
bilateral anterior thighs L>R. He has weakness of both legs L>R
and has had difficulty walking for 3 days. He had an MRI of his
L spine last week and MRI T spine yesterday. His doctor reviewed
the results and told him to be seen in the ED. He has not had
any fevers, saddle anesthesia or difficulty with urination or
stooling.
Past Medical History:
hypertension
Social History:
originally from ___, nonsmoker, no IVDU
Physical Exam:
Physical Exam-
General:Well appearing sitting up in bed, NAD, comfortable,
pleasant
CV:RRR
Resp:CTAB
Abd:soft,ntnd,+bs's
Extremities:wwp,2+rad/2+dp pulses
Strength:LLE Quad 4+/5, ___ ___, RLE ___ throughout,
BUE ___ throughout Del/EE/EF/WE/WF/IO/Grip
+SILT b/l
Pertinent Results:
___ 07:05AM BLOOD WBC-16.7*# RBC-4.29* Hgb-12.9* Hct-37.4*
MCV-87 MCH-30.1 MCHC-34.4 RDW-13.1 Plt ___
___ 02:42PM BLOOD Neuts-36.0* Lymphs-52.7* Monos-7.0
Eos-3.1 Baso-1.2
___ 07:05AM BLOOD Plt ___
___ 07:05AM BLOOD Glucose-94 UreaN-19 Creat-1.1 Na-140
K-3.2* Cl-101 HCO3-27 AnGap-15
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol.Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#1.Physical therapy
was consulted for mobilization OOB to ambulate. 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:
Amlodipine
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H pain
may take over the counter
2. Amlodipine 10 mg PO DAILY
3. Cyclobenzaprine ___ mg PO TID:PRN pain or spasm
RX *cyclobenzaprine 5 mg ___ tablet(s) by mouth three times a
day Disp #*50 Tablet Refills:*0
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:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
6. Senna 8.6 mg PO BID constipation
may take over the counter
Discharge Disposition:
Home
Discharge Diagnosis:
1. Cervical spondylitic myelopathy.
2. Acute disk herniation, C5-C6, C6-C7.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
ACDF:
You have undergone the following operation: Anterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit in a car or chair for more than ~45 minutes without
getting up and walking around.
Rehabilitation/ Physical Therapy:
___ times a day you should go for a walk for
___ minutes as part of your recovery. You can walk as much as
you can tolerate.
Swallowing: Difficulty
swallowing is not uncommon after this type of surgery. This
should resolve over time. Please take small bites and eat
slowly. Removing the collar while eating can be helpful
however, please limit your movement of your neck if you remove
your collar while eating.
Cervical Collar / Neck Brace: You have been
given a soft collar for comfort. You may remove the collar to
take a shower or eat. Limit your motion of your neck while the
collar is off. You should wear the collar when walking,
especially in public
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in narcotic (oxycontin,
oxycodone, percocet) prescriptions to the pharmacy. In
addition, we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your incision,
take baseline x rays and answer any questions.
We will then see you at 6 weeks from the day of
the operation. At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Followup Instructions:
___
|
19842175-DS-6
| 19,842,175 | 25,895,490 |
DS
| 6 |
2160-02-24 00:00:00
|
2160-02-24 15:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Oxycodone
Attending: ___
Chief Complaint:
Shingles
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of afib, chf, cad s/p pacemaker, COPD, and
menierre's disease who presens for evaluation of R chest pain
and R sided rash. Patient reports that the past 6 days she's
been having pain over the right hemithorax in bandlike
distribution roughly back to front at level of the breast. She's
been trying to self medicate by applying BenGay, no relief. 3
days prior to admission, vesicular rash broke out along same
distribution. On day of admission, patient complained of R ear
pain, with no associated neurologic deficits. Patient was seen
by her PCP today at which time the distribution was noted to be
dermatomal. At that time she complained of mild non-exertional
left-sided chest pain, without pleuritic component, without
short of breath or diaphoresis.
Patient also had urinalysis performed at doctor's office today
showing urinary tract infection (positive for nitrite and ___.
She did not have complaints of dysuria or urinary frequency,
however patient is incontinent of urine at baseline.
In the ED, initial vitals were 98.4 58 118/55 16 98% RA
EKG showed sinus rhythm, nonischemic.
Currently, patient complains of profound nausea which has
improved with zofran administration, R back and chest pain which
is adequately controlled.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, abdominal pain, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Atrial fibrillation: coumadin discontinued s/p fall
- CHF
- History of PE
- CAD s/p pacemaker
- COPD
- CKD Stage III
- Anemia of chronic disease
- Colonic adenoma
- Peripheral vascular disease
- Carpal tunnel syndrome
- GERD
- s/p fall with intracranial bleed
Social History:
___
Family History:
son had zoster few years ago.
Physical Exam:
ADMISSION EXAM
GENERAL - elderly female lying in bed, in NAD
HEENT - NC/AT, pupils pinpoint, EOMI, sclerae anicteric, MMM, OP
clear, mild erythema in external auditory canal on R, clear TM's
on R.
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, moderately decreased air
movement, resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, mildly distended soft/NT/ND, no masses or HSM,
no rebound/guarding
EXTREMITIES - chronic venous stasis changes bilaterally with
scaling, mild 1+ edema of b/l lower extremities
SKIN - Vesicular lesions in differing stages with ___ open
vesicles on an erythematous base extending along R T4 dermatome
from spine to underneath the breast
NEURO - awake, A&Ox3, no facial droop apparent on exam
DISCHARGE EXAM
VS - 97.9 102/50 61 20 93RA
GENERAL - elderly female lying in bed, in NAD
HEENT - NC/AT, pupils pinpoint, EOMI, sclerae anicteric, MMM, OP
clear, TM's clear on R. no erythema or exudate, no vesicular
lesions appreciated
LUNGS - CTA bilat, no r/rh/wh, moderately decreased air
movement, resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, mildly distended soft/NT/ND, no masses or HSM,
no rebound/guarding
EXTREMITIES - chronic venous stasis changes bilaterally with
scaling, mild 1+ edema of b/l lower extremities
SKIN - Vesicular lesions in differing stages with an
erythematous base extending along R T4 dermatome from spine to
underneath the breast, 1 area of open vesicle.
NEURO - awake, A&Ox3, no facial nerve palsy
Pertinent Results:
ADMISSION LABS
___ 03:00PM BLOOD WBC-3.8* RBC-3.20* Hgb-10.3* Hct-29.6*
MCV-92 MCH-32.0 MCHC-34.7 RDW-15.2 Plt ___
___ 03:00PM BLOOD Neuts-53 Bands-9* Lymphs-16* Monos-14*
Eos-1 Baso-0 Atyps-6* Metas-1* Myelos-0
___ 06:45AM BLOOD Neuts-73* Bands-0 Lymphs-13* Monos-12*
Eos-1 Baso-1 ___ Myelos-0
___ 03:00PM BLOOD Glucose-142* UreaN-36* Creat-1.5* Na-137
K-3.7 Cl-94* HCO3-29 AnGap-18
DISCHARGE LABS
___ 06:40AM BLOOD WBC-3.2* RBC-2.90* Hgb-9.4* Hct-27.2*
MCV-94 MCH-32.3* MCHC-34.5 RDW-15.5 Plt ___
___ 06:40AM BLOOD Glucose-97 UreaN-38* Creat-1.7* Na-135
K-4.0 Cl-98 HCO3-26 AnGap-15
PENDING LABS
___ BLOOD CX x 2 pending
Brief Hospital Course:
___ Year old female presenting with Herpes Zoster as well as
urinary tract infection
#HERPES ZOSTER: classic dermatomal distribution with history of
prior outbreaks. Likely in setting of concurrent UTI infection.
Patient initially had acyclovir IV as she was nauseous, however
transitioned to valacyclovir.. Concern for ___ syndrome
with concurent ear pain and vertigo, however TM's clear on exam,
no facial nerve palsy, vertigo chronic ___ menierre's disease,
unlikely to have 2 non-contiguous dermatomes involved.
-Valcyclovir x 10 more days day ___
-Tramadol for pain
-Gabapentin for pain (renally dosed)
#facial/ right ear pain: likely ___ Herpes Zoster, however
possible that patient has trigeminal neuralgia versus temporal
arteritis. Given no change in vision, and presence of pain in
ear, seems less likely to be Temporal arteritis. Patient told
if acute change in vision occurs, to call a physician.
#URINARY TRACT INFECTION: given positive UA from ___
___, treated empirically for UTI with TMP/SMX x 3
days.
___ on CKD: Baseline cr appears to be 1.2 - 1.4 from Atrius
records. Mildly elevated on admission, which has since
downtrended with gentle IV Fluid.
#ATRIAL FIBRILLATION: Paroxysmal. Pt noted to be in regular
rhythm at recent PCP ___. Not on anticoagulation ___ to
history of intracranial bleed previously while on coumadin.
#CHF: per echo ___: hyperdynamic EF (70-75%, moderate RV
dilation, mild MR, trace MS and TR. On lasix as an outpatient
as well as metoprolol. will continue home medications at this
time.
#COPD: patient was continued on home medications, except long
acting symbicort which was switched to advair because it was non
formulary.
#Urinary incontinence: chronic issue, may be contributing to
UTI.
#GERD: continued home medications
-omeprazole 40mg PO
TRANSITIONAL ISSUES:
-Blood cx from ___ is pending
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from At___.
1. Losartan Potassium 50 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Lorazepam 0.25 mg PO BID:PRN Agitation
4. Rosuvastatin Calcium 40 mg PO QHS
5. Omeprazole 40 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Furosemide 80 mg PO QAM
8. Furosemide 40 mg PO QPM
9. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation Twice daily
Rinse mouth afterward.
10. Ketoconazole 2% 1 Appl TP BID
11. Nitroglycerin SL 0.4 mg SL PRN Chest pain
12. Ipratropium Bromide Neb 1 NEB IH Q6H
13. Miconazole 2% Cream 1 Appl TP BID
14. Albuterol Inhaler 2 PUFF IH Q4H:PRN Dyspnea/Wheezing
15. Acidophilus *NF* (L.acidoph &
___ acidophilus) 175 mg Oral
Daily
16. Ferrous Sulfate (Liquid) 300 mg PO DAILY
17. Meclizine 12.5 mg PO TID:PRN Vertigo
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN Dyspnea/Wheezing
2. Ferrous Sulfate (Liquid) 300 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Furosemide 80 mg PO QAM
5. Ipratropium Bromide Neb 1 NEB IH Q6H
6. Ketoconazole 2% 1 Appl TP BID
7. Lorazepam 0.25 mg PO BID:PRN Agitation
8. Losartan Potassium 50 mg PO DAILY
9. Meclizine 12.5 mg PO TID:PRN Vertigo
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Miconazole 2% Cream 1 Appl TP BID
12. Nitroglycerin SL 0.4 mg SL PRN Chest pain
13. Omeprazole 40 mg PO DAILY
14. Rosuvastatin Calcium 40 mg PO QHS
15. ValACYclovir 1000 mg PO Q24H Duration: 10 Days
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth once a day Disp
#*10 Tablet Refills:*0
16. Acidophilus *NF* (L.acidoph &
___ acidophilus) 175 mg Oral
Daily
17. Furosemide 40 mg PO QPM
Start on ___
18. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation Twice daily
Rinse mouth afterward.
19. TraMADOL (Ultram) 50-100 mg PO Q6H:PRN pain
RX *tramadol 50 mg ___ tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
20. Gabapentin 600 mg PO DAILY
hold for sedation or rr<10
RX *gabapentin 600 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Herpes Zoster
UTI
secondary diagnoses:
___ on CKD stage III
atrial fibrillation
CAD
chronic CHF (details unknown)
s/p pacemaker
COPD
Menierre's disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were treated at ___ for Shingles and a Urinary infection.
Your shingles will likely still be painful for a few more days.
Please continue to take your medications for 10 more days. Your
ear pain may be related to the shingles. Your urinary infection
was treated with antibiotics. Please restart you lasix on
___.
For your pain, you can continue gabapentin and tramadol for your
pain, however if your pain stops, you no longer need those
medications. Please discontinue them when your pain subsides.
Please talk with your PCP if your pain continues.
Followup Instructions:
___
|
19842175-DS-7
| 19,842,175 | 29,997,917 |
DS
| 7 |
2161-08-05 00:00:00
|
2161-08-08 14:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Oxycodone / Penicillins
Attending: ___.
Chief Complaint:
leg swelling and fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH significant for CHF, CAD s/p pacemaker, Afib, COPD,
Meniere's dz, CKD, PVD presenting with worsening lower extremity
edema, erythema, warmth, low grade temps and purulent drainage
from LLE. Patient has had worsening b/l lower extremity
edema/venous stasis over last several weeks. Patient had
previously been taking 80 mg lasix QAM and 40 mg lasix QPM but
self-dc'ed her ___ dose 2 weeks ago out of concern for increased
urination. Her legs have been oozing more fluid (greenish in
color) and have appeared more red. She also was complaining of
chills and increased shortness of breath. She typically sleeps
in a recliner and has some orthopnea which has been going on for
___ years. She has been elevating her legs. Presented to urgent
care on ___ for concern of worsening drainage and was
received ceftriaxone 1 gm IM x1 in the clinic. She was also
prescribed keflex ___ mg TID which was not started until ___
(out of son's concern that she is at risk for Cdiff with
antibiotics per telephone records) and she has received 5 doses.
She was also instructed to increase her lasix dose to 80 mg QAM
and 40 mg QPM. Noted Tmax 100.7 on ___. Patient was brought
in by son for concern of worsening erythema, drainage of the LLE
and fever. Son reports that patient has been sitting in recliner
with posterior calves against recliner foot which has likely
caused skin breakdown on posterior calves. Per son patient has
not been eating and drinking much.
In the ED, initial vs were: T 99.2 P 62 BP 154/40 RR 16 SaO2
100% RA. Blood cultures were drawn. Labs were remarkable for Cr
elevated to 2.1 (from baseline 1.2-1.4), WBC 7.6, Hct 27.9
(baseline ___, lactate 1.6. Patient was enrolled in the
cellulitis pathyway and given vanco 1gm, ceftriaxone 1 gm,
tramadol 50 mg and lorazepam 1mg.
Vitals prior to transfer: 97.9 59 123/51 16 96% RA
On the floor, vs were: T 99 P 62 BP 127/72 R 20 O2 sat 99% RA
Past Medical History:
- Atrial fibrillation: coumadin discontinued s/p fall
- CHF
- History of PE
- CAD s/p pacemaker
- COPD
- CKD Stage III
- Anemia of chronic disease
- Colonic adenoma
- Peripheral vascular disease
- Carpal tunnel syndrome
- GERD
- s/p fall with intracranial bleed
- osteoarthritis
- hypercholesterolemia
- carpal tunnel syndrome
- herpes zoster
- macular degeneration and cataracts
Social History:
___
Family History:
son had zoster few years ago.
Physical Exam:
ADMISSION:
Vitals: T 99 P 62 BP 127/72 R 20 O2 sat 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: occasional expiratory wheezes
CV: Regular rate and rhythm, RRR, II/VI systolic murmur at RSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: bilateral venous stasis changes with hyperkeratotic
plate-like scales, skin break down and tears (with bloody
drainage) diffusely on posterior calves bilaterally, 3+ pedal
edema. Mild erythema extending past the RLE demarcated area, 5
cm ulcer on left dorsal foot, thick yellow toenails with scale
in between toes
Neuro:A+Ox3
DISCHARGE:
Pertinent Results:
----------------
ADMISSION LABS:
----------------
___ 04:45PM BLOOD WBC-7.6# RBC-2.95* Hgb-9.4* Hct-27.9*
MCV-95 MCH-31.8 MCHC-33.7 RDW-14.8 Plt ___
___ 04:45PM BLOOD Neuts-81.3* Lymphs-12.5* Monos-4.9
Eos-1.0 Baso-0.3
___ 04:45PM BLOOD Glucose-151* UreaN-35* Creat-2.1* Na-139
K-3.3 Cl-95* HCO3-30 AnGap-17
___ 04:45PM BLOOD Calcium-9.0 Phos-3.7 Mg-2.4
___ 04:57PM BLOOD Lactate-1.6
-----------
IMAGING:
-----------
ECHO:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF = 60%). However, the apex is severely hypokinetic, with
focal dyskinesis. Right ventricular chamber size and free wall
motion are normal. The aortic valve is not well seen. There is
mild aortic valve stenosis. The mitral valve leaflets are mildly
thickened. There is severe mitral annular calcification. There
is mild functional mitral stenosis (mean gradient 8 mmHg) due to
mitral annular calcification. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
LENIS:
IMPRESSION:
No evidence of deep venous thrombosis in the either leg
RIGHT HIP XRAY:
IMPRESSION:
1. Moderate sacroiliac joint degenerative change versus
sacroiliitis.
2. Mild femoroacetabular joint degenerative change. If there
is high concern
for a fracture, consider cross-sectional imaging.
---------------
DISCHARGE LABS:
---------------
Brief Hospital Course:
___ with PMH significant for CHF, CAD s/p pacemaker, Afib, COPD,
Meniere's dz, CKD, PVD presenting with worsening lower extremity
edema, erythema, warmth, low grade temps and drainage from lower
extremities.
___ edema, skin breakdown and bloody drainage: Patient has
severe stasis dermatitis with skin breakdown on posterior calves
which is likely related to pressure contact from recliner. Given
fevers and chills, cellulitis is also possible. Differential
also includes DVTs given history of PE. LENIs were negative for
DVTs. Patient was initially treated with vancomycin (and
received 1 dose of ceftriaxone in ED) and given clinical
improvement and that patient had only received 5 doses of
cephalexin and 1 dose of IM ceftriaxone prior to admission (and
therefore failure of PO therapy was unlikely), she was
transitioned to PO cephalexin 500 TID and doxycycline 100 mg
Q12H on ___. A wound care C/S was placed and recommended BID
dressings with melgisorb to areas that were broken down,
aquaphor to surrounding intact skin and softsorb and kerlex.
Patient was evaluated by ___ who recommended discharge to SNF.
After discussion with patient and her family, it was decided
that patient would benefit from rehab and possibly longer-term
care after rehab to help her with her dressing changes and other
care.
___: Patient with Cr elevation to 2.1 from baseline 1.2-1.4,
most likely prerenal in setting of increased lasix dose and
decreased PO intake. Cr was 1.7 upon discharge. Her lasix dose
was decreased to 60 mg QAM (from 80 mg QAM and 40 mg QPM)as
patient's standing weight (188lb) was decreased from previous
weights.
#Right hip pain: Patient complained of right hip pain on ___,
most likely musculoskeletal given patient's deconditioning and
position in bed. Given that patient is prone to falls and has
fallen in past, Xray of right hip was obtained to rule out
fracture and was negative.
CHRONIC ISSUES:
#HTN: Patient was continued on home metoprolol and losartan.
#Afib: Patient was in sinus rhythm and was continued on home
metoprolol. She is not on anticoagulation due to intracranial
bleed after fall in past.
#COPD: Patient received albuterol and ipratropium nebs.
#diastolic CHF: No evidence of decompensated heart failure on
presentation. Patient was continued on home metoprolol and
statin. A repeat ECHO showed LVEF 60%, apex is severely
hypokinetic, with focal dyskinesis, mild aortic valve stenosis,
severe mitral annular calcification, mild functional mitral
stenosis (mean gradient 8 mmHg) due to mitral annular
calcification, and mild (1+) mitral regurgitation. Patient
should follow up with her cardiologist Dr. ___. Patient's
lasix dose was decreased to 60 mg QAM (from 80 mg QAM and 40 mg
QPM) as her standing weight (188lb) was decreased from prior
weights.
#h/o zoster: Patient was continued on home tramadol.
#Hypercholesterolemia: Patient was continued on home statin.
#anxiety: Patient was continued on home lorazepam prn.
TRANSITIONAL ISSUES:
-Follow-up final blood cultures from ___
-Please monitor daily standing weights (patient's discharge
standing weight is 85.7 kg or 188 lb) and if weight increases
more than 3 lbs, please check Cr and consider increasing lasix
dose to 80 mg QAM (from 60 mg QAM); if weight continues to
increase more than 3 lbs, consider increasing lasix dose further
(after discussion with her cardiologist Dr. ___
-Please continue to discuss need for longer term care facility
after discharge from rehab
-Please ensure patient takes a 7 day course of doxycycline 100
mg Q12H and cephalexin 500 mg TID (started on ___ and will end
on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADOL (Ultram) 100 mg PO DAILY:PRN pain
2. Cephalexin 500 mg PO Q8H
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Furosemide 80 mg PO QAM
6. Furosemide 40 mg PO QPM
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Lorazepam 0.25-0.5 mg PO BID:PRN anxiety
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
10. Rosuvastatin Calcium 40 mg PO QHS
11. Omeprazole 40 mg PO DAILY
12. Nitroglycerin SL 0.3 mg SL PRN chest pain
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H shortness of breath
14. Acetaminophen 1000 mg PO DAILY:PRN pain
15. Acidophilus (L.acidoph &
___ acidophilus) 300 mg oral
daily
Discharge Medications:
1. Acetaminophen 1000 mg PO DAILY:PRN pain
2. Cephalexin 500 mg PO Q8H
RX *cephalexin 500 mg 1 capsule(s) by mouth three times a day
Disp #*9 Capsule Refills:*0
3. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*6 Capsule Refills:*0
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Lorazepam 0.25-0.5 mg PO BID:PRN anxiety
6. Losartan Potassium 50 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Rosuvastatin Calcium 40 mg PO QHS
10. TraMADOL (Ultram) 100 mg PO DAILY:PRN pain
RX *tramadol 100 mg 1 tablet extended release 24 hr(s) by mouth
daily Disp #*30 Tablet Refills:*0
11. Nitroglycerin SL 0.3 mg SL PRN chest pain
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H shortness of breath
13. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
14. Acidophilus (L.acidoph &
___ acidophilus) 300 mg oral
daily
15. Aquaphor Ointment 1 Appl TP BID
16. Docusate Sodium 100 mg PO BID
Please hold if patient having loose stool.
17. Senna 8.6 mg PO BID:PRN constipation
Please hold if patient has loose stool.
18. Outpatient Lab Work
Please electrolytes and Cr every other day to ensure Cr trends
back to baseline (1.4)
19. Furosemide 60 mg PO QAM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses: cellulitis, venous stasis dermatitis, acute
kidney injury
Secondary Diagnoses: diastolic congestive heart failure, chronic
obstructive pulmonary disease, hypertension, atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___ was a pleasure taking care of you at ___. You were admitted
with worsening leg swelling and wounds. You were treated with
antibiotics. You were also evaluated by the wound care team who
recommended certain dressings and wound care for your legs. You
were also evaluated by physical therapy and it was decided that
you would benefit from rehab and possibly a longer term care
facility to help with your dressing changes and care.
Please keep your follow-up appointments as below. Please return
to the emergency room if you experience fevers, chills, chest
pain, shortness of breath, worsening leg pain or drainage or any
other new or concerning symptoms. Your weight on discharge from
the hospital is 188 lb (or 85.7 kg), please check your weight
daily and tell your doctor if your weight goes up more than 3
lbs.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
19842518-DS-10
| 19,842,518 | 25,697,860 |
DS
| 10 |
2118-09-30 00:00:00
|
2118-09-30 16:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
RUQ Abdominal pain
Major Surgical or Invasive Procedure:
EUS ___
History of Present Illness:
Ms. ___ is a ___ with a history of asthma, s/p
cholecystomy, appendectomy and infectious colitis who presents
with RUQ and midepigastric pain. The patient describes
intermittent sharp pain lasting 10 minutes that comes in waves
at a time that started 3 days ago without radiation to the back.
Pt endorses nausea and has not had any PO intake for >24hrs. She
denies vomiting, diarrhea, bloody or melenotic stool. Denies
fever, chills, dysuria, recreational drug use of EtOH, rash or
joint pain.
She denies any recent travel, not currently sexually active
Last BM was 2 days ago.
In the ED, inital VS were: 98.0 99 130/86 18 98% RA
Exam notable for severe RUQ and midepigastric tenderness w/
rebound tenderness. Labs were notable for a normal CBC, normal
chemistry panel, normal LFTs, urinalysis bland.
Patient received a CT abdomen/pelvis w/ IV contrast which showed
minimal bladder wall thickening but otherwise no cause for her
abdominal pain. ERCP was consulted in the ED who did not
recommend ERCP at this time but who agreed to follow the patient
on the floor.
The patient received 2L NS, a total of 23 mg IV morphine, a
total of 20 mg IV ondansetron and 25 mg diphenhydramine.
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 nausea or vomiting. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
Asthma
s/p Appendectomy at age ___
s/p Cholecystectomy at age ___
Social History:
___
Family History:
Denies family history of inflammatory bowel disease, gastritis
or
autoimmune diseas. Maternal grandmother with breast cancer.
Maternal grandfather with bipolar disorder
Physical Exam:
ADMISSION EXAM:
===============
Vitals: 98.6 127/78 67 16 98% RA
General: NAD female resting in bed.
HEENT: clear oropharynx, mmm, sclera anicteric
Neck: supple
Lungs: CTA b/l no w/r/r
CV: RRR, no m/r/g
Abdomen: soft, minimal tenderness diffusely, no rebound/guarding
GU: no foley
Ext: no edema
Neuro: alert and conversant
DISCHARGE EXAM:
==============
Vitals: 98.2 100s/60s-70s ___ 16 98%RA
General: NAD female resting in bed.
HEENT: clear oropharynx, mmm, sclera anicteric
Neck: supple
Lungs: CTA b/l no w/r/r
CV: RRR, no m/r/g
Abdomen: soft, tenderness to palpation mostly in RUQ, no
rebound/guarding
GU: no foley
Ext: no edema
Pertinent Results:
ADMISSION LABS:
===============
___ 08:10PM PLT COUNT-276
___ 08:10PM NEUTS-61.0 ___ MONOS-7.0 EOS-2.7
BASOS-0.3 IM ___ AbsNeut-4.01 AbsLymp-1.89 AbsMono-0.46
AbsEos-0.18 AbsBaso-0.02
___ 08:10PM WBC-6.6 RBC-4.09 HGB-13.0 HCT-38.5 MCV-94
MCH-31.8 MCHC-33.8 RDW-12.9 RDWSD-44.3
___ 08:10PM ALBUMIN-4.8
___ 08:10PM LIPASE-25
___ 08:10PM ALT(SGPT)-25 AST(SGOT)-24 ALK PHOS-74 TOT
BILI-0.6
___ 08:10PM estGFR-Using this
___ 08:10PM GLUCOSE-92 UREA N-14 CREAT-0.7 SODIUM-140
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-30 ANION GAP-12
___ 08:30PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-3
___ 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
___ 08:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:30PM URINE UHOLD-HOLD
___ 08:30PM URINE UCG-NEGATIVE
___ 08:30PM URINE HOURS-RANDOM
___ 12:25AM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-1
___ 12:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 12:25AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:25AM URINE GR HOLD-HOLD
___ 12:25AM URINE UHOLD-HOLD
___ 12:25AM URINE HOURS-RANDOM
___ 12:25AM URINE HOURS-RANDOM
PERTINENT LABS:
===============
___ 08:30AM BLOOD ALT-195* AST-131* AlkPhos-101
TotBili-1.9*
___ 08:00AM BLOOD Acetmnp-7*
___ 08:00AM BLOOD ALT-135* AST-63* LD(LDH)-142 AlkPhos-91
TotBili-1.5
___ 08:10AM BLOOD ALT-117* AST-55* AlkPhos-90 TotBili-1.9*
___ 07:00AM BLOOD ALT-128* AST-85* AlkPhos-88 TotBili-1.7*
___ 08:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
___ 08:00AM BLOOD ___
___ 08:00AM BLOOD HCV Ab-NEGATIVE
___ 07:00AM BLOOD ALT-128* AST-85* AlkPhos-88 TotBili-1.7*
DirBili-0.4* IndBili-1.3
___ 07:00AM BLOOD Triglyc-139 HDL-42 CHOL/HD-3.6 LDLcalc-82
___ 07:00AM BLOOD Ferritn-116
___ 07:00AM BLOOD TSH-3.0
___ 11:53AM BLOOD AMA-PND Smooth-PND
___ 08:00AM BLOOD ___
___ 07:00AM BLOOD PEP-PND IgG-692* IgA-96 IgM-91
___ 11:53AM BLOOD tTG-IgA-PND
___ 01:35PM BLOOD ANTI-LIVER-KIDNEY-MICROSOME ANTIBODY-PND
MICRO:
=====
___ SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY
TEST-PENDING INPATIENT
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 1:35 pm SEROLOGY/BLOOD
**FINAL REPORT ___
MONOSPOT (Final ___:
NEGATIVE by Latex Agglutination.
(Reference Range-Negative).
___ 1:35 pm Blood (CMV AB)
CMV IgG ANTIBODY (Pending):
CMV IgM ANTIBODY (Pending):
IMAGING/STUDIES:
================
+ ___BD & PELVIS WITH CO
IMPRESSION:
1. Minimal thickening of the bladder wall which could suggest
cystitis and clinical correlation with urinalysis is
recommended.
2. Borderline enlarged spleen, unchanged.
3. No cause for the patient's right upper quadrant and
epigastric pain
identified.
+ ___ Imaging MRCP (MR ___
IMPRESSION:
Status post cholecystectomy with a normal appearance of the
biliary system. No acute abnormality to explain the patient's
pain.
+ ___ - upper EUS report
Findings: Esophagus: Minimal exam of the esophagus was normal
with the echoendoscope.
Stomach:
Contents: Food residua was found in the stomach
Duodenum: Limited exam of the duodenum was normal with the
echoendoscope.
Other
findings: EUS was performed using a linear echoendoscope at 7.5
MHz frequency: The head and uncinate pancreas were imaged from
the duodenal bulb and the second / third duodenum. The body and
tail (partially) were imaged from the gastric body and fundus.
Pancreas parenchyma: The parenchyma in the uncinate, head, body
and tail of the pancreas was homogenous, with a normal salt and
pepper appearance.
Pancreas duct: The pancreas duct was normla in diameter. The
duct was normal in echotexture and contour. No intra-ductal
stones were noted. No dilated side-branches were noted.
___ vasculature: Portal vein, splenic vein and
porto-splenic confluence were imaged and appeared normal. The
imaged superior mesenteric vein and artery were imaged and
appeared normal. Ampulla appeared normal both endoscopically and
sonographically.
Common bile duct: The common bile duct measured 4mm in size.
There was no ductal wall thickening or evidence of stones.
Impression: Food in the stomach
Normal EUS: normal pancreas; normal peripancreatic vasculature,
no dilation of the CBD or PD; no CBD or PD stones
ERCP not performed given above findings
DISCHARGE LABS:
===============
___ 06:05AM BLOOD WBC-4.0 RBC-3.75* Hgb-11.7 Hct-35.9
MCV-96 MCH-31.2 MCHC-32.6 RDW-12.9 RDWSD-44.9 Plt ___
___ 06:05AM BLOOD Glucose-123* UreaN-5* Creat-0.8 Na-141
K-4.1 Cl-104 HCO3-27 AnGap-14
___ 06:05AM BLOOD ALT-161* AST-111* AlkPhos-83 TotBili-1.1
Brief Hospital Course:
Ms. ___ is a ___ with a history of cholecystomy,
appendectomy, acne vulgaris on minocycline and recent admission
with infectious colitis who presented with RUQ and midepigastric
pain. CT scan showed no evidence of peritonitis or colitis.
Morning after admission the patient developed a mild
transaminitis and elevated T bili. Pt underwent MRCP ___ which
was normal. EUS also showed no abnormalities. Hepatitis A,B,C
serologies all WNL, TSH, lipid panel, iron studies normal,
H.pylori serum antibody negative, Monospot negative. Autoimmune
hepatitis in the setting of minocycline use was considered;
however ___ was negative. On ___ hepatology was consulted and
no immediate cause of transaminitis could be elucidated.
Transaminitis remained stable but did not improve prior to
discharge (ALT in the 120s-160s, AST ___. Elevated T bili
thought to be secondary to ___ syndrome (given indirect
hyperbilirubinemia) and T bili normalized. The patient's
symptoms of abdominal pain improved and she was able to tolerate
PO and had decreasing pain medication requirements and so it was
determined that she should be followed up by hepatology as an
outpatient. Of note, the patient's home minocycline was stopped
in the setting of transaminitis.
TRANSITIONAL ISSUES:
[] Patient needs to establish care with new PCP at ___ within 1
week and needs to follow up with Hepatology within 2 weeks after
discharge.
[] Please check LFTs at PCP discharge follow up appointment.
[] The following lab tests were pending at discharge and need to
be followed up: tTG-IgA, AMA, anti-smooth muscle Ab, SPEP,
anti-liver kidney microsome Ab, CMV serologies.
[] Patient was advised to stop taking minocycline upon
discharge.
[] If patient complains of odynophagia, may consider EGD as an
outpatient (r/o minocycline-induced esophagitis).
[] Patient was started on omeprazole 40 mg daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Minocycline 100 mg PO EVERY OTHER DAY
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q8h:PRN Disp #*12
Tablet Refills:*0
2. OxycoDONE (Immediate Release) 2.5 mg PO Q8H:PRN pain
This can cause drowsiness. Do not take before driving or
operating machinery.
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q8h:PRN
Disp #*10 Tablet Refills:*0
3. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Abdominal pain
Transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were recently admitted to the ___
___ abdominal pain. You had an MRI of your abdomen as
well as an endoscopic ultrasound, neither of which could
determine the cause of your pain. After you were admitted your
liver function tests were elevated and so you were seen by our
liver doctors. You had tests that were sent off that were
pending by the time you were discharged. Because you were
tolerating a regular diet and your pain improved, we determined
it was safe for you to go home.
You should stop taking your minocycline because you have some
liver lab abnormalities. Please discuss this with your primary
care doctor before restarting. Also, you should avoid taking
acetaminophen (Tylenol) and ibuprofen (Aleve, Motrin).
It is very important that you call to schedule an appointment
with a new primary care provider at ___. You need to be seen
within 1 week. The number is provided below. You also need to be
seen by our liver doctors for follow up within 2 weeks.
If you experience any worsening symptoms including pain, fever,
nausea or vomiting, please call seek medical attention.
Thank you for allowing us to participate in your care. We wish
you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19842794-DS-17
| 19,842,794 | 23,833,239 |
DS
| 17 |
2160-08-05 00:00:00
|
2160-08-06 05:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, vomiting
Major Surgical or Invasive Procedure:
___ ___ biopsy of liver mass
History of Present Illness:
Mr. ___ is a ___ man with history of colon cancer
s/p resection with diverting ileostomy, chemo/XRT and lost to
follow up, DVT/PE s/p IVC filter not on anticoagulation, atrial
fibrillation, hypertension, depression presenting with abdominal
pain, nausea, vomiting, transferred from an outside hospital for
small bowel obstruction and concern for liver metastases.
The patient reports that ___ years ago he developed bright red
blood per rectum. He underwent colonoscopy, that revealed colon
cancer. He underwent resection with diverting ileostomy, and
chemotherapy/radiation. His post-operative course was
complicated
by sepsis due to bowel perforation that required ?additional
bowel resection and repositioning of his ostomy. His surgery was
also complicated by incisional hernia. Due to this difficult
experience, he did not attend any follow up regarding his colon
cancer and has not had any surveillance imaging. He previously
received his oncologic care at ___.
Two days ___ to admission on ___, the patient ate eggs and
toast around 1:30 pm, and subsequently had nausea and projectile
vomiting. He was able to tolerate some water. Later than
evening,
around 10 pm, he developed severe, bilateral lower abdominal
pain. The pain was the worse pain that he has ever experienced.
This pain lasted for about ___ minutes and then resolved. On
___, he tried to drink Ensure. He initially tolerated this,
but
subsequently had projectile vomiting. He was not able to
tolerate
water either without vomiting. He denies any abdominal pain at
this time. He states his ostomy output was slightly more liquid,
but this occurs when he does not eat. He felt subjectively
feverish but did not check his temperature. Patient states that
he has been feeling depressed around the holidays and believes
the increased stress has given him "colitis."
On ___, given his ongoing inability to tolerate any oral
intake, he presented to ___. There, labs
were notable for: WBC 15.9, Hb 14.7, Cr 1.3, lactate 5.9. CT A/P
obtained that demonstrated possible small bowel obstruction,
ventral hernia without incarceration, small-volume ascites,
numerous liver metastases. He was given IVF, Zofran, morphine.
Given these findings, he was transferred to ___ for further
management.
In the ED, initial vitals: 2 98.1 84 129/82 16 100% RA
Labs notable for: WBC 11 (87N), Hb 12.8, INR 1.3; lactate
2.2->1.3; AST 49, ALT 22, AP 335, Tb 0.6; BMP wnl
Consults: ACS
Patient given: Ceftriaxone 1 gm, Flagyl 500 mg IV, 2L NS
On arrival to the floor, the patient reports that he feels well.
He denies any abdominal pain. No nausea. No vomiting. No change
in ostomy output. No fevers or chills.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Colon cancer s/p resection with diverting ileostomy and
XRT (diagnosed ___ lost to follow up before getting adjuvant
chemotherapy)
-- Complicated by incisional ventral hernia
- DVT/PE in ___ in setting of colon cancer, previously on
rivaroxaban but discontinued due to bleeding; s/p IVC filter
- Atrial fibrillation
- Hypertension
- Depression
Social History:
___
Family History:
No known family history of colon cancer or other
gastrointestinal malignancy.
Physical Exam:
Admission exam:
===============
VITALS: 98.1 128/74 74 20 97 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart irregular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen with large reducible ventral hernia, left ostomy
with
pink stoma and soft stool output, no abdominal tenderness to
palpation, no rebound or guarding
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
.
.
Discharge exam:
===============
24 HR Data (last updated ___ @ 726)
Temp: 98.5 (Tm 99.1), BP: 127/76 (109-127/65-76), HR: 73
(73-78), RR: 18, O2 sat: 97% (94-97), O2 delivery: Ra
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft, nontender; no rebound/guarding; normal bowel sounds;
ostomy bag with brown liquid stool;
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
Admission
___ 02:20PM BLOOD WBC-11.2* RBC-4.42* Hgb-12.8* Hct-39.4*
MCV-89 MCH-29.0 MCHC-32.5 RDW-13.9 RDWSD-45.1 Plt ___
___ 02:20PM BLOOD Glucose-108* UreaN-22* Creat-1.0 Na-134*
K-4.4 Cl-95* HCO3-23 AnGap-16
___ 02:20PM BLOOD ALT-22 AST-49* AlkPhos-335* TotBili-0.6
WORKUP
___ CEA: 264.9*
DISCHARGE
___ 06:42AM BLOOD WBC-8.5 RBC-4.23* Hgb-12.2* Hct-38.0*
MCV-90 MCH-28.8 MCHC-32.1 RDW-13.6 RDWSD-44.7 Plt ___
___ 06:42AM BLOOD Glucose-92 UreaN-14 Creat-0.8 Na-138
K-4.2 Cl-99 HCO3-22 AnGap-___/P - see paper chart
CT NECK W/CONTRAST (EG:
No mass, no adenopathy.
Mildly prominent partially seen aortic arch, chest PA and
lateral recommended.
RECOMMENDATION(S): Chest PA and lateral.
CT HEAD W/O CONTRAST
Findings consistent with mild-to-moderate chronic small vessel
ischemic
changes. Posterior right centrum semiovale, parietal lobe small
low-attenuation areas, may represent chronic or subacute
infarct.
CHEST (PORTABLE AP)
there is no evidence of pneumonia, pleural effusion, or
pneumothorax. The cardiomediastinal structures are otherwise
unremarkable. There is no acute osseous abnormalities
An equivocal circular projection with central radiolucency
within the right lung of unclear etiology. This does not
resemble pneumonia. Recommend repeat chest radiograph with
frontal and lateral views for comparison.
CXR
There is no focal consolidation, pleural effusion or
pneumothorax identified. The previously described circular
projection with central radiolucency projecting over the right
medial hemithorax is not evident on this radiograph and may
have been projectional. The size and appearance of the
cardiomediastinal silhouette is unchanged. Incompletely
evaluated cervical spinal hardware.
BX-NEEDLE LIVER BY RADI
1. Uncomplicated 18-gauge targeted liver biopsy x 4, with
specimen sent to
pathology.
2. Uncomplicated small volume paracentesis.
Brief Hospital Course:
___ year old male with past medical history of colon cancer s/p
resection with diverting ileostomy and XRT, history of pulmonary
embolism status post IVC filter but not on anticoagulation due
to reported history of bleeding, atrial fibrillation,
hypertension admitted ___ with abdominal pain and
vomiting, found to have small bowel obstruction and liver
masses, clinically improving with conservative management, able
to tolerate regular diet, course otherwise notable for biopsy of
liver mass, biopsy results pending at time of discharge
# Small Bowel Obstruction
Patient presented with several days of worsening abdominal pain,
nausea, vomiting, inability to tolerate PO, with cross-sectional
imaging showing small bowel obstruction. Patient seen by
general surgery service and recommended for conservative
management. Of note, per review of CT scan, transition point
felt to be unrelated to patient's abdominal wall hernia (patient
was concerned this had been the cause), and was felt to be more
likely related to possible scar tissue from ___ operation.
Patient's symptoms improved with NPO, IV fluids. He
subsequently was able to have diet slowly advanced without
issue. ___ to discharge, he received nutrition counseling re:
low fiber diet.
# Secondary malignancy of liver
# Likely metastatic colon cancer
Cross-sectional imaging incidentally showed numerous liver
metastases. Patient CEA markedly elevated. He underwent
ultrasound guided biopsy of liver mass. Clinical picture felt
to suggest metastatic colon cancer, but biopsy pathology still
pending at discharge. Coordinated with ___ oncology and
arranged for appointment in ___ GI ___ clinic--per discussion,
biopsy results will be discussed with patient at time of
appointment.
# Abdominal wall hernia
Hospital course notable for patient anxiety about abdominal wall
hernia. As above, was seen by general surgery service who felt
chronic hernia was unrelated to his small bowel obstruction.
Given ___ radiation, likely diagnosis of recurrent malignancy,
they recommended against repair of hernia at this time. Patient
provided with education re: abdominal binder use. Has general
surgery follow-up appointment.
# Paroxysmal atrial fibrillation
Continued metoprolol
# History of DVT/PE s/p IVC filter:
Patient reported he was not on anticoagulation due to ___ head
bleed. Continued home ASA. Would consider consider outpatient
risk/benefit discussion re: anticoagulation in patient with IVC
filter in place.
# Depression:
Continued mirtazapine
# Patient and family concerns
Patient and sister were concerned about home support for
patient. ___ recommended home ___, case management helped arrange
home services, assisted with elder
services referral and provided contact information for private
pay help. Patient and sister agreed that discharge home was a
safe plan.
Transitional issue
- Discharged home with services, including ___, ___
- Results of biopsy to be discussed with patient at scheduled
oncology follow-up
- Has discharge follow-up scheduled with PCP, general surgery
(for abdominal wall hernia, small bowel obstruction follow-up)
and ___ oncology
> 30 minutes spent on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Mirtazapine 7.5 mg PO QHS
3. Aspirin 243 mg PO DAILY
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
Discharge Medications:
1. Aspirin 243 mg PO DAILY
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Mirtazapine 7.5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Suspected Small Bowel Obstruction
# Liver lesions concerning for cancer
# Personal History of Colon cancer
# Paroxysmal atrial fibrillation
# History of DVT and pulmonary embolism
# Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___. You were
admitted with nausea, vomiting and abdominal pain.
You underwent a CAT scan that showed a mild obstruction of your
intestines. You were seen by surgeons. You improved with
fasting and IV hydration. You were able to eat a regular low
fiber diet without recurrence of your symptoms.
Your CAT scan also showed masses in your liver that were
concerning for cancer. You underwent biopsy--the results of this
test were still pending at the time of your discharge. We have
made an oncology appointment for you--they will have the final
results and will be ready to discuss them with you at the
appointment.
You are now ready for discharge home. We have arranged for
visiting nursing and physical therapy to help with your
transition back home.
Followup Instructions:
___
|
19842794-DS-18
| 19,842,794 | 21,205,299 |
DS
| 18 |
2161-06-09 00:00:00
|
2161-06-09 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: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
___ 09:09PM WBC-20.8* RBC-3.02* HGB-8.9* HCT-27.4* MCV-91
MCH-29.5 MCHC-32.5 RDW-18.8* RDWSD-61.2*
___ 09:09PM PLT COUNT-466*
___ 09:09PM GLUCOSE-181* UREA N-17 CREAT-0.6 SODIUM-139
POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-23 ANION GAP-15
___ 09:09PM ALT(SGPT)-81* AST(SGOT)-122* ALK PHOS-1038*
TOT BILI-2.1* DIR BILI-1.5* INDIR BIL-0.6
___ 09:09PM ALBUMIN-2.9*
___ 09:09PM cTropnT-<0.01
___ 12:17PM STOOL CDIFPCR-POS* CDIFTOX-NEG
IMAGING:
CXR
IMPRESSION:
Compared to chest radiographs since ___ most recently ___. Small right pleural effusion is new. Right lower lobe, as
evaluated on the lateral view has either new basal atelectasis
or
small pneumonia. Left lung clear. No left pleural abnormality.
Heart size top-normal. Right supraclavicular central venous
infusion catheter ends in the right atrium.
RUQ US
IMPRESSION:
1. Patent portal vein with hepatopetal flow.
2. Stable moderate intrahepatic biliary ductal dilatation within
the left hepatic lobe. No new biliary ductal dilatation.
3. Extensive hepatic metastatic disease, better assessed on
___
CT from ___.
4. Cholelithiasis without acute cholecystitis.
Brief Hospital Course:
SUMMARY:
___ yo M PMHx rectal cancer s/p neoadjuvant chemoRT, right
hemicolectomy with diverting ileostomy, also with DVT/PE s/p IVC
filter, now with metastatic colorectal cancer, recent c diff
infection, who has been on home hospice since ___ who
presented to the ED with acute GI bleeding and acute blood loss
anemia from his ileostomy that could not be managed at home.
His hospital course is complicated by transaminitis,
hyperbilirubinemia and fevers.
___ HOSPITAL COURSE:
# Acute blood loss anemia
# Acute GI bleeding
# Metastatic colon cancer on home hospice
# Acute cancer pain
Likely related to metastatic colon cancer in the setting of both
systemic Anticoagulation and antiplatelet use. Patient received
1 unit pRBCs. Home apixaban and aspirin were stopped. Bleeding
stopped with cessation of anti coagulation. Patient was
counseled on increased risks of DVT/PE and stroke while he is
off anticoagulation. He accepted these risks and stated a
preference to remain off anticoagulation. Home dexamethasone,
tylenol, tramadol, and morhphine were continued for symptom
control.
# Fevers
Ultimately attributed to C diff. The initial differential was
broad including fevers ___ infectious process (such as recurrent
c diff or cholangitis) vs. metastatic malignancy. Based on
discussion with patient's HCP sister ___, patient would
want basic infectious w/u to see if easily reversible cause. UA
and CXR unremarkable. RUQUS without acute process or signs of
cholecystitis, though notable for diffuse hepatic mets. C diff
PCR returned positive. Patient was started on PO vancomycin.
While the c diff toxin confirmatory test resulted negative,
patient symptomatically improved with PO vancomycin so suspect
true infection. He will complete a 2 week course of vancomycin
for first recurrence of c diff.
# Transaminitis/Hyperbilirubinemia
Suspect ___ liver mets, though was noted to rise precipitously
in only a few days this hospitalization. RUQ US was without
signs of cholecystitis or worsening biliary ductal dilation. We
discussed with patient and sister how there is no
intervention we can offer for this based on patient's overall
goals of care, whether this be from cancer or cholangitis. Labs
were not further trended.
# Goals of care
Patient is DNR/DNI, and has chosen comfort focused care. He is
on home hospice. However, patient has continued to ask for
interventions to treat easily reversible conditions (such as
UTI, c diff, etc).
# Anxiety
# Depression
Continued Mirtazipine and Ativan.
# GERD
Continued Ranitidine
> 30 minutes spent in discharge planning and counseling
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
2. Dexamethasone 2 mg PO DAILY
3. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever
4. Mirtazapine 7.5 mg PO BID
5. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
6. LORazepam 0.5 mg PO Q8H:PRN nausea, anxiety, insomnia
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Apixaban 2.5 mg PO BID
9. Ranitidine 150 mg PO BID
10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
11. Multivitamins W/minerals Chewable 1 TAB PO DAILY
12. Aspirin 81 mg PO DAILY
13. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q1H:PRN
Pain - Severe
Discharge Medications:
1. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q1H:PRN
BREAKTHROUGH PAIN
pain
2. Tylenol 8 Hour (acetaminophen) 1300 mg oral BID
home med
3. Vancomycin Oral Liquid ___ mg PO QID
through ___
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*42 Capsule Refills:*0
4. Acetaminophen 1000 mg PO BID
5. Dexamethasone 2 mg PO DAILY
6. LORazepam 0.5 mg PO Q8H:PRN nausea, anxiety, insomnia
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Mirtazapine 7.5 mg PO BID
9. Multivitamins W/minerals Chewable 1 TAB PO DAILY
10. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
11. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
12. Ranitidine 150 mg PO BID
13. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic rectal cancer
C. diff infection
GI bleeding
DVT/PE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital with bleeding in your ostomy. You
received a blood transfusion. Blood thinning medications
Eliquis and aspirin were stopped. Your bleeding resolved with
these interventions. You opted not to restart the blood
thinners.
While in the hospital, you were noted to have fevers. The
screening test for c diff was positive so you were started on
antibiotic vancomycin. Please take vancomycin for two weeks to
treat c diff infection.
Please follow-up with your hospice team after discharge.
Followup Instructions:
___
|
19842829-DS-14
| 19,842,829 | 26,573,640 |
DS
| 14 |
2140-04-19 00:00:00
|
2140-04-19 12:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with history of NIDDM who presents with chest
pain. He was in his usual state of good health until
approximately 12:30am on the night prior to admission, when he
developed dull chest pain wrapping across his chest to his back,
awakening him from sleep. Chest pain was ___ at maximal
intensity, waxing and waning over a period of hours. Chest pain
was unaffected by position or exertion and accompanied by
nausea, but no diaphoresis, lightheadedness, palpitations,
shortness of breath, or pleuritic chest pain. He has never
experienced such pain before and points out that he has
excellent exercise tolerance, cycling frequently without
exertional chest pain or dyspnea. When his pain did not subside,
he called EMS and was given aspirin 324mg and SL nitroglycerin
x2 en route to ___, with effective relief of chest pain and no
recurrence since that time.
In the ED, initial vital signs were: 98.1 90 130/80 16 99% 1L
Nasal Cannula. Admission labs were notable for TnT <0.01 x2 and
uremarkable CBC, chemistries, and LFTs. CXR was negative for an
acute cardiopulmonary process. He was placed initially under
observation for a stress test, with ETT demonstrating 0.5-1 mm
upsloping ST segment depressions inferiorly and in leads V4-V6,
resolved 1 minute post-exercise; he remained asymptomatic
throughout. Given stress test findings, he was admitted for
further evaluation. He received famotidine and simethicone.
Vital signs prior to transfer were as follows: 98.2 84 128/74 16
98% RA.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
NIDDM
GERD
Gout
OSA on CPAP
Fatty liver
Subclinical hypothyroidism
Renal mass
Social History:
___
Family History:
No known family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
==========
ADMISSION
==========
VS: 98.5, 126/98, 102, 19, 97% RA
General: Well-appearing in NAD
HEENT: PERRL, MMM
Neck: No JVP
CV: Slight regular tachycardia, no murmurs
Lungs: Breathing comfortably, CTAB
Abdomen: Soft, NT/ND
Ext: WWP, no edema
Neuro: Appropriately interactive, CNs grossly intact, strength
and sensation grossly intact, gait deferred
Skin: No visible lesions
==========
DISCHARGE
==========
vs: 97.8 124/75 86 16 98% RA
General: Well-appearing in NAD
HEENT: PERRL, MMM
Neck: No JVP
CV: Slight regular tachycardia, no murmurs
Lungs: Breathing comfortably, CTAB
Abdomen: Soft, NT/ND
Ext: WWP, no edema
Neuro: Appropriately interactive, CNs grossly intact, strength
and sensation grossly intact, gait deferred
Skin: No visible lesions
Pertinent Results:
================
ADMISSION LABS
================
___ 09:45AM BLOOD WBC-9.9 RBC-4.64 Hgb-13.9* Hct-41.3
MCV-89 MCH-30.0 MCHC-33.7 RDW-13.7 Plt ___
___ 09:45AM BLOOD Neuts-92.8* Lymphs-3.1* Monos-3.4 Eos-0.5
Baso-0.3
___ 09:45AM BLOOD Plt ___
___ 09:45AM BLOOD Glucose-126* UreaN-24* Creat-0.8 Na-135
K-3.7 Cl-104 HCO3-21* AnGap-14
___ 09:45AM BLOOD ALT-37 AST-25 AlkPhos-46 TotBili-0.5
___ 09:45AM BLOOD cTropnT-<0.01
___ 01:50PM BLOOD cTropnT-<0.01
___ 12:06AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:50AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:45AM BLOOD Lipase-15
___ 09:45AM BLOOD Albumin-4.2
==========
IMAGING
==========
CXR PA/lateral (___): No acute cardiopulmonary process.
ETT (___):
INTERPRETATION: ___ yo man with DM and BMI of 38 was referred to
evaluate an atypical chest discomfort, shortness of breath and
generalized fatigue over the past weeks. The patient completed
10.5
minutes of a modified ___ protocol representing an average
exercise tolerance; ~ ___ METS. The exercise test was stopped
due to fatigue. No chest, back, neck or arm discomforts were
reported by the patient during the procedure. At peak exercise,
0.5-1 mm upsloping ST segment depressions were noted inferiorly
and in leads V4-V6. These ST segment changes were absent 1
minute post-exercise. The rhythm was sinus with no ectopy noted.
The hemodynamic response to exercise was appropriate.
IMPRESSION: Average exercise tolerance. No anginal symptoms with
nonspecfic ST segment changes. Appropriate hemodynamic response
to
exercise.
================
DISCHARGE LABS
================
___ 05:50AM BLOOD WBC-5.0 RBC-4.38* Hgb-13.3* Hct-39.1*
MCV-89 MCH-30.3 MCHC-34.0 RDW-13.7 Plt ___
___ 05:50AM BLOOD Glucose-118* UreaN-16 Creat-0.9 Na-133
K-3.6 Cl-102 HCO3-24 AnGap-11
___ 05:50AM BLOOD CK(CPK)-129
___ 05:50AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.4
Brief Hospital Course:
Mr. ___ is a ___ with history of NIDDM who presents with chest
pain, no elevation in troponin, no signs of infarct or ischemia
on EKG, normal stress test.
=================
ACUTE ISSUES
=================
# Chest pain: He presents with chest pain potentially concerning
for unstable angina in its occurence at rest and with relief
with nitroglycerin, though stress test negative. Patient was
asymptomatic with ETT and reports excellent exercise tolerance.
Alternative causes of chest pain, including dissection and
pneumonia, have been precluded by CXR, and there is low clinical
suspicion for PE in the absence of shortness of breath or
hypoxia, though he is mildly tachycardic on arrival to the
floor. He does carry a history of GERD, but chest pain was not
reminiscent of GERD episodes. He remained chest pain free for
the rest of his hospitalization.
===============
CHRONIC ISSUES
===============
# NIDDM: Hold home metformin in favor of Humalog insulin sliding
scale. Continue metformin on discharge
# Gout: Continue home allopurinol.
# OSA: Continue CPAP.
====================
TRANSITIONAL ISSUES
====================
[]Further ___ year risk stratification work up -> Consider
starting low dose Aspirin as outpatient
[]Follow up with Cardiology as an outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
2. Allopurinol ___ mg PO BID
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. Allopurinol ___ mg PO BID
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Atypical Chest Pain
Secondary Diagnosis:
DIabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to the hospital for chest pain. Your EKG was
normal and your lab tests did not reveal anything concerning for
a heart attack. Your stress test also did not show any signs of
heart damage. We recommend that you follow up with cardiology as
an outpatient for further work up.
It was a pleasure meeting and taking care of you while you were
in the hospital.
-Your ___ Team
Followup Instructions:
___
|
19843082-DS-6
| 19,843,082 | 23,323,137 |
DS
| 6 |
2151-06-20 00:00:00
|
2151-06-20 15:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
intubation
bronchoscopy
PICC placement
History of Present Illness:
___ year old woman with history of depression with psychotic
features, ___ esophagus, HLD, GERD, who presented with a
one-week history of altered behavior, confusion, and paranoia.
Husband reports that the patient has been confused and paranoid
for the past week, believing that people are stealing from her.
Per husband, the patient has not been sleeping for several days,
she also has had polyuria, apparently lost control of bowels a
few times over past several days. Patient was at a ___
and pulled off her pants and refused to put them up. Patient has
been refusing to see Psychiatry and was refusing to physically
come in to the ED and had to be ___ from the ___ Lobby.
Pt was restless/hyperactive, inattentive, fluctuating arousal,
rambling almost incoherent narrative, denies SI/HI.
Per Psych note ___: No current medications per her husband
and has been off her psychiatric medications in ___. or ___. Her meds were: Lorazepam, Mirtazapine, Nadolol,
Risperidone, Venlafaxine
In the ED, she met criteria for ___. Patient became
somnolent, and she was intubated. She was given fentanyl,
midazolam, ativan for sedation, haldol and risperidone for
altered behavior; received 5 L NS; azithromycin 500 mg,
ceftriaxone 1 g. Patient spiked a fever to 102.8, given Tylenol,
blood cx sent. Pressure stabilized to map of 65-70. Stable on
vent, O2 100%, HR 84
In the ED, VS: T 97.3 --> 102.8 BP 147/71 --> 89/46 RR ___
SatO2 94%/NC --> 100% intubation
ED notable labs: Na 131, K 3.3, Cl 92, bicarb 21, AGap 21
CBC 17.9 (N 74.7, AbsNeut 13.38), plts 495
VBG: pH 7.29 pCO2 49 pO2 59;
Utox neg (Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne,
Oxycodone); Serum Tox neg (ASA, EtOH, Acetmnphn, Benzo, Barb,
Tricyc)
In ED: sent blood cx
Imaging:
Chest XR (___): Endotracheal tube tip is noted 5.6 cm from
the carina. Enteric tube passes below the inferior field of
view. New left-sided central venous catheter tip projects over
the mid SVC. Otherwise, there has been no change. Persistent
bilateral parenchymal opacities worse at the bases are again
noted. There are
also possible bilateral effusions. There is no pneumothorax.
Consults:
PSYCH:
Pt is restless/hyperactive, inattentive, fluctuating arousal,
rambling almost incoherent narrative, denies SI/HI. Pt appears
restless, no gross focal neuro deficits, no grasp reflex. Na
131, AG 21 WBC 17.9. Pt denies dysuria. Ddx delirium v. delirium
superimposed on underlying psychosis/mania
- For agitation: Haldol 0.5 - 1 mg PO Q4H PRN mild-mod agitation
Ativan 0.5 mg PO PRN anxiety/agitation not responsive to Haldol
- Will continue to follow w/ primary team to serially assess
mental status
On arrival to the FICU, patient was intubated, non-responsive,
stable.
Past Medical History:
Depression
HLD
GERD
Social History:
___
Family History:
Mother with COPD.
Physical Exam:
==================
ADMISSION PHYSICAL
==================
Vitals: T: 98.5 BP: 79/36 P: 80 R: 20 O2: 92% on FiO2 60%
GENERAL: intubated, non-responsive
HEENT: PERLA, anicteric sclera
NECK: supple
LUNGS: coarse ventilation sounds
CV: RR, no murmurs
ABD: soft, non-distended
EXT: no leg edema
===================
DISCHARGE PHYSICAL
===================
well appearing, o2 sat 98%RA
Pertinent Results:
===============
ADMISSION LABS
===============
___ 12:44PM BLOOD WBC-17.9*# RBC-4.17 Hgb-12.8 Hct-36.2
MCV-87# MCH-30.7 MCHC-35.4 RDW-12.7 RDWSD-40.1 Plt ___
___ 12:44PM BLOOD Neuts-74.7* Lymphs-12.9* Monos-9.5
Eos-1.6 Baso-0.6 Im ___ AbsNeut-13.38* AbsLymp-2.32
AbsMono-1.71* AbsEos-0.29 AbsBaso-0.11*
___ 11:40PM BLOOD ___ PTT-49.3* ___
___ 12:44PM BLOOD Glucose-151* UreaN-9 Creat-0.9 Na-131*
K-3.3 Cl-92* HCO3-21* AnGap-21*
___ 11:40PM BLOOD ALT-33 AST-54* AlkPhos-119* TotBili-0.6
___ 11:40PM BLOOD proBNP-242*
___ 11:40PM BLOOD Albumin-2.9* Calcium-8.0* Phos-4.0 Mg-1.6
___ 11:40PM BLOOD Osmolal-279
___ 12:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:41PM BLOOD Type-ART pO2-65* pCO2-33* pH-7.46*
calTCO2-24 Base XS-0
___ 05:49PM BLOOD Lactate-1.2
___ 01:23PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 01:23PM URINE RBC-3* WBC-6* Bacteri-FEW Yeast-NONE
Epi-1 TransE-<1
___ 06:00AM URINE CastGr-5* CastHy-8*
___ 01:23PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
=
Blood cultures x6 (___) - no growth
___ sputum - yeast - sparse growth
___ BAL - no growth
___ Urine cx x2 - no growth
___ Sputum - yeast
___ BAL - no growth
==============
STUDIES
==============
___ CXR
- Pulmonary vascular congestion with possible bibasilar
consolidations which could be due to infection
___ ___
- Exam is mildly motion limited. No acute intracranial process.
___ CXR:
- As compared to the previous radiograph, no relevant change is
seen. Moderate cardiomegaly and very extensive bilateral
diffuse parenchymal opacities, predominating at the lung bases
and in the perihilar lung regions, are constant in appearance.
No new opacities. No pneumothorax.
___ CXR:
- Left PICC line tip is at the level of lower SVC. Heart size
and mediastinum appear to be unchanged since the prior study but
there is progression of left basal opacity and to even more
pronounced extent right perihilar and lowerlobe opacity as well
as there is unchanged appearance of multifocal consolidations.
No interval increase in pleural effusion or development of
pneumothorax demonstrated
Brief Hospital Course:
___ year old woman with history of depression with psychotic
features, ___ esophagus, HLD, GERD who presented with a
one-week history of altered behavior, .confusion, and paranoia
concerning for delirium due to multifocal pneumonia.
# Respiratory failure secondary to pneumonia, pulm edema, COPD
with exacerbation:
Patient intubated for tachypnea and hypoxia, likely due to
bilateral PNA vs pulmonary edema. Pt was initially treated with
ceftriaxone, azithromycin and vancomycin for concern of
community acquired MRSA. She was then broadened to vanc/Zosyn
for worsening CXR and increased secretions. In addition the
patient was diuresed with Lasix which allowed for her extubation
on ___. After extubation the patient developed stridor which
was improved with methylpred and racemic epinephrine.
However, on ___, the patient's respiratory status again
worsened. She had increased work of breathing with sats down to
___, RR 44. She was placed on BiPAP and diuresed. However, she
was unable to tolerate BiPAP, and was re intubated later that
day. A chest x-ray was concerning for ARDS vs fluid overload.
She was continued on vanc until ___ and Zosyn (planned until
___, and was started on a pred taper as patient has a long
smoking history, and there was concern for COPD. She was
aggressively diuresed over the course of the next few days, and
was able to be extubated to NC on ___. She remained stable
overnight, and was able to be transferred to the floor.
.
On the floor she continued to improve. She had 1 isolated
episode of bedtime desaturation which resolved spontaneously.
Her 02 sat was otherwise 96-98%RA. She will complete a steroid
taper. She was initiated on Advair. She completed her course
of antbx.
# Sepsis due to PNA:
The patient presented with fever, tachycardia, tachypnea to ___,
hypoxia, and leukocytosis, and had a chest XR showing bilateral
opacities and possible bilateral pleural effusions, concerning
for pneumonia. She was initially treated with ceftriaxone,
azithromycin and vancomycin for concern of community acquired
MRSA pneumonia. She was then broadened to vanc/Zosyn for
worsening CXR and increased secretions. As above, the patient's
course was complicated by intubation, extubation on ___, and
reintubation on ___. She was extubated on ___. She completed a
course of vancomycin on ___, and was continued on Zosyn until
(___). She had persistent leukocytosis, but was thought to be
secondary to her prednisone taper.
# Acue encephalopathy:
Patient with recent one-week history of sleeplessness,
agitation, confusion, and paranoia. Delirium most likely
multifactorial in the setting of infection and underlying
psychosis. Utox and serum tox negative. The patient remained
anxious throughout her hospitalization, but her mental status
otherwise improved. At time of transfer from the unit, she was
alert and oriented x3.
# Anxiety:
Patient has a psychiatric history, but by report had not been
taking home medications for over a year. She remained very
anxious throughout her hospitalization. Psych saw the patient,
and recommended treatment with Seroquel. She also required
trazodone for insomnia. She will be discharged on Seroquel 50mg
BID prn and recommend close PCP and ___ follow up
# Hyponatremia:
Initial Na 131, thought to be secondary to hypovolemic
hyponatremia. After receiving IVF, improved to 138, and remained
normal throughout the rest of the hospitalization.
FLOOR COURSE:
#Multifocal pneumonia: likely health care associated vs. VAP,
possible gram positive possible gram negative. Severe, causing
ARDS and respiratory failure. Now improved but with persistent
hypoxemia requiring supplemental O2
-cont Zosyn until ___
.
#Acute on chronic diastolic congestive heart failure: f/u TTE,
PRN furosemide to maintain goal net negative 1L daily. Patient
auto-diuresing and has had >3L urine output daily since arriving
on the floor, while Cr has normalized.
Medications on Admission:
None
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Multivitamins 1 TAB PO DAILY
3. NexIUM (esomeprazole magnesium) 20 mg oral QAM
4. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour 1 patch transdermally daily Disp #*14
Patch Refills:*0
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
puff inhaled twice a day Disp #*1 Disk Refills:*0
6. QUEtiapine Fumarate 50 mg PO BID:PRN anxiety
RX *quetiapine 50 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
7. PredniSONE 10 mg PO DAILY Duration: 2 Doses
complete final part of taper
RX *prednisone 10 mg 1 tablet(s) by mouth once a day Disp #*1
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Multifocal pneumonia
respiratory failure with acute respiratory distress syndrome
COPD exacerbation (chronic obstructive pulmonary disease)
nicotine addiction
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ for confusion and found to have a
severe pneumonia. You were in the ICU and required being placed
on a ventilator after developing a condition called ARDS (acute
respiratory distress syndrome). You were eventually liberated
from the ventilator and continued antibiotics, which ended on
___. You may have a condition called sleep apnea. Please
follow up closely with your PCP and ask for a pulmonology
referral for a sleep study. Regarding smoking, you did great
with the nicotine patch for three weeks! We congratulate you on
your decision to quit smoking and encourage you to work with
your PCP to wean off the patch. Lastly, for your anxiety, you
were seen by the psychiatry team, who recommended seroquel.
Also, please see below.
Followup Instructions:
___
|
19843082-DS-8
| 19,843,082 | 21,504,147 |
DS
| 8 |
2155-05-28 00:00:00
|
2155-05-28 15:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Groin pain
Major Surgical or Invasive Procedure:
Excisional lymph node biopsy ___
History of Present Illness:
___ w/ hx of COPD, HLD, DMII, depression with paranoia and
psychotic features, and recent prolonged hospital admission
complicated by hypoxic respiratory failure, MDR VAP, ARDS,
trach/PEG w/ subsequent gastric perforation requiring s/p ex lap
and gtube replacement who presents with shock in the setting of
necrotic appearing lymph nodes.
As noted, the pt had an extended hospitalization from
___, in which she was initially admitted for
hypoxemia iso ___, however early course significant for massive
epistaxis requiring intubation. Subsequently, she developed MDR
pseudomonas VAP, ARDS, and biopsy proven DILI. Eventually
underwent trach/PEG placement on ___, which was complicated
by
gastric perforation, pneumoperitoneum, and pneumonitis requiring
ex lap and resection/replacement of gtube. Post ___ hospital
course notable for ongoing intraabdominal and pulmonary sepsis
on
broad spectrum abx (daptomycin, meropenem, and micafungin), ___
and progression to ATN, HSV flare, afib with RVR, and
encephalopathy. Ultimately the pt was stabilized from the above
acute issues and able to be discharged to rehab after over a
month in the hospital.
The pt was doing well after her admission and had transitioned
back to living at home. However, she began to complain of
progressive inguinal pain for the past 3 weeks w/ worsening
erythema and swelling. The right groin grew particularly
inflamed
and opened up about 1 week ago w/ drainage of thick white fluid.
She also endorsed intermittent chills, however denied fevers,
nausea, vomiting, dysuria, frequency, cough, or shortness of
breath. On evaluation by the pt's home ___, she was referred to
the ___ ED due to concern for infection.
In the ED, initial VS were T 99.1, HR 124, BP 110/64, RR 25, O2
98% on RA.
Exam was notable for axillary and inguinal lymphadenopathy w/
large necrotic appearing LN and purulent drainage as well as
open
chronic abdominal wounds.
Labs on arrival were significant for mild leukocytosis w/ WBC
11.7, Cr 1.2, lactate wnl, and U/A w/ 29 WBC, few bacteria, and
large leuks.
Imaging:
CXR w/o acute intrathoracic process.
CT A&P w/ contrast which showed prominent bilateral inguinal
lymph nodes w/ R hypodense lesion c/f necrotic lymph node vs
fluid collection as well as soft tissue stranding over L sided
lymph nodes.
Surgery was consulted and assessed the pt as having no surgical
indication.
The patient was given:
- 4.5mg IV zosyn
- 1500mg IV vancomycin
- 2L IVF
While in the ED the pt spiked a fever to 101 and became
progressively hypotensive requiring initiating of peripheral
norepinephrine and additional IVF. She received 4L IVF in total.
Her labs were trended and significant for an increase in lactate
from 1.8-> 8.2-> 3.4 with concomitant WBC increase to 17.2 and
Cr
elevation to 1.5. The pt was also noted to have worsening
tachypnea and hypoxia so was placed on BiPAP.
She was admitted to the FICU for further management.
Past Medical History:
COPD
Anxiety/Depression with psychosis
Hyperlipidemia
NAFLD
Pre-diabetes
Hypoxic respiratory failure
Ventilator associated pneumonia
Drug induced liver injury
Bowel perforation with peritonitis
Acute renal failure
s/p exploratory laparotomy, abdominal washout, gastric wedge
resection, placement of gastrostomy tube
Social History:
___
Family History:
Mother with COPD.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: T 98.5, HR 119, BP 114/66, RR 33, O2 97% on RA
GENERAL: Alert, highly anxious, in NAD
NECK: Supple, no cervical lymphadenopathy
CARDIAC: Tachycardic rate, regular rhythm, no m/r/g
LUNGS: Tachypneic, no increased WOB, no wheezes or crackles
ABDOMEN: Soft, non tender, non distended, midline surgical scar
w/ 3 areas of open chronic wounds showing underlying viscera, no
surrounding erythema, scant white drainage
EXTREMITIES: No cyanosis or edema; L axilla w/ non tender
lymphadenopathy and prominent node ~2cm diameter; bilateral
inguinal lymphadenopathy w/ large R sided non tender
erythematous
bulge, L side with large ~4cm area of ulceration and thick white
drainage
SKIN: Warm, no rashes
NEUROLOGIC: CNII-XII grossly intact, AOx2
DISCHARGE PHYSICAL EXAM:
VITALS: ___ 0745 Temp: 7.9 PO BP: 121/69 HR: 94 RR: 20 O2
sat: 100% O2 delivery: RA FSBG: 80
GENERAL: Alert, NAD
EYES: Anicteric, PERRL
ENT: mmm, OP clear
CV: NR/RR, no m/r/g
RESP: CTAB, no wheezes, crackles, or rhonchi
ABD/GI: Soft, ND, NTTP, normoactive bowel sounds, surgical
incisions is c/d/i and healing well
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
VASC/EXT: No ___ edema, 2+ DP pulses
SKIN: tender, erythematous, bulky lymphadenopathy in the right
and left inguinal regions, left inguinal incision appears
healthy with a small amount of white thin drainage
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
moves all limbs
PSYCH: anxious
Pertinent Results:
ADMISSION LABS
===============
___ 11:26AM BLOOD WBC-11.7* RBC-4.10 Hgb-12.2 Hct-39.1
MCV-95 MCH-29.8 MCHC-31.2* RDW-13.7 RDWSD-48.0* Plt ___
___ 11:26AM BLOOD Neuts-70.5 Lymphs-18.2* Monos-8.2 Eos-2.0
Baso-0.7 Im ___ AbsNeut-8.25* AbsLymp-2.13 AbsMono-0.96*
AbsEos-0.24 AbsBaso-0.08
___ 11:26AM BLOOD ___ PTT-36.5 ___
___ 11:26AM BLOOD Glucose-92 UreaN-11 Creat-1.2* Na-139
K-3.9 Cl-106 HCO3-18* AnGap-15
___ 08:02AM BLOOD ALT-16 AST-34 LD(LDH)-212 AlkPhos-225*
TotBili-0.6
___ 12:40AM BLOOD proBNP-1736*
___ 08:02AM BLOOD CK-MB-3 cTropnT-0.22*
___ 04:06AM BLOOD CK-MB-3 cTropnT-0.22*
___ 08:02AM BLOOD Albumin-2.6* Calcium-9.4 Phos-3.1 Mg-1.3*
___ 02:47PM BLOOD %HbA1c-4.6 eAG-85
___ 06:36PM BLOOD ___ pO2-28* pCO2-34* pH-7.30*
calTCO2-17* Base XS--9 Intubat-NOT INTUBA
___ 07:30PM BLOOD Lactate-2.7*
STUDIES/IMAGING
================
___ CT A&P
1. Prominent bilateral inguinal lymph nodes measuring up to 1.4
cm on the left and 1.0 cm on the right. Just superficial to the
prominent right inguinal lymph node is a peripherally
hyperdense, centrally hypodense lesion measuring up to 2.2 cm,
which may represent a necrotic lymph node or a focal fluid
collection. Nonspecific soft tissue stranding and skin
thickening overlying the dominant left inguinal lymph node
measuring up to 3.9 cm is also seen.
2. Nonspecific stranding around the bilateral kidney's.
Correlate with
urinalysis.
3. Stable 3 mm right renal and distal ureteral stones without
evidence of
hydroureteronephrosis.
4. Cholelithiasis without evidence of cholecystitis.
___ CXR
AP portable upright view of the chest. The lungs are
hyperinflated and clear.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous
structures are intact.
___ Groin US
Evaluation of the right inguinal region shows again
lymphadenopathy with suggestion of associated superficial
phlegmon.
MICROBIOLOGY
==============
BCx (___): no growth x2
UCx (___): BETA STREPTOCOCCUS GROUP B. >100,000 CFU/mL.
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2:
UNINTERPRETABLE DUE TO INADEQUATE SPECIMEN.
Swab L inguinal lymph node cx (___): MIXED BACTERIAL FLORA.
Swab L inguinal lymph node viral cx (___): No Herpes simplex
(HSV) virus isolated.
PATHOLOGY:
===============
Left inguinal excisional lymph node biopsy pathology: pending
Immunophenotyping: pending
DISCHARGE LABS
===============
___ 05:40AM BLOOD WBC-15.0* RBC-3.14* Hgb-9.4* Hct-29.4*
MCV-94 MCH-29.9 MCHC-32.0 RDW-14.9 RDWSD-50.8* Plt ___
___ 05:30AM BLOOD ___ PTT-34.5 ___
___ 05:40AM BLOOD Glucose-79 UreaN-8 Creat-1.0 Na-143 K-3.7
Cl-110* HCO3-19* AnGap-14
___ 05:40AM BLOOD Calcium-9.4 Phos-3.6 Mg-1.7
___ 05:30AM BLOOD ALT-40 AST-29 AlkPhos-536* TotBili-0.8
___ 08:02AM BLOOD CK-MB-3 cTropnT-0.22*
___ 04:06AM BLOOD CK-MB-3 cTropnT-0.22*
___ 12:14AM BLOOD Trep Ab-NEG
___ 12:14AM BLOOD HIV Ab-NEG
___ 12:35PM BLOOD Vanco-14.2
___ 03:33PM BLOOD QUANTIFERON-TB GOLD-PND
Brief Hospital Course:
TRANSITIONAL ISSUES
======================
[] Please follow up results of pathology and immunophenotyping
from excisional lymph node biopsy on ___
[] The patient reported noncompliance with advair and Spiriva
since her last discharge. Would recommend PFTs and re-evaluation
of COPD medication regimen.
[] The patient had a prior diagnosis of DMII, however after
significant weight loss since her last admission, her A1c had
decreased to < 5%. Her metformin was not restarted this
admission. Would recommend continued monitoring of glycemic
control.
[] The patient had paroxysmal episodes of atrial fibrillation
during a previous hospitalization, but was not started on
anticoagulation. Would recommend discussing risks and benefits
of anticoagulation with patient and husband.
___
==========
Ms. ___ is a ___ year old female with history of COPD,
hyperlipidemia, type 2 diabetes, depression with paranoia and
psychotic features, with recent prolonged ___
admission for acute hypoxic respiratory failure, ___,
complicated by massive epistaxis, multidrug resistant ventilator
associated pneumonia, ARDS, requiring trach and PEG, course
further complicated by ATN, drug-induced liver injury, gastric
perforation requiring ex-lap and gtube replacement, course
further complicated by HSV flare, new atrial fibrillation with
RVR, subsequently discharged to rehab ___, transferred home
in the interim, who was readmitted ___ with worsening
necrotic lymphadenopathy and sepsis, initially requiring
pressors in the ICU, then transferred to the medical floor for
further management. Ultimately the cause of her sepsis was felt
to be due to superinfection of necrotic inguinal lymph nodes.
She had an excisional left inguinal lymph node biopsy on ___
with path still pending at the time of discharge.
ACUTE ISSUES
=============
# Sepsis
# Inguinal lymphadenopathy
# Possible lymphadenitis
The patient was initially admitted to the ICU with hypotension
requiring pressors in the setting of several weeks of enlarging
groin lymphadenopathy. Given her hemodynamic instability, the
patient was treated with broad spectrum antibiotics, which was
eventually narrowed to vancomycin monotherapy for presumed
staph/strep skin and soft tissue superinfection of her
lymphadenopathy. Infectious work up proved to be unrevealing for
a more definite source. The underlying cause for her
lymphadenopathy was also not clear, with differential including
infectious tuberculous, and malignancy. Surgery was consulted
for excisional biopsy and this was completed on ___. The
patient's blood pressures improved and she was weaned off of
pressors before transferring to the medical floor for continued
care.
At discharge, the pathology from the lymph node biopsy is still
pending.
She was discharged to complete a 10 day course of antibiotics
(vancomycin switched to doxycycline on discharge per ID recs).
# ___
The patient also presented with ___ to as high as Cr of 1.5
from a baseline ~0.9. Etiology was felt to be most likely
pre-renal in the setting of her sepsis as discussed above.
Creatinine was trended and renal injury resolved by time of
discharge.
CHRONIC ISSUES
===============
# Generalized Anxiety Disorder
# Depression with psychosis
The patient was continued on her home risperidone, benztropine,
venlafaxine, and Ativan.
# COPD
The patient was given standing duonebs and as needed.
# Drug induced liver injury
The patient was started on urosdiol during her last admission in
setting of DILI. Given the normalization of her LFTs, it was not
continued this admission.
# Diabetes type 2
A1c < 5%. The patient's home metformin was held during
admission.
# GERD
The patient was continued on her home esomeprazole.
# Atrial fibrillation
Noted last admission; was seen by cardiology at that time who
recommended outpatient discussion regarding anticoagulation.
>30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam 1 mg PO QHS
2. RisperiDONE 0.5 mg PO QHS
3. Venlafaxine 150 mg PO DAILY
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
5. Ursodiol 600 mg PO BID
6. Benztropine Mesylate 1 mg PO BID
7. MetFORMIN (Glucophage) 500 mg PO DAILY
8. NexIUM 24HR (esomeprazole magnesium) 20 mg oral DAILY
9. LORazepam 0.5 mg PO BID:PRN anxiety
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
2. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*4 Capsule Refills:*0
3. Benztropine Mesylate 1 mg PO BID
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
5. LORazepam 1 mg PO QHS
6. LORazepam 0.5 mg PO BID:PRN anxiety
7. Multivitamins 1 TAB PO DAILY
8. NexIUM 24HR (esomeprazole magnesium) 20 mg oral DAILY
9. RisperiDONE 0.5 mg PO QHS
10. Venlafaxine 150 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Inguinal and axillary lymphadenopathy
Lymphadenitis
Sepsis
Acute kidney injury
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 due to tender swollen lymph
nodes and sepsis, most likely due to infection of the lymph
nodes ("lymphadenitis"). You were started on antibiotics and
your sepsis resolved. You will continue on oral antibiotics
after you leave the hospital. You had a lymph node biopsy by
surgery on ___. The results of the biopsy are still pending
at the time of discharge. You have an appointment in your
primary care doctor's office on ___ with the hopes that the
pathology results will be back at that time for review with your
doctor.
Best wishes for your continued healing.
Take care,
Your ___ Care Team
Followup Instructions:
___
|
19843240-DS-5
| 19,843,240 | 26,375,598 |
DS
| 5 |
2129-08-14 00:00:00
|
2129-08-17 16:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
rosuvastatin
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female w/HTN, DMII, and diabetic neuropathy with
recent discharge for acute on subacute bilateral lower extremity
weakness and severe joint stiffness in her limbs presenting for
chest pain and troponin elevation.
Patient was initially seen in ___ @ OSH for proximal muscle
weakness thought ___ statins. She failed to improve and was
started by an outpatient neurology on prednisone and
azathioprine for presumed inflammatory myositis (e.g.
polymyositis). She failed to improve and so was admitted to the
Neurology service here at ___ for subacute b/l ___ weakness.
Work up this admission included:
- LP with pleocytosis, c/w inflammatory process including
myelitis
- Infectious work up which wa negative
- Serology which found only Anti-HMG positivity
- Troponin which peaked at 1.71 before downtrend
- Initiation of methotrexate in addition to prednisone
- Cardiac MRI without evidence of myocarditis
She had slow if any improvement to prednisone and methotrexate.
Her final diagnosis is per neurology "[not] entirely
satisfactory... [with] confusion as to whether there is simply
an
inflammatory myositis with poor/slow response to treatment or
whether there is concurrent meningitis/myelitis."
She presents today from rehab for chest pain. The patient last
night felt chest discomfort in the setting of a coughing
episode.
This resolved. Cough was not productive. She complains of mild
dyspnea.
Denies fever, ns, chills. No significant sputum/phlegm.
No chest pain. She had labs drawn at the rehab during this
episode which found elevated troponin.
As such she was transferred to the outside hospital where
troponin continued to be elevated.
She was transferred here given her recent hospital stay. The
patient continues to state that she is not feeling any chest
pain, palpitations, dizziness, lightheadedness, or weakness.
Does
state mild dyspnea. No fevers or chills. No abdominal pain,
nausea, vomiting, or diarrhea. Feels her abdomen to be
distended.
Troponins at the outside hospital of 1.46, 1.68. Nonspecific EKG
changes. She denies leg pain or swelling.
In the ED:
- Initial vital signs were notable for
97.3, 77, 145/69, 18, 97% RA
- Exam notable for:
Distended abdomen, non-tender
- Labs were notable for:
Trop 1.45 -> 1.57 -> 1.85
MB 247
Mild leukocytosis 12.6 with left shift
- Studies performed include:
CTA chest
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Scattered ground-glass opacifications within the posterior
segments of the bilateral upper lobes likely represent
multifocal
infection.
3. Mild cardiomegaly.
- Patient was given:
Vanc/Cefepime
Dextrose IV (hypoglycemia)
Past Medical History:
HTN
DMII
Peripheral Neuropathy
Social History:
___
Family History:
Reports a brother with "weakness" but cannot further clarify
Otherwise denies strokes/seizures in family
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
GEN: relatively well appearing, NAD
HEENT: MMM
CV: RRR s1s2 no mrg
PULM: mild tachypnea but no wheezes, ronchi, crackles
GI: S/ND/NT
EXT: WWP
NEURO: ___ b/l hip flexors
4+/5 b/l knee flex/extension
___ b/l elbow flex/extension
4+/5 b/l triceps
DISCHARGE PHYSICAL EXAM
=======================
General: appears comfortable, NAD
Lungs: symmetric expansion, no increased WOB, CTAB
Heart: RRR, no M/R/G, 2+ radial pulses bilaterally
Abdomen: soft, non-distended, non-tender
Extremities:
- decreased passive ROM in shoulders, arms, and wrists
- L knee non-tender, non-erythematous, limited passive ROM
- no edema
- well-perfused, no bruising or bleeding
Neuro:
- alert, oriented, appropriate, +fluent
- RUE: ___ shoulder, ___ bicep, ___ tricep, ___ hand-grip
- LUE: ___ shoulder, ___ bicep, ___ tricep, ___ hand-grip
- RLE: ___ foot extension/flexion
- LLE: ___+/5 foot extension/flexion
Psych: appropriate affect and judgement
Pertinent Results:
INITIAL LABS
============
___ 02:59PM BLOOD WBC-12.6* RBC-3.74* Hgb-10.8* Hct-35.0
MCV-94 MCH-28.9 MCHC-30.9* RDW-17.4* RDWSD-58.6* Plt ___
___ 02:59PM BLOOD Plt Smr-NORMAL Plt ___
___ 02:59PM BLOOD Glucose-54* UreaN-17 Creat-0.4 Na-141
K-6.2* Cl-106 HCO3-25 AnGap-10
___ 02:59PM BLOOD CK(CPK)-2800*
___ 08:48PM BLOOD ALT-176* AST-123* LD(LDH)-812*
CK(CPK)-2573* AlkPhos-48 TotBili-0.3
___ 02:59PM BLOOD CK-MB-247* MB Indx-8.8*
___ 02:59PM BLOOD cTropnT-1.45*
___ 08:48PM BLOOD Albumin-3.3*
___ 06:50AM BLOOD Calcium-9.1 Phos-5.9* Mg-2.2
___ 08:48PM BLOOD CRP-12.1*
MICROBIOLOGY
============
___ 8:30 pm BLOOD CULTURE #1.
Blood Culture, Routine (Pending): No growth to date.
___ 8:48 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending): No growth to date.
___ 8:32 pm BLOOD CULTURE #1.
Blood Culture, Routine (Pending): No growth to date.
IMAGING
=======
CTA CHEST (___):
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Scattered ground-glass opacities within the upper lobes
concerning for
multifocal pneumonia. Nota segmental ble areas of atelectasis
in the
bilateral lower lobes.
3. Mild cardiomegaly.
MRI THIGH (___):
Diffuse subcutaneous, fascial, and intramuscular edema, most
notable involving the anterior left proximal thigh muscles which
are abnormally enhancing. Findings are compatible with myositis.
No drainable fluid collection or acute osseous abnormality is
seen.
PELVIS PLAIN FILM (___):
No acute fracture or dislocation.
SHOULDER PLAIN FILM (___):
No acute fracture, dislocation or significant degenerative
changes in either shoulder.
DISCHARGE LABS
==============
___ 07:06AM BLOOD Glucose-70 UreaN-29* Creat-0.4 Na-143
K-5.3 Cl-106 HCO3-25 AnGap-12
___ 07:06AM BLOOD ___ 07:07AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ with history of type 2 diabetes complicated
by peripheral neuropathy and subacute inflammatory myositis
(diagnosed in ___ who presented with chest tightness and was
found to have progressive anti-HMG-CoA inflammatory myositis
complicated by new pulmonary opacities. She was given pulse dose
steroids x 3 days, transitioned to pred 60mg qd for myositis
flare discharged to acute rehab.
ACTIVE ISSUES
=============
# Anti-HMG-CoA inflammatory myositis
# Dysphagia
# Atelectasis
Ms. ___ presented after an episode of chest tightness while
eating, concerning for aspiration. On presentation, she was
found to have worsening muscle weakness and rigidity. Initial
labs notable for CK 2800. CTA demonstrated scattered
ground-glass opacities concerning for multifocal pneumonia. She
was initially started on vancomycin-cefepime empirically for
HAP, though was discontinued after realizing that pulmonary
involvement is somewhat common with her inflammatory myositis
and her presentation was not consistent with pneumonia. She was
given three days of pulsed methylprednisolone, and her home
methotrexate was increased from 10mg to 12.5mg weekly. She was
seen by rheumatology and neuromuscular teams. Ultimately, her
muscle weakness was attributed to the refractory nature of
anti-HMG-CoA inflammatory myositis. Muscle biopsy was deferred
given low diagnostic yield after steroids and that neuro
remained convinced her presentation was consistent with her
prior diagnosis. Her initial presentation of chest pain while
eating was associated with an aspiration pneumonitis given her
underlying dysphagia. She was discharged to acute rehab on oral
prednisone 60 mg qd and MTX to 12.5 mg/wk.
CHRONIC ISSUES
==============
# HTN
She was continued on her home lisinopril
# DMII
Her home glipizide and metformin were held. She was given
insulin and a sliding scale.
# GERD
She was continued on her home ranitidine
TRANSITIONAL ISSUES
===================
[] Labs - CK, LFTs, GGT, CBC, creatinine weekly at rehab
- Fax to Drs. ___ (fax ___
[] Discharged on prednisone 60mg qd until outpatient neurology
follow up in 2 weeks
[] Continue ranitidine, vit D/Ca repletion while on high dose
steroids. Also continue atovaquone (switched from Bactrim while
on methotrexate)
[] Continue folate 1 mg po daily while on methotrexate
[] Should attempt to use night rest splints per neuro
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. PredniSONE 60 mg PO DAILY
3. Calcium Carbonate 500 mg PO BID
4. Vitamin D ___ UNIT PO 1X/WEEK (TH)
5. Aspirin 81 mg PO DAILY
6. Ranitidine 150 mg PO BID
7. Methotrexate 10 mg PO 1X/WEEK (TH)
8. Lisinopril 5 mg PO DAILY
9. Diazepam 2 mg PO BID
10. NPH 18 Units Breakfast
NPH 15 Units Dinner
Insulin SC Sliding Scale using REG Insulin
11. Ibuprofen 600 mg PO Q8H
Discharge Medications:
1. Atovaquone Suspension 1500 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. NPH 18 Units Breakfast
NPH 15 Units Dinner
Insulin SC Sliding Scale using REG Insulin
4. Lisinopril 20 mg PO DAILY
5. Methotrexate 12.5 mg PO 1X/WEEK (TH)
6. Aspirin 81 mg PO DAILY
7. Calcium Carbonate 500 mg PO BID
8. Diazepam 2 mg PO BID
9. Gabapentin 300 mg PO TID
10. PredniSONE 60 mg PO DAILY
11. Ranitidine 150 mg PO BID
12. Vitamin D ___ UNIT PO 1X/WEEK (TH)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
HMG-CoA inflammatory myositis
Secondary Diagnosis
===================
Atelectasis
Hypertension
Diabetes, type 2
GERD
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:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a privilege caring for you at ___
___!
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were having chest pain
and were found to have blood tests which showed damage to your
muscles.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We consulted with our rheumatology and neurology department
to help evaluate your leg weakness and severe joint stiffness as
well as elevated inflammatory markers in your blood.
- We did xrays to look at your shoulders and hips to ensure
there was not bone involvement in your stiffness.
- We gave you steroids to help treat your inflammation and
weakness.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___. We
wish you all the best,
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19843379-DS-9
| 19,843,379 | 23,613,882 |
DS
| 9 |
2172-01-25 00:00:00
|
2172-01-25 14:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
arm and leg numbness and weakness
Major Surgical or Invasive Procedure:
Lumbar puncture
Endotracheal intubation ___
History of Present Illness:
Mr. ___ is a ___ yo LHD man w/PMHx hemochromatosis who
presents with indolent bilateral hand and leg numbness and
weakness. Symptoms began two days prior to admission, ___, when
he woke up in the morning and noticed that the tips of all of
his fingers were numb or had a tingling/pins-and-needles
sensation. At the time, he thought that he had just slept in the
wrong position. He had no muscle weakness, and otherwise felt
fine and went to work that day. That night, he was trying to put
his daughter into a car seat when he noticed that it took him
significantly more effort than usual. He also noted some
difficulty turning on the ignition in his car and going up the
stairs, but assumed it was because he was tired from shoveling
snow the previous day. He also had some mid-back pain which he
attributed to shoveling, which has since resolved. On the
morning of ___, he awoke finding that he was also numb
/tingling in the legs as well, and throughout the course of the
day, he became progressively weaker such that he couldn't do
normal daily tasks like opening a jar. It got to the point that
he had difficulty going down stairs and felt unsteady. At one
point, his "legs gave out" and he fell on the ground. He denied
head strike or LOC and described it as a controlled fall. He
continued to feel weak this morning and presented to the ED this
afternoon.
Of note, he states that he had the "norovirus" in early ___,
which affected his wife and daughter as well. On neuro ROS, the
pt endorsed mild lightheadedness on the morning of presentation.
He denies headache, loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt endorsed fever, nausea, and
vomiting one month ago but 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 recent nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies rash.
Past Medical History:
HEMOCHROMATOSIS
IRRITABLE BOWEL SYNDROME
COLONIC POLYPS
HYPOGONADISM
Social History:
___
Family History:
Father, age ___, with hemochromatosis. Sister, age ___, with
Raynaud's. Maternal grandmather had breast cancer, paternal
grandmother had cervical cancer. No known neurologic history.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Vitals: 99 104 136/78 18 100%
General: Pleasant man in NAD
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Able to read without difficulty. Speech was not
dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had
good knowledge of current events. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 3mm and brisk. No RAPD. Acuity ___ ___. Color
plates accurate. VFF to confrontation. Funduscopic exam
revealed mild blurring of the right disc margin only possibly
due to pigmentation but without elevation/papilledema, exudates,
or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
on initial examination by MS3 ___
___ Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4 ___ ___ 4 4 4 5 5 4 5
R 4 ___ ___ 4 4 4 5 5 4 5
on later exam by Dr. ___
___ Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4 5- 5- 5- ___ 4 4 4 5- 5 4
R 4 5- 5- 4+ ___ 4 4 4 5- 5 4
-Sensory: Deficit in proprioception in toes noted. No deficits
to light touch, pinprick, cold sensation, vibratory sense. No
sensory level. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 0 0 0 0 0
R 0 0 0 0 0
No clonus on ankle jerk bilaterally
Plantar response was mute bilaterally.
-Coordination: +intention tremor vs mild weakness on FNF
testing, but no dysmetria on FNF or HKS bilaterally. No
dysdiadochokinesia noted.
-Gait: Difficulty getting off of bed. Immediately slumped into
the chair due to fatigue and weakness. Negative Romberg.
DISCHARGE PHYSICAL EXAMINATION:
Pertinent Results:
ADMISSION LABS:
___ 02:33PM ___ PTT-29.7 ___
___ 02:20PM GLUCOSE-122* UREA N-20 CREAT-0.7 SODIUM-141
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13
___ 02:20PM ALT(SGPT)-197* AST(SGOT)-152* LD(LDH)-385*
ALK PHOS-165* TOT BILI-0.7 LIPASE-29
___ 02:20PM ALBUMIN-4.0 CALCIUM-8.9 PHOSPHATE-1.3*
MAGNESIUM-1.9
___ 02:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:20PM WBC-6.3 RBC-4.69 HGB-14.4 HCT-44.0 MCV-94
MCH-30.7 MCHC-32.7 RDW-14
___ 08:00PM (CSF) PROTEIN-74* GLUCOSE-64 WBC-0 RBC-1*
POLYS-0 ___ ___ 06:25PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 06:25PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5
LEUK-NEG
___ 06:25PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
IMAGING:
CXR ___
Heterogeneous opacification at the lung bases could represent a
recent aspiration or even early pneumonia. Upper lungs are
clear. Heart size is normal. There is no pleural abnormality.
Brief Hospital Course:
42 LHM w/PMHx hemochromatosis p/w acute progressive proximal>
distal weakness and paresthesias with areflexia and antecedent
GI illness most c/w ___ Syndrome. His neurologic exam
is notable for significant proximal weakness, areflexia, and
proprioceptive deficits without other sensory loss or
bowel/bladder involvement. s/p Lumbar puncture showing
cytoalbuminologic dissociation c/w Guillain ___ syndrome.
# Neuro: Patient was admitted ___ and received 5 days of
IVIg treatment with progression of weakness. He also had
increased difficulty with swallowing and handling secretions. He
had NG tube placed for nutrition. With increased respiratory
distress and NIF/VC trending down, he was transferred to the ICU
and was intubated on ___. He then received PLEX for 5 days.
He completed PLEX course on ___. He was extubated on ___
with improved NIF/VC. His strength started to improve slowly.
Speech and Swallow continued to follow patient to assess
swallowing safety and recommended clear liquids and no purees
based on video swallow prior to discharge.
# Pulmonary: Patient began having increased difficulty with
secretions on ___ and was started on glycopyrrolate. Given
worsening difficulty handling secretions and worsening
respiratory status including increased work of breathing and
down-trending NIF/VC, patient was intubated on ___. He was
monitored closely with frequent NIF/VC checks which started
trending up and was succesfully extubated on ___. After
extubation, he continued to be monitored closely with frequent
NIF/VC checks and continued to do well.
#GI: Patient had significant issues with constipation. He did
not stool for three weeks despite an aggressive bowel regimen.
His bowel regimen was maximized the week of ___ to include
multiple PO and PR medications as well as manual disimpaction.
KUB on ___ showed no evidence of obstruction. He finally had a
bowel movement on ___ after receiving GoLytely. Patient had an
NG placed early in his course. He was cleared for clears prior
to discharge based on video swallow but his NG was left in place
due to concern for inability to take sufficient PO to meet
nutritional needs. He is not to have purees pending further
improvement in swallowing function.
# Anxiety: Given significant anxiety patient was started on
Sertraline 50 mg DAILY which was increased to 75mg daily. He was
continued on home Clonazepam. Per psychiatry consult on ___,
clonazepam was weaned to from 1.0mg to 0.5mg TID (qHS standing
and BID prn). Psychiatry recommended decreasing Klonopin to
0.5mg BID prn after transfer to rehab and discontinuing Klonopin
completely prior to discharge from rehab to home as tolerated.
#Infectious Disease: Course and intubation was complicated by
aspiration PNA (fever, CXR changes). He received a 7-day course
of Vancomycin and Zosyn from ___. Post-extubation course
was complicated by Pseudomonas UTI (fever, positive UA and
culture). Cefepime was initiated on ___ for a 7-day course.
# Cardiovascular: Stable Had initial autonomic dysfunction
secondary to GBS that had resolved prior to discharge.
#Endocrine: Patient was not maintained on home Clomid due to
medication not being available.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. clomiPHENE citrate 25 mg oral daily
2. econazole 1 % topical daily:prn fungal rash
3. LOPERamide 2 mg PO QID:PRN diarrhea
4. calcium carbonate-vitamin D3 600 mg(1,500mg) -200 unit oral
daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain/fever
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Calcium Carbonate 1000 mg PO DAILY
5. ClonazePAM 0.5 mg PO BID:PRN Anxiety
6. ClonazePAM 0.5 mg PO QHS
7. Docusate Sodium (Liquid) 100 mg PO BID
8. Gabapentin 200 mg PO TID
9. Glycopyrrolate 1 mg PO TID
10. Heparin 5000 UNIT SC TID
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
12. Polyethylene Glycol 17 g PO DAILY constipation
13. Senna 17.2 mg PO BID constipation
14. Sertraline 75 mg PO DAILY
15. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
16. Vitamin D 400 UNIT PO DAILY
17. clomiPHENE citrate 25 mg oral daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Guillain ___ Syndrome
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 progressive tingling in hands and then
weakness of arms and legs. You underwent a lumbar puncture which
was consistent with Guillain ___ syndrome, an acute
demyelinating polyneuropathy. You were started on IVIG treatment
for 5 days to treat this condition. Your strength and
respiratory status were monitored closely for any worsening.
You began to have trouble with breathing, so you were
transferred to the ICU. In the ICU, you were placed on a
ventilator, had a nasogastric tube placed for feeding, and were
treated with plasmaphoresis for 5 days. While on the
ventilator, you had a pneumonia which was treated with
antibiotics (Vancomycin and Zosyn) for 7 days. You recovered
well from the pneumonia. You were successfully extubated and
transferred to the Neurology floor. On the Neurology floor, you
had a urinary tract infection, which was treated with
antibiotics (cefepime). You will be treated with antibiotics for
7 days. Your strength started to improve slowly with working
with Physical Therapy. You were found to be safe to swallow
clear liquids.
Throughout your time with us, you had some anxiety and
constipation. Your anxiety was treated with Zoloft and
Klonopin, and you were also able to talk to someone about how
you were feeling. For your constipation, you were treated with
laxatives, enemas, and suppositories, as well as manual
disimpaction and GoLytely solution.
It was a pleasure caring for you at ___
___. We wish you the best in your recovery.
Followup Instructions:
___
|
19843475-DS-2
| 19,843,475 | 20,978,142 |
DS
| 2 |
2171-10-20 00:00:00
|
2171-10-20 09:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
left thigh deformity s/p fall
Major Surgical or Invasive Procedure:
___: IM nail of left femur fracture
History of Present Illness:
___ yo female with MS ___ and wheel chair bound since
___, multiple decubitus sacral/ischial ulcers (multiple
stages,
followed every 2 weeks at wound clinic, husband does ___ and dressing changes), and chronic foley catheter
presents as transfer from ___ with left proximal
femur fracture. Patient states that ___ night 1130pm while
examining her left leg in her wheelchair she externally rotated,
flexed knee, and abducted hip to bring her foot closer for
inspection, she noticed a pop noise but no pain. She awoke
yesterday at 1230pm and noticed swelling and ecchymosis at left
thight wih mild throbbing pain ___. Over the course of the
afternoon, the swelling increased and her husband took her too
___ where xrays demonstrated left spiral proximal
displaced femur fracture.
Past Medical History:
MS, decubitus ulcers, chronic catheter
Social History:
___
Family History:
NC
Physical Exam:
98 80 130/100 16 99%
A&O x 3
Calm and comfortable
Bilateral lower extremities left windswept legs (minimal
function; fires weakly only ___ and hip flexors
bilaterally)
Several decubitus ulcers including:
Healed ulcers (all formerly stage 4): sacrum/coccyx (now stage
2), right ischium (now stage 1), and left trochanter (now stage
1)
Healing ulcers: left ischium (open wound, stage 4)
LLE skin clean and intact, leftward windswept
mild tenderness, edema, ecchymosis
Thighs and legs are soft
mild pain with passive motion hip/femur
Saph Sural DPN SPN MPN LPN ___ FHL ___ Fire (no TA/PP firing)
1+ ___ and DP pulses
Pertinent Results:
___ 05:58AM BLOOD WBC-7.4 RBC-2.77* Hgb-8.7* Hct-25.8*
MCV-93 MCH-31.6 MCHC-33.9 RDW-15.4 Plt ___
___ 05:58AM BLOOD ___ PTT-36.8* ___
___ 05:58AM BLOOD Glucose-90 UreaN-11 Creat-0.6 Na-136
K-4.1 Cl-101 HCO3-26 AnGap-13
___ 05:58AM BLOOD Calcium-7.7* Phos-2.7 Mg-1.7
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left femoral shaft fracture and was admitted to the
orthopedic surgery service. Initially she declined operative
intervention for her fracture because she had no pain. However,
after working with physical therapy she decided that she did
want to proceed so that she could be weight bearing as tolerated
instead of non weight bearing while the fracture healed.
The patient was taken to the operating room on ___ for IM
nail left femur, which the patient tolerated well (for full
details please see the separately dictated operative report).
The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. She had an episode of tachycardia to the
110's and hypotension with SBP's in ___ overnight on POD#1 so
was given a bolus overnight and transfusion of 1u PRBCs on POD#2
for a Hct of 25.8 with improvement in her blood pressure and
pulse. The patient was given perioperative antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home was appropriate
given patient was at baseline level of function (wheelchair
bound requiring assitance from husband with transfers).
The patient was found to have multiple decubitus ulcers on
admission, for which Wound Care was consulted and recommended a
dressing regimen that was implemented while she was in-house.
Nutrition was also consulted and recommended supplements TID as
well as a 10 day course of zinc and vitamin C supplementation
which was started while she was in-house.
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 moving bowels
spontaneously and had her chronic Foley maintained in place. The
patient is weight bearing as tolerated in the left lower
extremity, and will be discharged on 2 weeks of Lovenox 40 mg SC
for DVT prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Baclofen 25 mg PO Q6H:PRN muscle spasms
2. Oxybutynin 10 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Levothyroxine Sodium 25 mcg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY Duration: 10 Days
RX *ascorbic acid ___ mg 1 tablet(s) by mouth once a day Disp
#*7 Tablet Refills:*0
2. Baclofen 25 mg PO Q6H:PRN muscle spasms
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Oxybutynin 10 mg PO DAILY
6. Calcium Carbonate 500 mg PO TID
7. Docusate Sodium 100 mg PO BID
8. Enoxaparin Sodium 40 mg SC DAILY Duration: 14 Days
RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*14
Syringe Refills:*0
9. Levothyroxine Sodium 25 mcg PO DAILY
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
11. Vitamin D 400 UNIT PO DAILY
12. Zinc Sulfate 220 mg PO DAILY Duration: 10 Days
RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth once
a day Disp #*7 Capsule Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left femoral shaft fracture
Multiple decubitus ulcers
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:
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 (for hip):
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- 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.
WOUND CARE (for ulcers):
For left ischium: Daily care: cleanse skin/ulcer and pat dry,
apply thin layer of critic aid clear or barrier wipe to
periwound tissue, fill/cover wound with aquacel rope, followed
by dry gauze, and secure with pink Hy Tape
For coccyx: Every 3 days: Mepilex dressing change
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated
Physical Therapy:
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated
Treatments Frequency:
WOUND CARE (for hip):
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- 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.
WOUND CARE (for ulcers):
For left ischium: Daily care: cleanse skin/ulcer and pat dry,
apply thin layer of critic aid clear or barrier wipe to
periwound tissue, fill/cover wound with aquacel rope, followed
by dry gauze, and secure with pink Hy Tape
For coccyx: Every 3 days: Mepilex dressing change
Followup Instructions:
___
|
19843520-DS-7
| 19,843,520 | 25,415,290 |
DS
| 7 |
2130-05-08 00:00:00
|
2130-05-08 14:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Shortness of breath, cough with blood-tinged sputum
Major Surgical or Invasive Procedure:
___ - 1. Aortic valve replacement with 23 ___
___ Ease tissue valve. 2. Mitral valve repair with P2
resection, NeoChords, and 28 mm Physio II ring. 3. Coronary
artery bypass graft x 3, skeletonized left internal mammary
artery sequential grafting to diagonal and distal left anterior
descending artery, and saphenous vein graft to posterior left
ventricular branch. 4. Closure of atrial septal defect. 5.
Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
Mr. ___ is a ___ year old man with a history of aortic stenosis,
atrial fibrillation, Hepatitis B, hyperlipidemia, and
hypertension. He initially presented to ___ with fatigue,
body aches, and shortness of breath x ___ days. A CTA chest and
CXR were notable for multifocal infiltrates. He ruled in for
non-ST elevation myocardial infarction with new ST depressions
in lateral leads and troponin of 0.375. He was transferred to
___ for further management. While at ___, an echocardiogram
demonstrated aortic stenosis and mitral regurgitation. A cardiac
catheterization revealed multivessel coronary artery disease. He
was referred to Dr. ___ surgical consultation.
Past Medical History:
Aortic Stenosis
Atrial Fibrillation
Gastroesophageal Reflux Disease
Glaucoma
Gout
Hepatitis B
Hyperlipidemia
Hypertension
Mitral Regurgitation
Patent Foramen Ovale
Social History:
___
Family History:
No significant family history
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.2 133 / 80 94 36 97 Ra
GENERAL: elderly man, tachypnea, dypsneic with answering
questions
HEENT: EOMI, R eye glassy due to lens removal? L pupil round and
reactive. anicteric sclera, pink conjunctiva, MMM
NECK: Supple. JVD up to ear lobe.
HEART: RRR, S1/S2, systolic murmur at aortic area, holosystolic
murmur loudest at apex, no gallops
LUNGS: scattered wheezes, and crackles loudest on the R side.
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical Exam:
Vital Signs and Intake/Output:
24 HR Data (last updated ___ @ 557)
Temp: 97.4 (Tm 98.6), BP: 113/63 (94-113/61-75), HR: 74
(74-97), RR: 18, O2 sat: 98% (97-98), O2 delivery: Ra
Wt: 75.7kg (73.3kg)
___: 121-165
In/Out: 1396/825++
Physical Examination:
General: deconditioned [x]
Neuro: NAD [x] A/O x3 [x] non-focal []
Cardiac: RRR [] Irregular [x] Nl S1 S2 []
Lungs: Diminished bases. No resp distress [x]
Abd: NBS [x]Soft [x] ND [x] NT [x] Dobhoff in place L nare[x]
Extremities: warm with ___ pedal edema.
Wounds: Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [x] Prevena []
Leg: Right [] Left[x] CDI [x] no erythema or drainage
[x]
Pertinent Results:
Cardiac Echocardiogram ___
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Mild symmetric left ventricular hypertrophy with
normal cavity size, and regional/global systolic function
(biplane LVEF = 61 %). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of mitral
and aortic regurgitation.] [The The estimated cardiac index is
normal (>=2.5L/min/m2). Right ventricular chamber size is normal
with moderate global free wall hypokinesis. The aortic root is
mildly dilated at the sinus level. The ascending aorta and
aortic arch are mildly dilated. The aortic valve leaflets are
moderately thickened. There is severe aortic valve stenosis
(valve area <1.0cm2). Moderate (2+) aortic regurgitation is
seen. There is partial posterior mitral leaflet flail (cannot
exclude vegetation if endocarditis is clinically suggested). An
eccentric, anteriorly directed jet of severe (4+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Severe aortic valve stenosis. Severe mitral
regurgitation with underlying partial posterior leaflet flail
(cannot exclude vegetation if endocarditis is clinically
suggested). Moderate pulmonary artery systolic hypertension.
Moderate aortic regurgitation. Moderate tricuspid regurgitation.
Mild symmetric left ventricular hypertrophy with preserved
regional and global systolic function.
Carotid Ultrasound ___
Right ICA no stenosis. Left ICA <40% stenosis.
Cardiac Catheterization ___
___: normal.
LAD: 50% ostial stenosis, diffuse 70% mid stenosis, 90% distal
stenosis.
___ Diagonal is a large vessel with 80% ___ stenosis.
LCX: appears to be a small vessel and appears 100% occluded
ostially. Weak collaterals from RCA.
RCA: hyperdominant vessel with 60% mid stenosis. Right PDA has
tandem 90% and 80% stenoses. Large posterolateral system with
70% ___ stenosis, 70% stenosis in PL-1 and 80% stenosis in
PL-2.
Transesophageal Echocardiogram ___
Pre-CPB:
The left atrium is moderately dilated. The left atrial appendage
emptying velocity is depressed (<0.4m/s). A left-to-right shunt
across the interatrial septum is seen at rest. An atrial septal
defect is present. Left ventricular wall thicknesses are normal.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] The calculated
cardiac output by continuity equation is 3.6 L/min. The right
ventricular cavity is mildly dilated with borderline normal free
wall function. The ascending aorta is mildly dilated. An
intra-aortic balloon pump is seen. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 1.0cm2). Moderate (2+) aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. Torn mitral
chordae are present. The p2 scallop is flail. An eccentric,
anteriorly directed jet of Severe (4+) mitral regurgitation is
seen.
Post-CPB:
A bioprosthetic valve is seen in the aortic position. The valve
appears well-seated with normally mobile leaflets. There are no
apparent paravalvular leaks. There is no AI. The peak gradient
across the aortic valve is 24mmHg, the mean gradient is 8mmHg
with CO of 6.3 L/min. An annular ring is seen in the mitral
position, consistent with mitral valve repair. The posterior
leaflet appears to be prolapsed relative to the anterior
leaflet. There is an eccentric, anteriorly directed jet of MR.
___ MR appears mild but may be underestimated due to its
eccentric nature.
The ASD is no longer seen. Biventricular systolic function is
preserved. The LVEF is >55%. There is no evidence of aortic
dissection.
Right Upper Quadrant Ultrasound ___
1. No gallstones and no sonographic evidence of cholecystitis.
No biliary
dilatation.
2. Borderline splenomegaly.
PA and Lateral CXR ___:
Since previous examination there is interval improvement in
pulmonary edema. Bilateral pleural effusions are small. No
appreciable pneumothorax is seen. Cardiomediastinal silhouette
is stable including replaced aortic and mitral valves. Sternal
wires are unremarkable. The up of tube tip is in the stomach.
___ 05:10AM BLOOD WBC-9.8 RBC-3.01* Hgb-8.8* Hct-28.1*
MCV-93 MCH-29.2 MCHC-31.3* RDW-18.6* RDWSD-60.1* Plt ___
___ 05:15AM BLOOD WBC-10.2* RBC-3.15* Hgb-8.9* Hct-29.1*
MCV-92 MCH-28.3 MCHC-30.6* RDW-18.4* RDWSD-58.5* Plt ___
___ 05:13AM BLOOD WBC-12.9* RBC-3.43* Hgb-9.8* Hct-31.4*
MCV-92 MCH-28.6 MCHC-31.2* RDW-18.0* RDWSD-57.4* Plt ___
___ 05:10AM BLOOD ___
___ 05:15AM BLOOD ___ PTT-35.1 ___
___ 05:13AM BLOOD ___
___ 05:10AM BLOOD Glucose-131* UreaN-44* Creat-1.3* Na-146
K-4.2 Cl-108 HCO3-28 AnGap-10
___ 05:15AM BLOOD Glucose-163* UreaN-46* Creat-1.2 Na-146
K-4.0 Cl-107 HCO3-27 AnGap-12
___ 05:13AM BLOOD Glucose-146* UreaN-49* Creat-1.2 Na-149*
K-3.7 Cl-108 HCO3-28 AnGap-13
___ 05:20AM BLOOD UreaN-57* Creat-1.4* Na-150* K-4.5
Brief Hospital Course:
He was admitted to ___ on ___ and underwent preoperative
testing and evaluation. He developed atrial fibrillation with
rapid ventricular response and was transferred to the CCU for
further management. He was loaded with amiodarone and had
conversion to sinus rhythm. He had worsening lactate and
decreased urine output. He went back to cath lab on ___ for
IABP placement. He was taken to the operating room the following
day where he underwent aortic valve replacement, mitral valve
repair, coronary artery bypass grafting x 3, and closure of
atrial septal defect. Please see operative note for full
details. He tolerated the procedure well and was transferred to
the CVICU in stable condition for recovery and invasive
monitoring.
He was transfused 2 units of PRBCs for acute blood loss anemia.
He was also transfused 1 unit of platelets to correct
coagulopathy. He developed acute kidney injury following surgery
with peak creatinine of 3.1. His creatinine trended down towards
baseline. He had bursts of atrial fibrillation postoperatively
and his heart rates were controlled with Lopressor. He had an
episode of bradycardia after amiodarone but this resolved by
holding IV amiodarone. He will be discharged in atrial
fibrillation. He was started on Coumadin for anticoagulation,
Xarelto was not restarted due to recent ___. He weaned from
sedation, awoke neurologically intact and was extubated on POD
3. He was weaned from inotropic and vasopressor support. Beta
blocker was initiated and he was diuresed toward his
preoperative weight. He remained hemodynamically stable and was
transferred to the telemetry floor for further recovery. Liver
function tests and lipase were elevated. A right upper quadrant
ultrasound was negative. The GI service was curbsided regarding
the elevated Lipase. Given that he was asymptomatic, no
treatment was recommended and was downtrending by the time of
discharge. An MRCP or CT could be considered if needed to
evaluate his elevated lipase. At the time of discharge,
amylase/lipase were decreasing and the patient remained
asymptomatic. The patient had mild post-operative dysphagia and
was followed by the speech team. He had a video swallow on ___
and was upgraded to ground diet with thin liquids. Patient had
been receiving tube feeding for 100% nutrition needs until ___
when feeds cycled x 10 hours in setting of increased oral
intake. Diet was initially puree solids and nectar thick liquids
and PO intake had been fair but not adequate enough to stop tube
feeding. Per nutrition recs, would continue w/ current tube
feeding and observe adequacy of PO intake on upgraded diet,
adjust tube feeding/ discontinue as needed pending intake at
rehab. At the time of discharge he was tolerating a ground thin
liquid diet with cycled tube feeds via Dobhoff. He was evaluated
by the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 13 he was OOB
assistance, the wound was healing, and pain was controlled with
Tylenol. He was discharged to ___ in good condition
with appropriate follow up instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Rivaroxaban 20 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Acyclovir 800 mg PO Q12H
7. Loratadine 10 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. Furosemide 40 mg PO DAILY Duration: 7 Days
6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
7. Glucose Gel 15 g PO PRN hypoglycemia protocol
8. Insulin SC
Sliding Scale
Fingerstick q 6 hours
Insulin SC Sliding Scale using REG Insulin
9. Isosorbide Dinitrate 10 mg PO TID Duration: 6 Months
10. Metoprolol Tartrate 75 mg PO TID
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
13. ___ MD to order daily dose PO DAILY AFib
14. Warfarin 2 mg PO ONCE Duration: 1 Dose
15. Acyclovir 800 mg PO Q12H
16. Allopurinol ___ mg PO DAILY
17. Fluticasone Propionate NASAL 2 SPRY NU DAILY
18. Loratadine 10 mg PO DAILY
19. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
CAD s/p CABG
Acute Blood Loss Anemia
Acute Kidney Injury
Aortic Stenosis
Atrial Fibrillation
Coronary Artery Disease
Mitral Regurgitation
Patent Foramen Ovale
Gastroesophageal Reflux Disease
Glaucoma
Gout
Hepatitis B
Hyperlipidemia
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
OOB with assistance
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the
chart.
****call MD if weight goes up more than 3 lbs in 24 hours or 5
lbs over 5 days****.
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
19843675-DS-3
| 19,843,675 | 28,083,447 |
DS
| 3 |
2138-01-01 00:00:00
|
2138-01-01 13:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bilateral elbow Pain
Major Surgical or Invasive Procedure:
___ - Open reduction internal fixation of right olecranon
fracture.
History of Present Illness:
___ year-old RHD gentleman who was in his USOH until the day of
presentation when the patient sustained a mechanical fall onto
his bilateral elbows after slipping on the ice, with immediate
bilateral elbow pain. The patient presented to the ED for
evaluation and the orthopaedic service was consulted when
imaging
was concerning for fracture.
Past Medical History:
None.
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Vital signs - AVSS
General - NAD
Left upper extremity Fires extensor pollicis longus, opponens
pollicis, flexors, and interossei. Sensation intact to light
touch in axillary, median, radial, and ulnar distributions.
Radial pulse 1+, distal extremity warm and well-perfused,
capillary refill less than 2 seconds. Skin intact with mild
echymosis and swelling about the elbow. No mechanical block to
supination/pronation or flexion/extension.
Right upper extremity Splint in place. Fires extensor pollicis
longus, opponens pollicis, flexors, and interossei. Sensation
intact to light touch in axillary, median, radial, and ulnar
distributions. Distal extremity warm and well-perfused,
capillary refill less than 2 seconds.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have non-displaced left radial head fracture and a right
olecranon fracture. He was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___
for open reduction internal fixation of his right olecranon
fracture, which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics per routine. The patient worked with OT who
determined that discharge to home with outpatient OT 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, and splint was
clean/dry/intact. He was given specific weight bearing and range
of motion instructions as well as outpatient OT prescription.
The patient will follow up in orthopedic trauma clinic in 2
weeks. A thorough discussion was had with the patient regarding
the diagnosis and expected post-discharge course, and all
questions were answered prior to discharge.
Medications on Admission:
Adderal
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. Calcium Carbonate 500 mg PO TID
4. Multivitamins 1 CAP PO DAILY
5. Vitamin D 400 UNIT PO DAILY
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth Q3 hours Disp #*90
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right olecranon fracture
Left radial head fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 medications.
- 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.
WOUND CARE:
- Keep your splint clean and dry at all times until seen in
follow up.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing right upper extremity with posterior
orthoplast splint, wrist free, wear for sleeping and ambulation
only. Sling for comfort. Sling and brace off when at rest. OT
orders: Passive range of motion and active assist range of
motion as able, no active extension, no resisted exercises.
- Weight bearing as tolerated left upper extremity, no splint,
sling for comfort only but remove whenever possible.
Passive/active range of motion as able. Focus on motion
restoration including pronation supination. No axial loading.
Followup Instructions:
___
|
19844063-DS-22
| 19,844,063 | 26,231,209 |
DS
| 22 |
2178-08-31 00:00:00
|
2178-08-31 17:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right facial droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of R ACA/MCA stroke s/p decompressive right crani (___)
s/p cranioplasty (___) c/b wound infection s/p 6 weeks of abx
for MSSA infection now txf from ___ for new right facial droop
seen by staff at long term care facility.
In the ED initial vitals were 98.3 74 115/78 14 99% ra. Labs
were significant for lactate 1.2, u/a: lg leuk, pos nitrite, mod
bacteria. Patient was evaluated by neurology and found to have
no appreciable right facial weakness on exam, but significant
edema of upper right face below cranial defect inhibiting
ability to open right eye; recommended eval by neurosurg.
Patient was given 1g ceftriaxone and transferred to the floor.
Vitals prior to transfer were: 0 97.9 83 107/61 16 100% RA
On the floor, pt was mildly uncomfortable, c/o baseline chronic
pain, reported no change.
Past Medical History:
- right carotid dissection
- right anterior cerebral artery and middle cerebral artery
stroke
- right hemicraniectomy and temporal lobectomy ___
- Right Cranioplasty ___
- trach and PEG reversed
- Migraine
- Iron deficiency anemia of childhood
- Cystic breasts
Social History:
___
Family History:
Brother passed at age ___ after 2 heart attacks. Mother with
heart disease. No known stroke.
Physical Exam:
Admission Physical Exam:
Vitals - T: 98.2 BP: 155/61 HR: 90 RR: 18 02 sat: 96 RA
GENERAL: NAD
HEENT: 10 x 10 cm skull indentation over R frontal/pariatel
area. No inflammation or purulence, no broken skin. Slight
swelling over R orbital area, non-tender
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: L hemiparesis c/w known. No edema
NEURO: L hemiparesis. Right ptosis, disconjugate gaze with right
eye not following left on EOM testing, left lower facial droop.
Sensation intact bilaterally although patient reports left side
more painful to touch.
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical Exam:
Vitals- Tm 98.8 BP 113/61 P 77 (77-89) RR 18 ___ 97-100 RA
General- Alert, oriented, sobbing saying she wants to go to
rehab
HEENT- Sclera anicteric, MMM, oropharynx unable to visualize due
to poor effort. Some minimal swelling over right eye with right
ptosis. No erythema or tenderness.
Neck- supple
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. Reproducible chest pain on palpation
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly appreciated
Back- No CVAT
Ext- warm, well perfused, 1+ pulses ___
Neuro- Right ptosis, PERRLA, EOMI but some loss of conjugate
gaze and poor effort. Able to smile with some left facial droop.
Able to raise both eyebrow but left > R. Left hemiparesis.
Strength 4+ on right. Sensation intact bilaterally
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Labs:
___ 10:00PM BLOOD WBC-6.6 RBC-4.18* Hgb-12.2 Hct-38.2
MCV-91 MCH-29.2 MCHC-32.0 RDW-15.5 Plt ___
___ 10:00PM BLOOD Glucose-83 UreaN-8 Creat-0.6 Na-142 K-4.4
Cl-107 HCO3-27 AnGap-12
___ 06:30AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.0
___ 10:07PM BLOOD Lactate-1.2
___ 10:00PM BLOOD ___ PTT-25.6 ___
___ 10:10PM URINE UCG-NEGATIVE
___ 10:10PM URINE Mucous-RARE
___ 10:10PM URINE RBC-2 WBC-5 Bacteri-MOD Yeast-NONE Epi-0
___ 10:10PM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG
___ 10:10PM URINE Color-Yellow Appear-Hazy Sp ___
Discharge Labs:
___ 06:00AM BLOOD WBC-5.9 RBC-4.18* Hgb-12.1 Hct-37.7
MCV-90 MCH-29.0 MCHC-32.2 RDW-15.4 Plt ___
___ 06:00AM BLOOD Glucose-80 UreaN-9 Creat-0.6 Na-139 K-4.0
Cl-102 HCO3-25 AnGap-16
Imaging:
- CT Head OSH Repeat Read ___: Unchanged appearance of the
brain with encephalomalacia and craniectomy changes.
Micro:
- Urine Cx ___: pnding
- Blood Cx x ___: pnding
Brief Hospital Course:
___ hx of R ACA/MCA stroke with left hemiplegia s/p
decompressive right crani (___) s/p cranioplasty (___) c/b
wound infection s/p 6 weeks of abx for MSSA infection
transferred from ___ for possible new right facial droop. Found
to have UTI on admission. Seen by neurology who states findings
consistent with previous, no concern for new neuro finding.
Concerned that helmet might be too tight causing some swelling
over right eye. Neurosurgery evaluated, stated swelling may be
due to excess skin from previous procedures. No concern for
cellulitis or new neurologic process. Recommended follow-up as
an outpatient as previously scheduled. Seen by NEOPS who state
helmet fit was appropriate. Throughout stay patient complained
of non-specific, reproducible pains throughout her body. Home
regimen was adjusted with some relief.
Active Issues:
# Facial droop vs swelling. No facial droop on right
appreciated, c/w prior neurology assessment. Pt states she can
not raise right eyebrow as high as left due to the cranioplasty.
Pt does have some mild edema over R orbital area, and eyelid
droop below known large right hemicrani defect. No erythema over
her head or face, or tenderness, or significant facial swelling
to suggest cellulitis. She is able to open her eye, CN 3 palsy
as previous. States she has some pain with eye movement to the
right but also complains of pain in multiple places. Pt without
erythema, fever, white count. Neurology and neurosurgery say no
change from previous, no concern for local infection. CT head
from OSH shows no changes. Concern that maybe helmet may be too
tight over that area but only soft shell with patient. Plan for
outpatient neurosurgical f/u.
# UTI: Positive sx, U/A, no fever, wbc count or CVAT concerning
for pyelo. Treated with rocephin IV x 3 days.
# CP: Pt complained of reproducible, pleuritic, chest pain, for
last 4 months, EKG without ST changes. Less concerning for acute
issue. Likely part of overall diffuse pain symptoms.
# Diffuse pains: Diffuse tenderness on exam. Likely
psychosomatic component. Continued home pain med regimen. Added
scheduled tylenol, ibuprofen prn, increased baclofen and
clonazepam with some improvement.
Chronic Issues:
# CVA. Exam findings consistent with prior stroke - left lower
facial droop, left hemiparesis. Aspirin continued. Has neuro and
neurosurg follow-up.
Transitional Issues:
- Neurosurgical f/u as outpt
- Neurology f/u
- F/u pain control on modified regimen
- F/u if patient has hard helmet for daily wear at long term
facility. If not, please call ___, CO ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
2. Acetaminophen-Caff-Butalbital 2 TAB PO DAILY
3. Aspirin 81 mg PO DAILY
4. Baclofen 5 mg PO BID
5. Bisacodyl 10 mg PO DAILY
6. ClonazePAM 0.5 mg PO BID
7. Docusate Sodium (Liquid) 100 mg PO BID
8. Lactulose 30 mL PO DAILY
9. Mag-Al Plus (alum-mag hydroxide-simeth) 200 mgs ORAL EVERY
6HOURS PRN indigestion
10. Senna 8.6 mg PO DAILY
11. Vitamin E 400 UNIT PO BID
12. Sertraline 37.5 mg PO DAILY
13. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
14. Polyethylene Glycol 17 g PO DAILY
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. Oxcarbazepine 150 mg PO BID
17. Milk of Magnesia 30 mL PO DAILY:PRN constipation
18. Omeprazole 20 mg PO DAILY
19. Metoclopramide 10 mg PO QIDACHS
20. melatonin 7 mg oral QHS
21. Fleet Enema ___AILY:PRN constipation
22. Ferrous Sulfate 325 mg PO DAILY
23. Calcium Carbonate 500 mg PO BID
24. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Aspirin 81 mg PO DAILY
3. Baclofen 5 mg PO TID
4. ClonazePAM 0.5 mg PO TID
5. Docusate Sodium (Liquid) 100 mg PO BID
6. Fleet Enema ___AILY:PRN constipation
7. Metoclopramide 10 mg PO QIDACHS
8. Milk of Magnesia 30 mL PO DAILY:PRN constipation
9. Omeprazole 20 mg PO DAILY
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Oxcarbazepine 150 mg PO BID
12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
13. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
14. Polyethylene Glycol 17 g PO DAILY
15. Senna 8.6 mg PO DAILY
16. Sertraline 37.5 mg PO DAILY
17. Acetaminophen 650 mg PO Q8H
not to exceed 4g total daily (including fioricet's
acetaminophen)
18. Acetaminophen-Caff-Butalbital 2 TAB PO DAILY
19. Calcium Carbonate 500 mg PO BID
20. Ferrous Sulfate 325 mg PO DAILY
21. Lactulose 30 mL PO DAILY
22. Mag-Al Plus (alum-mag hydroxide-simeth) 200 mgs ORAL EVERY
6HOURS PRN indigestion
23. melatonin 7 mg oral QHS
24. Vitamin E 400 UNIT PO BID
25. Bisacodyl 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Urinary Tract Infection
SECONDARY DIAGNOSES
Right ACA/MCA Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted for a possible facial droop. The
neurologists and neurosurgeons saw you who felt that there was
nothing concerning. We controlled your pain and increased some
of these medications to help with your comfort. You were also
found to have a urinary tract infection which we treated with
antibiotics.
We wish you a full and speedy recovery.
~ You ___ Team
Followup Instructions:
___
|
19844276-DS-18
| 19,844,276 | 24,559,189 |
DS
| 18 |
2156-12-02 00:00:00
|
2156-12-02 16:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sertraline / Hydrochlorothiazide
Attending: ___
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy ___
History of Present Illness:
Ms. ___ is an ___ y/o female with a hx of CAD s/p CABG
(___) with SVG-OM, SVG-RCA, SVG-LAD, HTN, HLD, PAD, and MDD
who presents with diarrhea.
History limited due to language barrier and patient difficulties
with using a phone interpreter.
The patient had been followed for several months for recurrent
chest pain. She ultimately underwent a coronary angiogram in
___ that showed proximal 70% LAD stenosis, mid diffuse 80%
LAD, 75% origin stenosis of a large S1, and disease involving
origin of tortuous D1. She initially declined surgery but
ultimately was admitted from ___ for CABG x3 (SVG-OM,
SVG-RCA, SVG-LAD). Her post op course was complicated by atrial
fibrillation, which resolved with amiodarone (anticoagulation
was
deferred). Ultimately, she remained clinically stable and was
discharged to ___. At cardiology follow up on ___,
she was doing well overall. Due to hypotension, her metoprolol
and valsartan doses were reduced at that time.
Today, the patient reports two weeks of diarrhea, noting ___
brown-watery bowel movements daily. She describes both small and
large volume BMs without hematochezia or melena. Also denies
abdominal pain, nausea, vomiting, fever, chills, or muscle
aches.
No sick contacts, new foods or recent travel. Of note, the
patient received IV vancomycin during her last admission.
Additionally, the patient reports two falls over the last two
days with headstrike to the ground. Unclear if she lost
consciousness or had associated lightheadedness or dizziness.
She
denies chest pain, shortness of breath, leg swelling/pain,
headaches, or new weakness. She typically walks with a walker.
She has a home ___ who felt that the patient appeared very
dehydrated and needed IV fluids, prompting presentation to the
ED.
In the ED:
Initial vital signs were notable for: Temp ___ BP 124/55 HR 80
RR
18 97% on RA
Exam notable for: None documented
Labs were notable for: BUN 43, Cr 1.4, WBC 12.9, H/H 10.4/32.4,
lipase 14, lactate 1.6
Studies performed include:
- CXR: small left pleural effusion w/ adjacent consolidation
- CT head: No acute process
- CT abd/pelvis w/ contrast: mild wall thickening with
surrounding fat stranding along the rectum may represent a mild
colitis
- DVT US: wall thickening of 1 of the left peroneal veins which
is not completely compressible, may represent chronic
nonocclusive thrombosis
Patient was given: 1L NS, IV Vancomycin, IV aztreonam, IV
azithromycin, metoprolol tartrate 50 mg, amiodarone 200 mg,
atorvastatin 80 mg, ranitidine 300 mg, notriptyline 10 mg
Consults: Cardiac surgery
Vitals on transfer: Temp 98.8 HR 87 BP 152/82 RR 18 99% RA
Upon arrival to the floor, the patient denies having any
abdominal pain, nausea, vomiting, fever, or chills.
REVIEW OF SYSTEMS:
==================
Complete ROS obtained and is otherwise negative.
Past Medical History:
Coronary Artery Disease s/p CABG x3 (SVG-OM, SVG-RCA, SVG-LAD)
Esophageal Spasm
Gastroesophageal Reflux Disease
Hyperlipidemia
Hypertension
Peripheral Arterial Disease - subclavian and aorta disease
Major depressive disorder
Osteoporosis
GERD
Ulcerative colitis
Social History:
___
Family History:
Her mother passed away from pneumonia at age ___. Father's health
history is unknown. No known history of early CAD or other
cardiac conditions.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Temp 98.6 BP 121/72 HR 71 RR 18 95% on RA
GENERAL: Alert and interactive. In no acute distress. Lying
comfortably in bed.
HEENT: NCAT. Pupils equal bilaterally. Sclera anicteric and
without injection. Dry mucous membranes. Oropharynx clear.
NECK: Supple, no cervical lymphadenopathy. JVP not elevated.
CARDIAC: RRR with normal S1 and S2. No murmurs, rubs or gallops.
LUNGS: Normal respiratory effort. No increased work of
breathing.
Faint bibasilar crackles, otherwise CTAB without wheezes or
rhonchi.
ABDOMEN: Soft, non-distended, mild TTP over LLQ. No rebound or
guarding. Normoactive BS.
EXTREMITIES: Trace ___ non-pitting edema. No erythema or TTP. 1+
DP pulses bilaterally.
SKIN: Warm, dry. No rashes. Sternotomy scar healing well without
surrounding erythema or drainage.
NEUROLOGIC: Alert and interactive. CN2-12 grossly intact.
Moving
all extremities.
PSYCH: Normal mood and affect.
DISCHARGE PHYSICAL EXAM:
VITALS: 98.1 PO |155 / 75| 73 |16 |97
GENERAL: Alert and interactive. In no acute distress. Sitting up
in bed, comfortable.
HEENT: Pupils equal bilaterally. Sclera anicteric and
without injection. Moist mucous membranes. Oropharynx clear.
CARDIAC: RRR with normal S1 and S2. No murmurs, rubs or gallops.
LUNGS: Normal respiratory effort. No increased work of
breathing.
Mild bibasilar crackles, otherwise CTAB without wheezes or
rhonchi.
ABDOMEN: Soft, non-distended, no TTP. No rebound or guarding.
Normoactive BS.
EXTREMITIES: No edema. No erythema or TTP. 1+ DP pulses
bilaterally.
PSYCH: Normal mood and affect. Alert.
NEURO: Alert and oriented x3. No gross focal deficits.
SKIN: Skin type IV. Warm, dry. No rashes. Sternotomy scar
healing well without surrounding erythema or drainage. RLE with
purpura along medial calf.
Pertinent Results:
ADMISSION LABS:
================
___ 12:20PM BLOOD WBC-12.9* RBC-3.23* Hgb-10.4* Hct-32.4*
MCV-100* MCH-32.2* MCHC-32.1 RDW-15.5 RDWSD-56.7* Plt ___
___ 12:20PM BLOOD Neuts-88.7* Lymphs-3.9* Monos-6.8
Eos-0.0* Baso-0.1 Im ___ AbsNeut-11.42* AbsLymp-0.50*
AbsMono-0.88* AbsEos-0.00* AbsBaso-0.01
___ 12:20PM BLOOD Glucose-103* UreaN-43* Creat-1.4* Na-139
K-5.1 Cl-103 HCO3-23 AnGap-13
___ 12:20PM BLOOD ALT-20 AST-35 AlkPhos-120* TotBili-0.4
___ 12:54PM BLOOD GGT-37*
___ 04:30AM BLOOD CK-MB-2 cTropnT-0.03*
___ 12:54PM BLOOD CK-MB-4 cTropnT-0.04*
___ 04:30AM BLOOD Calcium-7.6* Phos-2.6* Mg-2.2
___ 12:54PM BLOOD calTIBC-161* VitB12-1610* Ferritn-641*
TRF-124*
___ 06:35AM BLOOD CRP-157.7*
IMAGING AND STUDIES:
====================
SIGMOIDOSCOPY ___:
Ulceration, friability and exudate in the distal rectum
compatible with proctitis.
BILATERAL ___ US ___:
IMPRESSION:
1. Limited visualization of the right calf veins, otherwise no
evidence of
deep venous thrombosis in the right lower extremity veins.
2. Wall thickening of 1 of the left peroneal veins which is not
completely
compressible may represent chronic nonocclusive thrombosis.
3. Superficial thrombophlebitis of the right greater saphenous
vein without extension into the right common femoral vein.
CHEST X RAY ___:
IMPRESSION:
Small left pleural effusion. Adjacent consolidation in the left
lung is
likely in part due to atelectasis though superimposed infection
is also
suspected.
CT ABD/PELVIS W/O CONTRAST ___:
IMPRESSION:
1. Mild wall thickening with surrounding fat stranding along the
rectum may represent a mild proctitis.
2. Moderate left pleural effusion.
3. Distended gallbladder without wall thickening, recommend
clinical
correlation with fasting state or right upper quadrant
symptomatology.
4. The right greater saphenous vein appears expanded and
contains thrombus, consistent with superficial thrombophlebitis,
if there is clinical concern for DVT, a lower extremity
ultrasound can be performed.
MICROBIOLOGY:
___ 2:33 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT ___
VIRAL CULTURE (Final ___:
ENTEROVIRUS. PRESUMPTIVE IDENTIFICATION.
___ 2:33 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
___ 2:33 am STOOL CONSISTENCY: SOFT Source: Stool.
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
___:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH
DISCHARGE LABS:
==================
___ 04:30AM BLOOD WBC-8.5 RBC-3.09* Hgb-9.7* Hct-30.2*
MCV-98 MCH-31.4 MCHC-32.1 RDW-15.3 RDWSD-54.4* Plt ___
___ 04:30AM BLOOD ___ PTT-38.6* ___
___ 04:30AM BLOOD Glucose-128* UreaN-13 Creat-0.7 Na-144
K-3.8 Cl-106 HCO3-23 AnGap-15
___ 04:30AM BLOOD CK-MB-4 cTropnT-<0.01
___ 04:30AM BLOOD Calcium-7.0* Phos-3.2 Mg-1.9
___ 01:00PM BLOOD CRP-19.1*
Brief Hospital Course:
Ms. ___ is an ___ y/o female with a hx of CAD s/p CABG
___ with SVG-OM, SVG-RCA, SVG-LAD, HTN, HLD, PAD, and MDD
who presents with diarrhea and falls.
#Diarrhea
#Proctitis
#Leukocytosis
#Ulcerative colitis flare
Presented with two weeks of non-bloody diarrhea without
associated abdominal pain, N/V. During admission with one
episode of blood streaked stool. She was previously followed for
ulcerative colitis when she presented with hematochezia, treated
with sulfasalazine originally (remote history), during admission
with CRP elevated at 157.7. Stool studies were negative for
C.difficile, viral stool culture ultimately was positive for
enterovirus. A flexible sigmoidocopy was performed which showed
ulceration and friability of distal colon with biopsies
consistent with ulcerative colitis. She was started on oral
mesalamine, mesalamine suppository daily and hydrocortisone
enema nightly with improvement in her symptoms.
#Hypokalemia
She was found to have hypokalemia to 2.9 in the setting of GI
losses from diarrhea. She was repleted with with 20meq IV
potassium and 40meq PO potassium with resolution of her
hypokalemia.
#S/p Fall
Patient with at least two falls prior to presentation,
associated with headstrike, unclear if LOC, syncope,
lightheadedness or dizziness present. Differential included
weakness vs orthostatic hypotension ___ dehydration vs
mechanical fall vs syncope ___ arrhythmia, MI, PE, vasovagal,
etc. Orthostatic vital signs were negative. She was continued on
telemetry without arrhythmia. Troponin was ordered with morning
labs on admission
and was slightly elevated at 0.03 and up to 0.04 on further
trending with no associated rise in CKMB, making new or ongoing
ischemia very unlikely. She was evaluated by physical therapy
throughout admission which ultimately recommended home with
physical therapy.
#Acute kidney injury
Cr 1.4 on admission, up from baseline 0.7-0.9. BUN/Cr ratio ~30,
consistent with pre-renal etiology, particularly given history
of recent diarrhea and dehydration. Also likely worsened by home
___. She received 1.5L IVF and her creatinine improved to
baseline. Home valsartan was initially held and then later
resumed during hospitalization.
#Macrocytic Anemia
Baseline Hgb ___ last year, down to 9.5 in ___. Dropped to
<7 in the setting of blood loss from CABG, since
improving/stable around 10. Likely macrocytic due to increased
production. B12 level elevated, iron studies consistent with
ACD. She had one episode of BRBPR without change in hemoglobin.
Discharge hemoglobin 9.7.
#Concern for chronic dvt:
BLE US with wall thickening and incomplete compressibility of a
left peroneal vein concerning for chronic nonocclusive
thrombosis. Additionally, superficial thrombophlebitis of the
right greater saphenous vein without extension into the right
common femoral vein, asymptomatic. Given chronic nature, distal
location, high fall risk and recent head strike did not start
anticoagulation though patient is at increased risk of DVT given
ulcerative colitis.
#Malnutrition
Weight 87 lbs, down slightly from baseline. Thin appearing on
exam. Nutrition was consulted. Started multivitamins with
minerals.
===============
CHRONIC ISSUES:
===============
#CAD s/p CABG x 3 (SVG-OM,SVG-RCA, SVG-LAD)
- Continued home aspirin, atorvastatin, metoprolol
#Hypertension
On metoprolol 50 mg daily and valsartan 80 mg daily at home. BP
stable on admission.
- Continued home metoprolol
- Resumed home valsartan
#Atrial fibrillation
Post-op CABG c/b atrial fibrillation that improved with
amiodarone. Anticoagulation held due to brief episode. CHADSVASC
5. She was in NSR throughout admission.
- Rhythm control: Continued home amiodarone. She will need to
continue 200mg daily for 2 weeks, then stop.
- Rate control: continue home metoprolol
- Anticoagulation: none
#GERD
- Continued home raniditine, pantoprazole, and sucralfate
#Depression
- Continued duloxetine, nortriptyline, trazodone
=============
CORE MEASURES
=============
#CONTACT: ___ (Daughter) ___ cell phone:
___
TRANSITIONAL ISSUES:
[ ] Patient is to start mesalamine four times daily, mesalamine
suppository, and hydrocortisone suppository until she is seen by
her gastroenterologist, Dr. ___. She will likely be changed to
once daily Lialda as an outpatient.
[ ] Amiodarone should be reduced to 200mg daily (from twice
daily) and continued for two more weeks
[ ] Nutrition service recommended carnation instant breakfast to
increase calorie and protein intake. Patient should continue to
try to limit sodium intake to ___ grams of sodium daily.
[ ] Patient should have repeat serum chemistries performed
within 2 weeks of discharge to evaluate for maintained
resolution ___ and hypokalemia.
[ ] After discussion with GI, her acid reducing regimen was
decreased to once daily PPI. Her GERD symptoms improved after
cabg suggesting that much of her upper GI symptoms was likely
actually cardiac in origin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sulfacetamide-Prednisolone Ophth. Susp. ___ DROP BOTH EYES
3X/WEEK (___)
2. Amiodarone 200 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. DULoxetine 40 mg PO DAILY
6. Nortriptyline 10 mg PO QHS
7. Ranitidine 300 mg PO BID
8. TraZODone 75 mg PO QHS
9. Valsartan 80 mg PO DAILY
10. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral daily
11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
12. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
13. Pantoprazole 40 mg PO Q12H
14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
15. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
16. Sucralfate 1 gm PO BID
17. Fluocinolone Acetonide 0.025% Cream 1 Appl TP Frequency is
Unknown
18. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Hydrocortisone Acetate Suppository 1 SUPP PR QHS
RX *hydrocortisone acetate 25 mg 1 suppository(s) rectally daily
Disp #*30 Suppository Refills:*0
2. Mesalamine (Rectal) ___AILY
RX *mesalamine [Canasa] 1,000 mg 1 suppository(s) rectally daily
Disp #*30 Suppository Refills:*0
3. Mesalamine 1000 mg PO QID
RX *mesalamine 800 mg 1000 mg by mouth four times a day Disp
#*120 Tablet Refills:*0
RX *mesalamine [Pentasa] 500 mg 2 capsule(s) by mouth four times
a day Disp #*120 Capsule Refills:*0
4. Amiodarone 200 mg PO DAILY
5. Fluocinolone Acetonide 0.025% Cream 1 Appl TP ASDIR
6. Pantoprazole 40 mg PO Q24H
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral daily
11. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
12. DULoxetine 40 mg PO DAILY
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Nortriptyline 10 mg PO QHS
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
16. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
17. Sulfacetamide-Prednisolone Ophth. Susp. ___ DROP BOTH EYES
3X/WEEK (___)
18. TraZODone 75 mg PO QHS
19. Valsartan 80 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Ulcerative colitis
Viral gastroenteritis
Secondary:
Acute kidney injury
Hypokalemia
Coronary artery disease s/p CABG
Macrocytic Anemia
Hypertension
Atrial fibrillation
GERD
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were having
diarrhea and you fell at home.
In the hospital you had many studies performed to find the cause
of your diarrhea. You had a procedure called a sigmoidoscopy
which showed that you were having a flare of ulcerative colitis.
Additionally, you were found to have a viral infection that was
also causing your diarrhea. You were started on medicine to
treat your ulcerative colitis. Your diarrhea improved.
When you go home you should take all of your medicine as
prescribed. You should go to all of your doctor's appointments.
It was a pleasure caring for you. We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19844373-DS-7
| 19,844,373 | 28,527,464 |
DS
| 7 |
2184-12-05 00:00:00
|
2184-12-07 18:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Aspirin / Ciprofloxacin /
Urelle / Levaquin / Ampicillin / Haldol / Tramadol / Codeine /
Amoxicillin / clindamycin
Attending: ___
Chief Complaint:
Aspiration of Foreign Body
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of GERD (sp Nissen fundoplication, course
cb perforation and subsequent chronic aspiration) who presents
sp aspiration of an apple.
She presented to her PCP ___ ___ with concern that she aspirated
an apple. She had difficulty swallowing the apple, 1 hour later,
developed sharp pain in her chest and wheezing. She was able to
eat a hot dog after the event (thinking that this would
facilitate dislodgement of aspirated apple). PCP noted her not
to be in any acute respiratory distress and referred her to the
ED for further evaluation.
In the ED vitals were 99.1 79 112/59 18 96% ra. She was
complaining of a pressure in her chest and her back, but no
difficulty breathing. IP recommended a NCCT chest, which showed
evidence of .. UA showed trace leukocytes, 3wbcs, and no
bacteria. She received klonopin, albuterol, ipratropium and
trazodone prior to admission.
On ROS, she denied any vomiting or coughing.
Past Medical History:
- ANXIETY
- APPENDECTOMY
- CARPAL TUNNEL SYNDROME bilateral release 1980s- sx recurred
- DEPRESSION psych hospitalization ___ yrs ago - no suicide
attempt
- GASTROESOPHAGEAL REFLUX
- GENITAL HERPES outbreaks every ___ yrs - most recent outbreak
___
- HYPERCHOLESTEROLEMIA
- LIPOSUCTION approx 2000ish
- OSTEOPOROSIS Reclast infustion - ___ -
- PULMONARY NODULES
- SLEEP APNEA on CPAP
- TUBAL LIGATION
- ULCERATIVE COLITIS Most recent colonoscopy ___ -
___ polyps
- Frequent UTIs - ___ with Dr. ___ 3 mos - procedure
to open urethra
- SP NISSEN FUNDOPLICATION CB ESOPHAGEAL PERFORATION (___)
s/p thoracotomy - ongoing issues with swallowing - on and off
home TPN
- SP Bilateral Carpal Tunnel release 1980s- sx recurred
Social History:
___
Family History:
- Mother died of liver cancer in her ___
- Mother and maternal aunt had breast cancer
Physical Exam:
PHYSICAL EXAM:
VS: 98.2 118/78 69 96%RA
GENERAL: well appearing, no acute distress, speaking in full
sentences with occasional audible wheezing with coughing
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, JVD
LUNGS: Diffuse end exp wheezing, loudest at R mid-lung (after
coughing up apple piece, only occasional end expiratory wheezing
was noted in R lung)
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3
Pertinent Results:
ADMISSION LABS:
___ 07:15PM BLOOD WBC-8.5 RBC-4.18*# Hgb-13.6# Hct-41.3#
MCV-99* MCH-32.6* MCHC-33.0 RDW-12.1 Plt ___
___ 07:15PM BLOOD Neuts-56.0 ___ Monos-5.3 Eos-1.0
Baso-1.0
___ 07:15PM BLOOD Glucose-89 UreaN-16 Creat-0.8 Na-143
K-3.8 Cl-103 HCO3-30 AnGap-14
___ 07:50PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 07:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-TR
___ 07:50PM URINE RBC-0 WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-6.6 RBC-4.30 Hgb-13.8 Hct-43.2
MCV-101* MCH-32.2* MCHC-32.0 RDW-12.2 Plt ___
___ 06:30AM BLOOD ___ PTT-31.9 ___
___ 06:30AM BLOOD Glucose-95 UreaN-12 Creat-0.9 Na-145
K-3.8 Cl-104 HCO3-33* AnGap-12
___ 06:30AM BLOOD Albumin-4.5 Calcium-9.1 Phos-4.0 Mg-2.3
MICRO:
___ 7:50 pm URINE
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML: Alpha
hemolytic colonies consistent with alpha streptococcus or
Lactobacillus sp.
IMAGING:
CXR PA/LATERAL ___:
FINDINGS:
Postsurgical changes in the right upper hemithorax are again
seen with mild volume loss of the right lung and shift of
mediastinum to the right. The lungs are clear without focal
consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are
unremarkable. No radiopaque foreign body is seen aside from
stable appearing surgical clips over the right mediastinum.
IMPRESSION: Postoperative changes again seen. No new radiopaque
foreign body is seen.
CHEST CT WO CONTRAST ___:
IMPRESSION:
1. 1cm endobronchial structure within the bronchus intermedius
(400b: 22), correlates with the aspiration history and right
sided wheeze.
2. Unchanged multiple ground-glass and solid pulmonary nodules.
Subpleural ground-glass opacities within the right middle lobe
likely related to atelectasis/inflammatory changes.
EKG ___:
Sinus rhythm. Diffuse T wave changes which are non-specific.
Compared to the previous tracing of ___ the heart rate is
slower. Otherwise, no other significant diagnostic change.
Brief Hospital Course:
Ms. ___ is a ___ with a history of GERD (sp ___
fundoplication, course cb perforation and subsequent chronic
episodes of aspiration sensations) who presented after
aspiration of a piece of apple.
#ASPIRATION EVENT:
Patient aspirated apple piece into bronchus intermedius. Pt was
able to eat and had no sx of airway compromise. IP evaluated pt
and planned bronchoscopy for retireval of foreign body. Patient
continued to take psych meds despite recommendation to be NPO.
Shortly after admission, she coughed up the piece of apple and
after re-evaluation by IP, bronchoscopy was cancelled. Pt was
scheduled for outpatient eval by IP.
#Anxiety:
Continued home fluvoxaine, clonazepam and trazodone
#Osteoporosis:
Meds were initially held but were restarted after patient
coughed up apple. Restarted calcium, oscal and vitamin D prior
to discharge.
#HYPERCHOLESTEROLEMIA: Continued simvastatin after pt coughed up
apple
TRANSITIONAL ISSUES:
# CODE STATUS: Full Code
# CONTACT: Partner ___ ___
- Please consider further speech and swallow evaluation
- Please consider gastroenterology evaluation given recurrent
aspiration-like events reported by patient and attributed by
patient to ___
- Please note, patient had trace leukocytes on UA and culture
showed bacteria consistent with alpha hemolytic colonise
(___). This was likely a contaminant. Please assess for UTI
symptoms at follow-up given history of UTIs in the past.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 200 mg PO DAILY
2. Clonazepam 1.5 mg PO QHS
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Fluvoxamine Maleate 100 mg PO DAILY
5. RABEprazole *NF* 40 mg Oral daily
6. Simvastatin 80 mg PO DAILY
7. traZODONE 150 mg PO HS
8. Century Adults 50+ *NF* (mv with min-lycopene-lutein) unknown
Oral daily
9. Vitamin D ___ UNIT PO DAILY
10. Os-Cal 500 + D *NF* (calcium carbonate-vitamin D3) unknown
Oral TID
11. Magnesium Oxide Dose is Unknown PO ONCE
12. Phytonadione Dose is Unknown PO ONCE
Discharge Medications:
1. Clonazepam 1.5 mg PO QHS
2. Fluvoxamine Maleate 100 mg PO DAILY
3. traZODONE 150 mg PO HS
4. Acyclovir 200 mg PO DAILY
5. Century Adults 50+ *NF* (mv with min-lycopene-lutein) 1 tab
ORAL DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Magnesium Oxide 140 mg PO ONCE Duration: 1 Doses
8. Os-Cal 500 + D *NF* (calcium carbonate-vitamin D3) 1 tab ORAL
TID
9. Phytonadione 1 tab PO ONCE Duration: 1 Doses
10. RABEprazole *NF* 40 mg Oral daily
11. Simvastatin 80 mg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Aspiration
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 at ___. You were
admitted because you aspirated a piece of apple. You were
evaluated by interventional pulmonology and there was a plan to
perform a bronchoscopy but you coughed up the apple before this
was necessary. Your symptoms (cough, wheezing, pain) improved.
We offered you a speech and swallow evaluation however you opted
for discharge prior to completion. We spoke with your PCP who
will continue to monitor you closely. Please follow up with your
gastroenterologist and with the pulmonary clinic as below. Best
Regards.
Followup Instructions:
___
|
19844485-DS-22
| 19,844,485 | 25,614,594 |
DS
| 22 |
2184-07-08 00:00:00
|
2184-08-06 15:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ PMH of GIST tumor resection/partial gastrectomy and
past admissions for intraperitoneal bleed ___ omental
metastasis while on coumadin presents from rehab with anemia.
History is obtained with aide of translator phone. Her Hct was
42 on ___, and on routine recheck at rehab on the day prior to
admission, returned at 28. Of note, she started Sutent on
___ given progression of GIST on Gleevec, but this was
discontinued on ___ secondary to a painful dermatitis. She was
transferred to the ___ ER where she states that she has been
feeling overall weak and has increased edema in legs. She
denies DOE, BRBPR, hematuria, trauma, easy bruising, shortness
of breath. In the ER, she received a CT which did not show any
acute hemorrhage and was comparable to previous abdominal
imaging from 4 months prior. Stool was brown and guiac
negative. She started receiving 2 units of PRBCs and
transferred to the floor for further management.Of note, pt had
developed a wound post the skin biopsy and pt is concerned about
the dressing.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies cough, shortness of breath, or wheezes.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria, stool or
urine incontinence. Denies arthralgias or myalgias. Denies
rashes or skin breakdown. No numbness/tingling in extremities.
All other systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
- Mrs. ___ initially presented ___ with abdominal
pain. At that time, she was found to have a large mass in her
abdomen.
- On ___, she underwent an incomplete resection of this
tumor. It was found to be increasing in size and she was
treated
on Gleevec from ___ to ___. At that time, she stopped
it
as she was having some side effects from this therapy, most
notably severe cramping. On the Gleevec, her tumor had
decreased
in size. However, the mass grew while she was off the Gleevec
and she was restarted on it again in ___. She was restarted
at 200mg daily to avoid issues with cramping.
- On ___ she had a CT scan which showed new liver lesions
which were concerning. An ultrasound was obtained ___ which
showed these lesions and raised concern for metastatic disease.
- She was increased from Gleevec 200mg daily to 400mg daily on
___.
- She had stable CT scans and the liver lesions were determined
to be cysts, she was decreased from 400mg daily to 200mg daily
due to nausea on ___.
- Increased back to 400mg Gleevec daily on ___ but had
disease growth on CT
- Resection of GIST lesion by Dr. ___ on ___
- She was admitted to the hospital on ___ due to a GI
bleed
and a repeat GI bleed on ___, both of which were found to
be due to enlarging GIST.
- Started Sutent on ___ given progression on Gleevec,
discontinued on ___ secondary to a painful dermatitis
.
Other Past Medical History:
DM, HTN, HLD, paroxysmal Afib, CVA ___, TIA ___,
hypothyroidism
Grade II (moderate) left ventricular diastolic dysfunction
___
Pulmonary HTN
Admission ___ for abdominal pain and ascites from
metastatic disease
Admission ___ - ___ for intrabdominal hemorrhage
Admission ___ - ___ for intrabdominal hemorrhage
Admission ___ - ___ intrabdominal hemorrhage and
surgical resection of GIST tumor
Admission ___ - ___ for CHF exacerbation in setting of
hypertensive emergency
Admission ___ - ___ for CHF exacerbation
Hemangioma of the right thigh
Social History:
___
Family History:
No family history of cancer, lung disease or heart disease. +
for DM.
Physical Exam:
VS: T 97.6 bp 112/70 HR 72 RR 18 SaO2 98 on 3L NC
GEN: smiling, cooperative, morbidly obese
HEENT: MMM. no LAD. cannot appreciate JVD. neck supple. No LAD
Cards: irregularly irregular rhythm, normal rate; S1/S2 normal.
no murmurs/gallops/rubs appreciated
Pulm: slightly decreased breath sounds at bases with normal
effort, no crackles or wheezes
Abd: BS+, distended, obese, non-tender, no hepatosplenomegaly
although difficult to assess with habitus, no rebound or
guarding
Extremities: wwp, bilateral edema with normal perfusion; right
thigh wound from biopsy, serosanguinous drainage without warmth
or erythema around site
Skin: no rashes or bruising
Neuro: no focal deficits, sensation intact
Pertinent Results:
___ 04:00AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:00AM URINE BLOOD-NEG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
___ 04:00AM URINE RBC-3* WBC-8* BACTERIA-FEW YEAST-NONE
EPI-6
___ 04:00AM URINE HYALINE-1*
___ 04:00AM URINE MUCOUS-RARE
___ 09:40PM GLUCOSE-126* UREA N-20 CREAT-0.9 SODIUM-140
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-28 ANION GAP-13
___ 09:40PM LD(LDH)-522*
___ 09:40PM WBC-3.0* RBC-2.51* HGB-8.2* HCT-27.3*
MCV-109* MCH-32.7* MCHC-30.1* RDW-17.7*
___ 09:40PM PLT COUNT-277
___ 09:40PM ___ PTT-29.0 ___
___ 02:25PM UREA N-20 CREAT-0.9 SODIUM-143 POTASSIUM-3.8
CHLORIDE-104 TOTAL CO2-31 ANION GAP-12
___ 02:25PM ALT(SGPT)-18 AST(SGOT)-14 ALK PHOS-97 TOT
BILI-0.7
___ 02:25PM WBC-3.5* RBC-2.66*# HGB-9.1*# HCT-28.8*#
MCV-109* MCH-34.4* MCHC-31.7 RDW-18.0*
___ 02:25PM PLT COUNT-270#
___ 02:25PM ___ ___
CT abdomen and Pelvis ___ (Wet Read):
1. moderate high density free fluid in the abdomen and pelvis is
compatible with hemorrhage, new from ___ exam, but appears
stable over multiple prior studies dating back to ___.
2.large intraabdominal mass eminating from the greater curviture
of the stomach, with small additional perioneal masses,
compatible with metastatic GIST, stable.
3. small to moderate ___ pleural effusions, R>L, new since
___ exam.
EKG: A fib with normal rate, no ST-T segment, t-wave inversions
in lateral leads, unchanged from prior tracing
CXR ___. Overall cardiac enlargement and stable
cardiomediastinal contours. Interval decrease in lung volumes
with probable perihilar and mild pulmonary edema. No definite
pleural effusions. No evidence of pneumothorax. No acute bony
abnormality.
Trans Thoracic ___ left atrium is mildly dilated.
The right atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___, no
major change.
.
Urine ___ 2:52 pm URINE Site: CLEAN CATCH
Source: ___.
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML..
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-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ w/ PMH of GIST tumor resection/partial gastrectomy and
past admissions for intraperitoneal bleed ___ omental
metastasis while on coumadin (now stopped) presents from rehab
with anemia.
#Macrocytic anemia -Pt received 1 unit of PRBCs on admission
with appropriate response and stable hct thereafter. Anemia
panel not c/w hemolysis or occult blood loss. No evidence of
acute bleed during hospital stay. Anemia likely due to
malignancy and recent sunitinib. Normal iron levels as well as
B12, folate, retic count and TSH levels.
.
#GIST with metastases to the omentum Treatment on hold for now
until wound improves. Ct of abdomen showed stable disease.
.
#Chronic diastolic heart failure - Patient with increase in ___
edema over the past few days and increased DOE with evidence of
vascular congetsion on cxr.Cause of decompensation unclear;
possibly sunitinib,infection,anemia, or diet.
Given 2 doses of IV lasix with good response. Breathing improved
significantly and also improved lower extremity edema. TSH wnl,
echo -unchanged. UTI possibly contributing to decompensation as
well as sunitinib and anemia.Pt's weight and lower extremity
edema to be monitored as an oputpt and lasix to be given
accordingly. Pt also to follow a cardiac healthy diet with salt
restriction.
.
#AFIB: Rate controlled with diltiazem. Pt not on anticoagulation
given h/o GI bleed in the past.Aspirin held initially because of
concern of possible bleed , but since pt without evidence of
bleed aspirin 81 mg resumed. Pantoprazole started for GI
prophylaxis.
.
# HYPERTENSION: Continued Diltiazem. BP well controlled
throughout hospital stay.
.
#DM2: Continued to manage with Humalog insulin sliding scale in
the hospital.Januvia held on admission and resumed upon
discharge.
.
#Surgical wound: Cont dressings per wound care nurse. Surgery
consulted and did feel that there is any need for additional
debridement at this time. Pt also seen by wound care nurse and
pt to continue dressing per wound care nurse recs with outpt f/u
as well.
.
#UTI: U/A c/w a possible UTI. Cx positive for e.coli. UTI could
be contributing to CHF decompensation. No fever/dysuria.Pt to
complete a course of cipro.
.
PPx - Pneumoboots
.
Precautions for:none
.
Lines: peripheral
.
CODE: FULL.
.
Medications on Admission:
Diltiazem CD 180mg PO daily
Fluconazole 100mg PO q72h
Synthroid ___ PO daily
Miralax 1 packet PO daily
Januvia 50mg PO daily
Timolol 1 drop each eye BID
Oxycodone ___ PO q4 PRN pain
Duonebs q4 PRN dyspnea
ASA 81mg PO daily
Compazine 5mg PO daily PRN constipation
Ambien 10mg PO qHS PRN insomnia
Colace 100mg PO daily PRN constipation
Senna 1 tab daily PRN constipation
Regular insulin sliding scale as needed for hyperglycemia
Lasix 80mg PO daily
Discharge Medications:
1. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
2. levothyroxine 50 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily): hold for loose stools.
4. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic BID
(2 times a day).
5. oxycodone 5 mg Tablet Sig: ___ Tablets PO every six (6) hours
as needed for pain.
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath.
7. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for shortness of breath.
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
9. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
13. insulin lispro 100 unit/mL Solution Sig: Two (2)
Subcutaneous ASDIR (AS DIRECTED) as needed for hyperglycemia:
per sliding scale.
14. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day.
15. Lasix 40 mg Tablet Sig: ___ Tablets PO every twelve (12)
hours as needed for shortness of breath or wheezing: give based
on weight gain of more than 3 pounds or increased lower
extremity edema. Follow electrolytes.
16. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
17. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Anemia
diastolic heart failure-decompensated
gastro-intestinal stromal tumor
urinary tract infection
atrial fibrillation
open wound-lower extremity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms ___ was admitted because of a drop in red blood cell count
and hisptory of prior GI bleed. CT scan in the ED did not show
any evidence of active bleed. Ms ___ received 1 unit of
PRBCs with appropriate response and was monitored for any
evidence of bleed.Anemia is likely due to recent sunitinib and
cancer. Ms ___ also presented with volume overlaod (
increased lower extremity edema and fluid in her lungs) She
received IV diuretics with good reponse. As part of the work-up
fo rdecompensated heart failure she had a urine culture which
was positive for e.coli and Ms ___ was started on
ciprofloxacin.
Chnage in medications:
Ciprofolxacin 500 mg po bid x 6 days.
lasix to be adjusted based on weight/lower extremity edema and
chem 10.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19844485-DS-23
| 19,844,485 | 27,110,238 |
DS
| 23 |
2184-07-28 00:00:00
|
2184-07-29 13:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo ___ speaking female, h/o GIST on low dose sudent, DM,
diastolic CHF, PAF, not on AC, presenting with hypoxia. Her ___
found her to be hypoxic to the 70's associated with dyspnea. She
says the shortness of breath at rest started yesterday and is
associated with increased orthopnea and PND over the last 2
nights. She denies recent fevers, chills, or cough. Denies chest
pain, pleuritic or otherwise. She notes no dietary indiscretion.
Today, her ___ noted her to be hypoxic on RA and called EMS, who
found her to be in the ___ on 4L NC.
.
Of note, she was recently restarted on low dose of sudent for
GIST. Sudent had been on hold due to chronic right leg lesion
that developed following a punch biopsy a rash on her leg in
___. She was also recently hospitalized for decreased
hematocrit and received 1 unit pRBC. During that admission, she
was found to have decompensation of dCHF and which reponded well
to diuresis with IV lasix.
.
In the ED, initial VS: 98.6 102 142/67 20 87%. CXR noted
pulmonary edema, bilateral pleural effusions, and cardiomegaly
c/w CHF. Her Cr was 1.2 and BNP was 2824. She was given 1 SL NTG
and 40 IV lasix. Oncologist was called and advised stopping
Sudent during hospitalization. VS prior to transfer: 138/81, 92
afib, ___, RR 20, temp 98.4.
.
Currently, patient is comfortable on 2L, and requesting food.
.
ROS: Notable as above and for recent constipation. Otherwise
limited ROS negative for HA, fevers, chills, NVD, new rashes.
Past Medical History:
- RIGHT MEDIAL THIGH WOUND: Developed after developing severe
cellulitis in late ___ and underwent a biopsy of the area
___. Did not heal due to DM and chemo, as was on sudent.
Was on sunitinib and this was put on hold to allow further
healing, but has since restarted low dose. Measurement of wound
was 8 x 0.5cm. The first 4 cm on the right was still open with
hypergranulation tissue present on ___.
- GIST: Diagnosed in ___, treated with surgery and multiple
intermittant courses of gleevac, complicated by side effects.
She had partial gastrectomy and GIST resection in ___, and a
GIST omental metastasis resection in ___. Noted to have GIB
in ___ and ___ due to enlarging GIST lesions. Started
on Sutent since ___. Currently on low dose Sutent
following poor wound healing as above.
- ANEMIA, iron deficiency
- Paroxysmal ATRIAL FIBRILLATION, not on AC due to multiple RP
bleeds
- CONGESTIVE HEART FAILURE, Diastolic, ef >70%.
- DIABETES MELLITUS
- Chronic DYSPNEA, exertional
- HYPERTENSION
- HYPOTHYROIDISM
- CVA in ___, Residual R hemiparesis and intermittent aphasia,
- TIA in ___
- Status post knee surgery in ___.
Social History:
___
Family History:
No family history of cancer, lung disease or heart disease. +
for DM.
Physical Exam:
ON ADMISSION:
VS - Temp 98.2F, BP 153/87 , HR 96 , R 20 , O2-sat 98% 2L
GENERAL - well-appearing obese woman in NAD, comfortable,
appropriate. ___ speaking.
HEENT - PERRL, EOMI, sclerae anicteric, Dry MM, OP clear
NECK - supple, JVD difficult to appreciate
LUNGS - Mild expiratory wheeze, otherwise CTAB. Fair movement,
resp mildly labored with exertion
HEART - RRR, no MRG, nl S1-S2. No S3 appreciated
ABDOMEN - Obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - approx 7x0.25 cm healing wound with edges approximating
over rt medial thigh. Appears healthy. Dressing c/d/i.
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, cerebellar
exam intact to FTN
ON DISCHARGE:
Weight: 92.5 kg (from 93 kg yesterday)
Is&Os:
Yesterday - 1260/1590
First eight hours of today - ___
VS - Temp 97.6 F, BP 138/90 (120s-130s/60s-90s) HR 79 (70s -
90s), R 20, O2-sat 95% on RA
GENERAL - well-appearing obese woman in NAD, comfortable,
appropriate.
HEENT - sclerae anicteric, moist mucus membranes.
NECK - supple, JVD difficult to appreciate
LUNGS - Breathing non-labored. Very few bibasilar crackles, no
wheezes, no rhonchi
HEART - RRR, no MRG, nl S1-S2. No S3 appreciated
ABDOMEN - Obese, NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, 1+ lower extremity edema to mid-calf.
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Admission labs:
___ 01:10PM GLUCOSE-153* UREA N-25* CREAT-1.2* SODIUM-142
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15
___ 01:10PM cTropnT-<0.01
___ 01:10PM proBNP-2824*
___ 01:10PM WBC-6.0 RBC-2.81* HGB-8.6* HCT-28.5* MCV-101*
MCH-30.6 MCHC-30.2* RDW-17.0*
___ 01:10PM NEUTS-81.0* LYMPHS-13.7* MONOS-4.0 EOS-0.9
BASOS-0.5
___ 01:10PM ___ PTT-30.1 ___
___ 01:18PM LACTATE-1.7 K+-3.8
___ 09:29PM CK-MB-2 cTropnT-<0.01
___ 09:29PM CK(CPK)-51
___ 10:14PM URINE MUCOUS-RARE
___ 10:14PM URINE RBC-1 WBC-22* BACTERIA-NONE YEAST-NONE
EPI-1 TRANS EPI-<1
___ 10:14PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.5
LEUK-MOD
___ 10:14PM URINE COLOR-Yellow APPEAR-Clear SP ___
STUDIES:
CXR: prelim: Moderate pulmonary edema and small bilateral
pleural effusions and cardiomegaly consistent with congestive
heart failure.
Discharge labs:
___ 09:30AM BLOOD WBC-4.9 RBC-2.98* Hgb-9.5* Hct-30.9*
MCV-104* MCH-31.9 MCHC-30.8* RDW-17.0* Plt ___
___ 09:30AM BLOOD Glucose-203* UreaN-26* Creat-1.1 Na-140
K-4.1 Cl-101 HCO3-29 AnGap-14
___ 06:55AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:29PM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:10PM BLOOD cTropnT-<0.01
___ 09:30AM BLOOD Calcium-9.4 Phos-3.3 Mg-1.9
___ 10:14 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
ASSESSMENT & PLAN: ___ yo ___ speaking female, h/o GIST on
low dose sutent, DM, diastolic CHF, PAF, not on AC, presenting
with likely CHF exacerbation.
ACTIVE ISSUES:
1. Acute on Chronic Diastolic Congestive Heart Failure
exacerbation: Suspect due to ___ exacerbation given CXR
findings, symptoms of orthopnea and PND, and response to 40IV
lasix in ED. Etiology of CHF exacerbation was unclear.
Infectious process was not identified. Patient was ruled out
for myocardial infarction. It is possible that she was
hypertensive (possibly as a side effect of sutent) and this led
to worsening diastolic CHF.
Patient received lasix 40 mg IV x1 with excellent response. On
the first day of admission, she was weaned off oxygen
completely. She was restarted on her home dose of lasix 40 mg
PO daily. Her blood pressure was controlled with her home dose
of diltiazem and systolic blood pressure ranged 120 - 130 on the
day of admission.
# GIST: Patient with hx of GIST s/p incomplete resection in ___
and omental resections in ___. Intermittently treated with
gleevac complicated by side effects, now on low dose sutent. The
sutent was held during hospitalization and she will restart it
at home as discussed with the oncology fellow. She has ___
following her and they will check her blood pressure on ___.
# ARF: Cr mildly above baseline to 1.2 on admission. Likely due
to CHF. Improved to 1.1 with diuresis on discharge.
CHRONIC/INACTIVE ISSUES:
# Paroxysmal AFib: Patient was continued on diltiazem. She is
only on anticoagulation with aspirin 81 mg daily as she has had
GI bleeds from the GIST in the past. She will continue to
follow with cardiology as she has been doing.
#HTN: Stable. Takes 180mg diltiazem ER at home. Patient's
hypertension was well controlled during admission. Home dose of
diltiazem continued. ___ will continue to monitor her blood
pressure. Consider adding ACEI in future.
#Hypothyroidism: Continue home synthyroid.
#DM: Held Januvia in house and used HISS. Patient resumed home
dose at discharge.
TRANSITIONAL ISSUES:
#GIST - patient with ___ scheduled with heme/onc this
week. She will continue sutent at home.
Medications on Admission:
1. furosemide 40 mg DAILY
2. levothyroxine 200 mcg DAILY
3. timolol maleate 0.5 % One Drop DAILY
4. diltiazem HCl 180 mg DAILY
5. zolpidem 10 mg PO HS as needed for insomnia.
6. oxycodone 5 mg PO once a day as needed for pain
7. senna prn
8. Januvia 100 mg once a day.
9. docusate sodium prn
10. ASA 81
Discharge Medications:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic once
a day.
4. diltiazem HCl 180 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
5. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for Pain.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
8. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: Acute on chronic diastolic CHF exacerbation.
Hypertension.
SECONDARY: Gastro-intestinal stromal tumor.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure participating in your care Ms. ___. You
were admitted to the hospital with shortness of breath, which
was caused by extra fluid in your lungs. We gave you medication
(lasix) to help remove the extra fluid in your lungs. Your
breathing improved and you no longer required oxygen to breathe.
Please limit the salt intake in your diet. Weigh yourself every
morning, call MD if weight goes up more than 3 lbs.
No changes were made to your medications.
Please call your primary care doctor to make a ___
appointment within one week. See your oncology ___
appointments below.
Followup Instructions:
___
|
19844485-DS-24
| 19,844,485 | 29,909,611 |
DS
| 24 |
2184-11-07 00:00:00
|
2184-11-07 20:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
weakness, anemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F with GI stromal tumor most recently on Sutent with
recent CT scan showing progression of disease now on sorafenib,
past admissions for intraperitoneal bleed ___ omental metastasis
while on coumadin (now off), DM, hypothyroidism, atrial
fibrillation, ___ who presented to the ED yesterday (___)
with fatigue, weakness and sob for three days. Patient was found
to have a hematocrit of 16 (baseline ___. She was
hemodynamically stable and transfused 2 units of pRBCs. Patient
was guaiac negative. She had a CT of the abdomen with contrast
which showed hemoperitoneum with the origin of hemorrhage likely
near known soft tissue mass. Surgery was contacted and said that
she was not an operative candidate. ___ was consulted, reviewed
the CT, did not see any evidence of active extravasation and
felt that there was no indication for intervention at this time.
Patient was admitted to the FICU for further monitoring. Patient
was transfused a third unit of packed cells early this am and
kept NPO. During transfusion of third unit of packed cells
patient developed a red pruritic rash thought to be a
transfusion reaction, given iv benadryl. She had a new 2L oxygen
requirement which was thought to be due to increased cardiac
demand due to severe acute anemia. She was found to have new TWI
on ECG for which cardiac biomarkers were checked and negative x
3. Patient's sorafenib was held and per discussion with oncology
fellow, patient to restart at home after discharge. Patient had
mild ___ thought to be prerenal that improved with transfusions.
Patient started on clears today, hematocrit continued to
increase to 26.9 then 30.7 this evening.
.
Of note, patient had a recent admission ___ for acute on
chronic diastolic heart failure which improved with diuresis.
Also with multiple admissions in ___ for intraperitoneal bleed
due to omental metastasis in the setting of coumadin use for
atrial fibrillation. Patient also has a right medial thigh wound
that has been persistently open after cellulitis in ___.
.
Currently patient denies any abdominal pain. SOB and fatigue
have improved. Her oxygen has been weaned to off. Patient does
have constipation with last BM 2 days ago. Also continues to
have pruritis and red rash, managed with sarna lotion and one
dose of po benadryl today.
.
ROS as per HPI, 10 pt ROS otherwise negative
Past Medical History:
- RIGHT MEDIAL THIGH WOUND: Developed after developing severe
cellulitis in late ___ and underwent a biopsy of the area
___. Did not heal due to DM and chemo, as was on sudent.
Was on sunitinib and this was put on hold to allow further
healing, but has since restarted low dose. Measurement of wound
was 8 x 0.5cm. The first 4 cm on the right was still open with
hypergranulation tissue present on ___.
- GIST: Diagnosed in ___, treated with surgery and multiple
intermittant courses of gleevac, complicated by side effects.
She had partial gastrectomy and GIST resection in ___, and a
GIST omental metastasis resection in ___. Noted to have GIB
in ___ and ___ due to enlarging GIST lesions. Started
on Sutent since ___. Currently on low dose Sutent
following poor wound healing as above.
- ANEMIA, iron deficiency
- Paroxysmal ATRIAL FIBRILLATION, not on AC due to multiple RP
bleeds
- CONGESTIVE HEART FAILURE, Diastolic, ef >70%.
- DIABETES MELLITUS
- Chronic DYSPNEA, exertional
- HYPERTENSION
- HYPOTHYROIDISM
- CVA in ___, Residual R hemiparesis and intermittent aphasia,
- TIA in ___
- Status post knee surgery in ___.
Social History:
___
Family History:
No family history of cancer, lung disease or heart disease. +
for DM.
Physical Exam:
VS: 98.5 130/78 97P 18 100%RA
Appearance: alert, NAD, obese
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmm, no JVD, neck supple
Cv: +s1, s2 -m/r/g, tr peripheral edema, 1+ dp/pt bilaterally
Pulm: clear bilaterally, diminished at bases
Abd: soft, nt, nd, +bs
Msk: ___ strength throughout
Neuro: cn ___ grossly intact, no focal deficits
Skin: diffuse blanching confluent erythematous rash involving
back, upper arms and upper chest
Psych: appropriate, pleasant
Heme: no cervical ___
___ Results:
___ 06:10PM BLOOD Hct-26.8*
___ 07:05AM BLOOD WBC-2.9* RBC-2.62* Hgb-8.2* Hct-26.6*
MCV-102* MCH-31.4 MCHC-30.9* RDW-20.0* Plt ___
___ 10:15PM BLOOD Hct-25.8*
___ 02:35PM BLOOD Hct-27.9*
___ 07:08AM BLOOD WBC-3.3* RBC-2.96* Hgb-9.4* Hct-29.6*
MCV-100* MCH-31.9 MCHC-31.9 RDW-20.2* Plt ___
___ 04:28PM BLOOD Hct-30.7*
___ 11:57AM BLOOD Hct-28.2*
___ 05:30AM BLOOD WBC-2.5* RBC-2.73* Hgb-8.9*# Hct-26.9*
MCV-99* MCH-32.7* MCHC-33.2 RDW-20.1* Plt ___
___ 10:00PM BLOOD WBC-3.1* RBC-2.24*# Hgb-7.1*# Hct-22.4*#
MCV-100*# MCH-31.8 MCHC-31.8# RDW-20.8* Plt ___
___ 02:00PM BLOOD WBC-3.7* RBC-1.54*# Hgb-4.7*# Hct-16.7*#
MCV-108* MCH-30.2 MCHC-27.9* RDW-20.9* Plt ___
___ 10:00PM BLOOD WBC-3.1* RBC-2.24*# Hgb-7.1*# Hct-22.4*#
MCV-100*# MCH-31.8 MCHC-31.8# RDW-20.8* Plt ___
___ 02:00PM BLOOD WBC-3.7* RBC-1.54*# Hgb-4.7*# Hct-16.7*#
MCV-108* MCH-30.2 MCHC-27.9* RDW-20.9* Plt ___
___ 07:05AM BLOOD Neuts-70.4* Lymphs-13.6* Monos-4.2
Eos-11.7* Baso-0.1
___ 02:00PM BLOOD Neuts-79.8* Lymphs-14.8* Monos-4.8
Eos-0.2 Baso-0.3
___ 07:05AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Target-2+ Schisto-1+
Burr-OCCASIONAL Stipple-1+ Acantho-1+
___ 10:00PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-1+ Polychr-1+ Ovalocy-1+ Schisto-1+
Burr-OCCASIONAL Stipple-1+
___ 02:00PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Target-OCCASIONAL Schisto-OCCASIONAL Tear Dr-OCCASIONAL
___ 07:08AM BLOOD ___ PTT-25.9 ___
___ 05:56PM BLOOD ___ PTT-29.8 ___
___ 07:05AM BLOOD Glucose-104* UreaN-26* Creat-1.3* Na-139
K-4.2 Cl-104 HCO3-26 AnGap-13
___ 07:08AM BLOOD Glucose-116* UreaN-25* Creat-1.3* Na-140
K-4.1 Cl-103 HCO3-27 AnGap-14
___ 05:30AM BLOOD Glucose-112* UreaN-30* Creat-1.3* Na-140
K-4.0 Cl-104 HCO3-24 AnGap-16
___ 10:00PM BLOOD Glucose-102*
___ 02:00PM BLOOD Glucose-131* UreaN-37* Creat-1.5* Na-136
K-4.3 Cl-102 HCO3-25 AnGap-13
___ 07:08AM BLOOD ALT-9 AST-15 AlkPhos-57 TotBili-1.4
___ 02:00PM BLOOD LD(LDH)-319* CK(CPK)-79 TotBili-0.8
___ 05:30AM BLOOD CK-MB-2 cTropnT-<0.01
___ 10:00PM BLOOD CK-MB-2 cTropnT-<0.01
___ 02:00PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-2632*
___ 07:05AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.3
___ 07:08AM BLOOD Phos-2.7 Mg-2.3
___ 05:30AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3
___ 02:00PM BLOOD Hapto-111
.
EKG:Atrial fibrillation. Poor R wave progression. Non-specific T
wave inverions in leads V4-V6. Compared to the previous tracing
of ___ atrial fibrillation remains present but now is
slightly slower. Otherwise, no interval change.
.
CXR:
IMPRESSION: Mild pulmonary vascular congestion. Cardiomegaly.
Pulmonary
nodules documented on CT from ___ are better appreciated
on that study
.
CT abdomen/pelvis:
IMPRESSION:
1. Interval increase in heterogeneous intra-abdominal fluid,
consistent with hemoperitoneum. The higher density material is
present along the lesser sac and along the gallbladder fossa,
likely indicating the region of origin of hemorrhage near known
soft tissue mass.
2. Multilobulated soft tissue masses consistent with known GIST
recurrence
with increased omental nodularity. Stable liver lesions.
Brief Hospital Course:
___ y/o F PMH significant for metastatic intra-abdominal GIST
tumor, anemia, dCHF (last EF 55% ___ presents with lethargy,
SOB and weakness x3 days found with HCT of 16.7.
.
#ACUTE ON CHRONIC ANEMIA/acute blood loss - presented with H/H
4.7/16.7. More recent baseline values were HCT of ___ as
recently as ___ suggesting acute change. MCV was chronically
>100. Anemia w/u including b12/folate/fe studies checked in ___ wnl. Hemoperitoneum noted on abd CT presumably from
metastatic GIST. Stool was guiaic negative so unlikely
intra-intestinal bleeding. Pt with Afib but not on coumadin, INR
wnl on presentation. Her hemolysis labs were negative. ___ and
surgery evaluated the pt and noted no acute intervention needed
to be taken. She was transfused a total of 3U PRBCs with good
effect. She was restarted on aspirin therapy. Oncology team's
plan is to stop sutent and start pt on sorefenib as an
outpatient.
.
#SHORTNESS OF BREATH - pt reported 3 days of increasing DOE on
admission with oxygen saturation in the high ___ on 2L NC. This
was felt to be due to acute severe anemia. Her SOB improved
after blood transfusions. Her EKG was significant for new TWI on
ECG and slightly deeper 1mm ST dep in lateral leads which was
felt to be due to demand ischemia in the setting of her acute
anemia. Her cardiac enzymes were negative times three.
.
# GIST: Patient with hx of GIST s/p incomplete resection in ___
and omental resections in ___. Intermittently treated with
gleevac now on low dose sutent. The sutent was initially held on
admission. Heme/onc was consulted for further recommendations an
decided to stop sutent and start pt on sorafenib after
discharge.
# ARF: Cr at 1.5 on admission above b/l 1.1-1.2. Improved after
PRBC transfusions back to her baseline.
.
#Pruritic rash: initially thought to be due to transfusion
reaction from ___, unusual that it was initially persistent. No
hives seen, rash was generalized erythema. No new medications. ?
Malignancy related. ?chemo related. Bilirubin was normal. Pt was
given benedryl and sarna lotion prn with good effect. This
resolved.
.
CHRONIC/INACTIVE ISSUES:
# Paroxysmal AFib: Given h/o bleeding, pt is no longer on
warfarin, on ASA only. We continued ASA but held Diltiazem in
the setting of acute bleed. Diltiazem was restarted on the
medical floor. Need to address whether the benefits of ASA
outweight the risks in this patient.
.
#HTN: Stable. Takes 180mg diltiazem ER at home. Thus far
normotensive. Diltiazem was held in setting of actue bleed but
restarted on the floor.
.
#Hypothyroidism: Continued home synthyroid.
.
#DM: placed on insulin sliding scale. Pt can resume Januvia upon
discharge.
Medications on Admission:
diltiazem 180mg ER daily Am
furosemide 60mg daily
levothyroxine 200mcg daily
oxycodone - unclear if currently taking
- rx is for 5mg q4-6hrs for pain prn
sitagliptin 100mg tab daily
sunitinib 25mg daily
timolol 0.5% drops right eye bid
zolpidem 10mg qhs prn insomnia
asa 81mg daily
docusate
senna
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic BID
(2 times a day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic Left eye
qhs ().
7. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
8. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
9. sitagliptin 100 mg Tablet Sig: One (1) Tablet PO once a day.
10. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
acute blood loss anemia due to intraperitoneal bleeding
GI stromal tumor with metastasis
atrial fibrillation
DM type II
hypothyroidism
chronic diastolic heart failure
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with weakness and found to have anemia. You
had a CT scan of your abdomen that showed recurrence of bleeding
from your cancer. For this, you were initially evaluated in the
ICU and given blood transfusions. Your anemia improved and your
aspirin was restarted.
.
Medication changes: lasix and Januvia were stopped but you can
restart them at home tomorrow.
.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19844782-DS-9
| 19,844,782 | 26,377,517 |
DS
| 9 |
2178-03-25 00:00:00
|
2178-03-25 15:58:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Simvastatin
Attending: ___.
Chief Complaint:
Visual changes, slurred speech and generalized weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ yo lady with a past medical
history of HTN,hypercholesterolemia, depression and a distant
history of migraine without aura who is present today after an
episode of visual change, slurred speech and diffuse weakness.
Prior to this morning, the patient was at her baseline state of
health.
This ___, she awoke at 10am and noticed that her vision was
filled with "white spots, like little clouds". They were
throughout her visual field, seen in both eyes. Despite the
white spots, she was able to see.
She attempted to get out of bed to go to the bathroom, but felt
diffusely weak (no sensory changes). Her husband hand to help
her to the bathroom. She was able to urinate w/o difficulty and
by the time she was being helped back to her bed, her visual
changes had resolved (lasting a total of ___ minutes).
While in bed, she had onset of a mild frontal headache
(bilateral
___ on pain scale, dull, not throbbing, never had before, not
like previous migraines).
She attempted to call her daughter on the phone, and when she
did
felt like she was "slurring" her speech, which her daughter
endorses. Her husband who also spoke with her did not notice
any
difference. When asked if there was any facial droop or
asymmetry, all the husband can say is that it looked "twisted"
but cannot specify further.
During this episode, the patient reports having a hot flash.
They called her physician who recommended she come to the ED.
Patient and husband do volunteer the information that she has
recent been having episodes of hot flashes (primarily during the
night and also during the day) for the past 1.5 months. She is
up to date on cancer screenings. Has not been losing weight.
No
true night sweats, most just subjective sensation of hot.
Past Medical History:
Hx of malignant melanoma- local per report, removed surgically.
ACTINIC KERATOSIS
ALLERGIC RHINITIS
ATYPICAL NEVI
ASTHMA
BASAL CELL CARCINOMA
CARPAL TUNNEL SYNDROME
COMPRESSION FRACTURE (L1 vertabre-MVA 1970s)
L1 vertabre-MVA 1970s
DE QUERVAIN'S TENOSYNOVITIS
DEPRESSION
DUODENAL ULCER
HELICOBACTER PYLORI
HERPES SIMPLEX I
HYPERCHOLESTEROLEMIA
HYPERTENSION
HYPOTHYROIDISM
KERATOSIS
LOW BACK PAIN
MIGRAINE (not since menopause, ___ ago)
OBESITY
OSTEOPENIA
SCOLIOSIS
TINEA PEDIS
URINARY INCONTINENCE, URGE
Social History:
___
Family History:
- No family history of neurologic disease.
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin- ? small rash on bilateral legs. Pimply.
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 slowly. Pt. was
able to register 3 objects and recall ___ at 5 minutes. There
was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, pinprick in all
distributions, and ___ strength noted bilateral in masseter
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
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 3 2
R 2+ 2+ 2+ 3 2
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are present.
-Sensory: No deficits to cold sensation, proprioception
throughout. She does have patchy sensory loss to light touch -
70% decreased sensation in R anterior shin to light touch, L
lateral leg has decreased sensation, R dorsal surface of hand
has
50% sensation compared to left. Noextinction to DSS.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem, but with difficulty difficulty.
Romberg absent.
Pertinent Results:
___ 01:16PM BLOOD WBC-8.8 RBC-4.09* Hgb-12.8 Hct-36.8
MCV-90 MCH-31.3 MCHC-34.7 RDW-13.0 Plt ___
___ 01:16PM BLOOD Glucose-98 UreaN-14 Creat-0.7 Na-137
K-4.5 Cl-100 HCO3-28 AnGap-14
___ 01:16PM BLOOD ALT-30 AST-25 LD(LDH)-163 AlkPhos-72
TotBili-0.1
___ 01:16PM BLOOD Albumin-4.2 Cholest-169
___ 11:45AM BLOOD %HbA1c-5.8 eAG-120
___ 01:16PM BLOOD Triglyc-59 HDL-73 CHOL/HD-2.3 LDLcalc-___
Brief Hospital Course:
# TIA vs Complex mirgraine
Patient was admitted given her symptoms of visual change and
husband's report of facial "twisting" which he was unable to
clarify and was concerning for possible facial asymmetry or TIA.
Her labwork on admission was benign. Stroke Risk factors were
evaluated and well controlled. She was planned to undergo MRI
to evaluate for ischemic changes in the brain. However, patient
was frustrated with delay in MRI requiring prolonged hospital
stay. After extensive discussion, patient about patient
frustrations, she did not leave AMA. However, unclear timeline
of acquiring MRI, compromise was reached with patient. She was
to to be discharged with PCP and ___. She was
ordered for outpatient same day MRI at ___ MRI. Indeed,
her MRI was performed the same day after discharge. The official
report was only notable for microvascular ischemic changes
without evidence of acute infarcts. If there were any recurrent
symptoms or concerning findings, she was to seek emergent
medical evaluation.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? () Yes [performed
and documented by admitting resident] (X) No - NO evidence of
dysphagia
2. DVT Prophylaxis administered by the end of hospital day 2?
(X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented (required for all patients)? (X) Yes (LDL =84
) - () No
5. Intensive statin therapy administered? () Yes - (X) No [if
LDL >= 100, reason not given: Reportedly poorly tolerated statin
changes, defer to outpt management]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (X) No [if no,
reason: (X) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (X) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
() Yes - (X) No [if no, reason not assessed: Fully functional at
home with no residual defecit]
9. Discharged on statin therapy? (X) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (X) N/A
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
aerosol inhaler. ___ puffs ih every 6 hours as needed for for
shortness of breath
ATENOLOL - atenolol 50 mg tablet. 1 (One) Tablet(s) by mouth
once
a day
ATORVASTATIN [LIPITOR] - Lipitor 40 mg tablet. 1 (One) Tablet(s)
by mouth every other day
BUDESONIDE-FORMOTEROL [SYMBICORT] - Symbicort 160 mcg-4.5
mcg/actuation HFA aerosol inhaler. 2 puffs ih twice daily rinse
mouth after use
CARBAMAZEPINE - carbamazepine 200 mg tablet. 1 tablet(s) by
mouth
1 in am; 1 @ noon; 2 at bedtime - (Dose adjustment - no new Rx)
KETOCONAZOLE - ketoconazole 2 % topical cream. apply to nails
and
scaling areas on feet once a day as needed for PRN 3 month
supply
LEVOTHYROXINE (SYNTHROID)- SYNTHROID ___ mcg tablet. 1 (One)
tablet(s) by mouth once a day for six days weekly and 1.5
tablets
for one day weekly. Please give the same generic preparation.
NORTRIPTYLINE - nortriptyline 50 mg capsule. 2 (Two) Capsule(s)
by mouth once a day - (Prescribed by Other Provider)
Medications - OTC
ASPIRIN [ASPIRIN LOW DOSE] - Aspirin Low Dose 81 mg
tablet,delayed release. 1 (One) Tablet(s) by mouth once a day -
(Prescribed by Other Provider)
CA CARB & GLUC-MAG OX & GLUC [CALCIUM MAGNESIUM] - Dosage
uncertain - (OTC)
LORATADINE-PSEUDOEPHEDRINE [CLARITIN-D 24 HOUR] - Claritin-D 24
Hour 10 mg-240 mg tablet,extended release. 1 Tablet(s) by mouth
once a day as needed for prn - (Prescribed by Other Provider)
LYSINE [L-LYSINE] - L-Lysine 500 mg tablet. 1 (One) Tablet(s) by
mouth once a day - (Prescribed by Other Provider; ___)
MULTIVITAMIN - multivitamin tablet. 1 (One) Tablet(s) by mouth
once a day - (OTC; 400 iu vitamin D/30 mg calcium)
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN Wheezing
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Atorvastatin 40 mg ORAL EVERY OTHER DAY
5. carBAMazepine 200 mg oral q0900, q 1600
6. Carbamazepine 400 mg ORAL Q2200H
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Loratadine 10 mg PO Q24H PRN allergies
9. Multivitamins 1 TAB PO DAILY
10. Nortriptyline 100 mg ORAL QHS
11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID bid
Discharge Disposition:
Home
Discharge Diagnosis:
TIA vs Complex Migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized for diffuse weakness, visual changes and
slurred speech. You doctors were worried this was either a
complex migraine or a possible TIA (mini-stroke).
Unfortunately, MRI was delayed in the hospital. After talking
with your doctors, it was felt safe to do a same day outpatient
MRI. Though this is not idea, this was what worked best for
your. Additionally, you were ordered an outpatient
Echocardiogram. Please follows up with this.
Followup Instructions:
___
|
19845085-DS-9
| 19,845,085 | 22,998,557 |
DS
| 9 |
2163-04-24 00:00:00
|
2163-04-24 16:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cipro / citalopram / Sulfa(Sulfonamide
Antibiotics)
Attending: ___.
Chief Complaint:
s/p mechanical fall
Major Surgical or Invasive Procedure:
femoral neck fixation surgery
History of Present Illness:
___ yo F with hx of OSA, HTN, GERD, OA who presents s/p fall.
Patient reports that she was sitting in her chair and fell
asleep. The phone rang and she got up to answer the phone. She
usually puts on her slippers when walking around the house, but
she did not. She slipped on a floor rug and fell. She denies any
LOC, head strike. She denied any prior chest pain, palpitations
or lightheadedness. She denies any prior seizure history. She
fell on her left side and hurt her hip. She subsequently was
taken to the ED for evaluation.
The patient at baseline is not very active. She is able to
ambulate only 1 block or 1 flight of stairs without getting SOB.
She denies history of chest pain, palpitations, orthopnea,
syncope or presyncope. She has chronic ___ edema since her knee
replacement surgeries several years ago.
In the ED, initial vs were 98 175/99 88% ra.
Labs were unremarkable
Past Medical History:
- OSA - uses 3L O2 at night
- HTN
- GERD
- skin CA
- breast mass s/p resection
- hysterectomy
- b/l knee replacements
Social History:
___
Family History:
cousin with cancer of unknown type
Physical Exam:
Vitals: T 97.9, BP 175/85, HR 90, RR 20, O2 92%5L
GENERAL: obese woman laying in bed, alert and oriented, in no
acute distress
HEENT: moist mucous membranes, extraoccular movements intact,
sclera anicteric, OP clear
NECK: supple, no LAD, neck obesity
PULM: decreased breath sound anteriorly on the right and left,
with some wheeazing.
CV: Very distant heart sounds. normal S1/S2, no mrg
ABD: soft NT ND normoactive bowel sounds, no r/g
EXT: LLE shorter than right and externally rotated. Pain with
palpation at left hip. Distal pulses palpable. Bilateral ankle
edema with signs of venous stasis on left foot.
NEURO: Alert and orientedx3. CNs2-12 intact, motor function
limited due to left hip pain. Sensory function grossly intact
Pertinent Results:
ADMISSION:
___ 10:14PM BLOOD WBC-9.2 RBC-4.92 Hgb-14.2 Hct-43.0 MCV-88
MCH-28.9 MCHC-33.1 RDW-14.0 Plt ___
___ 10:14PM BLOOD Neuts-82.4* Lymphs-12.1* Monos-3.8
Eos-1.5 Baso-0.2
___ 10:14PM BLOOD Plt ___
___ 10:14PM BLOOD ___ PTT-20.3* ___
___ 10:14PM BLOOD Glucose-120* UreaN-18 Creat-0.7 Na-145
K-4.4 Cl-105 HCO3-34* AnGap-10
DISCHARGE:
___ 03:34AM BLOOD WBC-8.2 RBC-3.80* Hgb-10.9* Hct-33.6*
MCV-89 MCH-28.6 MCHC-32.3 RDW-14.0 Plt ___
___ 05:20AM BLOOD Neuts-80.7* Lymphs-11.2* Monos-4.9
Eos-3.1 Baso-0.1
___ 05:20AM BLOOD ___ PTT-28.5 ___
___ 03:34AM BLOOD Glucose-114* UreaN-20 Creat-0.6 Na-139
K-4.1 Cl-100 HCO3-33* AnGap-10
___ 03:34AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.9
___ 08:34AM BLOOD Type-ART pO2-123* pCO2-51* pH-7.39
calTCO2-32* Base XS-5
IMAGING:
CTA chest ___
1. Limited evaluation for PE. No large main or segmental
pulmonary embolism.
2. Small pleural effusions and perifissural fluid.
3. Enlarged pulmonary artery can be seen in pulmonary
hypertension.
4. Extensive irregular calcified and noncalcified
atherosclerotic plaque of the descending aorta.
TTE ___:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Doppler parameters are most consistent with Grade II
(moderate) left ventricular diastolic dysfunction. The right
ventricular free wall is hypertrophied. The right ventricular
cavity is dilated with normal free wall contractility. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The ascending aorta is
mildly dilated. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. No
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
NOTE: Report edited at 6:21 pm on ___ to remove mention of
lack of spontaneous echo contrast in the left atrium (this could
not be adequately assessed).
Brief Hospital Course:
Ms. ___ is a ___ yo F with hx of OSA, HTN, GERD, OA who
presented after a mechanical fall resulting in a left hip
fracture. Hip Surgery was performed on ___, and patient
required ICU admission post-operatively because of poor
respiratory status.
.
## LEFT FEMORAL NECK FRACTURE (s/p Hemiarthroplasty on ___:
The surgery proceeded without any major complications.
Post-operatively the patient was not extubated due to poor
respiratory status and she was transferred to the medical ICU.
In the ICU, her respiratory status rapidly improved and she self
extubated on the morning of ___. She started working with
physical therapy shortly therefater. She will need 2 weeks of
lovenox post operatively for DVT prophylaxis. She will follow-up
in orthopedics clinic in ~2 weeks as scheduled.
.
## HYPOXEMIA - The patient has hypoxemia at baseline. She
reports that her oxygen saturation on room air is normally "Very
Low" at home. She wears 3 liters of nasal cannula at night
normally. Her chronic hypoxemia is likely from obstructive sleep
apnea and obesity hypoventilation syndrome. CTA and TTE during
this admission showed pulmonary hypertension which is likely
from chronic hypoxemia. She likely also had some acute insults
superimposed including post-op atelectasis due to pain and
shallow breathing. Workup for other contributing factors
included a CTA which was negative for PE. A chest x-ray
indicated a possible aspiration pneumonia and therefore the
patient was started on clindamycin. She has two days remaining
of a 7 day course. She was able to be weaned to 4L NC by
discharge.
.
CHRONIC MED CONDITIONS
## GERD - continue home dose of omeprazole
.
## ___ edema - trace edema on exam. will continue home lasix
TRANSITIONAL ISSUES:
# Anticoagulation with lovenox x 2 weeks.
Medications on Admission:
1. Omeprazole Dose is Unknown PO DAILY
2. Furosemide 40 mg PO 2X/WEEK (___)
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Furosemide 40 mg PO 2X/WEEK (___)
3. Omeprazole 20 mg PO DAILY
4. Acetaminophen 1000 mg PO TID
5. Vitamin D 800 UNIT PO DAILY
6. Calcium Carbonate 500 mg PO TID
7. Bisacodyl 10 mg PO DAILY:PRN constipation
8. Docusate Sodium 100 mg PO BID
9. Clindamycin 450 mg PO Q6H Duration: 2 Days
last dose ___
10. Lidocaine 5% Patch 2 PTCH TD DAILY
apply along left hip, long incision
11. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
hold for sedation or RR < 12; use only for severe breakthrough
pain if tramadol doesn't work
12. Polyethylene Glycol 17 g PO DAILY
13. Senna 1 TAB PO BID:PRN constipation
14. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
15. Enoxaparin Sodium 30 mg SC Q12H Duration: 2 Weeks
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left femoral neck fracture s/p mechanical fall
Primary
- Hip Fracture
- Hypoxemia
- Aspiration pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair
Discharge Instructions:
Ms. ___, it was a pleasure taking care of you here at
___. You were admitted to the hospital after you fractured
your hip. Afterwards, you came to the medical instensive care
unit because you required a higher than normal breathing support
to maintain normal oxygen levels. We are also treating you with
2 more days of antibiotics for a pneumonia.
******WOUND CARE******
- You can get the wound wet/take a shower immediately. 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 continued to be
non-draining.
******WEIGHT-BEARING******
- Weight-bearing as tolerated left lower extremity
******MEDICATIONS******
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink eight 8-oz glasses of water daily and take a stool
softener (colace) to prevent this side effect.
- Medication refills cannot be written after 12 noon on ___.
******ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 2 weeks post-operatively.
Followup Instructions:
___
|
19845104-DS-6
| 19,845,104 | 25,066,258 |
DS
| 6 |
2150-09-23 00:00:00
|
2150-09-23 20:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left hand hematoma, concern for compartment syndrome
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man with Alzheimer dementia and
AFib/A-flutter on sotalol and rivaroxaban who presented to the
___ ___ with worsening left hand swelling after an injury
sustained a few days prior.
Early on the morning of ___, Mr. ___ presumably
banged his left hand in the bathroom. His wife reported that he
went in the bathroom and when he came out his hand started to
swell, but he was unable to verbalize what had happened. At this
point, patient went to ___ where he had negative hand
films and was splinted. Swelling was thought to be due to
extensive subcutaneous bleeding in the setting of rivaroxaban
anticoagulation (last dose was ___ in the morning). He
was discharged with instructions to elevate the LUE and continue
to hold rivaroxaban.
Unfortunately, patient unable to keep extremity wrapped and
elevated and had worsening swelling and pain. He returned to
___ where they noted progressive swelling and diffuse left
hand to mid-left forearm ecchymosis with overlying blistering
and bleeding. Reportedly, patient was not having pain in left
hand at rest, but he was unable to flex the digits. Given
concern for possible compartment syndrome, he was referred to
___ for further evaluation.
Of note, he has been on Sotalol for rhythm control as prescribed
by his cardiologist for a long time, but only recently started
anticoagulation with rivaroxaban, which was prescribed by his
PCP ___ weeks prior to the current admission.
In the ___ ___, initial vitals were: T 97.6, HR 76, BP 181/98,
RR 18, O2 96% RA.
- Exam notable for: L hand edema and ecchymosis w/ overlying
taut serous vesicles over dorsal and palmar aspects; patient
unable to flex digits beyond ___ degrees. LUE distal sensation
intact.
- Labs notable for: WBC=9.3, H/H=13.0/41.2, Plt=155 with
INR=1.2.
Chemistry panel wnl except for phos=2.6.
- Patient was given: Olanzapine 5mg PO for agitation
Hand surgery was consulted and determined no need for emergent
surgical intervention. Recommended admission to medicine with
q.2H assessments for the LUE and re-evaluation for surgical need
in the morning.
Upon arrival to the floor, patient is minimally verbally but
reasonably calm and comfortable.
Past Medical History:
- Atrial flutter/A-fib, on Sotalol and Xarelto
- Alzheimer's dementia
- Hyperlipidemia
Social History:
___
Family History:
Denies FHx of heart disease.
Half-brother (via mother) with CVA.
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: T 98.6F | HR 69 | BP 176/72 | RR 20 | O2 93% RA
General: Alert, disoriented, minimally verbal. No acute distress
but writhing when LUE manipulated.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated.
CV: Irregular 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: B/L Lower Ext Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema.
Left UE wrapped with gauze and ACE, some blood seeping through
gauze. Fingertips dusky. ___ fingers cool to touch, not
cold. Thumb warmer, pinker. Thumb pad pulse dopplerable.
Tenderness to palpation and manipulation of all fingers.
Neuro: CNII-XII grossly intact. Strength grossly intact in
upper/lower extremities. Gait deferred.
=======================
DISCHARGE PHYSICAL EXAM
=======================
Vital Signs: T 97.6 F | BP 131/83 | HR 76 | RR 16 | O2 96% RA
General: Alert, disoriented, verbal.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
CV: Irregular 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
GU: No foley
Ext: B/L Lower Ext Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema.
Neuro: CNII-XII grossly intact. Strength grossly intact in arms.
Able to move legs.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 03:50PM BLOOD WBC-9.3 RBC-4.48* Hgb-13.0* Hct-41.2
MCV-92 MCH-29.0 MCHC-31.6* RDW-13.5 RDWSD-45.5 Plt ___
___ 03:50PM BLOOD Neuts-74.7* Lymphs-12.1* Monos-9.3
Eos-3.1 Baso-0.5 Im ___ AbsNeut-6.94* AbsLymp-1.13*
AbsMono-0.87* AbsEos-0.29 AbsBaso-0.05
___ 03:50PM BLOOD ___ PTT-25.8 ___
___ 03:50PM BLOOD Glucose-99 UreaN-16 Creat-0.9 Na-141
K-4.4 Cl-104 HCO3-23 AnGap-18
___ 03:50PM BLOOD Calcium-9.3 Phos-2.6* Mg-2.1
=========================
DISCHARGE LABS
=========================
___ 07:50AM BLOOD WBC-10.1* RBC-4.24* Hgb-12.6* Hct-38.9*
MCV-92 MCH-29.7 MCHC-32.4 RDW-14.0 RDWSD-46.8* Plt ___
___ 07:50AM BLOOD Glucose-97 UreaN-17 Creat-0.9 Na-141
K-4.2 Cl-107 HCO3-18* AnGap-20
=========================
IMGAGING/STUDIES
=========================
___ EKG:
Atrial flutter with 4:1 conduction. Abnormal R wave transition
which may be due to lead positioning. No previous tracing
available for comparison.
Read ___.
Intervals Axes
RatePRQRSQTQTc ___
69 ___ ___ CXR IMPRESSION:
No previous images. Relatively low lung volumes are
accentuating the
prominence of the transverse diameter of the heart no vascular
congestion, pleural effusion, or acute focal pneumonia.
Brief Hospital Course:
___ with A-fib/flutter on Xarelto, Alzheimer's dementia
presented from ___ for Hand Surgery eval with large left
arm hematoma. After serial evaluations, he was determined to not
have a compartment syndrome, and was discharged with wound care
after stopping xarelto.
ACTIVE ISSUES:
# Left hand injury with hematoma:
Swelling and pain secondary to bleeding. Evaluated by Hand
Surgery serialy who deemed no role for surgical intervention.
Pain improved during stay. Plan for ongoing wound care with
daily dressing changes, continued elevation and splinting.
Decision to discontinue xarelto due to involvement risk benefit
to patient.
# A-fib/A-Flutter:
Started on Xarelto by his cardiologist Dr. ___ at the
beginning of the year which was discontined at the time of the
initial injury. On sotalol 40 mg BID chronically, however per
most recent cardiologist note it was discontinued in ___ as
was in flutter but rate normal without symptoms. Patient was
initially started on metoprolol 12.5mg TID for rate control.
However soon became bradycardic to 50's with frequent ___ second
pauses. Metoprolol discontinued and HR stable in 80-90's at
discharge.
# Alzheimer's dementia:
Per wife, dementia has recently worsened precipitously. Had one
episode of aggition treated with olanzipine. Continued home
Donepizil and memantine once more settled.
CHRONIC ISSUES:
# BPH: Continued home doxasosin
=====================
TRANSITIONAL ISSUES
=====================
- Xarelto discontinued given complications and ongoing bleeding
risk
- Sotalol discontinued given patient assymptomatic and per most
recent cardiologist note
- Hand should be splinted with daily dressing changes using
xeroform and gauze and elevated as much as possible
- Follow up with ___ Fellow Hand clinic in 2 weeks for further
evaluation
- Patient is DNR/DNI
# CODE: DNR/DNI
# CONTACT: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxazosin 2 mg PO HS
2. Donepezil 10 mg PO DAILY
3. Sotalol 40 mg PO BID
4. Memantine 10 mg PO BID
5. Simvastatin 20 mg PO QPM
6. Rivaroxaban 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Donepezil 10 mg PO DAILY
3. Doxazosin 2 mg PO HS
4. Memantine 10 mg PO BID
5. Simvastatin 20 mg PO QPM
6. HELD- Sotalol 40 mg PO BID This medication was held. Do not
restart Sotalol until told to restart it by your cardiologist
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
==========================
PRIMARY DIAGNOSIS
==========================
Left Hand Hematoma
==========================
SECONDARY DIAGNOSIS
==========================
Atrial Flutter
Delirium
Alzheimer Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were seen in the hospital for your hand injury. It was
determined that the bleeding was just into the superficial
tissues of the hand, and that it can now be safely managed with
wound care.
For ongoing care of your hand you should do the following until
your follow up appointment.
- Keep the hand elevated at or above the level of your heart as
much as possible
- Wear the splint at all times and do not get it wet If you
shower it should be covered with a plastic bag. If you bathe it
should be kept out of the water.
- You should do dressing changes once daily with xerofoam and
___ per wound care recommendations.
Please follow up in hand clinic in two weeks.
In addition to your hand, two medications have been held. Your
blood thinner is being held as your risk of bleeding is high at
this time. Your sotalol is also being held as your cardiologist
most recently recommended stopping it in his notes. It was
stopped here without issues.
It was a pleasure taking care of you!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
19845120-DS-15
| 19,845,120 | 21,428,433 |
DS
| 15 |
2178-05-20 00:00:00
|
2178-05-20 14:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Acute kidney injury
Major Surgical or Invasive Procedure:
Intubation in the ICU
CVVH in the ICU
History of Present Illness:
___ with DMII, CKD, HTN, afib on coumadin who presents from
___ for acute kidney injury with Cr ___ and
hyperkalemia to 8 Cr ___. He reports he stopped taking his
coumadin a few days ago due to falls. His son was unable to get
in touch with him and called EMS, who broke down the door and
found patient sitting in his home, AxOx3 per report and was
brought to ___. He received regular insulin 10u IV with
1 amp D50, albuterol, and was sent to ___ for further
management.
Upon arrival in the ED, BP 110s, bradycardic to the ___ without
complaints. K on arrival was 7.3, Cr 6.8. He received another
10u insulin, another amp D50, calcium gluconate, kayexalate. He
was mentating well throughout. He was also found to be acidemic
with vBG pH 7.19 pCO2 46. He was tachypneic but not subjectively
short of breath. Per patient no UOP all day, foley placement
with 250cc upon placement.
Renal was consulted in the ED who recommended ___ NS bolus with
___ amps HCO3, and admission recommended to ICU for anticipated
need for urgent HD.
Due to elevated INR, he received CT abd/pelvis and CT head in ED
though hemodynamically stable without evidence of acute bleed.
On the floor, patient does not wish to answer further questions.
He states he wants to sleep. Able to tell me he has been uneasy
on his feet "on and off" over the past year.
Past Medical History:
HYPERLIPIDEMIA
HYPERTENSION
OBESITY with bariatric screening
DIABETES TYPE II
VENOUS STASIS
BLOOD CLOT
CKD
ANEMIA
AFIB on coumadin
GOUT
PVD
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
Vitals: T 99.0 HR 90 BP 151/54 RR 93% 4L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: bilateral venous stasis changes, ulcer 3x6
DISCHARGE EXAM:
Vitals: 98 BP 106/70 HR 103 RR 20 Sats 93 RA
General: Awake, alert to name,place and date.
HEENT: EOMI, sclera anicteric, oropharynx normal
Neck: No JVD
CV: Distant heart sounds, irregular rhythm, tachycardic. No
murmurs
Lungs: Rhonchi and crackles bilaterally (slight improvement from
___
Abdomen: +BS, soft, NT, distended c/w body habitus.
Ext: 1+ ___ pulses b/l, trace pitting edema at ankles b/l.
Hyperpigmentation of both lower extremities.
Pertinent Results:
ADMISSION LABS
===========
___ 12:10AM BLOOD WBC-9.7 RBC-3.78* Hgb-12.3* Hct-40.1
MCV-106* MCH-32.6* MCHC-30.8* RDW-14.1 Plt ___
___ 12:10AM BLOOD Neuts-82.9* Lymphs-10.7* Monos-5.8
Eos-0.3 Baso-0.3
___ 12:10AM BLOOD ___ PTT-50.1* ___
___ 12:10AM BLOOD Glucose-143* UreaN-80* Creat-6.8* Na-138
K-7.8* Cl-110* HCO3-16* AnGap-20
___ 12:10AM BLOOD CK(CPK)-100
___ 12:10AM BLOOD Calcium-10.0 Phos-6.5* Mg-2.2
___ 12:18AM BLOOD ___ pO2-47* pCO2-46* pH-7.19*
calTCO2-18* Base XS--10
___ 12:22AM BLOOD Lactate-2.2* Na-139 K-7.3* Cl-109*
calHCO3-17*
IMAGING
=======
___ CXR:
Left subclavian PICC line continues to have its tip in the mid
SVC. Lung volumes are slightly lower with persistent
consolidation at the left base likely reflecting combination of
pleural fluid and left lower lobe atelectasis or pneumonia.
Streaky opacities at the right base are slightly worse,
suggestive of increasing atelectasis. No pulmonary edema. No
pneumothorax.
Given the left basilar airspace process, assessment of cardiac
and mediastinal
contours is limited on this study.
___ CXR:
Interval removal of right internal jugular vascular catheter
with no visible pneumothorax. Stable cardiomegaly. Slight
improved aeration at right lung base, but no appreciable change
in left retrocardiac opacity with adjacent small left pleural
effusion. Small right pleural effusion extending
into the minor fissure appears unchanged.
___ CXR:
Dense consolidation and volume loss at the left lung base are
diagnostic of left lower lobe collapse, present without
appreciable change since ___. Pulmonary vascular
congestion persists in the right lung and a small region of
basal atelectasis or consolidation has changed in severity and
precise location over the past several days but not in overall
severity. Severe enlargement of the cardiac silhouette is
unchanged. ET tube and right internal jugular line are in
standard placements and an upper enteric drainage tube passes to
the upper stomach and out of view. No pneumothorax. At least a
small left pleural effusion is present, secondary to the left
lowerlobe collapse.
___ RENAL US:
Limited examination due to poor acoustic penetration. 2.7 cm
left kidney upper pole lesion appears consistent with simple
cyst.
___ CT CHEST:
1. Bibasilar atelectasis and left basilar mucus plugging of the
subsegmental airways.
2. 7 mm right middle lobe lung nodule. As per the ___
___ Pulmonary Nodule Guidelines, followup chest CT is
recommended in ___ months for a low risk patient and ___ months
for a high risk patient.
3. Dilated main pulmonary artery compatible with pulmonary
arterial
hypertension.
___ CT HEAD:
1. No evidence of acute intracranial process.
2. Opacification of the left mastoid and middle ear cavity with
pooled
secretions in the nasopharynx are likely related to the
patient's intubated status.
3. Evidence of global atrophy
___ CTAB:
1. No explanation for hypotension.
2. Nonspecific free fluid underneath both diaphragms and along
the right
pericolic gutter. This may be a result of volume resuscitation.
3. Questionable small bowel wall thickening most likely
represent s
undermixing of oral contrast and fluid in small bowel loops.
4. Upper pole left renal lesion does not meet criteria for a
simple cyst, but may represent a complex cyst. Further
evaluation with ultrasound is
recommended.
___ LENIs:
No right or left leg DVT.
___ echo:
The left atrium is normal in size. The left ventricular cavity
is unusually small. Overall left ventricular systolic function
is normal (LVEF 55%). Right ventricular chamber size is normal.
with normal free wall contractility. The diameters of aorta at
the sinus, ascending and arch levels are normal. There are
simple atheroma in the ascending aorta. There are three aortic
valve leaflets. No aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: No ascending aortic dissection. Small LV cavity with
normal systolic function.
___ portable abdomen:
Limited study demonstrates moderately prominent loops of small
bowel similar to that seen previously, which may be due to air
swallowing
versus obstruction. If there is high suspicion for obstruction,
an abdominal CT may be obtained.
___ CT HEAD: no acute intracranial process
___ CT abd/pelvis: no RP bleed or solid organ injury.
4mm right lung base nodule, ___ f/u if hx of malignancy or
smoking. otherwise, no f/u needed. hypodense hepatic lesion,
incompletely characterized, likely cysts or hemangiomas.
MICROBIOLOGY
===========
___ 4:03 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 4:03 pm 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).
___ 9:30 am BRONCHIAL WASHINGS
PLEASE RUN DESPITE ORAL FLUID . IRREPLACEABLE SPECIMEN.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): SQUAMOUS EPITHELIAL CELLS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of
commensal respiratory flora.
GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML..
___ 4:00 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___: NO GROWTH.
___ 9:20 am STOOL CONSISTENCY: LOOSE PRESENCE OF
BLOOD.
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS:
==============
___ 05:34AM BLOOD WBC-9.6 RBC-2.59* Hgb-8.3* Hct-26.9*
MCV-104* MCH-32.1* MCHC-31.0 RDW-14.5 Plt ___
___ 05:34AM BLOOD Glucose-100 UreaN-37* Creat-1.5* Na-142
K-4.0 Cl-113* HCO3-26 AnGap-7*
___ 02:30AM BLOOD ALT-31 AST-40 AlkPhos-93 TotBili-0.7
___ 05:34AM BLOOD Calcium-8.8 Phos-2.1* Mg-1.7
___ 11:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-NEGATIVE
Brief Hospital Course:
___ year old male with diabetes, chronic kidney disease, atrial
fibrillation on warfarin presents with acute on chronic renal
failure and associated electrolyte and metabolic abnormalities,
admitted to the ICU for further management.
ACTIVE ISSUES
-------------
# Shock: Developed during early part of hospitalization.
Etiologies considered were cardiogenic, septic, and neurogenic.
Most likely etiology septic based on improvement with broad
spectrum antibiotics. Required three pressors (norepinephrine,
phenylepherine, and vasopressin) for maintenance of MAPs>60mmHg.
These were down-titrated as tolerated. The patient was also
fluid resuscitated with boluses of NS. He was empirically
started on vancomycin, cefepime, and metronidazole, and
eventually transitioned to meropenem secondary to persistence of
leukocytosis and fevers. Antibiotics were discontinued on ___.
Culture data was all negative. Echocardiogram revealed normal
ventricular function. Patient continued to be afebrile and
without leukocytosis throughout the remainder of his hospital
course.
# Respiratory failure: Patient was electively intubated for
worsening metabolic abnormalities. Mechanical ventilation was
weaned as tolerated and he was extubated on ___. Following
extubation, the patient was weaned to room air, but later on in
his hospital course, he developed a new oxygen requirement.
Furosemide trial was attempted, and incentive spirometry was
encouraged. Patient was satting at92% RA on day of discharge
and no longer had a demand for oxygen.
# Hyperkalemia: Likely elevated in the setting of renal failure.
Had questionable peaked T-waves in the ED. He received
treatment with D50, insulin, and albuterol at OSH with
persistently elevated potassium. He also received kayexelate,
calcium gluconate, D50, insulin in fluids in the ___ ED. Due
to persistent metabolic abnormalities, he was started on CVVH.
His potassium improved and normalized with return of his kidney
function.
# Acute on chronic kidney injury: Patient with elevated
creatinine in the acute setting. FeNa of 1% which is equivocal
for prerenal vs ATN. Nephrotoxic medications were avoided and
his medications were renally dosed. He was started on CVVH as
above and nephrology recommendations were followed. Ultimately,
his kidney function improved and he did not require any renal
replacement therapy. Cr at the time of discharge was 1.5.
# Atrial fibrillation: CHADS score of 3. Required cardioversion
several times secondary to hypotension and RVR with HR to the
160s. An amiodarone drip was initiated but aborted ___ after no
improvement in heart rate. He was also refractory to diltiazem
gtt and esmolol gtt. This likely was exacerbated by metabolic
derangements, refractory shock, and atrial stretch from
hypervolemia. He was digoxin loaded ___ and this was
continued during his hospitalization. Amiodarone was restarted
___. As pressors were weaned off and blood pressure
stabilized, metoprolol was intiated with improvement in his
heart rate. Further, he was reinitiated on an amiodarone drip
for loading for a total of ten grams. His anticoagulation
originally was held secondary to supratherapeutic levels. It was
not reinitiated at the time of call out from the MICU.
Cardiology recommended call out to the cardiology service for
further management. Once on the cardiology service, the patient
continued to be in atrial fibrillation, with rates into
100-120s. Patient was initially maintained on digoxin and
metoprolol, but was not well rate controlled. Diltiazem was
added, but heart rates continued to be elevated. This lack of
response to oral medications was thought to be due to
malabsoption in the setting of large-volume diarrhea discussed
below. As such, efforts were made to better control the
diarrhea, and as his bowels slowed, heart rates became better
controlled. Patient's warfarin was restarted on ___ when his
INR came back down to 2.7. It was initiated at a dose of 2.5
mg. Patient's INR will need to be rechecked on ___.
# Diarrhea: At baseline the patient has a protuberant abdomen.
Clinically, there was a concern for intraabdominal process
contributing to his refractory shock. His stool cultures,
including C. diff PCR, were negative. He had a Flexiseal placed
for rectal decompression. He continued to have diarrhea that
was believed to be non-infectious and related to bowel loss of
his normal gut flora. He was started on loperamide and tincture
of opium while in the MICU. Once the floor, the patient was
given cholestyramine in addition to loperamide with eventual
improvement in his diarrhea.
# Anemia: Patient with baseline hematocrit in ___. This has
been downtrending since admission. Patient has had guaiac
positive stools this admission, but no overt melena. Guaiac
positive stools were not unexpected in the setting of large
volume diarrhea. Iron studies were consistent with anemia of
chronic disease. On ___, the patient was experiencing some
bright blood mixed with stool, likely from active hemorrhoids.
Hematocrit was stable between ___, and he was not orthostatic.
He will need daily hematocrit checks and hemorrhoid care.
# Citrate administration: Iatrogenic administration into
systemic circulation. Discovered in the ___ of ___ with
toxicology consulted for recommendations. Calcium was checked
q2hrs for monitoring of hypocalcemia with calcium gluconate for
repletion. Adverse side effects of citrate toxicity include
hypocalcemia and QTc prolongation. Ionized Ca++ was monitored
and was maintained >1 with calcium gluconate administration. Per
toxicology, likely cleared from system over 24hrs. Never
experienced QTc prolongation.
# Metabolic acidosis: Likely secondary to renal failure and
inability to clear hydrogen ions. Lactic acid normal. Patient
received bicarbonate in the ED. Improved with management and
resolution of shock.
# Toxic metabolic encephalopathy: Following extubation the
patient's mental status waxed and waned. This continued for a
majority of his hospital stay. The cause was thought to be
secondary to many of the metabolic derangements discussed above
as well as disturbances in sleep/wake cycles. As the ___
hospital course became more stable, his mental status improved
as well.
# Hyperphosphatemia: Elevated on admission likely in the setting
of renal failure. Improved with CVVH and return of renal
function.
INACTIVE ISSUES
---------------
# Diabetes mellitus: Blood glucose monitored and managed with
insulin sliding scale.
# Hypertension: Anti-hypertensives initially were held secondary
to triple pressor requirement. They were restarted as tolerated.
# Hyperlipidemia: On simvastatin
TRANSITIONAL ISSUES:
--------------------
- 7 mm right middle lobe lung nodule. As per the ___
___ Pulmonary Nodule Guidelines, followup chest CT is
recommended in ___ months for a low risk patient and ___ months
for a high risk patient.
- needs follow up with renal in ___ months with ___
-Please check Chem 10 daily and give IVF if Cr bumps and patient
appears volume depleted
- Monitor stool output, loperamide as needed
- Monitor daily hematocrit to check for stability and please
provide hemarrhoid wound care
- Monitor heart rates, titrate rate controlling agents as needed
- Monitor digoxin levels every ___ days or if renal function
worsens to ensure not accumulating toxic levels
- Please check daily INR and adjust warfarin dose as needed
- Please d/c PICC line when not needed for access
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxazepam 15 mg PO HS:PRN insomnia, anxiety
2. Simvastatin 20 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. Warfarin 5 mg PO DAILY16
6. Tamsulosin 0.8 mg PO HS
7. Lisinopril 20 mg PO DAILY
8. Zolpidem Tartrate 10 mg PO HS
9. Acetaminophen w/Codeine ___ TAB PO DAILY:PRN pain
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Tamsulosin 0.8 mg PO HS
2. Warfarin 2.5 mg PO DAILY16
3. Acetaminophen 650 mg PO Q6H:PRN fever, pain
4. Artificial Tear Ointment 1 Appl BOTH EYES QID:PRN dry eyes
5. Cholestyramine 4 gm PO TID
6. Aspirin 81 mg PO DAILY
7. Allopurinol ___ mg PO DAILY
8. Simvastatin 20 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO DAILY
10. Psyllium 1 PKT PO TID:PRN diarrhea
11. TraZODone 100 mg PO HS:PRN insomnia
12. LOPERamide 2 mg PO QID:PRN diarrhoea
13. Metoprolol Tartrate 50 mg PO Q6H
14. Neomycin-Polymyxin-Bacitracin 1 Appl TP ASDIR
15. Pantoprazole 40 mg PO Q12H
16. Diltiazem 30 mg PO QID
17. FoLIC Acid 1 mg PO DAILY
18. Digoxin 0.125 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
1. Septic shock
2. Atrial fibrillation
3. Acute on chronic kidney disease
4. Metabolic acidosis
5. Antibiotic associated diarrhea
6. Hypernatremia
7. Toxic metabolic encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
You were admitted to the hospital intensive care unit (ICU) with
a severe infection of unknown source. During your stay you
required a number of different antibiotics to help eliminate a
suspected infection. You were also found to be in an abnormal
heart rhythm, called atrial fibrillation. Due to this abnormal
heart rhythm and your infection, your blood pressures dropped
and you needed special medications to help you maintain a good
blood pressure. In order to help you breathe, you needed to be
intubated and you also required a form of dialysis to help
remove fluid from your lungs. After an extended stay in the ICU,
you eventually were able to be taken off the ventilator and you
blood pressure stabilized. You were transferred to the floor.
While on the floor your kidney function, diarrhea, rapid heart
rate and mental status slowly improved.
Please follow-up at the appointments listed below and continue
to take your medications, as prescribed.
Followup Instructions:
___
|
19845120-DS-16
| 19,845,120 | 22,726,949 |
DS
| 16 |
2178-07-08 00:00:00
|
2178-07-09 14:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / lisinopril
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy ___
EGD ___
___ guided arteriogram with embolization ___
Colonoscopy ___
Right hemicolectomy ___
EGD ___
Colonoscopy ___
Blood transfusions
Arterial Line Placement
History of Present Illness:
___ with DMII, CKD, HTN, afib on coumadin recently admitted to
___ for AKF and septic shock and discharged to ___
yesterday. He now returns with several episodes of brbpr, and
dizziness. At ___, he was found to be tachycardic to the
120s and hypotensive with blood pressures 103/65.
In the ED, initial vs were: 98.4 113 94/44 32 100% 2L Nasal
Cannula. Labs were notable for CBC with leukocytosis of 16.3 (up
from ___ yesterday), H/H 6.4/20.7 down from ___ yesterday.
INR was 2.9. LFTs WNL, UA was remarkable, and blood cx were
sent. NG lavage was negative. GI was consulted who desired a
CTA to evaluate for extravasation, which was negative. ACS was
consulted and is following along.
In the ED, he was intubated for volume overload, respiratory
distress, and aiway protection. He was given kcentra with
repeat INR of 1.3. He also received 7 units of PBRCs, 2L IVF, 1
Unit FFP.
On arrival to the MICU, he is intubated and sedated, unable to
perform ROS.
Past Medical History:
HYPERLIPIDEMIA
HYPERTENSION
OBESITY with bariatric screening
DIABETES TYPE II
VENOUS STASIS
BLOOD CLOT
CKD
ANEMIA
AFIB on coumadin
GOUT
PVD
Social History:
___
Family History:
Non-contributory
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
General: intubated, sedated, follows commands
HEENT: oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregular, tachycardic
Abdomen: soft, nondistended
GU: foley in place
Ext: bilateral ___ edema
=========================
DISCHARGE PHYSICAL EXAM
=========================
Vitals: Tm 98.1, Tc 98.1 BP 133/88 HR 110 RR 20 SaO2 98% RA
I/O (24 hr): 540/inc BMx1 (no melena)
GENERAL: NAD, awake and alert & oriented to person and place,
able to speak in short phrases
HEENT: EOMI, anicteric sclera, MMM
NECK: Supple, no JVD
CARDIAC: Irreg irreg, nl S1 S2, no MRG
LUNG: Decreased breath sounds bilaterally, CTAB, no accessory
muscle use
ABDOMEN: +BS, tympanic and slightly distended, soft, non-tender,
no rebound or guarding, no HSM, Surgical incisions are clean,
dry, and intact, bandages are c/d/i.
EXT: Warm and well-perfused, no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
SKIN: Warm and well perfused, chronic venous stasis changes b/l
to mid-shin
Pertinent Results:
===============
ADMISSION LABS
===============
___ 05:34AM BLOOD WBC-9.6 RBC-2.59* Hgb-8.3* Hct-26.9*
MCV-104* MCH-32.1* MCHC-31.0 RDW-14.5 Plt ___
___ 05:40PM BLOOD Neuts-84.2* Lymphs-10.4* Monos-3.1
Eos-1.8 Baso-0.4
___ 05:34AM BLOOD ___ PTT-36.8* ___
___ 05:34AM BLOOD Glucose-100 UreaN-37* Creat-1.5* Na-142
K-4.0 Cl-113* HCO3-26 AnGap-7*
___ 05:40PM BLOOD ALT-12 AST-14 CK(CPK)-40* AlkPhos-68
TotBili-0.2
___ 05:40PM BLOOD Lipase-48
___ 05:40PM BLOOD CK-MB-3 cTropnT-0.09*
___ 05:34AM BLOOD Calcium-8.8 Phos-2.1* Mg-1.7
___ 05:34AM BLOOD Digoxin-1.1
___ 09:32PM BLOOD Type-ART Temp-37.3 Rates-14/ Tidal V-500
PEEP-5 FiO2-100 pO2-239* pCO2-53* pH-7.26* calTCO2-25 Base XS--3
AADO2-423 REQ O2-73 -ASSIST/CON Intubat-INTUBATED
___ 05:48PM BLOOD Hgb-3.8* calcHCT-11
___ 09:32PM BLOOD freeCa-1.17
================
DISCHARGE LABS
================
___ 06:14AM BLOOD WBC-6.9 RBC-2.59* Hgb-7.9* Hct-25.6*
MCV-99* MCH-30.7 MCHC-31.1 RDW-17.6* Plt ___
___ 06:14AM BLOOD Plt ___
___ 06:14AM BLOOD Glucose-86 UreaN-13 Creat-1.6* Na-142
K-3.6 Cl-112* HCO3-21* AnGap-13
___ 06:14AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.5*
___ 05:08AM BLOOD WBC-6.9 RBC-2.57* Hgb-7.9* Hct-24.8*
MCV-96 MCH-30.8 MCHC-31.9 RDW-17.4* Plt ___
___ 05:08AM BLOOD Plt ___
___ 06:58AM BLOOD ___
___ 05:08AM BLOOD Glucose-87 UreaN-13 Creat-1.5* Na-143
K-3.5 Cl-113* HCO3-21* AnGap-13
___ 05:08AM BLOOD Calcium-7.9* Phos-3.4 Mg-1.3*
=============
MICROBIOLOGY
=============
___ BLOOD CULTURE - FINAL
___ BLOOD CULTURE - FINAL
___ MRSA SCREEN - FINAL
___ BLOOD CULTURE - FINAL
___ 1:35 pm SPUTUM
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
GRAM NEGATIVE ROD #3. RARE GROWTH.
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
URINE CULTURE (Final ___:
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ urine culture pending
___ blood culture pending
___ urine culture pending
=========
RADIOLOGY
=========
CTA Abd/Pelvis ___
1. No evidence of active extravasation.
2. Diverticulosis without evidence of diverticulitis.
3. Simple bilateral renal cysts.
EGD ___
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
SIGMOIDOSCOPY ___
Several ulcerations noted with associated edema of the colon
suggestive of colitis. Given the clinical context, ischemia is
most likely.
CXR ___
Improved aeration in the right lower lobe.
BEDSIDE SIGMOIDOSCOPY ___
normal mucosa in the colon
Diverticulosis of the colon
Otherwise normal colonoscopy to cecum
Findings consistent with severe ischemic colitis in ascending
colon.
Supportive care with permissive hypertension and blood
transfusions are recommended.
Repeat colonoscopy in ___ weeks.
___ ___:
No acute intracranial abnormality. Please note that CT is not
sensitive for the detection of acute stroke. MR can be obtained
for further evaluation if clinically indicated.
EEG ___:
This was an abnormal routine EEG due to generalized background
slowing with frontal and left hemispheric rhythmic delta
activity, consistent with a mild to moderate encephalopathy and
left hemispheric dysfunction. There were no epileptiform
features or electrographic seizures.
Renal u/s ___:
The right kidney measures 14.1 cm. No hydronephrosis is seen in
the right kidney. No cyst or stone or solid mass is identified.
No perinephric fluid collection is identified. Note is made that
the left kidney was not imaged as the patient refused to
complete the examination.
IMPRESSION: No hydronephrosis of the right kidney. The left
kidney was not imaged as the patient refused to complete the
exam.
LUE u/s ___:
Deep vein thrombosis seen within 1 of the 2 left brachial veins
with
nonocclusive thrombus extending into the left axillary and
subclavian veins. No DVT identified in the right arm.
CXR ___:
The right PICC is unchanged in position, ending in the low SVC.
Left lower lobe collapse persists. There is mild right lower
lung atelectasis. There may be mild pulmonary edema. Moderate
cardiac enlargement is unchanged. The mediastinal contours are
unchanged. There is no pneumothorax.
IMPRESSION:
1. Unchanged left lower lobe collapse.
2. Unchanged moderate cardiac enlargement.
3. Possible mild pulmonary edema.
NCHCT ___:
There is no intracranial hemorrhage, edema, mass effect or major
vascular territorial infarct. Prominent ventricles and sulci
are unchanged and compatible with global age-related atrophy.
Basal cisterns are preserved. There is no shift of normally
midline structures. Mild hypoattenuation in the periventricular
white matter is likely sequelae of chronic microvascular
ischemic disease. Otherwise, the gray-white matter
differentiation is preserved. Atherosclerotic calcifications
are seen in the intracranial internal carotid arteries. No
osseous abnormality is identified. Partial opacification of the
left mastoid air cells is unchanged from ___. Otherwise,
the visualized paranasal sinuses, middle ear cavities, and right
mastoid air cells are clear.
IMPRESSION: No acute intracranial abnormality. If clinical
concern for ischemic stroke is high, MRI is more sensitive.
FEES ___:
RECOMMENDATIONS:
1. PO diet of ground solids and thin liquids
2. PO meds whole if small or crushed if larger
3. TID oral care
4. Strict Aspiration Precautions:
a. small single bites/sips - no chugging!
b. slow rate
c. sip fully upright when eating/drinking
d. swallow 2x per bite/sip
5. Continued investigation into etiology of left sided VF
immobility
6. Continued SLP tx here and upon d/c to rehab to improve
- Pt likely safe for trials of tsps thin liquids in
swallow tx with SLP, also consider trial of left ___ turn
in clinical setting to see if subjective s/sx change
7. We will f/u next week
TTE ___:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. The right ventricular cavity is mildly dilated
with mild global free wall hypokinesis. There is abnormal
systolic septal motion/position consistent with right
ventricular pressure overload. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. An eccentric,
posteriorly directed jet of mild to moderate (___) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mildly dilated right
ventricle with mild global right ventricular hypokinesis in the
setting of moderate pulmonary hypertension. Normal left
ventricular regional/global systolic function. Mild to moderate
mitral regurgitation. Moderate tricuspid regurgitation.
Compared with the prior study (images reviewed) of ___,
the degree of mitral regurgitation seems to have worsened
however may be due to slightly better image quality on the
current study.
MR ___ ___:
No evidence for acute ischemia. Mild volume loss with
prominence of ventricles and sulci.
Colonoscopy ___:
The ileocolonic anastamosis looked healthy and normal (expected
3 weeks post-op appearance). There was very mild ulceration at
the suture line, but no evidence of bleeding or stigmata. There
was dark/melenic liquid issuing from the ileum. The ileum could
not be entered deeply with the scope because of angulation.
Diverticulosis of the colon
Polyp in the descending colon (biopsy) --> adenoma
Tagged RBC scan ___ and ___:
No active bleeding.
___ PICC line placement:
1. Occlusive right basilic and axillary thrombus. Patent right
brachial and
cephalic veins.
2. Partially occlusive right internal jugular thrombus.
3. Widely patent left internal jugular vein.
IMPRESSION: Unsuccessful placement of a PICC via the right
cephalic vein. The patient has no suitable option for a PICC in
the right or left arm. A tunneled central catheter could be
placed for long-term access via the left IJ, but the right IJ
demonstrates partially occlusive thrombus.
Brief Hospital Course:
====================================
PRIMARY REASON FOR HOSPITALIZATION
====================================
Mr. ___ is a ___ with DMII, CKD, HTN, afib on coumadin
recently admitted to ___ for AKF and discharged to ___
rehab on ___ now readmitted to the ICU on ___ for GI bleed. He
underwent ___ embolization of right sided colonic angiodysplasia
on ___ and then was then found to have ischemic colitis on
sigmoidoscopy on ___. He underwent right hemicolectomy on ___.
He continued to have melena in the MICU and after transfer to
the floor, with multiple workups to localize the bleeding, which
did not show definitive results. His GIB gradually slowed down
and stopped ___, and his hct remained stable over a course
of several days. He no longer required blood transfusions at the
time of discharge, and he was no longer producing melanotic
stools. He was discharged to a long term acute care facility and
will have further followup with GI, surgery, and ENT, Renal.
==============
ACTIVE ISSUES
==============
# GI Bleed:
Patient at rehab with brbpr, dizziness and tachycardia. Upon
arrival to the ED H/H 6.4/20.7 down from 8.3/26.9 on the day
prior. He received 7 units of pRBCs, 1 unit of FFP and INR was
reversed with K centra. GI was consulted and requested a CTA
abd/pelvis, which did not localize the bleed. Flex sig was
performed in the MICU and revealed mucosal ulceration consistent
with ischemic injury thought secondary to hypotension in the
setting of his recent shock. He continued to have extensive
bloody/melanotic stools requiring frequent transfusions and
hypotension requiring pressor support. On ___ he went for an
___ guided angiography which showed right sided colonic
angiodysplasia which was successfully embolized. He required
intermittent blood transfusions over the next few days to keep
his HGB >7, GI following. GI performed bedside sigmoidoscopy
again on ___ which showed ischemic colitis. On the evening of
___ he began to once again have large-volume melena, was
transferred back to MICU for management. He was taken to the OR
___ for R colectomy for ischemic colitis. Was given 5U
PRBCs, 3U FFP in OR. Post-op continued to have melanotic bowel
movements requiring intermittent transfusions. EGD was performed
___ and was negative, colonoscopy was planned but aborted as Hct
then became stable. On ___ the patient was transferred back to
the MICU service for persistent GI bleeding, hypotension and
___. Patient was intermittantly hypotensive that was responsive
to fluids, but was overall hemodynamically stable. Over his MICU
course he he was given a total of 7 units PRBCs as his H/H were
continuosly down trending. H/H stabilized and patient was
subsequently called out to the floor. After transfer to the
floor, he underwent colonoscopy on ___, which showed no acute
bleeding from the colon and was notable for an adenomatous polyp
requiring outpatient followup and polypectomy. He also underwent
tagged RBC scans x2 which did not show active bleeding. He
started a capsule study which did not show definitive results
because the capsule remained in his stomach. Toward the latter
part of the week on ___, his GIB had gradually slowed down, and
by ___, he had stopped having melenic stools. His hct remained
stable at 25.6 on the day of discharge. He will followup with GI
after discharge. Given his long course of GI bleeding of unknown
source, his warfarin was held during his hospitalization and
will continue to be held on discharge to rehab. Both the patient
and his family understand the risks of the GI bleeding
outweighing the benefits and have agreed to hold warfarin for
now. He was started on 81 mg aspirin on ___.
# Confusion/Delirium
Patient initially had nighttime delirium in the MICU. Patient
was maintained on Seroguel 200mg qHS, tapered down to 100mg over
several weeks. Attempted to minimize disturbances and encourage
appropriate day/night cycle. Continued to have altered mental
status post-op, in the setting of increasing BUN, possibly due
to uremia, although dialysis with a lower BUN did not improve
his mental status. Was following commands intermittently, and
more consistently after extubation #2. After transfer to the
floor, patient required Seroquel infrequently and his confusion
had resolved on the day of discharge.
# Afib
Upon admission, his INR was reversed and his home meds of
coumadin, metop, dig and dilt were all held. Rate control agents
were restarted with dose adjusted to maintain SBP 100-110 and HR
100-110. Cardiology consulted for aid in management. They
concluded rhythm control would not be helpful given prior failed
attempts. Will need further discussions to discuss restarting
coumadin (currently being held). Post-op he continued to have
afib with HR in the 100s, controlled initially on a dilt gtt and
digoxin. POD 4 had increasing HR to 130s -> changed to amio gtt
from dilt gtt then transitioned to PO amio with adequate rate
control prior to discharge.
# Nutrition
Dobhoff was placed and the patient received tube feeds while PO
intake was poor. The tube came out and was not replaced given
respiratory distress and the need for face mask ventilation.
PICC placed and TPN started and continued until ___. FEES ___
showed still not safe for thin liquids, although may do short
trials. Failed speech and swallow again ___. TFs started
___, then restarted again ___. He pulled out his NG tube on
___ and refused NGT replacement. He was evaluated by speech and
swallow via fiberoptic swallow study and placed on a
honeythickened liquid and pureed solid diet. He tolerated this
diet well.
# Respiratory distress: Likely due to mucous plugging given
inability to cough up secretions, acute onset of episodes of
distress, and improvement with deep suctioning. LLL collpse
persists in the wake of VAP. Aspiration another likely
contributor. s/p treatment for VAP/Pseudomonas with cefepime
(___). Treated with saline nebs, pulmonary toilet,
humidified oxygen, chest ___ for secretions, and guaifenesin as
mucolytic. Was exubated ___ -> then failed and reintubated ___
for worsening mental status. Was reextubated ___. After transfer
to the floor, his secretions were cleared with suctioning.
# Hoarse voice and vocal cord dysfunction: Since extubation,
the patient has had hoarse voice. Per ENT, L vocal cord
paralysis and mild loss of sensation. While this is likely
age-related change combined with ETT injury, they do note that
it could be neurologic deficit. If there is persistent
recurrent laryngeal nerve injury, he would be a candidate for
possible vocal cord medialization as an outpatient. His vocal
cord dysfunction is contributing to his respiratory distress, as
he has poor cough and ability to protect his airway. High
aspiration risk. Voice now stronger, cough still impaired.
Given possible tongue deviation and persistent difficulty
swallowing, as well as FEES findings of persistent vocal cord
dysfunction, performed MRI which did not show ischemia. Treated
with high-dose reflux therapy, aggressive humidification with
shovel mask and Q2-4 hr saline nebs, even if patient has no O2
requirement.
# AoCKD: Significantly worsening ___ ___. FeNa 0.43%,
renal u/s ruled out R-sided hydro (L side not examined), Foley
draining well. Held diuresis despite slight volume overload on
exam. Of note, patient required CRRT for oliguric renal failure
during last admission. Concern for poor forward perfusion
causing ATN, although etiology of hypotension or AF with RVR is
debatable. ___ d/c tamsulosin and reduced Seroquel and
metoprolol doses to maintain SBP > 100. per Cardiology, prefer
no midodrine, maintain SBP 100 by reducing rate control
medications if necessary and using pRBCs for hydration. CVVH
post-op until ___, followed by intermittent lasix, converting
from anuric to nonoliguric renal failure. Then HD ___, started
autodiuresing thereafter and no longer required HD. After
transfer to the floor, his creatinine continued to trend down to
1.6 on the day of discharge.
# LUE DVT: Noticed ___ ___ swelling of LUE, where PICC is
placed. DVT Confirmed by u/s. Per Renal, no immediate plans for
HD thus can switch to R arm. Resited PICC ___. New US ___
showed L axillary, subclavian, 1 of 2 brachial veins, and new
cephalic vein DVT LUE. As GI bleed continued, no anticoagulation
was started.
==========================
RESOLVED ISSUES IN MICU
==========================
# VAP: Concern for VAP given leukocytosis and fevers during
intubation. Sputum growing Pseudomonas. Completed 2-week course
cefepime ___ with resolution of leukocytosis and fever.
# BPH: Currently with Foley for urinary retention. Unable to
take tamsulosin via NGT, therefore voiding trial deferred
pending ability to swallow pills. d/c tamsulosin.
# Unresponsive episode
Patient with unresponsive episode on ___. It is unclear
what happened but he has since resolved. Ddx includes seizure
vs. stroke vs. hypoactive delirium. Per neurology, 20 minute
EEG shows no seizures. Ultimately, neurology felt this was
likely a hypoactive delirious episode.
# Respiratory distress
In the ED, patient felt to be clinically volume overloaded, as
he was unable to lay flat. Given the need for massive
transfusion of blood products, he was intubated and sedated. On
___, he was successfully extubated.
# CKD
Patient recently admitted for ___ (thought to be pre-renal in
nature) improved to 1.6 upon day of discharge. Now returns with
Cr at 1.4- seems to be at baseline.
On day of admission, he underwent CTA and then underwent ___
angiography on ___. Cr initially was elevated in the setting
of likely pre-renal due to GI bleed but downtrended with fluid
rescusitation.
# Diarrhea
Patient with severe diarrhea on prior admission, felt to be
mainly due to nutritional status. Was discharged on loperamide.
Loperamide was held upon admission given his brbpr/melanotic
stools. C. diff negative ___.
# Troponin Elevation
On recent admission, patient with mild troponin elevation to .04
in the setting of ___. Now admitted with troponin elevatinon to
.09 in the setting of GI bleed. EKG in the ED showed afib with
new ST depressions in V2-V4 and slightly worsening ST
depressions in V4-V6 from prior. Taken together, his troponemia
likely represents demand ischemia in the setting of hypotension
on top of known CKD.
===============
CHRONIC ISSUES
===============
# BPH: initially held tamsulosin as foley wasin place, then
restrated
# DMII: holding held metformin, on ISS
# HLD: held simvastatin initially then restarted
# Gout: initially held home allopurinol
===================
TRANSITIONAL ISSUES
===================
-discussion about restarting anticoagulation when he follows up
with GI (he has DVTs in his arms, non occlusive, and Afib RVR
CHADS=2), anticoag has been held in setting of GIB and when
stable discussion can be made about restarting those agents
- Patient has scheduled followup with GI, surgery, and ENT and
renal
- 7 mm right middle lobe lung nodule. As per the ___
___ Pulmonary Nodule Guidelines, followup chest CT is
recommended in ___ months for a low risk patient and ___ months
for a high risk patient.
- Please check Chem 10 once a week
- Monitor hematocrit weekly
- Monitor heart rates, titrate rate controlling agents as needed
- Once patient restarts warfarin, please check daily INR and
adjust warfarin dose as needed
- Once patient is discharged from rehab, he will need followup
with his PCP ___ ___ days.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.8 mg PO HS
2. Warfarin 2.5 mg PO DAILY16
3. Acetaminophen 650 mg PO Q6H:PRN fever, pain
4. Artificial Tear Ointment 1 Appl BOTH EYES QID:PRN dry eyes
5. Cholestyramine 4 gm PO TID
6. Aspirin 81 mg PO DAILY
7. Allopurinol ___ mg PO DAILY
8. Simvastatin 20 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO DAILY
10. Psyllium 1 PKT PO TID:PRN diarrhea
11. TraZODone 100 mg PO HS:PRN insomnia
12. LOPERamide 2 mg PO QID:PRN diarrhoea
13. Metoprolol Tartrate 50 mg PO Q6H
14. Neomycin-Polymyxin-Bacitracin 1 Appl TP ASDIR
15. Pantoprazole 40 mg PO Q12H
16. Diltiazem 30 mg PO QID
17. FoLIC Acid 1 mg PO DAILY
18. Digoxin 0.125 mg PO DAILY
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
2. Metoprolol Tartrate 25 mg PO Q6H
3. Neomycin-Polymyxin-Bacitracin 1 Appl TP ASDIR
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
5. Amiodarone 400 mg PO DAILY
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
7. Allopurinol ___ mg PO DAILY
8. Artificial Tear Ointment 1 Appl BOTH EYES QID:PRN dry eyes
9. Aspirin 81 mg PO DAILY
10. Cholestyramine 4 gm PO TID
11. FoLIC Acid 1 mg PO DAILY
12. Psyllium 1 PKT PO TID:PRN diarrhea
13. Pantoprazole 40 mg PO Q12H
14. Simvastatin 20 mg PO DAILY
15. Tamsulosin 0.8 mg PO HS
16. Ferrous Sulfate 325 mg PO DAILY
17. Heparin 5000 UNIT SC TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY: GI bleeding of unknown source
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 hospitalization
at ___. You were admitted for
bleeding from your intestinal tract. You underwent a resection
of part of the large intestine (colon) to stop the bleeding, and
you stayed in the intensive care unit for a while before being
transferred to the general medical floor. You underwent a
colonoscopy, tagged red blood scan, and capsule study to find
the source of the bleeding but the results did not reveal any
definitive location of bleeding. Your gastrointestinal bleeding
slowed down and stopped gradully. Your blood counts were
monitored daily and remained stable without further need for
blood transfusions.
The gastroenterologists do recommend that you repeat the capsule
study at some time in the future for further evaluation of your
intestinal tract. They also recommend that you undergo a repeat
colonoscopy to remove the benign polyp that was seen on the
colonoscopy during this current hospitalization.
You have clots in your arm but given your GI bleed we recommend
you hold off on anticoagulation till your bleed is stable.
You will be discharged to a long term acute care facility.
Followup Instructions:
___
|
19845120-DS-17
| 19,845,120 | 23,336,413 |
DS
| 17 |
2178-10-04 00:00:00
|
2178-10-05 19:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / lisinopril
Attending: ___.
Chief Complaint:
PRIMARY:
Clostridium difficile Colitis
Acute Kidney Injury / Prerenal Azotemia
SECONDARY:
Atrial Fibrillation on warfarin
Type II Diabetes Mellitus
Postive Leukocyte Esterase
Hyperlipidemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old man with a past medical
history of atrial fibrillation on coumadin, HTN, HLD, s/p
laparoscopic converted to open right colectomy on ___ for
right ischemic colitis who presents with diarrhea, black stool
and weakness. Patient reports watery-oatmeal black stools about
8 times per day with severe urgency for the past 2 weeks. He
notes over the past 1 week his diarrhea has been getting worse
with increased urgency and frequency. He reports associated mild
right-sided abdominal tenderness for the past one day that is
only apparent with pressure. He notes generalized weakness and
fatigue due to his frequent diarrhea. He notes that he has been
eating and drinking normally as he has food delivered via Meals
on Wheels. He notes he had UTI about a week prior to the onset
of diarrhea and was on antibiotics (cipro and a ___ unknown) for
a 10-day course. He presents today because he feels weak and is
tired of having accidents trying to reach the bathroom. Denies
CP, dyspnea, abd pain, fevers/chills, and nausea/vomiting.
In the ED initial vitals were: 97.5 56 92/41 18 98% RA.
- Admission labs were notable for Hgb/Hct of ___ (versus
baseline of ___, INR of 2.3, bicarbonate of 16 (versus
baseline of 22), normal LFTs and lipase, and lactate of 1.5. UA
was positive for large leukocytes, negative nitrite, 56 Wbc, and
few bacteria.
Blood and urine cultures were drawn. C. difficile assay returned
positive.
- CT abdomen/pelvis with PO contrast revealed minimal bowel wall
thickening of the colon in the left lower quadrant with
adjacent mild pericolonic fat stranding suggestive of colitis,
as well as extensive colonic diverticulosis within and
equivocally inflamed diverticulum in the left lower quadrant,
possibly representing a focus of diverticulitis.
- He received ciprofloxacin 500mg PO x1 for possible urinary
tract infection, followed by metronidazole 500mg PO x1 after C.
difficile colitis assay returned positive.
- EKG: A fib @72, NANI, no STE, PVCs.
Vitals prior to transfer were: 98.1 80 113/69 18 100% RA.
On the floor, patient reports that he is feeling better as he
has been able to rest more.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, nausea, vomiting, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
Atrial Fibrillation on warfarin/diltiazem/amiodarone
Ischemic Colitis status-post Right Partial Colectomy
Dysphagia/Dysphonia with Bilateral Vocal Fold
Hypomobility/Atrophy
Hypertension
Hyperlipidemia
Obesity
Type II Diabetes not on medications
Chronic Kidney Disease baseline Cr 1.1
Gout
Peripheral Vascular Disease
Anemia
Upper Extremity Deep Venous Thrombosis
Chronic Lower Extremity Venous Stasis
Social History:
___
Family History:
Patient was adopted and therefore his biological family medical
history is unknown.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T: 98.2 BP: 141/63 HR: 74 RR: 18 02 sat: 98% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM.
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: Irregularly irregular rhythm, S1/S2, no murmurs,
gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Obese, nondistended, right-sided tenderness to
palpation, well-healed midline incision, +BS, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, 1+ pitting bilateral
lower extremity edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals 98.5, 66-76, 115-145/50-59, 18, 96% on RA
GENERAL: NAD, A+Ox3, angry, walking with walker around CC6
waiting to be discharged
HEENT: NCAT, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM.
NECK: Nontender supple neck, no LAD, no JVD
CARDIAC: Roughly regular rhythm, normal rate, normal S1/S2, no
MRG
LUNG: Mild expiratory wheezes more prominent in bases, normal
respirations and airflow
ABDOMEN: Obese, nondistended, mild right-sided tenderness to
palpation, well-healed midline incision, +BS, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Moving all extremities well, 1+ pitting bilateral
lower extremity edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, motor and sensory grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 08:57AM BLOOD WBC-8.0 RBC-3.02* Hgb-9.7* Hct-31.0*
MCV-103* MCH-32.0 MCHC-31.2 RDW-18.0* Plt ___
___ 08:57AM BLOOD ___ PTT-34.9 ___
___ 06:25AM BLOOD ___ PTT-36.7* ___
___ 08:57AM BLOOD Glucose-94 UreaN-19 Creat-1.1 Na-136
K-3.9 Cl-108 HCO3-16* AnGap-16
___ 08:57AM BLOOD ALT-8 AST-18 AlkPhos-76 TotBili-0.2
___ 08:57AM BLOOD Lipase-18
___ 08:57AM BLOOD Albumin-3.4*
___ 06:25AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.3*
___ 09:04AM BLOOD Lactate-1.5
___ Blood Culture x2 - Pending
___ Urine Culture - Pending
___ C. Diff - Positive
CT Abdomen/Pelvis w/ Contrast ___
IMPRESSION: Minimal bowel wall thickening of the colon in the
left lower quadrant with adjacent mild pericolonic fat stranding
suggestive of colitis. Extensive colonic diverticulosis within
and equivocally inflamed diverticulum in the left lower
quadrant, of which may represent a focus of diverticulitis.
___ 12:45PM BLOOD UreaN-19 Creat-1.9* Na-137 K-3.9 Cl-106
HCO3-19* AnGap-16
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-8.1 RBC-2.89* Hgb-9.2* Hct-29.9*
MCV-104* MCH-31.9 MCHC-30.8* RDW-17.7* Plt ___
___ 10:35AM BLOOD ___
___ 06:45AM BLOOD Glucose-92 UreaN-22* Creat-2.0* Na-136
K-4.1 Cl-108 HCO3-16* AnGap-16
___ 06:45AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.1
Brief Hospital Course:
___, ___ yo M PMHx prolonged admissions for septic
shock and ischemic colitis status-post right partial colectomy
and urinary tract infection 1 week ago treated with
ciprofloxacin, presented with watery black diarrhea and was
found to have C. difficile colitis. He was treated with oral
metronidazole (mild abdominal pain, no fever, no leukocytosis),
his diarrhea improved (less urgency, loose but not watery
stools), he tolerated PO intake and could ambulate at baseline,
and he was discharged home to continue his course of
antibiotics.
# Clostridium difficile Colitis: Patient presents with diarrhea
and found to have a positive C. diff in the setting of recent
antibiotics for UTI. Patient would be categorized as
mild-moderate infection as afebrile, WBC less than 15k, no known
inflammatory bowel disease, normal albumin and creatinine, and
no fevers. His exam is overall benign with stable vitals signs
and he appears non-toxic. He tolerated PO without any issues.
Differential diagnosis includes diverticulitis (less abdominal
pain and more diarrhea than would be expected), other infectious
colitis (toxin, viral, bacterial), inflammatory colitis
(microscopic colitis, IBD), medication-induced (no new
medication changes); however his clinical scenario and positive
C. difficile PCR indicated C. diff colitis as the by far the
most likely clinical explanation. He was treated with
metronidazole 500mg PO q8hours, was given IV fluids and
magnesium repletion as necessary. Physical Therapy evaluated
the patient and recommended following up with his preexisting
home ___ services. After a day of clinical improvement, he was
discharged on a 14 day course of metronidazole (last day
___.
# Acute Kidney Injury: Creatining was 1.1 on admission increased
to 1.9 on HD2; likely prerenal secondary to GI losses.
Encouraged PO intake, gave additional IV fluids, and Cr was 2.0
on discharge; patient was improving clinically and "was going to
leave at 2PM no matter what!"
# Atrial Fibrillation: Chronic stable issue with INR 2.3-3.0.
Maintained on home amiodarone, diltiazem, and warfarin for
rhythm/rate control and anticoagulation.
# Positive Leukocyte Esterase: Many WBC but no nitrites. Had
previous treated urinary tract infection. ___ be chronic
bladder colonization or bacterial prostatitis. He was
asymptomatic when he was treated last time and remains
asymptomatic. Differential includes asymptomatic bladder
colonization versus chronic bacterial prostatitis; this can be
investigated as an outpatient as appropriate.
# DMII: Not currently on any diabetes medications, maintained on
ISS while in hospital.
# BPH: Chronic stable issue continued on home tamsulosin.
# HLD: Chronic stable issue continued on home simvastatin.
# Gout: Chronic stable issue continued on home allopurinol.
# Code Status: Full Code, contact and healthcare proxy is his
son ___ at ___
# Disposition: Home with preexisting services
# Transitional Issues:
- Ensure clinical resolution of C. diff colitis
- Follow up positive leukocyte esterase
- Obtain INR and BMP at next followup appointment
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Psyllium 1 PKT PO TID:PRN diarrhea
6. Simvastatin 20 mg PO DAILY
7. Tamsulosin 0.8 mg PO HS
8. Ferrous Sulfate 325 mg PO BID
9. Acetaminophen w/Codeine ___ TAB PO Q8H:PRN pain
10. Warfarin 2.5 mg PO 3X/WEEK (___)
11. Warfarin 5 mg PO 4X/WEEK (___)
12. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
14. Vitamin D ___ UNIT PO DAILY
15. Omeprazole 40 mg PO DAILY
16. Taztia XT (diltiazem HCl) 240 mg oral Daily
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
Do not take allopurinol for the next 7 days to help your kidneys
heal
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Ferrous Sulfate 325 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Omeprazole 40 mg PO DAILY
8. Simvastatin 20 mg PO DAILY
9. Tamsulosin 0.8 mg PO HS
10. Vitamin D ___ UNIT PO DAILY
11. Warfarin 2.5 mg PO 3X/WEEK (___)
12. Warfarin 5 mg PO 4X/WEEK (___)
13. Taztia XT (diltiazem HCl) 240 mg ORAL DAILY
14. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 14 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*40 Tablet Refills:*0
15. Acetaminophen w/Codeine ___ TAB PO Q8H:PRN pain
16. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
17. Psyllium 1 PKT PO TID:PRN diarrhea
18. Outpatient Lab Work
Please draw INR and chem7 on ___
ICD9 Code: 427.31 Atrial Fibrillation
Please fax results to Dr. ___ at ___
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY:
Clostridium Difficile Colitis
SECONDARY:
Atrial Fibrillation on warfarin
Positive Leukocyte Esterase
Type II Diabetes Mellitus
Hyperlipidemia
Gout
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___, it was a pleasure to take care of you at ___
___. You were admitted to the
hospital because you were having severe diarrhea that was due to
Clostridium diffile colitis (diarrhea due to bacteria that can
happen after you get antibiotics). You were started on
antibiotics (metronidazole) to treat this infection, you were
able to eat/drink and walk well, your diarrhea improved, and you
were discharged with oral antibiotics. Please do not drink
alcohol while on this antibiotic. Best of luck to you in your
future health.
Please take all medications as prescribed, attend all doctor
appointments as scheduled, and call a doctor if you have any
questions or concerns.
We will have labs drawn this week and sent to Dr. ___
office to monitor your INR and kidney function.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19845148-DS-11
| 19,845,148 | 21,505,737 |
DS
| 11 |
2145-03-16 00:00:00
|
2145-03-16 13:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Nitrofurantoin / Yellow Dye / Iron / Calcium
Attending: ___.
Chief Complaint:
Increased abdominal pain
Leukocytosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman known well to the ___
surgical service. Briefly, ___ she underwent a vagotomy,
antrectomy and bilroth II repair for gastric outlet obstruction
secondary to PUD. This was complicated by a duodenal stump leak.
She has had multiple ICU stays and admissions for sepsis,
hepatic
abscesses/thromboses, pneumonia and small bowel obstructions
since then. She was most recently discharged on ___ after
being
admitted for an elevated INR and urinary retention. She
presents
today stating that for the past 2 days she has had progressively
worsening diffuse abdominal pain, nausea, and bilious emesis
which all began after discharge. She denies any fevers, chills,
CP, or SOB, and states the pain is somewhat worse than her
baseline pain.
Past Medical History:
chronic back pain
sciatica
HTN
PUD
adrenal adenoma
uterine CA s/p hysterectomy
depression
anemia of chronic disease
recurrent hepatic abscess
Polymicrobial bacteremia - Enterobacter cloacae, VRE, MRSA,
Clostridium - s/p several month course of abx, most recently
daptomycin and meropenem (see ID OPAT note for details)
Abdominal fluid collections growing ___ albicans and
tropicalis, VRE
Right hepatic vein thrombosis, on warfarin
.
PSH:
EUS, pyloric ulcer bx, perigastric LNB (___)
EGD with duodenal stricture dilation (___)
Vagotomy and antrectomy with B2 reconstruction (___)
Re-exploration,lateral duo tube and feeding J-tube (___)
CT-guided catheter drainage of liver abscess (___)
perforated cyst/appendix s/p SBR, appendectomy
cystectomy as a teenager
s/p hysterectomy for uterine cancer @age ___
Social History:
___
Family History:
Father with peptic ulcer disease
Physical Exam:
On Admission:
Vitals - 98.2 78 115/49 18 95% RA
Gen - AOx3, lying in bed in mild distress
HEENT - PERRL, EOMI b/l, mucous membranes moist
CV - RRR, no r/m/g
R - CTA b/l
Abd - soft, moderately distended, diffusely TTP. No
rebound/gaurding or peritonitis. Fistula on right productive of
thin stool. well healed midline laparotomy incisions.
Ext - no edema
On Discharge:
VS: 98.5, 77, 96/50, 12, 96% RA
GEN: Cachectic female, but NAD
HEENT: NC/AT, EOMI, PERRL
CV: RRR
Lungs: Diminished b/l
Abd: Old incisions healed well. RLQ with fistula, covered with
ostomy pouch and patent with thin stool. Tender diffusely.
Extr: Warm, no c/c/e
Pertinent Results:
___ 01:52AM BLOOD WBC-24.8*# RBC-3.37* Hgb-9.3* Hct-28.6*
MCV-85 MCH-27.7 MCHC-32.7 RDW-16.6* Plt ___
___ 01:52AM BLOOD Glucose-61* UreaN-10 Creat-0.8 Na-129*
K-4.8 Cl-101 HCO3-17* AnGap-16
___ 01:52AM BLOOD ___ PTT-26.8 ___
___ 07:10AM BLOOD WBC-17.7* RBC-3.13* Hgb-8.5* Hct-27.5*
MCV-88 MCH-27.2 MCHC-30.9* RDW-16.5* Plt ___
___ 07:10AM BLOOD ___
___ 07:10AM BLOOD Glucose-73 UreaN-3* Creat-0.5 Na-130*
K-4.1 Cl-100 HCO3-19* AnGap-15
___ 07:10AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.1
___ 3:00 am URINE Site: CLEAN CATCH
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ BLOOD CULTURE: Pending
___ DUPLEX DOPPLER:
IMPRESSION:
1. Persistent obliteration or occlusion of the left portal vein.
2. Probable stenosis with high velocity within the main portal
vein, with
patency of the right portal vein.
3. Patent hepatic veins.
___ CT ABD:
IMPRESSION:
1. Persistent dilation of the afferent and efferent limbs with
contrast
passing distally consistent with partial efferent limb
obstruction possibly due to an internal hernia or adhesion.
2. Slightly dilated fluid-filled colon, likely colonic ileus.
3. Interval resolution in porta hepatic fluid collection. No new
fluid
collections or abscesses seen.
4. Stable intrahepatic biliary dilatation and expected
post-surgical
pneumobilia.
5. Stable enterocutaneous fistula in the right upper quadrant
with no
adjacent fluid collection.
Brief Hospital Course:
The patient well known for Pancreatico-biliary Surgical Service
was admitted with increased abdominal pain, nausea/vomiting and
leukocytosis (28.3). The patient was made NPO and started on
IVF. On HD # 1 patient underwent abdominal CT scan, which
revealed persistent partial SBO and colonic ileus. The patient
was started on aggressive bowel regiment with Dulcolax and
Fleets. The patient had bowel movement x 8 on HD 1 and 2. Her
abdominal pain improved and her WBC started to downward.
Patient's diet was advanced and was well tolerated.
Neuro: The patient received her regular pain medication during
hospitalization. She was given Lidocaine patch x 1 secondary to
right back muscle spasm.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Incentive
spirrometry were encouraged throughout hospitalization.
GI: Abdominal CT scan revealed persistent partial bowel
obstruction with large amount of stool. The patient was given
suppository and fleet enema. She had multiple bowel movement
after the intervention. Her abdominal pain improved to her
baseline. Diet was advanced slowly to regular and was well
tolerated. Patient's intake and output were closely monitored.
Electrolytes were routinely followed, and repleted when
necessary.
Hyponatremia: The patient was hyponatremic on admission. She was
started on Na tabs and her sodium level started to improve.
Patient will continue on salt tabs in Rehab, it will be stop
when Na within normal limits.
GU/FEN: The patient finished treatment for UTI on HD # 3, her
Foley catheter was removed and she subsequently voided without
problem. Follow up urine cultures were negative.
ID: The patient's white blood count was elevated on admission,
and started to downward on HD # 2. WBC returned to the patient's
baseline on HD # 4, patient remained afebrile. Augmentin was
d/cd on HD # 3, patient continued on Po Bactrim
and Fluconazole per ID recommendation.
Hematology: The patient on Coumadin for treatment of the right
hepatic vein thrombosis. Her INR on admission was 1.1, she was
continued on 1mg of Coumadin QD. Her INR prior discharge was
1.4. The patient required daily INR monitoring in Rehab and home
with ___.
The patient's HCT was stable; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
The patient is unsafe to be discharge home, she was evaluated
for Rehab. At the time of discharge, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating with bystander assist, and pain was
well controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
fluconazole 400', bactrim DS", carisoprodol 350''', dilaudid
2prn, hyoscyamine 0.375", metoprolol 50", pantoprazole 40",
docusate 100", senna", megestrol 400/10", tylenol PRN,
citalopram 10', lisinopril 20', coumadin 1', fentanyl patch
25mcg, MVI, augmentin 875''
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
3. hyoscyamine sulfate 0.375 mg Capsule,Extended Release 12 hr
Sig: One (1) Capsule,Extended Release 12 hr PO BID (2 times a
day).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for SBP < 100 or HR < 60.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. carisoprodol 350 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
11. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
12. Tylenol ___ mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for fever or pain.
13. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Check INR daily. Please hold Coumadin if INR > 3.0. .
14. Ondansetron 4 mg IV Q8H:PRN nausea
15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
16. Senna Lax 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
17. Fleet Enema ___ gram/118 mL Enema Sig: One (1) Enema Rectal
every other day.
18. sodium chloride 1 gram Tablet Sig: One (1) Tablet PO BID (2
times a day): please check patient's Na on ___. Stop salt
tabs if Na within normal limits .
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. RUQ enterocutaneous fistula
2. Partial small bowel obstruction
3. Leukocytosis
4. Chronic constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Fistula care:
1. Change ostomy pouch every ___ days or PRN
2. Monitor for signs and symptoms of infection
.
INR:
You will continue to take Warfarin (Coumadin) at home after
discharge. ___ will check your INR daily and report the results
to your PCP (Dr. ___. You PCP ___ adjust the dosage of
the Warfarin (Coumadid). \
Coumadin (Warfarin):
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 ___ 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 ___ 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:
___
|
19845348-DS-11
| 19,845,348 | 26,521,439 |
DS
| 11 |
2169-02-10 00:00:00
|
2169-02-10 15:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cont. vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M ___ cardiomyopathy, atrial fibrillation on Coumadin, DM,
h/o colon cancer, mitral valve repair who presented to ___
___ with 4 days of vomiting and was found to have gastric
volvulus then transferred to ___ for further evaluation.
Per EMS reports, patient found by neighbors who endorsed black
vomit. He was taken to ___, where a gastric
volvulus was found. He was given 1 l fluid, vitamin k, 40mg
pantoprazole and sent here for further evaluation. OSH labs: H/H
14.1/___, lactate 4.6
In the ED, initial vital signs were noteable for HR 110. Labs
were noteable for WBC 12.7, Hb 14.0, Na 152, HCO 38, BUN 85, Cr
3.3, Glc 243, INR 3.3. CT scan from OSH was uploaded to life
image, although there is no formal read by our radiology team.
CT at the OSH revealed "fluid Surgery was consulted and the
patient was admitted to the surgical service. Warfarin has been
held and patient has been started on a heparin drip.
Upon evaluation of the patient, pt reports that he is "okay." He
cannot tell why he is in the hospital or where he is. He denies
all symptoms to me [He endorsed emesis, abd pain, vomiting and
constipation previously], including chest pain, difficulty
breathing, abdominal pain or nausea. He had self-discontinued
his NGT. He is amenable to having the NGT replaced. Overall, the
history is difficult to gather as patient is confused.
Per son-in-law, patient has been doing well. Pt has reported
intermittent lightheadedness and dizziness. Pt reported that he
had vomited a few days ago. ___ got a phone call from neighbor
saying that ___ "didn't look so well." ___ arrived and pt
looked tired, lethargic. He watched him eat banana and ___
started "raising phlegm from his throat." Then he looked at a
basket next to the patient and there was vomit. ___ noted that
he had been vomiting for three days. Denies history of reflux.
He says that he is very alert, can eat and dress himself. Over
the past one year, he was noted to have dementia. His license
was removed as he was found many miles away using his car after
a car accident. Pt doesn't complain of chest pain or difficulty
breathing. Per the son-in-law, hernia has been present for many
years. Per the son-in-law, code status was discussed at ___,
and Mr. ___ indicated that he would not want to be
resuscitated or intubated.
ROS:
Unable to obtain
Past Medical History:
Hypertension
Hyperlipidemia
Severe mitral regurgitation/prolapse
Atrial fibrillation, on Coumadin; last dose WED ___
Diabetes type II
Prostate cancer- elevated PSA (not treated)
Colon polyps s/p polypectomy
Bilateral Inguinal hernia repair
remote trauma to leg involving pitchfork
Social History:
___
Family History:
non contributory
Physical Exam:
ADMISSION:
97.9 110 116/60 16 93%
General: no acute distress, not cachectic, AOx2
CV: systolic murmur, tachycardic, irregular, sternotomy scar
well
healed
Lungs: clear bilaterally, good inspiratory effort
Abdomen soft, non-tender, non-distended, no palpable masses, no
rebound, no surgical scars
ext: WWP
DISCHARGE:
Vitals: 98.2 PO 149/78, HR ___, RR 18 97-99% RA
I/O: ___ ; add'nal -175 since MN
General: Older appearing male, no acute distress, lying in bed
HEENT: NCAT, EOMI, tongue w/ white scale less than yesterday,
wearing dentures today
CV: Irregularly irregular, s1 and s2 heard, no m/r/g are
appreciated
Lungs: Coarse breath sounds in left lower base, improved from
yesterday
Abdomen: BS+, soft abdomen, non distended, no rebound or
guarding
GU: No foley
Ext: Warm, resolving ecchymoses on b/l UE, LLE WWP
Neuro: CN II-XII intact, strength testing limited by
positioning, but ___ in UE, knee flexion and extension;
sensation intact to light touch throughout
Psych: AOx1 and city, knows that he is in the hospital for an
intestinal blockage. Mood is good.
Pertinent Results:
ADMISSION:
=========
___ 06:43PM BLOOD WBC-12.7*# RBC-4.70 Hgb-14.0 Hct-44.8
MCV-95 MCH-29.8 MCHC-31.3* RDW-16.5* RDWSD-57.8* Plt ___
___ 06:43PM BLOOD Neuts-84* Bands-8* Lymphs-5* Monos-2*
Eos-0 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-11.68*
AbsLymp-0.64* AbsMono-0.25 AbsEos-0.00* AbsBaso-0.00*
___ 06:43PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
___ 06:43PM BLOOD ___ PTT-29.6 ___
___ 06:43PM BLOOD Glucose-243* UreaN-85* Creat-3.3*#
Na-152* K-5.0 Cl-91* HCO3-38* AnGap-28*
___ 06:43PM BLOOD ALT-13 AST-63* AlkPhos-57 TotBili-0.8
___ 01:45PM BLOOD CK(CPK)-327*
___ 06:43PM BLOOD cTropnT-0.09*
___ 06:43PM BLOOD Albumin-4.1
___ 04:00AM BLOOD Calcium-9.8 Phos-5.0* Mg-2.6
___ 06:48PM BLOOD Lactate-4.2*
OTHER LABS:
==========
___ 04:00AM BLOOD WBC-13.3* RBC-4.07* Hgb-12.1* Hct-39.2*
MCV-96 MCH-29.7 MCHC-30.9* RDW-16.4* RDWSD-58.1* Plt ___
___ 06:40AM BLOOD WBC-11.5* RBC-3.74* Hgb-11.0* Hct-36.9*
MCV-99* MCH-29.4 MCHC-29.8* RDW-15.9* RDWSD-57.6* Plt ___
___ 06:15AM BLOOD WBC-10.4* RBC-3.75* Hgb-11.2* Hct-36.2*
MCV-97 MCH-29.9 MCHC-30.9* RDW-15.5 RDWSD-54.8* Plt ___
___ 05:39PM BLOOD WBC-7.3 RBC-3.73* Hgb-11.0* Hct-35.8*
MCV-96 MCH-29.5 MCHC-30.7* RDW-15.4 RDWSD-53.4* Plt ___
___ 04:00AM BLOOD Glucose-272* UreaN-93* Creat-4.2* Na-149*
K-3.1* Cl-93* HCO3-47* AnGap-12
___ 06:15AM BLOOD Glucose-131* UreaN-58* Creat-1.8*#
Na-147* K-3.1* Cl-102 HCO3-36* AnGap-12
___ 04:00AM BLOOD CK-MB-5 cTropnT-0.11*
___ 01:45PM BLOOD CK-MB-5 cTropnT-0.08* proBNP-3507*
___ 06:40AM BLOOD CK-MB-8 cTropnT-0.06*
___ 06:15AM BLOOD CK-MB-3 cTropnT-0.03*
___ 12:07AM BLOOD Lactate-4.8*
___ 04:09AM BLOOD Lactate-2.6*
___ 01:58PM BLOOD Lactate-1.6
___ 04:01PM URINE Color-Red Appear-Hazy Sp ___
___ 04:01PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.0 Leuks-LG
___ 04:01PM URINE RBC->182* WBC-42* Bacteri-FEW Yeast-NONE
Epi-1
___ 04:01PM URINE CastHy-13*
___ 09:48AM URINE Hours-RANDOM Creat-199 Na-23
MICRO:
======
___ 01:45PM BLOOD PROCALCITONIN-Test 3.19 (H)
___ 4:01 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 4:01 pm URINE Source: Catheter.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 6:40 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth x5d
IMAGING:
=======
___ 2:18 AM
CHEST (PORTABLE AP)
RECOMMENDATION(S): NG tube tip is prepped acting over the
distended stomach. Heart size is enlarged but unchanged. Left
retrocardiac consolidation is unchanged. No appreciable
pulmonary edema is seen. Sternotomy wires are unremarkable.
Note is made that the apices were included from the field of
view.
Old fracture of the right humerus is partially imaged.
Portable TTE (Complete) Done ___ at 1:00:00 ___ FINAL
The left atrium is markedly dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
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
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. A bioprosthetic
mitral valve prosthesis is present. The mitral prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular gradients. Trivial mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is mild tricuspid
valve prolapse. Moderate [2+] tricuspid regurgitation is seen.
The tricuspid regurgitation jet is eccentric and may be
underestimated. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Low-normal left ventricular systolic function.
Normally-functioning mitral valve bioprosthesis. TVP with
moderate tricuspid regurgitation. Mild pulmonary hypertension.
Marked biatrial dilation.
Compared with the prior study (images reviewed) of ___,
there has been an interim mitral valve replacement. LV cavity is
smaller. The other findings are similar.
DISCHARGE:
==========
___ 06:31AM BLOOD WBC-7.9 RBC-3.73* Hgb-11.1* Hct-34.8*
MCV-93 MCH-29.8 MCHC-31.9* RDW-15.9* RDWSD-53.4* Plt ___
___ 06:31AM BLOOD ___ PTT-33.0 ___
___ 06:31AM BLOOD Glucose-160* UreaN-27* Creat-1.1 Na-143
K-4.1 Cl-107 HCO3-25 AnGap-15
___ 06:31AM BLOOD Calcium-7.8* Phos-2.7 Mg-1.7
Brief Hospital Course:
SURGERY (ACS) COURSE:
====================
The patient with the above HPI and PE was admitted to the ___
service with gastric outlet obstruction d/t mesoaxial gastric
volvulus c/b pre-renal azotemia NGT was placed and drained about
a liter of static content that later became coffee ground.
His lactate trended down and his abdomen soft and non tender ACS
surgery decided the patient does not need emergency surgery and
it was agreed upon that the patient will be followed by ___
surgery service. Cardiology were consulted to optimize him for
the possibility of emergent / semi elective surgery. and
medicine were consulted for his ___.
At the point as there is no surgical emergency the patient will
be transferred to medicine team and ___ will follow along.
MEDICINE COURSE:
===============
#Volvulus: Continued NGT for decompression. NGT output declined
to 40cc and it was discontinued on HD3. Diet was advanced as
tolerated. The patient will have an appointment to discuss
possible elective hiatal hernia surgery.
___: Pre-renal etiology, possibly intrinsic given significiant
hypovolemia on presentation. Improved with IVF. Discharge BUN/Cr
at baseline.
#Metabolic alkalosis/hypernatremia: Consistent with history of
emesis and poor PO intake x several days. Free water deficit on
admission from OSH about 3L. Improved with administration of
___. Daily BMP were followed and other electrolytes
repleted as necessary. Normalized by the time of discharge.
#Troponinemia: Found to have elevated cardiac biomarkers. Denied
CP throughout. This was felt to be most likely demand ischemia
in the setting of his acute illness, T2 NSTEMI. Troponins were
trended to peak.
#Community-acquired pneumonia: Imaging findings demonstrated
consistent retrocardiac and LLL opacities with associated
pleural effusions. The differential considered was aspiration
pneumonitis versus CAP. Given the patient's leukocytosis, high
CURB-65, Ceftriaxone + Azithromycin were initiated (d1 ___ -
d5 ___. Procalcitonin was sent and returned positive, which
emphasized the need to continue the antibiotic course for CAP.
Strep pneumo and legionella antigens returned negative.
#Anticoagulation, #AFib on Coumadin: No rate control as outpt.
Per medical records on warfarin 2.5mg daily. Monitored on
telemetry during hospitalization. On admission, started on
heparin gtt given possible procedure. However, once the volvulus
resolved, warfarin was restarted @ 2.5mg daily (d1 ___. For
the remainder of hospitalization, received SQH for DVT PPX until
INR > 2.0.
CHRONIC:
========
#T2DM: Held glimepiride and metformin while inpt. ISS in house.
Restarted home meds on discharge.
#Prostate cancer - ___ 7 per Atrius notes
#h/o MVR - bioprosthetic valve
#CAD, HLD, HTN - holding PO home meds while NPO
TRANSITIONAL ISSUES:
====================
[] antibiotics - two more days of levofloxacin to complete 7d
course for CAP
[] elective outpatient work-up and possible repair if the
patient desires if he is able to be advanced now that
decompressed
[] Code status: Per patient's son, patient is DNR/DNI since last
hospitalization. This was confirmed in multiple conversations
including with ___ intern, MERIT, and Medicine intern
[] Cardiology f/u for rate control, HTN mgmt: Had some PVCs in
setting of acute illness and BPs to 180s/80s. Not on medication
for either as outpatient. Tolerated metoprolol tartrate 25mg BID
while inpatient. Please continue medication titration as
outpatient.
Important values
BUN/Cr: 27/ 1.1
Hgb/Hct: 11.1/ 34.___
Expected discharge stay: < 30 days
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 1 mg PO DAILY16
2. Simvastatin 20 mg PO QPM
3. glimepiride 8 mg oral BREAKFAST
4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
5. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
6. Lipo-Flavonoid Plus (vitamins-lipotropics) 200-100 mg oral
DAILY
7. Melatin (melatonin) 3 mg oral QHS
Discharge Medications:
1. Levofloxacin 500 mg PO Q48H Duration: 2 Days
last dose ___
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. glimepiride 8 mg oral BREAKFAST
5. Lipo-Flavonoid Plus (vitamins-lipotropics) 200-100 mg oral
DAILY
6. Melatin (melatonin) 3 mg oral QHS
7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
8. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
9. Simvastatin 20 mg PO QPM
10. Warfarin 1 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
=================
Gastric outlet ___ d/t gastric mesoaxial gastric volvulus
Hiatal hernia type 2
Acute kidney injury
Type 2 non-ST Elevation Myocardial Infarction
Hypernatremia
Toxic-metabolic encephalopathy
Community acquired pneumonia
SECONDARY DIAGNOSES:
====================
Atrial fibrillation on warfarin
Mild cognitive impairment
Discharge Condition:
Mental Status: Confused - always (AO to self, long term memory
intact).
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (___
or cane).
Discharge Instructions:
Dear Mr ___,
You were transferred to ___
with persistent vomiting and were diagnosed with twisting of
your stomach in a defect that caused a blockage to food.
What was done during this hospitalization?
- Your blood work showed that you were dehydrated, so you were
given fluids
- You were seen by the surgeons and a nasogastric tube was
placed to relieve the pressure in your stomach
- Your belly became soft and you were able to eat, drink,
swallow pills, and move your bowels
- Tests also showed that you had pneumonia. You received
antibiotics for this.
- You were confused when you arrived at the hospital. Your
thinking improved as your stomach condition was treated, you
were rehydrated, and you received antibiotics.
- You were evaluated by a physical therapist who is recommending
you go to rehab to get your strength back before returning home
What should you do now that you are leaving the hospital?
- Work on getting your strength back
- Continue taking your medications as prescribed
- Return to the hospital if you have new or concerning symptoms,
listed below
- If you develop nausea and vomiting, you must get an Xray or CT
scan of your stomach right away. You may have another volvulus
and this is an emergency.
It was a pleasure taking care of you. Wishing you the best in
health.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19845944-DS-8
| 19,845,944 | 28,570,119 |
DS
| 8 |
2164-05-27 00:00:00
|
2164-05-28 15:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Wellbutrin
Attending: ___.
Chief Complaint:
R ankle pain
Major Surgical or Invasive Procedure:
R ankle ORIF
History of Present Illness:
___ s/p MVC found to have a right medial malleolar fracture.
Patient was the restrained driver involved in a head-on ___
about 35mph.
Past Medical History:
ADHD, back pain
Social History:
___
Family History:
___
Physical Exam:
HR 110 BP 130/80 RR 13 Sat 100%
Superficial abrasions over hips and knees bilaterally
RLE with ankle swelling and tenderness
___ pulses. foot warm and well perfused.
Leg compartments soft
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
___ FHS ___ TA Peroneals Fire
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of a R medial malleolar fracture. The patient was taken
to the OR and underwent an uncomplicated open reduction internal
fixation. The patient tolerated the procedure without
complications and was transferred to the PACU in stable
condition. Please see operative report for details. Post
operatively pain was controlled with a PCA with a transition to
PO pain meds once tolerating POs. The patient tolerated diet
advancement without difficulty and made steady progress with ___.
The patient was transfused 0 units of blood for acute blood loss
anemia.
Weight bearing status: nonweightbearing.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with 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.
Discharge Medications:
1. DiphenhydrAMINE 25 mg PO Q6H:PRN insomnia, puritis
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC QPM Duration: 2 Weeks
RX *enoxaparin 40 mg/0.4 mL please inject subcutaneously into
abdomen every night Disp #*14 Syringe Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours as
needed Disp #*60 Tablet Refills:*0
5. Ranitidine 150 mg PO BID
6. Topiramate (Topamax) 50 mg PO HS
Discharge Disposition:
Home
Discharge Diagnosis:
R medial malleolar fracture
Discharge Condition:
stable
Discharge Instructions:
Wound Care: You have been placed in a splint and should not get
this wet. You may shower but should cover your splint to prevent
it from getting wet. 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.
******WEIGHT-BEARING*******
non-weight bearing right lower extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 2 weeks post-operatively.
Followup Instructions:
___
|
19846087-DS-16
| 19,846,087 | 28,616,880 |
DS
| 16 |
2149-06-05 00:00:00
|
2149-06-05 18:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shellfish derived / prednisone
Attending: ___
___ Complaint:
febrile neutropenia
Major Surgical or Invasive Procedure:
PIGTAIL PLACEMENT ___
PIGTAIL REMOVAL ___
History of Present Illness:
___ PMH of ITP, Obesity, SVT, Recently Diagnosed Nodular
Sclerosis Classic Hodgkin Lymphoma Stage IV (s/p C1D1 ___
brentuximab plus doxorubicin, vinblastine, and dacarbazine), who
presents from home with neutropenic fever
As per review of prior notes, he was hospitalized in late
___ when lymphoma was suspected and had VATS + biopsy which
ultimately revealed Nodular Sclerosis Classic Hodgkin Lymphoma
Stage IV for which he was started on A+AVD (brentuximab plus
doxorubicin, vinblastine, and dacarbazine) C1D1 ___. Had
port placed as well.
Patient was then seen in ED on ___ for left sided pain, for
which he was noted to be tachycardic but afebrile and CTA was
negative for PE/infection, so was other infectious w/u, so
patient was discharged by ED and informed to take Tylenol as
needed. Since then he has seen thoracic surgery in clinic who
felt that he had healed appropriately and noted that he does not
need to followup with them any further.
Today he called the oncall fellow to report left sided
chest/flank/back pain for which he was taking Tylenol instead of
oxycodone. Dr ___ him to stop Tylenol as it masks
fever and to take oxycodone, and call back if symptoms change.
Hours later he called and reported fever, so she referred him to
the ED.
Pt reported that his left sided chest/back/flank pain started on
___ the day of his ED visit, and has fluctuated on/off since
then, is typically felt as a sharp/stabbing/poking sensation,
worse when lying down or taking a deep breath, better when
sitting up. He noted that he feels like he has difficulty taking
big breaths, and has occasional wheeze. He noted that he has had
a persistent dry cough since his VATS procedure. He endorsed
fever with Tmax of 102.1 in ED, denied headache, sore throat,
rhinorrhea, nausea, vomiting, diarrhea, rash, sick contacts. He
noted that he had no pain or discomfort at port site. Reported
tolerating a normal diet.
In the ED, initial vitals: 99.0 121 117/83 16 99% RA. Temp then
increased to 102.1. CBC with WBC of 3./4 (ANC 918), Hgb 12.4,
plt 286, INR 1.3, CHEM wnl, ALT 120, lactate 1.2, flu negative,
UA tr ketones, few bacteria, but no pyuria.
Past Medical History:
Obesity
GERD
Vitamin D deficiency
SVT - poorly characterized but on metoprolol xl
ITP s/p steroids in ___
Social History:
___
Family History:
Mother with breast cancer and thymoma. Grandfather with lung
cancer. Grandfather with brain cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vitals: 98.8 ___ 20 97RA
GENERAL: sitting in bed, mother at bedside, appears tired but
NAD
EYES: anicteric, PERRLA
HEENT: OP clear, has some mucosal irregularity in the left
cheek,
but no obvious ulcers, MMM
NECK: supple
LUNGS: CTA with exception of right mid and lower lung which has
predictable wheeze at mid expiration, all other areas clear.
normal RR, no increased WOB, dry cough very sporadic
CV: tachycardic, regular rhythm, normal distal perfusion, no
edema
ABD: soft, NT, ND, normoactive BS
MSK: PAtient without any bony/palpable abnormalities of ribcage,
unable to elicit pain which he reported on history
GENITOURINARY: no foley
EXT: normal muscle bulk, no deformity
SKIN: multiple tatoos, no rash
NEURO: AOX3, fluent speech
ACCESS: has PORT over right chest with dressing c/d/I with
irritation of a few follicles which were shaved for port
placement, but no frank erythema/warmth/induration concerning
for abscess
DISCHARGE PHYSICAL EXAM:
==========================
Vitals: ___ 0804 Temp: 98.7 PO BP: 122/80 HR: 93 RR: 18 O2
sat: 98% O2 delivery: RA
___ Total Intake: 2875ml
___ Total Output: 2280ml
GEN: NAD, lying in bed
EYES: Anicteric, PERRLA
HEENT: OP clear, no obvious ulcers, MMM
NECK: Supple
LUNGS: CTA. Normal RR, no increased WOB, dry cough
intermittently. Old L. chest tube site w/o drainage
CV: regular rate and rhythm, normal distal perfusion, no edema
ABD: soft, NT/ND, normoactive BS
EXT: normal muscle bulk, no deformity
SKIN: multiple tattoos > LLE, no rashes or lesions
NEURO: AOX3, fluent speech
ACCESS: POC C/D/I
Pertinent Results:
ADMISSION LABS:
================
___ 09:51PM BLOOD WBC-3.4* RBC-4.38* Hgb-12.4* Hct-36.4*
MCV-83 MCH-28.3 MCHC-34.1 RDW-11.7 RDWSD-35.0* Plt ___
___ 09:51PM BLOOD Neuts-27.3* ___ Monos-15.7*
Eos-8.6* Baso-1.2* Im ___ AbsNeut-0.92* AbsLymp-1.58
AbsMono-0.53 AbsEos-0.29 AbsBaso-0.04
___ 09:51PM BLOOD Glucose-110* UreaN-14 Creat-1.0 Na-137
K-3.6 Cl-98 HCO3-23 AnGap-16
___ 09:51PM BLOOD ALT-120* AST-29 AlkPhos-122 TotBili-0.5
___ 06:43AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.0
___ 09:51PM BLOOD Albumin-3.7
___ 09:58PM BLOOD Lactate-1.2
DISCHARGE LABS:
===============
___ 05:07AM BLOOD WBC-11.1* RBC-3.86* Hgb-11.0* Hct-32.5*
MCV-84 MCH-28.5 MCHC-33.8 RDW-12.5 RDWSD-37.6 Plt ___
___ 05:07AM BLOOD Neuts-57 Bands-1 ___ Monos-11 Eos-2
Baso-1 ___ Metas-7* Myelos-2* AbsNeut-6.44* AbsLymp-2.11
AbsMono-1.22* AbsEos-0.22 AbsBaso-0.11*
___ 05:07AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 05:07AM BLOOD Plt Smr-NORMAL Plt ___
___ 05:07AM BLOOD Glucose-90 UreaN-9 Creat-0.7 Na-143 K-4.2
Cl-105 HCO3-25 AnGap-13
___ 06:12AM BLOOD ___
___ 05:07AM BLOOD ALT-68* AST-26 LD(LDH)-232 AlkPhos-86
TotBili-<0.2
___ 05:07AM BLOOD Albumin-3.4* Calcium-8.5 Phos-4.1 Mg-2.2
___ 11:48PM BLOOD HIV Ab-NEG
___ 06:00PM BLOOD Vanco-14.4
___ 11:48PM BLOOD CMV VL-NOT DETECT
___ 11:48PM BLOOD HIV1 VL-NOT DETECT
___ 09:58PM BLOOD Lactate-1.2
MICROBIOLOGY:
==============
___ FLUID RECEIVED IN BLOOD CULTURE BOTTLES
Fluid Culture in Bottles-PRELIMINARY INPATIENT
___ PLEURAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARY; ACID FAST
CULTURE-PENDING; ACID FAST SMEAR-PENDING; FUNGAL
CULTURE-PRELIMINARY INPATIENT
___ SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-FINAL; Respiratory Viral Antigen
Screen-FINAL INPATIENT
___ Blood (EBV) ___ VIRUS VCA-IgG
AB-FINAL; ___ VIRUS EBNA IgG AB-FINAL; ___
VIRUS VCA-IgM AB-FINAL
___ SEROLOGY/BLOOD MONOSPOT-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
IMAGING:
=========
CXR ___
IMPRESSION:
1. Interval removal of left pigtail pleural drainage catheter.
No
pneumothorax.
2. Low lung volumes with stable small left residual effusion
with subjacent atelectasis at the left lung base.
CXR ___
IMPRESSION:
Lungs are low volume with stable loculated left pleural
effusion. Right IJ
catheter is unchanged. There is stable subsegmental atelectasis
in the left lung base. No pneumothorax is seen. The pigtail
catheter in the left lower pleura is unchanged
CTA CHEST ___
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. New moderate left pleural effusion with adjacent atelectasis.
3. New mediastinal lymph node measuring 1.1 cm in short axis.
4. Re-demonstration of multiple bilateral pulmonary nodules, a
few of which have slightly decreased in size compared to prior.
5. No evidence of splenic infarct.
CXR ___
IMPRESSION:
New small left pleural effusion. No definite new focal
consolidation. Right upper lobe mass appears somewhat less
conspicuous as compared to the prior study. Mediastinal and
hilar adenopathy and multiple pulmonary nodules seen on prior CT
were better assessed on CT, a more sensitive study.
Brief Hospital Course:
ASSESSMENT & PLAN: ___ PMH of ITP, Obesity, SVT, Recently
Diagnosed Nodular Sclerosis Classic Hodgkin Lymphoma Stage IV
(s/p C1D1 ___ brentuximab plus doxorubicin, vinblastine, and
dacarbazine), who presents with neutropenic fever.
#Neutropenic Fever: Given cough, pneumonia is possible however
chest imaging (including CXR/CTA) was unremarkable except for
new moderate pleural effusion as below. Wheezing on exam is
highly reproducible in single/discrete location and is likely
___ bronchus impingement by node/malignancy and not acute
process. Viral URI is also possible (respiratory viral panel
negative so low suspicion). UTI is less
likely as no pyuria. Bacteremia is possible as well given recent
instrumentation for POC placement. Consulted ID ___ to help
guide our infectious workup and overall unclear source of
fevers. He was treated empirically with cefepime (___) and
___. He is no longer neutrapenic since
___. Fevers have resolved since ___. Blood and urine
cultures without any growth. Viral studies are all negative
(respiratory panel, EBV, monospot, HIV) as well as fungal
markers. Pleural fluid (see below as s/p pigtail placement for
pleural effusion management) preliminary did not show any growth
at discharge.
#Left sided flank pain: Ongoing since VATs procedure but less
frequent overall. Given positional pain and worse intensity with
deep breath, there was suspicion for PE in the context of
tachycardia. However, patient's CTA did not show evidence of
pulmonary embolism. No history of trauma, or bony abnormalities
seen. Does have pain on palpation which is suggestive of
musculoskeletal cause and could have neuropathic pain post
operatively. No EKG findings to suggest pericarditis. Repeat CTA
on ___ did show new moderate L pleural effusion. Given this
finding, consulted thoracic surgery who recommended IP
consultation for evaluation for thoracentesis with possible
pigtail placement as well as sending pleural fluid for full
infectious workup and for cytology to evaluate for malignancy.
In consultation with IP on ___, bedside repeat U/S showed
small anechoic septated pleural effusion that has decreased in
size; therefore, procedure was not performed. However, in the
setting of counts recovery, repeat U/S ___ showed moderate
effusion; therefore, IP placed a ___ L chest tube given
serosanguinous fluids and sent fluids for analysis. Pigtail was
removed on ___. Repeat CXR on ___ showed small effusion.
There was some thought that his pain may be neuropathic;
therefore, he was initiated on Neurontin 300mg BID ___ ___
and was discharged with the same dosing.
#Transaminitis: Largely resolved, now with mild ALT elevation.
Resolving as compared to LFTs from ___, so was likely
transient liver damage ___ recent chemotherapy.
-Trend LFTs outpatient
#Sinus Tachycardia:
#History of SVT: Improved. Patient notes in between SVT
episodes. EKG on ___
is c/w sinus tachycardia. Suspect exacerbated in the setting of
febrile neutropenia and decreased oral intake. Monitor and trend
outpatient
#Nodular Sclerosis Classic Hodgkin Lymphoma Stage IV (s/p C1D1
___ brentuximab plus doxorubicin, vinblastine, and
dacarbazine). Today is D+20. Held his chemotherapy during his
infectious workup. However, given clinical improvement and
cessation of fevers, was discharged with plan to receive
chemotherapy on ___.
-Received neupogen ___ while he was briefly neutropenic
[consider neulasta for next cycle]
-Advised to take Tylenol and Allegra on ___ evening and
___ morning prior to appointment on ___
CORE MEASURES:
==============
#Access: POC
#HCP/Contact: Mother, ___ (___)
#Code: Full
#Disposition: Discharged ___. RTC ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Loratadine 10 mg PO DAILY:PRN allergies
2. Metoprolol Succinate XL 25 mg PO QHS
3. Omeprazole 40 mg PO DAILY
4. Ranitidine 150 mg PO QHS
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
8. Vitamin D ___ UNIT PO 1X/WEEK (___)
9. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
10. Multivitamins 1 TAB PO DAILY
11. Cyanocobalamin 500 mcg PO DAILY
12. LORazepam 0.5 mg PO QHS:PRN insomnia
13. Docusate Sodium 100 mg PO BID:PRN constipation
14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
Discharge Medications:
1. Fexofenadine 60 mg PO DAILY Duration: 2 Doses
TAKE 60MG ON ___ EVENING AND 60MG ON ___ BEFORE YOUR
APPOINTMENT ON ___
2. Gabapentin 300 mg PO BID
3. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
4. Acetaminophen 1000 mg PO ASDIR pre-appointment on ___
Duration: 2 Doses
TAKE 100OMG ON ___ ___ AND TAKE ANOTHER 1000MG ON ___
MORNING BEFORE YOUR APPOINTMENT
5. Cyanocobalamin 500 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. LORazepam 0.5 mg PO QHS:PRN insomnia
8. Metoprolol Succinate XL 25 mg PO QHS
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
14. Ranitidine 150 mg PO QHS
15. Senna 8.6 mg PO BID:PRN Constipation - First Line
16. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
#HODGKINS LYMPHOMA
#FEBRILE NEUTRAPENIA
SECONDARY DIAGNOSIS:
====================
#SVT
#TRANSAMINITIS
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.
We did an extensive work up which did not reveal a source of
infection. You were given intravenous antibiotics and your
counts improved and your fevers subsided. You will be discharged
today and will follow up with Dr. ___ as stated below. Please
continue to take all of your medications as instructed. It was
an absolute pleasure taking care of you.
Followup Instructions:
___
|
19846426-DS-2
| 19,846,426 | 28,080,724 |
DS
| 2 |
2152-11-03 00:00:00
|
2152-11-05 19:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___: Cardiac catheterization
History of Present Illness:
Per admission HPI:
Mr. ___ is a ___ M (___) w/ a PMH significant
for
T2DM, HTN, HLD and right>left PVD who went to his PCP ___ ___
with complaints of chest pain.
He reports that yesterday on ___, he began to have twisting,
squeezing pain in his left chest while on the telephone. It
radiated to his left arm, causing pain and weakness. He took
suxiao jiuxin wan, a ___ supplement used for angina. The
pain
got better with this and deep breaths, and resolved at noon.
Pain
was been unrelated to exertion. He reports that he had a similar
episode of pain earlier this year in ___ or ___ that
was
much less severe and only radiated to his upper arm, and
resolved
after a few minutes. He has had no intervening episodes. He
otherwise has had an EKG done in ___ but no previous cardiac
workup.
He went to his PCP who told him to come to the ED for emergency
evaluation, given his risk factors for CAD. He denies
lightheadedness, dizziness, dyspnea, nausea/vomiting, abdominal
pain, diarrhea. He has lower extremity swelling, R>L, for more
than ___ year; he has PVD on that side and reports never having
pulses in his foot.
In the ED
---------
- Initial vitals: 4 | 96.8 | 82 | 125/71 | 16 | 100% RA
- EKG: Sinus rhythm, no STEMI but <1mm STE in V2/3
- Labs/studies notable for: Troponin of 0.32
- Patient was given: ASA 243mg, Heparin gtt
- Vitals on transfer: 80 | 135/75 | 16 | 98% RA
Patient was given additional aspirin to complete 325mg dose, and
started on a heparin drip for presumed NSTEMI. Troponins
elevated
to 0.32, with repeat to 0.27. He remained chest pain free during
time in ED.
On the floor, he confirms the above history and continues to
deny
any active chest pain REVIEW OF SYSTEMS is notable for absence
of
chest pain, dyspnea on exertion, orthopnea, palpitations,
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS
- Insulin-Dependent Type 2 Diabetes Mellitus (A1c 5.8 in ___
improved from 8.3 in ___
- Hypertension
- Hyperlipidemia
2. CARDIAC HISTORY
- No previous cardiac events
3. OTHER PAST MEDICAL HISTORY
- Peripheral vascular disease
Social History:
___
Family History:
Sister has "cardiac issues," but no family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death.
Dad with diabetes, "heart disease."
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
GENERAL: Well appearing gentleman sitting in bed in no acute
distress, communicating with nurse in ___.
HEENT: MMM, no gross abnormalities.
NECK: No elevated JVP at 90 degrees, no lymphadenopathy.
CARDIAC: Normal rate, regular rhythm. No murmurs/rubs/gallops
appreciated.
LUNGS: Lungs clear to auscultation bilaterally without wheezes
or
crackles. No increased work of breathing.
ABDOMEN: Soft, non-tender, non-distended. Insulin pump in place.
EXTREMITIES: Trace peripheral edema on the right without
palpable DP pulse. No peripheral edema and 1+ pulses on the
left.
SKIN: Warm and well perfused.
NEURO: Alert & oriented; tells cogent history with interpreter
and to ___ nurse. ___ grossly intact. Moving
independently.
DISCHARGE PHYSICAL EXAM
======================
___ 0733 Temp: 98.7 PO BP: 122/74 L Sitting HR:
67 RR: 20 O2 sat: 97% O2 delivery: RA FSBG: 115
GENERAL: Well appearing gentleman sitting in bed in no acute
distress.
HEENT: MMM, EOMI, no gross abnormalities.
NECK: No elevated JVP or lymphadenopathy.
CARDIAC: Normal rate, regular rhythm. No murmurs/rubs/gallops
appreciated.
LUNGS: Lungs clear to auscultation bilaterally without wheezes
or
crackles. No increased work of breathing.
ABDOMEN: Soft, non-tender, non-distended. Insulin pump in place.
EXTREMITIES: Trace peripheral edema on the right. 1+ pulses
bilaterally.
SKIN: Warm and well perfused.
NEURO: Alert & oriented; ___ grossly intact. Moving
independently.
Pertinent Results:
ADMISSION LABS
=============
___ 02:00PM BLOOD WBC-7.5 RBC-4.91 Hgb-14.3 Hct-43.7 MCV-89
MCH-29.1 MCHC-32.7 RDW-12.5 RDWSD-40.6 Plt ___
___ 02:00PM BLOOD Neuts-62.0 ___ Monos-6.7 Eos-3.3
Baso-0.4 Im ___ AbsNeut-4.65 AbsLymp-2.03 AbsMono-0.50
AbsEos-0.25 AbsBaso-0.03
___ 02:00PM BLOOD Plt ___
___ 02:00PM BLOOD Glucose-78 UreaN-18 Creat-1.1 Na-145
K-4.5 Cl-106 HCO3-28 AnGap-11
___ 02:00PM BLOOD CK-MB-9 cTropnT-0.32*
___ 07:35PM BLOOD CK-MB-7 cTropnT-0.27*
___ 02:00PM BLOOD Calcium-9.3 Phos-4.0 Mg-2.2
___ 02:04PM BLOOD Lactate-0.9
STUDIES
=======
EKG: ___, 12:43
Sinus rhythm. Possible <1mm ST elevation in V2 & 3
EKG: ___, 18:27
Unchanged from prior
#cath ___
Single vessel LAD disease succesfully treated with ___ 2.
Recommendations
ASA 81mg per day indefinitely. Ticagrelor/DAPT for at least 12
months, ideally longer if
tolerated.
Secondary prevention of CAD
DISCHARGE LABS
=============
___ 06:55AM BLOOD WBC-8.5 RBC-4.59* Hgb-13.4* Hct-40.6
MCV-89 MCH-29.2 MCHC-33.0 RDW-12.4 RDWSD-40.0 Plt ___
___ 06:55AM BLOOD Plt ___
___ 06:55AM BLOOD Glucose-111* UreaN-18 Creat-1.1 Na-146
K-4.0 Cl-107 HCO3-24 AnGap-15
___ 06:55AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0
Brief Hospital Course:
SUMMARY:
=========
Mr. ___ is a ___ M (___) w/ a PMH significant
for T2DM, HTN, HLD and right>left PVD who went to his PCP ___
___ with complaints of chest pain, found to have an NSTEMI,
underwent cardiac catheterization with placement of 2 stents in
the LAD.
ACUTE ISSUES:
=============
#NSTEMI
Chest pain and troponin of 0.36 on admission concerning for
NSTEMI. ~1mm ST elevations in precordial leads on EKG. Pt had no
previous cardiac hx but, given troponins & symptoms, was
admitted on a heparin drip and scheduled for cardiac
catheterization. Cath on ___ w/ 2 DES placed in ___ and mid
LAD. Pt was started on ASA 81mg & Atorvastatin 80mg daily, as
well as Metoprolol 12.5mg BID & Ticragrelor 90mg BID post-cath
for dual antiplatelet therapy. Initiation of ACE inhibitor was
deferred given low blood pressure, but should be reconsidered in
the outpatient setting if BP allows.
CHRONIC ISSUES
==============
#Type 2 Diabetes Mellitus. Diagnosed ___ years ago; on insulin
pump. Last A1c 5.8 in ___, improved from 8.3 in ___. Pt
managed w/ home insulin pump. ___ consulted for further
management. Will f/u w/ ___.
#Hypertension
- Nifedipine d/ced, begun on Metoprolol 12.5mg BID
#Hyperlipidemia
#PVD
- Continued Atorvastatin 80mg
TRANSITIONAL ISSUES
[] Please ensure patient follows up with cardiology
[] We explained the importance of taking his aspirin and
Brilinta every day to Mr. ___. Please reinforce the importance
of the medicines at his PCP ___.
[] Would recommend initiation of an ace inhibitor if blood
pressure allows
# CODE: Presumed full code
# CONTACT: Wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY
3. Atorvastatin 40 mg PO QPM
4. NIFEdipine (Extended Release) 30 mg PO DAILY
5. Insulin Pump SC (Self Administering Medication)
Target glucose: 80-180
Discharge Medications:
1. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*30 Tablet Refills:*0
2. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Insulin Pump SC (Self Administering Medication)
Target glucose: 80-180
6. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
- Non ST Elevation Myocardial Infarction
- Coronary Artery disease
SECONDARY DIAGNOSIS
===================
- Hypertension
- Hyperlipidemia
- Type 2 Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had chest pain.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You had a cardiac catheterization. This is a procedure that
looks at the pictures of your heart. You were found to have
blockages in a blood vessel that required placement of 2
"stents", which help keep the blood vessel open.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please follow up with your primary care provider and your
cardiologist. We have made appointments for you.
- Please take all your medications as prescribed, ESPECIALLY
your aspirin and Brillinta (Ticagrelor), as these will help
prevent another heart attack.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19846500-DS-6
| 19,846,500 | 26,510,613 |
DS
| 6 |
2161-06-15 00:00:00
|
2161-06-16 19:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___
Chief Complaint:
dyspnea/ chest pain
Major Surgical or Invasive Procedure:
Pericardiocentesis, pericardial drain placement and removal
___
History of Present Illness:
Mr. ___ is a ___ year old male transferred from OSH with
pericardial effusion. Patient has experienced both dull and
sharp chest pain, centered around left chest, but radiating to
substernal area and left shoulder, for past 5 weeks. Pain was
sometimes so severe that he had to take vicodin to relieve it.
Pain is also associated with shortness of breath that comes and
goes, with no specific alleviating or exacerbating factors.
Patient was seen 5 weeks ago when he first experienced the pain
at OSH. The pain was persistent but did worsen at times. He had
an extensive work up at OSH including a CTA which excluded
aortic dissection, pericardial effusion and pulmonary embolus.
He was seen in the ED by a cardiology attending who thought
there was a very low probability of atherosclerotic CAD. He was
ruled out by 3 cycles of cardiac enzymes, all of which were
negative, and he was discharged. Since then, he has seen his
primary care doctor for persistent dyspnea, gotten several CXR
at OSH all of which were negative for abnormality, and has been
prescribed flovent and albuterol, and recently a Zpack, none of
which have provided any relief. His left sided chest pain was
assessed to be MSK by an orthopedist, and he has been receiving
muscular massages by a massage therapist, as well as taking
vicodin for his pain. He presented to OSH today with similar
symptoms, was found to be febrile to 102.7F and on Echo was
found to have a pericardial effusion. He was transferred to the
BI for further evaluation.
On ROS, patient notes extreme fatigue and loss of appetite. He
does not believe he's lost weight, but his wife does. He
endorses frequently feeling fevers/chills, but until today has
not taken his temperature. He has drenching night sweats at
times. He has also had some upper respiratory symptoms
including cough, white phlegm production and sore throat. He
denies lightheadedness, dizziness, confusion, abdominal pain or
distension, changes to his bowel habits, dysuria or frequency,
muscular weakness or sensory changes besides pain in left
shoulder and extreme fatigue. He denies easy bruising, bleeding
while brushing his teeth or overt bleeding from elsewhere in his
body. He denies rashes, joint swelling, or joint pain. He
denies cold intolerance, proximal muscle weakness, or weight
gain.
.
Cardiac review of systems is notable for absence of chest
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
In the ED, patient was found to have pulsus 10. Cardiology
fellow bedside echo confirmed pericardial effusion and early
tamponade physiology. He received 1L NS and levaquin for fever
and pleural effusion. He received tylenol for his fever.170cc
fluid taken out during pericardiocentesis and drain left in
place.
Most Recent Vitals prior to transfer: 99.1 101 121/71 18 98%2L
Past Medical History:
hand surgery for tendon release
sebaceous cysts on his head
borderline hypertension, hyperlipidemia
Social History:
___
Family History:
Father had an MI at age ___ and died during CABG at age ___. Uncle
had MI in late ___. Grandmother had GI cancer. Daughter has
mild ebstein's anomaly and accessory pathways - treated with
ablation. History of DM. No hx of autoimmune or rheumatologic
conditions.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS: T=98.9 BP=137/75 HR=109 RR=27 O2 sat=100(RA)
GENERAL: NAD. Orientedx3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis or petechia of the oral mucosa.
oropharynx without erythema or exudate. No cervical or axillary
lymphadenopathy. No thyroid enlargement or goiters.
NECK: Supple with JVP of 13 cm, no Kussmaul's sign.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. +friction rub. no murmurs.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: normoactive bowel sounds, soft, nondistended. pain in
epigastrum with abdominal pressure. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or rashes.
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
PHYSICAL EXAM ON DISCHARGE:
Vitals - Tm/Tc: 97.2/___.5 ___ RR:18 02
sat:100% RA
GENERAL: ___ yo M in no acute distress
HEENT: mucous membs moist, no lymphadenopathy, JVP non elevated
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2 Normal in quality and intensity RRR, no rubs.
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding.
EXT: wwp, no edema.
___ strength in U/L extremities.
PSYCH: A/O
Pulsus ___
Pertinent Results:
Labs on Admission:
___ 04:45PM BLOOD WBC-12.1* RBC-3.94* Hgb-11.5*# Hct-34.1*#
MCV-87 MCH-29.2 MCHC-33.7 RDW-12.7 Plt ___
___ 04:45PM BLOOD Neuts-74.1* ___ Monos-6.2 Eos-0.1
Baso-0.2
___ 04:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Spheroc-OCCASIONAL Burr-1+
___ 04:45PM BLOOD ___ PTT-29.2 ___
___ 04:45PM BLOOD ___
___ 10:15PM BLOOD FDP-40-80*
___ 05:02AM BLOOD ESR-83*
___ 04:45PM BLOOD Ret Aut-1.6
___ 04:45PM BLOOD Glucose-117* UreaN-17 Creat-1.3* Na-135
K-3.8 Cl-99 HCO3-24 AnGap-16
___ 04:45PM BLOOD ALT-21 AST-14 LD(LDH)-208 AlkPhos-74
TotBili-0.6
___ 04:45PM BLOOD Lipase-71*
___ 04:45PM BLOOD cTropnT-<0.01
___ 05:02AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0
___ 04:45PM BLOOD Albumin-3.6 UricAcd-4.6
___ 10:15PM BLOOD Iron-14*
___ 04:45PM BLOOD Hapto-445*
___ 10:15PM BLOOD calTIBC-196* Ferritn-934* TRF-151*
___ 04:45PM BLOOD TSH-1.6
___ 04:48PM BLOOD Lactate-1.1
Cardiac Cath ___:
FINAL DIAGNOSIS:
1. Pericardial Tamponade with sucessful removal of 160 cc of
bloody
pericardial fluid via a sub-xiphoid approach.
2. Reduction in pericardial pressure from 25 mmHg to 13 mmHg
after
pericardiocentesis.
TTE ___:
The estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%), although there is beat
to beat variation in the ejection fraction due to abnormal
septal motion. Right ventricular chamber size and free wall
motion are normal. The aortic valve is not well seen. The mitral
valve leaflets are structurally normal. No mitral regurgitation
is seen. There is a moderate sized pericardial effusion. There
is brief right ventricular diastolic collapse and significant,
accentuated respiratory variation in mitral/tricuspid valve
inflows, consistent with impaired ventricular filling and early
tamponade physiology.
IMPRESSION: Moderate circumferential pericardial effusion with
early tamponade physiology. Normal biventricular function with
abnormal septal motion.
TTE ___:
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. There is abnormal
septal motion/position. There is a very small pericardial
effusion. The effusion is echo dense, consistent with blood,
inflammation or other cellular elements. There are no
echocardiographic signs of tamponade.
IMPRESSION: Small residual pericardial effusion without
echocardiographic signs of tamponade.
Labs on Discharge:
___ 06:55AM BLOOD WBC-6.3 RBC-4.41* Hgb-12.5* Hct-37.7*
MCV-86 MCH-28.3 MCHC-33.1 RDW-12.7 Plt ___
___ 06:55AM BLOOD Glucose-101* UreaN-18 Creat-1.0 Na-141
K-5.1 Cl-105 HCO3-29 AnGap-12
___ 06:55AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.3
Brief Hospital Course:
Primary Reason for Hospitalization:
Mr. ___ is a ___ with no signficant PMH who is transfered
from an OSH for evaluation of a pericardial effusion and found
to have tamponade physiology.
.
# PERICARDIAL EFFUSION: Patient has had intermittent chest pain
since ___. At that time, there was no EKG evidence of
pericarditis or low voltage suggestive of effusion. He was
observed and sent home after three set of negative cardiac
enzymes. He now represents with dyspnea and chest pain, this
time found to have effusion with early tamponade physiology.
Pulsus was 10 in ED. Patient was sent directly to cath lab for
fluoro-guided pericardiocentesis. He drained 160 ccs of
pericardial fluid, after which his drain was pulled. Repeat echo
on HD#2 showed increase in pericardial effusion, pulsus 12. His
chest pain was initially managed with IV dilaudid and tylenol.
He then underwent ASA desensitization (given h/o eye swelling
with ASA), after which he was started on indomethacin and
colchicine for pericarditis. His symptoms improved significantly
with these treatments. DDx for pericardial effusion included
viral, TB, post-MI, uremia, hypothyroidism, malignancy or
collagen vascular disease. Initially most concerned for either
malignancy (given recent weight loss, fatigue, night sweats, new
anemia) or viral (given recent URI, fever, leukocytosis with
left shift). Pt ruled out for MI. Pericardial fluid cell count
had 12:1 ratio of RBC:WBC, with left shift. Pericardial fluid
cytology negative for malignant cells. Pericardial fluid culture
(including acid fast) and gram stain were negative. ___, anti-DS
DNA and complement panel were checked to screen for lupus and
other collagen vascular diseases. ___ and anti-DS DNA were
negative. C3 and C4 were mildly elevated at 191 and 59. ESR was
markedly elevated at 83 (ref range ___. CT ___
with contrast was performed to work up for occult malignancy,
and showed mild non-pathologic mediastinal lymph node
enlargement more concerning for infection. HIV test was
negative. TSH WNL. Other viral cultures checked were negative.
Based on these studies and clinical picture, it was found that
pericardial effusion was most likely due to a viral etiology.
Patient received a cardiac MRI that showed some restrictive
physiology.
.
# Elevated INR: Patient's INR was 1.1 in ___, now 1.9.
Patient does not take coumadin. PTT is not prolonged.
Differential includes nutritional deficiencies, liver synthetic
dysfunction, DIC. After receiving vitamin K 5mg on HD#2, INR
remained elevated at 2. LFTs are not significantly elevated,
nor is albumin low, to suggest liver synthetic dysfunction. DIC
labs negative. Blood smear showed no schistocytes. INR came
down by itself to 1.3 by discharge.
.
# Anemia: Patient's Hct was 44 in ___, but now is 34,
signifying a 10 pt drop within the last month. Patient has
pericardial effusion, but otherwise has no overt evidence of
bleeding. Hemodynamically stable. His iron studies shows
possible anemia of chronic disease, but extremely elevated
ferritin levels are difficult to interpret in the setting of
high inflammation (acute phase reactant). Hemolysis labs
signify no hemolysis.
.
# ___: Cr 1.3, up from baseline 1.0. Differential includes
pre-renal vs. intrinsic renal failure from systemic disease.
After IV fluids, creatinine improved to 0.9, indicating
pre-renal etiology.
.
# Fevers: Differential includes infectious, malignant, vs.
auto-immune. Patient's history and CXR with effusions does not
make it seem infectious; therefore azithromycin was
discontinued. Bloody pericardial effusion, night sweats, and
fatigue were concerning for malignancy, although CT
chest/abdomen/pelvis did not show any gross evidence of
malignancy. Auto-immune disease also a possibility, but not
consistent with patient's clinical picture; also ESR elevated
but ___, anti-DS DNA and C3/C4 were normal. Patient remained
afebrile starting HD#3.
Transitional Issues:
Patient was discharged to rehab.
He will continue indomethicin for 2 weeks and colchicine for ___
years.
His oxygen levels were noted to be low overnight, so he was
recommend to obtain an outpatient sleep study to evaluate for
sleep apnea.
Medications on Admission:
tylenol prn pain
flovent prn dyspnea (stopped bc not helping)
albuterol inhaler prn dyspnea (stopped bc not helping)
azithromycin 250 daily (today is day ___
vicodin prn pain
Discharge Medications:
1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
2. indomethacin 25 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day) for 1 weeks.
Disp:*42 Capsule(s)* Refills:*0*
3. indomethacin 25 mg Capsule Sig: One (1) Capsule PO three
times a day for 1 weeks.
Disp:*21 Capsule(s)* Refills:*2*
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial Effusion
Anemia
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a pericardial effusion or a collection of fluid in the
sac around your heart. We think this is because of a virus and
we have sent many tests to make sure it is not for another
reason. All of these tests are negative and a few cultures are
still not finalized. You had a cardiac MRI top further assess
your heart and the fluid. There is still some fluid that we hope
will be absorbed over time. You have been started on some
medicines, indomethicin and colchicine to help decrease the
inflammation of the lining around your heart and help to prevent
the fluid from reaccumulating. You should take the indomethicin,
50 mg (2 25 mg tablets) three times a day for one week and then
decrease to 25 mg (1 pill) three times a day for one week. At
that time, you will see Dr. ___ and can discuss
your medicines. Colchicine will be taken twice daily for at
least one year. You will also take prilosec (omeprazole) twice
daily as these medicines can irritate your stomach. Please call
Dr. ___ your chest pain worsens and call the Heartline
for any urgent symptoms you may have at home.
You will get an echocardiogram during the appt with Dr.
___ on ___.
You had a low blood count or anemia during your hospital stay.
You should have your blood studies rechecked in a few weeks to
see if there is any need to treat or do further testing.
Your kidneys function declined but have now normalized.
Followup Instructions:
___
|
19846500-DS-7
| 19,846,500 | 29,306,073 |
DS
| 7 |
2163-02-20 00:00:00
|
2163-02-22 09:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Epidural steroid injection (___)
History of Present Illness:
___ y/o M with history of lumbar disc herniation who presents
with acute on chronic LBP. Pt reports herniated discs without a
known acute injury this past ___. States MRI at that time
showed herniations at L3-4 and L4-5. He was prescribed ___ which
he reports did not help. The pain resolved around ___. On
___ while lifting a box, he heard a pop in his back,
followed by pain. He states the pain is similar to his prior
back pain, but more severe. It has been increasing over the last
several weeks. It is located in his lower back, L>R, is nearly
constant, and exacerbated by movement or standing. The pain
radiated down his L buttocks and thigh, the lateral side of his
L leg, and around his L ankle. It occasionally radiates down his
R leg as well. He notes slight relief with advil, tylenol, one
vicodin (unknown dose) and an unknown muscle relaxant. He has
been unable to walk the last 4 days due to pain. He denies
weakness, bowel or bladder incontinence, history of cancer,
fever, IVDU In recent weeks he has seen a chiropractor, but the
pain progressed. He had an appointment to see an orthopedist
___.
In the ED, initial vitals 97.8 97 140/107 18 96%. Neuro exam
showed normal strength, intact sensation, equal DTRs, with +
straight leg raise. Pt was given oxycodone 10mg + 5mg, diazepam
5mg po x2, and morphine 5mg IV once. Neurology saw pt, felt had
bilateral sciatica L>R without signs or symptoms of cord
compression, likely due to disk herniation. Pt was admitted for
pain control.
On the floor, initial vitals were 98.1 131/90 76 20 99% RA.
Past Medical History:
-idiopathic acute pericarditis complicated by pericardial
effusion and pericardial tamponade
-hand surgery on R ___ digit
-borderline hypertension, hyperlipidemia
Social History:
___
Family History:
Father with MI at age ___ and died during CABG at ___. Uncle with
MI in late ___. Grandmother had GI cancer. Daughter with
___ anomaly. History of DM.
Physical Exam:
Admission:
Vitals: 98.1 131/90 76 20 99% RA.
GENERAL: NAD, awake and alert
HEENT: anicteric sclera, MMM, OP clear
NECK: nontender and supple, no LAD, no JVD
BACK: no spinal process tenderness, mild tenderness to
palpation of paraspinal lumbar area L>R
CARDIAC: RRR, nl S1 S2, no MRG
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding
EXT: warm and well-perfused, no cyanosis, clubbing or edema;
mild tenderness to palpation of lateral L leg
NEURO: positive straight leg test on L and R, strength ___ in ___
bl, sensation to light touch intact in ___ bl, 2+ patellar
reflexes bilaterally, unable to elicit achilles reflex, pain in
L lumbar area/L buttocks with forward flexion at waist
Discharge:
Vitals: 98.1 126/79 77 18 99%RA
GENERAL: NAD, awake and alert
HEENT: anicteric sclera, MMM, OP clear
BACK: reports pain and tingling down left buttocks, thigh,
lateral leg with palpation of lumbar spine and L paraspinal area
CARDIAC: RRR, nl S1 S2, no MRG
LUNG: CTAB, no rales wheezes or rhonchi
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding
EXT: warm and well-perfused, no cyanosis, clubbing or edema
NEURO: pt able to stand erect and take steps comfortably, ___
strength in legs bl
Pertinent Results:
=====================
Labs:
=====================
___ 07:50AM BLOOD WBC-5.9 RBC-5.10 Hgb-15.5 Hct-45.1 MCV-88
MCH-30.4 MCHC-34.5 RDW-12.9 Plt ___
___ 07:50AM BLOOD Glucose-97 UreaN-19 Creat-1.0 Na-139
K-4.2 Cl-101 HCO3-29 AnGap-13
___ 07:50AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.3
=====================
Micro:
=====================
None
=====================
Imaging:
=====================
MR ___ SPINE W/O CONTRASTStudy Date of ___ 9:38 AM
FINDINGS:
From T11-12 to L3-4 levels, no significant abnormalities are
seen.
At L4-5 level, there is a small left-sided disk herniation seen
which extends inferiorly to the left lateral recess of L5. Disc
herniation is in position to irritate the left L5 nerve roots.
At L5-S1 level, mild degenerative changes are seen without
spinal stenosis or foraminal narrowing.
Conus is located at a normal level. The distal spinal cord
shows a normal
signal intensity. The paraspinal soft tissues are unremarkable
except for a simple appearing cyst in the right kidney.
IMPRESSION:
Small left-sided disk herniation at L4-5 level which could
irritate the left L5 nerve root.
Brief Hospital Course:
___ y/o M with history of lumbar disc herniation who presented
with acute on chronic low back pain radiating to left leg, with
inability to ambulate, likely secondary to lumbar disc
herniation.
# Lumbar disc herniation with radicular pain: Pt has history of
low back pain from lumbar disc herniation starting in ___
___ which resolved over the ___ months. His lower back pain
on this admission was likely again secondary to lumbar disc
herniation. Pain character of "tingling" and distribution with
radiation down leg leg were consistent with radiculopathy. He
did not have alarm symptoms such as fever, muscle weakness, hx
of cancer, hx of IV drug use, or incontinence. MRI spine showed
L4-5 herniation. During course, pt was initially unable to
ambulate secondary to pain. He was treated with a multi-agent
regimen which ultimately included tylenol, naproxen, tizanidine,
gabapentin, and dilaudid po prn. Other agents which were tried
during his admission but discontinued prior to discharge
included cyclobenzaprine and diazepam. Neurology evaluated him
and felt pain was consistent with sciatica. Neurosurgery
recommended steroid course, and he was given was given a dose of
dexamethasone and a 6 day taper of methylprenisolone. Given the
relatively recent onset of his pain, he was not a candidate for
surgery at this time. Pain service gave him an epidural steroid
injection ___. His pain became better controlled near the end
of his admission, and he regained the ability to ambulate with a
walker. He was discharged on tylenol, naproxen, tizanidine,
gabapentin, and dilaudid po prn with plan for outpatient
physical therapy. He has follow up appointments with his PCP,
orthopedics at ___, pain ___, and
neurosurgery.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Naproxen 500 mg PO Q12H Duration: 10 Days
RX *naproxen 500 mg 1 tablet(s) by mouth twice daily Disp #*30
Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*90 Tablet Refills:*0
3. Gabapentin 600 mg PO Q8H
Do NOT drive while taking.
RX *gabapentin 600 mg 1 tablet(s) by mouth three times daily
Disp #*45 Capsule Refills:*0
4. Tizanidine 4 mg PO TID
Do NOT drive while taking this medication.
RX *tizanidine 4 mg 1 tablet(s) by mouth three times daily Disp
#*45 Tablet Refills:*0
5. Outpatient Physical Therapy
ICD-9 code: ___
6. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain
Do not drive while using this medication
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth every 6
hours Disp #*5 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
left-sided disk herniation at L4-5 level
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted for increasing lower back and leg pain. Your
pain most likely due to left-sided disk herniation at L4-5
level, which was seen on MRI. You were given medications to
treat the pain and inflammation, including a course of oral
steroids and an epidrual steroid injection. Please keep your
follow up appointments with Dr. ___ your other providers
and take your medications as prescribed. As your pain improves,
consider stopping your morning and then your afternoon doses of
tizandine.
Please, Do NOT drive when you are using hydromorphone
(Dilaudid), gabapentin (Neurontin) or tizanidine (Zanaflex).
Followup Instructions:
___
|
19846637-DS-11
| 19,846,637 | 26,486,783 |
DS
| 11 |
2180-09-25 00:00:00
|
2180-09-25 14:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Amoxicillin / Penicillins
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with longstanding history of ulcerative colitis s/p total
abdominal colectomy w/ ileoanal pouch and loop ileostomy ___
with complicated course including wound infection,
intraabdominal abscess requiring percutaneous drainage, and
development of SMV/splenic vein thromboses for which he is now
anticoagulated. Pt was discharged home ___ to complete a
total 2 week course
of cipro/Flagyl, which he finished yesterday. Pt reports to
have been doing well after discharge, tolerating a regular diet
and having formed stool in his ostomy, approximately 600-1000cc
daily. Two days ago, however, he gradually began having
episodes of cramping ___ pain. Yesterday the pain
migrated tohis right abdomen and became more severe, and his
ostomy output
dramatically decreased and became almost entirely liquid in
quality. He had associated nausea and refrained from PO intake,
however, he denies emesis, fevers, or chills. Today he
experienced a large release of gas into his ostomy bag and
subsequently felt some relief in pain. Given his persistent
decreased ostomy output, howevever, he presented to the ED for
further evaluation.
.
Pt currently reports his pain to be back to baseline and denies
any residual cramping pain or nausea. He has had approximately
150cc of particulate liquid stool this afternoon. Of note, he
has been requiring significant narcotic pain control, reporting
approximately 10mg of oxycodone every 3 hours (script he
received from his PCP when his ___ supply ran out last
___.
.
(+) per HPI. Pt was also started on Paxil 4 days ago for
depression.
(-) Denies fevers, chills, night sweats, unexplained weight
loss, fatigue/lethargy, changes in appetite, trouble with sleep,
pruritis, jaundice, rashes, bleeding, easy bruising, headache,
dizziness, vertigo, syncope, weakness, paresthesias, vomiting,
hematemesis, bloating, melena, BRBPR, dysphagia, chest pain,
shortness of breath, cough, edema, urinary frequency, urgency
Past Medical History:
-Inflammatory bowel disease (initially diagnosed as ulcerative
colitis, however, most recent path suspicious for Crohn's) s/p
TAC/ileoanal pouch/loop ileostomy w/ course c/b intraabdominal
abscess s/p drainage and SMV/splenic vein thromboses (started on
Coumadin); Depression
.
PAST SURGICAL HISTORY:
-Skin graft LLE
-Total abdominal colectomy w/ ileoanal pouch, loop ileostomy
(___)
Social History:
___
Family History:
Denies history of IBD
Physical Exam:
Vitals: 98.0 82 135/78 16 97% RA
.
GEN: NAD. Alert, oriented x3.
HEENT: No scleral icterus. Mucous membranes mildly dry.
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, fullness/firmness over R abdomen but not overtly
distended. Bilateral tenderness, R>L, which pt reports to be at
baseline from discharge. Ostomy pink with particulate liquid
stool and small amount of gas in bag. Digital exam easily
performed without palpable mass, obstruction. Heme-occult
positive. No R/G.
EXT: Warm without ___ edema.
Pertinent Results:
ADMISSION LABS:
___ 03:57PM BLOOD WBC-11.1* RBC-4.37* Hgb-12.8* Hct-40.4
MCV-92 MCH-29.3 MCHC-31.7 RDW-14.1 Plt ___
___ 03:57PM BLOOD Neuts-79.7* Lymphs-12.8* Monos-4.9
Eos-2.1 Baso-0.5
___ 03:57PM BLOOD Glucose-95 UreaN-8 Creat-1.0 Na-134 K-4.2
Cl-95* HCO3-30 AnGap-13
.
___ CT ABDOMEN/PELVIS WITH CONTRAST:
FINDINGS: There is a 6-mm lung nodule in the right middle lobe
and a 4-mm
nodule in the right lower lobe (2:1, 8). These nodules are
stable from the
prior examinations. There is bibasilar dependent atelectasis.
Lower chest is otherwise unremarkable.
.
ABDOMEN: There is a 1.6 cm hypodensity adjacent to the middle
hepatic vein, which is unchanged from the prior examination
(2:23). Remainder of the liver is unremarkable. The gallbladder,
pancreas, adrenal glands, and spleen are unremarkable. The
kidneys enhance normally and excrete contrast
symmetrically. Main portal vein, splenic vein, SMV are patent,
and the
previously noted apparent filling defect in the splenic vein is
not seen.
Abdominal aorta is normal in caliber.
.
There is a residual lobulated, multilocular fluid collection
superior to the ostomy site in the right anterolateral
hemiabdomen, which is markedly
decreased in size since the prior study and measures 5.4 x 1.8
cm (2:52). The collection also has a more posterior component
measuring 2.3 x 1.8 cm (2:56) and does extend into the pelvis.
There are small foci of air within the collection. This
collection is more organized than on the prior study with
increased, marked thickening and enhancement of the wall of the
collection. There is no evidence of free air within the abdomen.
No parastomal herniation seen.
.
The patient is status post total colectomy. There are multiple
air and
fluid-filled loops of small bowel dilated up to 4.9 cm with a
transition point roughly adjacent to the fluid collection in the
right hemiabdomen where the bowel loops demonstrate marked mural
thickening and edema, adjacent fat stranding, as well as luminal
narrowing. The exact point of transition cannot be determined
due to lack of progress of oral contrast in this area, though
the distal ileal loops leading up to the ostomy are collapsed.
There are several visible mesenteric lymph nodes which are
likely reactive.
.
PELVIS: Ileoanal anastomosis is seen. The anastomosis cannot
fully be
evaluated without enteric contrast at this location; however,
there is no new fluid collection within this area compared to
the prior study. Bladder, prostate and seminal vesicles appear
normal. There is no pelvic
lymphadenopathy.
.
MUSCULOSKELETAL: There are several focal densities within the
imaged
skeleton, consistent with benign bone islands and stable from
the prior
examination. There are no focal osseous lesions concerning for
malignancy.
.
IMPRESSION: Small-bowel obstruction with transition point
adjacent to
residual abscess in the right hemiabdomen, which shows increased
organization and marked rim enhancement. The small bowel in the
region of the abscess demonstrates marked mural thickening and
edema, as well as luminal narrowing, likely all reactive
inflammation.
.
ANTICOAGULATION LABS:
___ 06:25PM BLOOD ___ PTT-50.1* ___
___ 07:10AM BLOOD ___ PTT-48.9* ___
___ 04:45AM BLOOD ___ PTT-49.3* ___
.
LABS ON DAY OF DISCHARGE:
___ 04:45AM BLOOD WBC-8.8 RBC-3.80* Hgb-11.1* Hct-35.8*
MCV-94 MCH-29.2 MCHC-31.0 RDW-14.1 Plt ___
___ 04:45AM BLOOD Glucose-74 UreaN-6 Creat-0.8 Na-134 K-4.2
Cl-98 HCO3-27 AnGap-13
___ 04:45AM BLOOD Albumin-PND Calcium-8.7 Phos-4.1 Mg-1.8
Iron-PND
Brief Hospital Course:
Mr. ___ is a ___ year old male with recent diagnosis of
Crohn's Disesae, s/p TAC w/ ileoanal pouch, loop ileostomy
___ which was complicated by intrabdominal abscess,
SMV/splenic vein thrombus (on coumadin) who re-presented to the
hospital with abdominal pain and decreased ostomy output. He was
admitted to the ___ service from ___ to ___.
.
On HD#1 the patient was afebrile, had a mild leukocytosis at
11.1, and had a CT scan that demonstrated a small bowel
obstruction adjacent to the ileostomy site with some small bowel
thickening (see full report above). The patient was made NPO,
placed on maintenance IVF, given IV pain meds (dilaudid,
tylenol), and started on Cipro and Flagyl. Based on the imaging
on his scan, his prevoius intrabdominal abscess was noted to be
smaller. Of note the patient had a previously diagnosed SMV
thrombus for which he was on coumadin, and on admission his INR
was 4.8, therefore his coumadin was held. The patient did not
experience any nausea/emesis, and performed well with
conservative management.
.
On HD#2, the patient had increased ostomy output, pain was well
controlled, and he was maintained NPO with maintenance IVF. He
was started on octreotide 100mg TID, but refused to have
injections. He remained stable, afebrile. His INR remained
elevated, and his coumadin continued to be held.
.
On HD#3, the patient continued to have adequate pain contol, and
was stable. His diet was advanced starting at clear liquids and
he tolerated this welll. He was switched to PO pain medications
(scheduled tylenol, PRN dilaudid) and tolerated this well. His
INR continued to be elevated, and his coumadin was held once
again. He was deemed stable for discharge.
.
Patient was not satisified with his previous ___ services, and
therefore declined these at time of discharge. His girlfriend is
a ___, and patient said he was more comfortable with her help.
TRANSITIONAL ISSUES:
1) Continue PO Cipro/Flagyl, last day ___
2) Follow up with PCP for management of anticoagulation
(appointment scheduled prior to discharge)
3) Follow up with Dr. ___ scheduled prior
to discharge)
Medications on Admission:
Coumadin 5, Paxil 20, oxycodone 10 Q3H PRN
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: ___ Tablets PO every four (4)
hours as needed for pain: please do not drive, or operate
machinery while taking. can cause constipation and slow down
ostomy output. only take as needed.
Disp:*60 Tablet(s)* Refills:*0*
2. loperamide 2 mg Capsule Sig: One (1) Capsule PO twice a day
as needed for high ostomy output: Please titrate to desired
stool output 1000-1200cc per day.
.
Disp:*90 Capsule(s)* Refills:*0*
3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours: last day is ___.
Disp:*14 Tablet(s)* Refills:*0*
4. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): last day is ___.
Disp:*21 Tablet(s)* Refills:*0*
5. psyllium 1.7 g Wafer Sig: One (1) PO once a day as needed
for high ostomy output: as needed for
high output: Start with ___ wafer up to 1 wafer per day. Do not
follow with water.
.
Disp:*30 wafers* Refills:*0*
6. acetaminophen 500 mg Tablet Sig: ___ Tablets PO every eight
(8) hours: please take every 8 hours as baseline pain
medication, use dilaudid for breakthrough pain only. do not
exceed 4000mg in 24 hours.
Disp:*100 Tablet(s)* Refills:*0*
7. Paxil 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstruction, Intrabdominal Abscess, SMV thrombus,
Crohn's Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of ___ at ___. ___ were
admitted due to having pain in your abdomen and also decreased
ostomy output. Imaging was obtained of your abdomen (CT scan)
and showed some thickening of your small bowel, a residual
abscess that has improved since your last admission, and an
obstruction your bowels. ___ were managed conservatively and ___
improved over the subsequent days. ___ were also given
antibiotics. ___ are now ready to continue your recovery at
home.
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 take the prescribed analgesic
medications as needed. ___ not drive or operate heavy
machinery while taking narcotic analgesic medications. ___
also take acetaminophen (Tylenol) as directed, but do not exceed
4000 mg in one day. Please get plenty of rest, continue to walk
several times per day, and drink adequate amounts of fluids.
In regards to your Ileostomy: The most common complication from
an ileostomy placement is dehydration. The output from the stoma
is stool from the small intestine and the water content is very
high. The stool is no longer passing through the large intestine
which is where the water from the stool is reabsorbed into the
body and the stool becomes formed. ___ must measure your
ileostomy output for the next few weeks. The output from the
stoma should not be more than 1200cc or less than 500cc. If ___
find that your output has become too much or too little, please
call the office for advice. The office nurse or nurse
practitioner can recommend medications to increase or slow the
ileostomy output. Keep yourself well hydrated, if ___ notice
your ileostomy output increasing, take in more electrolyte drink
such as Gatorade. Please monitor yourself for signs and symptoms
of dehydration including: dizziness (especially upon standing),
weakness, dry mouth, headache, or fatigue. If ___ notice these
symptoms please call the office or return to the emergency room
for evaluation if these symptoms are severe. ___ eat a
regular diet with your ileostomy. However it is a good idea to
avoid fatty or spicy foods and follow diet suggestions made to
___ by the ostomy nurses.
___ monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it ___ ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as ___ have been instructed by
the wound/ostomy nurses. ___ will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. ___
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until ___ are comfortable caring
for it on your own.
Monitoring Ostomy Output:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid drinking only plain water. Include gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If ostomy output exceeds 1 liter, take 4mg of Imodium, repeat
2mg
with each episode of loose stool. Do not exceed 16 mg in one
day.
We made the following changes to your medications:
STOP Coumadin, ___ will need to have your blood checked by your
primary care physician to see how thin it is (INR), and also
your doctor ___ tell ___ when to resume your coumadin and what
dose ___ should take
START Ciprofloxacin (last day ___
START Metronidazole (Flagyl)(last day ___
We have scheduled follow-up appointments for ___. Please be sure
to see your primary care provider as the dosing of your coumadin
will be important. Please see below for your appointment times.
Followup Instructions:
___
|
19846637-DS-13
| 19,846,637 | 29,936,707 |
DS
| 13 |
2181-06-20 00:00:00
|
2181-06-20 10:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Amoxicillin / Penicillins
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
pouch/ileoscopy ___
History of Present Illness:
___ with UC s/p TAC and J pouch ___ with reversal ileostomy
___ now presents with crampy chronic suprapubic abdominal
pain
x 6 months with acute worsening of his abdominal pain x 4 days.
He denies fevers, but endorses chills. He endorses frequent
trace bloody loose stools. He reports occasional nausea and
reports that he vomitted twice last week, but has feels well
currently. He has continued to have persistent abdominal
cramping. He frequently has ___ loose bowel movements per day
and reports that this has been progressively worsening since his
ileostomy closure 5 months ago. He stopped taking his metameucil
wafers and frequently drinks energy drinks. He stopped taking
anabolic steroids a few months ago.
He completed a course of flagyl 6 weeks ago for presumed
pouchitis, reported no improvement of his symptoms. He has been
taking ciprofloxacin for the past 3 days.
Past Medical History:
-Inflammatory bowel disease (initially diagnosed as ulcerative
colitis, however, most recent path suspicious for Crohn's) s/p
TAC/ileoanal pouch/loop ileostomy w/ course c/b intraabdominal
abscess s/p drainage and SMV/splenic vein thromboses (started on
Coumadin but self discontinud by patient ___
-iliostomy closure ___
-Depression
PAST SURGICAL HISTORY:
-Skin graft LLE
-Total abdominal colectomy w/ ileoanal pouch, loop ileostomy
(___)
-iliostomy closure ___
Social History:
___
Family History:
Denies history of IBD, his grandmother and grandfather had
colitis
Brief Hospital Course:
Mr. ___ was admitted to the ___ surgical service.
The gastroenterology team was consulted. He had a pouchoscopy
on HD 2 which demonstrated mild erosions in the pouch but
otherwise was normal. He had an MRE the same evening which was
normal -- no pouchitis or enteritis or abcess. He was started
on flagyl, hyosycamine, loperamide and creon supplementation.
His diarrhea and abdominal pain improved dramatically. On the
day prior to discharge he only had one bowel movement. Stool
studies were negative as of date of discharge.
He was counseled by both the surgical and GI teams to
decrease/eliminate his intake of high-caffeine sugar-free energy
drinks. The GI team recommended a two-week course of
ciprofloxacin in addition to the flagyl.
He is being discharged with followup with both GI and Dr.
___ on cipro/flagyl, creon, hyoscyamine and loperamide.
At time of discharge he is ambulating, tolerating a regular
diet, his pain is minimal and his diarrhea has resolved.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 500 mg PO Q12H
2. Loperamide 2 mg PO QID:PRN loose stool
Discharge Medications:
1. Loperamide 2 mg PO QID:PRN loose stool
2. Creon 12 1 CAP PO TID W/MEALS
RX *lipase-protease-amylase [Creon] 6,000 unit-19,000
unit-30,000 unit 1 capsule(s) by mouth three times a day Disp
#*42 Capsule Refills:*1
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*8 Tablet Refills:*0
4. Hyoscyamine 0.25 mg PO Q4H
RX *hyoscyamine sulfate 0.125 mg 2 tablet(s) by mouth every four
(4) hours Disp #*168 Tablet Refills:*1
5. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*28 Tablet Refills:*0
6. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Ulcerative Colitis (and possibly Crohn's disease)
S/p total abdominal colectomy and J pouch ___ with reversal
ileostomy ___
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with worsening of you crampy chronic abdominal
pain. You received a CT scan with IV and PO contrast and also MR
___ which showed no evidence of pouchitis or source of
abdominal infection.
Per Dr. ___ caffeine in your diet as this can
exacerbate having loose stools. Also you should take Flagyl
until your follow up appointment with Dr. ___.
Followup Instructions:
___
|
19846807-DS-4
| 19,846,807 | 22,801,444 |
DS
| 4 |
2115-03-12 00:00:00
|
2115-03-12 13:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
erythema and drainage from LUE AVF
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with CKD V s/p LUE brachiocephalic AVF ___ with Dr. ___ presents with erythema and drainage at his incision. The
fistula was created out of concern that he may need dialysis in
the near future, however, he has not yet required dialysis. For
the past ___ days he has noticed that the incision has been
draining and he has subjective fevers and chills. He denies
paresthesia or pain of the ipsilateral hand.
ROS:
(+) per HPI
(-) Denies night sweats, unexplained weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
nausea, vomiting, hematemesis, bloating, cramping, melena,
BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
Alport's Syndrome
Autoimmune hemolytic anemia
Cataracts
Chronic Renal Failure, baseline creatinine 3.0
Coronary Artery Disease s/p drug-eluting stents in ___ and ___
Gout
Hearing loss
Hereditary nephritis, stage IV kidney disease
Hyperlipidemia
Hypertension
Hypothyroid
Social History:
___
Family History:
Father - died in his ___ of coronary artery disease
Mother - history of hemodialysis
Brother - history of end-stage renal disease, on hemodialysis
Physical Exam:
Exam on Admission:
Vitals: 99 95 138/49 18 100RA
GEN: A&O
CV: RRR, No M/G/R
PULM: Clear to auscultation
ABD: Soft, nondistended, nontender, no rebound or guarding
Extremities: LUE AVF with palpable thrill. Incision well healing
but with surrounding erythema and induration. No fluctuance
noted. ___ cc purulent material expressed from medial incision.
.
Exam at Discharge:
24-HOUR EVENTS:
-erythema much improved; L arm elevated
-leukocytosis resolved
-drainage becoming serous
-dosed vancomycin for low level
PHYSICAL EXAMINATION:
24 HR Data (last updated ___ @ 2354)
Temp: 98.8 (Tm 98.8), BP: 126/64 (108-162/58-75), HR: 68
(67-83), RR: 18 (___), O2 sat: 96% (95-99), O2 delivery: Ra
Fluid Balance (last updated ___ @ 2210)
Last 8 hours Total cumulative -380ml
IN: Total 120ml, PO Amt 120ml
OUT: Total 500ml, Urine Amt 500ml
Last 24 hours Total cumulative -400ml
IN: Total 600ml, PO Amt 600ml
OUT: Total 1000ml, Urine Amt 1000ml
GENERAL: [ x]NAD [X]A/O x 3
CARDIAC: [ x]RRR
LUNGS: [x ]no respiratory distress
ABDOMEN: [x ]soft
WOUND: [x ]abnormal, minimal erythema and serous drainage.
EXTREMITIES: [ x]palpable thrill. Palpable LUE radial pulse.
Pertinent Results:
Labs on Admission: ___
WBC-12.5* RBC-2.48* Hgb-8.4* Hct-25.8* MCV-104* MCH-33.9*
MCHC-32.6 RDW-13.7 RDWSD-52.0* Plt ___ PTT-29.5 ___
Glucose-91 UreaN-89* Creat-6.2* Na-136 K-7.7* (specimen grossly
hemolyzed) Cl-103 HCO3-17* AnGap-16
Calcium-8.4 Phos-5.5* Mg-1.5*
Hapto-196
Lactate-1.5 K-5.1
.
Labs at Discharge: ___
WBC-8.1 RBC-2.23* Hgb-7.5* Hct-23.2* MCV-104* MCH-33.6*
MCHC-32.3 RDW-13.7 RDWSD-51.5* Plt Ct-98*
Glucose-91 UreaN-88* Creat-6.6* Na-143 K-4.9 Cl-110* HCO3-18*
AnGap-15
Vanco-22.4* (21 hour trough)
.
___ 7:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
.
___ 8:05 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Brief Hospital Course:
___ y/o male with CKD (not yet on hemodialysis) who had dialysis
access created ___, who now returns with evidence of
infection at the antecubital incision area.
.
Patient received IV Vancomycin during his stay. The cellulitis
and erythema as well as purulent discharge evident on admission
have decreased significantly. Access remains with positive bruit
and thrill.
Blood and urine cultures were sent, Urine has no significant
growth and blood cultures are negative to date.
.
He will be discharged with 5 days of PO Keflex and a dry
dressing over the incision area. Patient states wife will assist
with dressing changes.
.
He is tolerating a regular diet. Home medications were continued
as indicated. Appointment with Dr. ___ has been moved to
___ at 12 noon.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Calcitriol 0.25 mcg PO DAILY
4. irbesartan 150 mg oral DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Metoprolol Tartrate 25 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
9. Tamsulosin 0.4 mg PO QHS
10. Torsemide 60 mg PO DAILY
11. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
12. Nephrocaps 1 CAP PO DAILY
13. FoLIC Acid ___ mg PO DAILY
14. Sodium Bicarbonate 650 mg PO QID
15. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral BID
16. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Cephalexin 500 mg PO TID
RX *cephalexin 500 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*15 Capsule Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Calcitriol 0.25 mcg PO DAILY
7. FoLIC Acid ___ mg PO DAILY
8. irbesartan 150 mg oral DAILY
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Metoprolol Tartrate 25 mg PO BID
11. Nephrocaps 1 CAP PO DAILY
12. Omeprazole 20 mg PO DAILY
13. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral BID
14. Sodium Bicarbonate 650 mg PO QID
15. Tamsulosin 0.4 mg PO QHS
16. Torsemide 60 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
CKD Stage 5
Dialysis access incision infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the access clinic at ___ if you have fevers
or chills, yourleft hand has increased pain, is cold, has blue
fingers, has numbness or tingling this may be a medical
emergency and you should call right away.
Please also monitor for increased incisional redness, drainage
or bleeding, arm swelling or increased pain or the development
of a foul odor on the dressing, at the access site or any other
concerning symptoms.
.
You should check the left arm access daily for a thrill (buzzing
sensation) and if this is not present, you should call the
access clinic right away.
.
Keep the left arm elevated on ___ pillows when sitting or lying
down to help swelling decrease.
.
The arm may be gently washed but do not submerge or soak the
arm. Keep the arm elevated when you are sitting or laying down
to help the swelling decrease. Dressing should be changed daily
and more often as needed. Please report increased drainage or
bleeding or if the wound develops a foul odor.
.
Do NOT allow any blood pressures or lab draws from the access
arm. No tight or constrictive clothing or jewelry to the access
arm and no lifting more than 10 pounds.
.
Continue home medications, dietary and fluid restrictions as you
have been instructed.
.
Followup Instructions:
___
|
19846911-DS-8
| 19,846,911 | 23,802,159 |
DS
| 8 |
2186-04-10 00:00:00
|
2186-04-10 12:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
avulsion of the acetabular component of the left total hip
arthroplasty
Major Surgical or Invasive Procedure:
___: left revision hip arthroplasty
History of Present Illness:
___ year old female s/p recent revision L THA on ___ ___ w/ avulsion of the acetabular component of the
left total hip arthroplasty from the left acetabular fossa with
superolateral subluxation.
Past Medical History:
PMH: HTN, hyperlipidemia
PSHx: right foot hammer toe, left foot cyst excision,
diverticulum surgery, L THA on ___ by DKA, Revision L THA on
___ by ___, Revision L THA ___ by ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Aquacel with scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 07:30AM BLOOD WBC-8.7 RBC-2.74* Hgb-8.2* Hct-25.3*
MCV-92 MCH-29.9 MCHC-32.4 RDW-15.2 RDWSD-50.9* Plt ___
___ 05:54AM BLOOD WBC-10.6* RBC-2.37* Hgb-7.4* Hct-22.5*
MCV-95 MCH-31.2 MCHC-32.9 RDW-13.1 RDWSD-45.3 Plt ___
___ 05:58PM BLOOD WBC-11.4*# RBC-3.07* Hgb-9.5* Hct-29.4*
MCV-96 MCH-30.9 MCHC-32.3 RDW-13.2 RDWSD-46.7* Plt ___
___ 06:06AM BLOOD WBC-5.2 RBC-3.08* Hgb-9.4* Hct-29.4*
MCV-96 MCH-30.5 MCHC-32.0 RDW-13.6 RDWSD-47.1* Plt ___
___ 03:33PM BLOOD WBC-7.3 RBC-3.38* Hgb-10.5* Hct-32.3*
MCV-96 MCH-31.1 MCHC-32.5 RDW-13.4 RDWSD-47.5* Plt ___
___ 03:33PM BLOOD Neuts-75.6* Lymphs-15.5* Monos-6.7
Eos-1.1 Baso-0.7 Im ___ AbsNeut-5.49 AbsLymp-1.13*
AbsMono-0.49 AbsEos-0.08 AbsBaso-0.05
___ 07:30AM BLOOD Glucose-102* UreaN-15 Creat-0.6 Na-144
K-4.3 Cl-105 HCO3-27 AnGap-12
___ 05:54AM BLOOD Glucose-106* UreaN-10 Creat-0.6 Na-138
K-4.6 Cl-101 HCO3-27 AnGap-10
___ 06:06AM BLOOD Glucose-106* UreaN-12 Creat-0.6 Na-143
K-4.6 Cl-102 HCO3-29 AnGap-12
___ 03:33PM BLOOD Glucose-95 UreaN-14 Creat-0.6 Na-142
K-4.3 Cl-101 HCO3-26 AnGap-15
___ 03:33PM BLOOD CRP-34.8*
Brief Hospital Course:
The patient was admitted to the orthopedic surgery service and
was taken to the operating room two days after her admission for
above described procedure. Please see separately dictated
operative report for details. The surgery was uncomplicated and
the patient tolerated the procedure well. Patient received
perioperative IV antibiotics.
Postoperative course was remarkable for the following:
On POD#1, she was given a unit of blood for a hematocrit of
22.5.
On POD#2, her hematocrit improved to 25.3. Patient remained
asymptomatic.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient received Lovenox daily for DVT
prophylaxis starting on the morning of POD#1. The surgical
dressing will remain on until POD#7 after surgery. Foley was
discontinued on POD#1 and patient was voiding independently
after. The patient was seen daily by physical therapy. Labs were
checked throughout the hospital course and repleted accordingly.
At the time of discharge the patient was tolerating a regular
diet and feeling well. The patient was afebrile with stable
vital signs. The patient's hematocrit was acceptable and pain
was adequately controlled on an oral regimen. The operative
extremity was neurovascularly intact and the dressing was
intact.
The patient's weight-bearing status is toe touch weight bearing
on the operative extremity with STRICT posterior precautions.
Walker or two crutches while toe touch weight bearing.
Ms. ___ is discharged to home with services in stable
condition.
Medications on Admission:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID:PRN Constipation
3. Aspirin 325 mg PO BID
4. Gabapentin 100 mg PO TID
5. Pantoprazole 40 mg PO Q24H
6. Simvastatin 20 mg PO QPM
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
8. Senna 8.6 mg PO BID:PRN Constipation
Discharge Medications:
1. Enoxaparin Sodium 40 mg SC DAILY
2. Acetaminophen 1000 mg PO TID
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
5. Gabapentin 100 mg PO TID
6. Senna 8.6 mg PO BID:PRN Constipation
7. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
avulsion of the acetabular component of the left total hip
arthroplasty
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Please continue your Lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots).
9. WOUND CARE: Please remove Aquacel dressing on POD#7 after
surgery. It is okay to shower after surgery after 5 days but no
tub baths, swimming, or submerging your incision until after
your four (4) week checkup. Please place a dry sterile dressing
on the wound after aqaucel is removed each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow
___
10. ___ (once at home): Home ___, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
11. ACTIVITY: Touch down weight bearing with walker or 2
crutches x 6 weeks. STRICT posterior precautions. No strenuous
exercise or heavy lifting until follow up appointment. Mobilize
frequently.
Physical Therapy:
TTWB LLE x 6 weeks
Strict posterior hip precautions
Assistive devices (i.e., walker, 2 crutches) while TTWB
Mobilize frequently
Treatments Frequency:
remove aquacel POD#7 after surgery
apply dry sterile dressing daily if needed after aquacel
dressing is removed
wound checks daily after aquacel removed
Followup Instructions:
___
|
19847176-DS-21
| 19,847,176 | 29,522,861 |
DS
| 21 |
2187-08-05 00:00:00
|
2187-08-05 19:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
odontoid fracture s/p fall
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with PMHx significant for atrial fibrillation (on warfarin)
& PAD s/p stents, and vertigo who presents s/p mechanical fall.
He reports that he felt dizzy at home last night while walking
to the bathroom. He states that he typically has more warning
when a vertiginous episode is coming on, but that his symptoms
came on suddenly this time. He fell around 11:00 ___ and struck
his head on a coffee table. Denies any loss of consciousness,
and denies any chest pain, shortness of breath, or palpitations
prior to the fall. It took him about an hour to get up, but he
was able to do so. This morning he noticed several bumps on his
head and so he went to ___, where he was found
to have a minimally displaced odontoid fracture on CT ___
CT head was reportedly negative. The patient remained
neurologically intact and was transferred to ___ for further
management.
In the ED, initial VS were 98.2 118 129/93 18 95% RA. He
reported mild upper neck pain, but denied weakness, numbness,
tingling in his extremities, or bowel or bladder incontinence.
Labs were significant for WBC 12.6 (N 86.5%). Prelim read of CXR
did not show any displaced rib fractures or acute
cardiopulmonary process. Patient was given morphine 2mg IV x 1
and percocet. He was seen by ___ surgery who placed him in a
___ J collar and recommended cervical ___ immobilization at
all times. He was admitted for further evaluation by ___ and
management of his pain. Vital signs on transfer were 98.3 90
132/87 20 96% RA.
On arrival to the floor, patient appears comfortable and is
complaining of 4 out of 10 pain (improved).
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills. Denied cough, shortness of breath.
Denied chest pain or tightness, palpitations. Denied nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria.
Past Medical History:
Atrial fibrillation on warfarin
PAD s/p stenting ___
Vertigo
Asthma
Seasonal allergies
S/p sinus surgery
S/p tonsillectomy
Social History:
___
Family History:
Unknown (patient was adopted).
Physical Exam:
ADMISSION EXAM
VS: T 98.6, BP 131/77, HR 95, RR 18, SpO2 98% RA
GEN: A+Ox3, NAD
HEENT: NCAT. EOMI, PERRL, sclerae anicteric. MMM. ___ J collar
in place
CV: irregular rhythm, regular rate, normal S1/S2, no murmurs,
rubs or gallops.
LUNG: CTA anteriorly & in axillae, no wheezes, rales or rhonchi
ABD: soft, NT/ND, +BS. no rebound or guarding. neg HSM.
EXT: W/WP, no edema, no C/C. 2+ ___ pulses bilaterally.
SKIN: W/D/I
NEURO: CNs II-XII intact. ___ strength in U/L extremities.
sensation intact to LT.
PSYCH: appropriate affect, patient very talkative
DISCHARGE EXAM
VS: Tc 97.4, Tm 98.6, BP 119/79, HR 93, RR 18, SpO2 100% RA
GEN: A+Ox3, NAD
HEENT: NCAT. EOMI, PERRL, sclerae anicteric. MMM. ___ J collar
in place
CV: irregular rhythm, regular rate, normal S1/S2, no murmurs,
rubs or gallops.
LUNG: CTAB, no wheezes, rales or rhonchi
ABD: soft, NT/ND, +BS. no rebound or guarding. neg HSM.
EXT: W/WP, no edema, no C/C. 2+ ___ pulses bilaterally.
SKIN: W/D/I
NEURO: CNs II-XII intact. ___ strength in U/L extremities.
sensation intact to LT.
PSYCH: appropriate affect
Pertinent Results:
# ADMISSION LABS
___ 11:00AM BLOOD WBC-12.6* RBC-4.46* Hgb-15.0 Hct-43.7
MCV-98 MCH-33.5* MCHC-34.2 RDW-12.8 Plt ___
___ 11:00AM BLOOD Neuts-86.5* Lymphs-9.1* Monos-3.8 Eos-0.4
Baso-0.2
___ 11:00AM BLOOD ___ PTT-38.5* ___
___ 11:00AM BLOOD Glucose-118* UreaN-16 Creat-0.7 Na-138
K-4.2 Cl-102 HCO3-24 AnGap-16
___ 11:00AM BLOOD Calcium-9.4 Phos-2.4* Mg-2.1
___ 11:00AM BLOOD CK(CPK)-72
# DISCHARGE LABS
___ 08:00AM BLOOD WBC-11.4* RBC-4.27* Hgb-14.4 Hct-42.4
MCV-99* MCH-33.7* MCHC-34.0 RDW-12.8 Plt ___
___ 08:00AM BLOOD Neuts-81.4* Lymphs-12.1* Monos-5.2
Eos-1.2 Baso-0.3
___ 08:00AM BLOOD ___ PTT-40.2* ___
___ 08:00AM BLOOD Glucose-114* UreaN-13 Creat-0.6 Na-137
K-4.1 Cl-102 HCO3-25 AnGap-14
___ 08:00AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.9
# IMAGING
___ CT/HEAD/CERVICAL ___
(Performed at ___
2.5 mm axial tomographic sections were obtained through the
brain without the use of intravenous contrast. 1.25 mm helical
CT scans were obtained from the base of the skull to a level
below the sternal notch of the cervical ___. Images were
reformatted in the sagittal and coronal planes. The patient is
being evaluated following a fall. The patient is in a cervical
collar.
Findings
BRAIN: There is no high density abnormalities seen in the brain
to suggest any acute hemorrhage. There is mild generalized
peripheral atrophy. There are calcifications in the basal
ganglia regions bilaterally. There is no significant dilatation
of the ventricular system. There is a midline third and fourth
ventricle. There is evidence of chronic sinus disease with
absence of the medial wall of the left and maxillary sinuses.
Rounded soft tissue densities are seen in the nasal cavity
suggesting polyps. There is mucoperiosteal thickening seen in
the maxillary, frontal, and ethmoid sinus regions. Vascular
calcifications are seen in the internal carotid artery adjacent
to the sella. Cerumen is seen in the auditory canals
bilaterally.
Impressions: No evidence for any acute hemorrhage within the
brain.
Status post previous sinus surgery with soft tissue rounded
densities in the nasal cavity compatible with polyps. Evidence
of chronic sinusitis.
Vascular calcifications internal carotid artery adjacent to the
sella. Cerumen in the auditory canals bilaterally.
Findings
CERVICAL ___: There is a cervical collar in place. The
sagittal view shows a discontinuity of the cortex of the base of
the odontoid adjacent to the ring C1. This has the appearance
of being an acute nondisplaced fracture. There is no
significant soft tissue swelling about the atlantoaxial
articulation. The spinal canal is well preserved. There is some
soft tissue calcification posterior to the odontoid. This may
be in some pannus formation. There is disc space narrowing at
C3-C4. There is considerable disc space narrowing at C5-C6 and
C6-C7. Anterior osteophyte formation is seen at C5 and C6. The
lateral neural foraminal regions are widely patent. There is
sclerosis and degenerative changes of the facet joints C2-C5.
Greatest area of changes at C4-C5 on the left. There is
incidentally noted an area of increased bone density in the
inferior anterior T1 thoracic vertebral body.
Impression: Undisplaced fracture base of the odontoid at the
edge of the ring of the C1. This is probably acute in nature.
Multiple levels of combined degenerative and discogenic disease
C3-C7 as described. Well-preserved spinal canal. No abnormal
soft tissue swelling adjacent to the fracture site as to the
base of the odontoid.
___ CHEST (Single view)
FINDINGS:
The cardiac silhouette is mildly enlarged with prominence of the
left atrial appendage. There may be slight prominence of the
main pulmonary artery. No large pleural effusion or evidence of
pneumothorax is detected on this single supine view. There is
no focal consolidation concerning for pneumonia. The trachea is
midline. No displaced rib fractures are identified. The
sternum is not evaluated on this frontal view.
IMPRESSION:
1. No displaced rib fractures ; however, conventional
radiography has limited sensitivity and, if there is clinical
concern, a dedicated rib series should be obtained.
2. The sternum is not evaluated on this frontal radiograph.
3. Mild cardiomegaly with slight prominence of the atrial
appendage. Possible slight prominence of the main pulmonary
artery could relate to component of pulmonary hypertension.
# MICROBIOLOGY: None.
Brief Hospital Course:
___ with PMHx significant for atrial fibrillation (on warfarin)
& PAD s/p stents, and vertigo who presents s/p mechanical fall
after having an episode of vertigo and was found to have a
minimally displaced odontoid fracture.
# S/p mechanical fall w/odontoid fracture: Patient was found to
have a minimally displaced type II odontoid fracture s/p
mechanical fall after having an episode of vertigo and striking
his head on a coffee table. He was seen by the ___ surgery
service in the ED and remained neurologically intact. They
placed him in a ___ and recommended that he go home
with ___ immobilization. Per ___, while this fracture has
a high risk of nonunion in the elderly, given the morbidity
associated with both primary repair and halo, the ___ surgery
they recommend conservative management intially. He was
evaluated by ___ who recommended going home with physical
therapy, but patient adamantly refused. Pain was well-controlled
on standing acetaminophen 1000mg Q8H and oxycodone 5mg prn. He
will follow up with Ortho ___ in two weeks. Patient was
counseled extensively that, until his ___ is cleared by
Ortho ___, he should not drive because he cannot turn his head
and it will be extremely unsafe. He expressed understanding.
# Vertigo: Patient's fall was secondary to an acute vertiginous
episode. He reports that the etiology of his vertigo was never
elucidated, and he was just started on meclizine for symptomatic
control when the episodes started. Physical therapy was unable
to perform vestibular evaluation due to ___ immobilization
in the ___ collar, but recommneded that he pursue outpatient
vestibular ___ when gets ___ clearance by Ortho ___. He
received meclizine prn during this admission.
# Atrial fibrillation: Patient is therapeutically anticoagulated
on coumadin and adequately rate-controlled. INR 3.0 on the day
of discharge, so he received only 2.5mg of coumadin (instead of
5mg). He was continued on verapamil. Recommended that patient
get INR rechecked on ___.
# Leukocytosis: Likely a stress response from acute fracture. No
fevers or evidence of infection on CXR. WBC was trending down on
discharge.
# Asthma: Continued Flovent. Patient had no respiratory
complaints.
# PAD: Continued simvastatin.
# DVT Prophylaxis: Systemic anticoagulation with coumadin.
# Code status: Confirmed full code.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 2.5 mg PO DAYS (___)
2. Warfarin 5 mg PO DAYS (___)
3. Verapamil SR 240 mg PO Q24H Hold for SBP < 100 or HR < 60 &
notify H/O
4. Valsartan 80 mg PO DAILY Hold for SBP < 100 & notify H/O
5. Simvastatin 40 mg PO QHS
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Meclizine Dose is Unknown mg PO Frequency is Unknown
Discharge Medications:
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Meclizine 12.5 mg PO Q6H:PRN vertigo
4. Simvastatin 40 mg PO QHS
5. Valsartan 80 mg PO DAILY Hold for SBP < 100 & notify H/O
6. Verapamil SR 240 mg PO Q24H Hold for SBP < 100 or HR < 60 &
notify H/O
7. Warfarin 2.5 mg PO DAYS (___)
8. Warfarin 5 mg PO DAYS (___)
9. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
This medication can make you drowsy. Do not drive or operate
machinery while taking it.
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Odontoid fracture
Vertigo
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 taking care of you during your stay at ___.
You were transferred to ___ because you were found to have an
odontoid (cervical ___ fracture after you fell. You were
evaluated by the Ortho ___ team who determined that you do not
need surgery, but you will need to wear a hard cervical collar
at all times until you follow up with them.
You were also evaluated by physical therapy, who recommended
home ___, which you refused. Once your cervical ___
is cleared by the Ortho ___ doctors, you should start
vestibular physical therapy to further evaluate and treat your
vertigo, and hopefully prevent falls in the future.
**YOU CANNOT DRIVE WHILE YOU ARE WEARING THE ___ COLLAR
BECAUSE YOU CANNOT TURN YOUR HEAD, AND THAT IS UNSAFE.**
Followup Instructions:
___
|
19847287-DS-24
| 19,847,287 | 21,631,643 |
DS
| 24 |
2202-09-20 00:00:00
|
2202-09-20 16:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Erythromycin Base / Sulfa (Sulfonamide
Antibiotics) / Penicillins / Macrodantin / Trimethoprim /
Influenza Virus Vaccine / Simvastatin / atorvastatin / aspirin
Attending: ___.
Chief Complaint:
weakness, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ woman with a history of TIAs,
hypothyroidism who presented to the ED with weakness and
fatigue.
She was in her USOH until the morning of ___ when her son
found her still in bed at noon (she usually is out of bed in the
morning to make coffee and watch Catholic Mass). She required
assistance from her son to ambulate and get to the bathroom
(usually ambulates independently with a cane) and noted to be
mildly confused. EMS was called and she was brought to ___.
In the ED, initial VS were: 98.6 82 124/58 16 96%RA. She was
noted to have ___ grip strength on exam, consistent with
residual
deficits from prior CVAs. Urinalysis was positive for leukocytes
and nitrites. She was given 1gm of ceftriaxone and 500mL of NS.
A
NCHCT was negative for any acute intracranial process.
Transfer VS were: 98.2 75 169/71 96%RA.
On arrival to the floor, she endorses weakness and fatigue that
began today when her son arrived to her apartment. She also felt
dizzy when she was in bed and sat up this morning. She had
difficulty walking to the bathroom and required assistance from
her son. She also felt a little mentally slower and like it was
taking her a long time to wake up. Her son confirms the above
history and also notes that his mother was having more
difficulty
with pedaling at her bike over the past few days. He does not
recall her complaining about any urinary symptoms or other
generalized symptoms.
She has not been hospitalized or in rehab facilities. She lives
at home.
She denies burning with urination, urinary frequency, hematuria.
She has not had any fevers, chills, nausea, vomiting, abdominal
pain, constipation, or diarrhea.
Past Medical History:
Hypothyroidism
CVA with residual LUE weakness (Mild)
Carotid stenosis s/p CEA
B12 Deficiency
GERD
HLD
Osteoarthritis
Anemia
Irritable Bowel
Back Pain
Social History:
___
Family History:
Brother with colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: reviewed in e-Flowsheets, unremarkable
GENERAL: NAD AO to hospital, year, Pats loosing the Super Bowl.
HEENT: temporal wasting, AT/NC, EOMI, PERRL, anicteric sclera,
pink conjunctiva
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, ___ SM
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mildly TTP suprapubic area
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all ___, LUE ___ strength
DISCARHGE PHYSICAL EXAM:
VS: reviewed in e-Flowsheets, unremarkable
GENERAL: NAD AO to hospital, year, Pats loosing the Super Bowl.
HEENT: temporal wasting, AT/NC, EOMI, PERRL, anicteric sclera,
pink conjunctiva
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, ___ SM
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, no abdominal pain or TTP (including
in suprapubic region)
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all ___, LUE ___ strength
Pertinent Results:
RELEVANT LABS
==============
Hematology, Chemistries:
___ 04:10PM BLOOD WBC-7.3 RBC-3.76* Hgb-12.3 Hct-37.1
MCV-99* MCH-32.7* MCHC-33.2 RDW-11.4 RDWSD-41.2 Plt ___
___ 04:10PM BLOOD Neuts-80.2* Lymphs-12.2* Monos-6.6
Eos-0.1* Baso-0.5 Im ___ AbsNeut-5.84 AbsLymp-0.89*
AbsMono-0.48 AbsEos-0.01* AbsBaso-0.04
___ 04:10PM BLOOD Glucose-85 UreaN-18 Creat-0.7 Na-135
K-6.3* Cl-99 HCO3-24 AnGap-12
___ 04:10PM BLOOD cTropnT-<0.01
___ 06:57PM BLOOD Lactate-1.4 K-3.8
Urinalysis:
___ 06:30PM URINE Color-Straw Appear-Clear Sp ___
___ 06:30PM URINE Blood-NEG Nitrite-POS* Protein-NEG
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD*
___ 06:30PM URINE RBC-1 WBC-9* Bacteri-FEW* Yeast-NONE
Epi-0
MICROBIOLOGY
============
___ URINE CULTURE -- pending at time of discharge
Brief Hospital Course:
___ is a ___ woman with a history of CVAs s/p
CEA, hypothyroidism who presents with weakness and confusion
found to have urinalysis c/w UTI.
ACUTE ISSUES:
==============
#Acute uncomplicated cystitis/Urinary Tract Infection: Based on
clinical history of weakness, fatigue, and confusion plus
urinalysis with positive nitrites and leukocytes. She is a
community dweller and has no risk factors for a multidrug
resistant organism. Her allergies are listed as penicillins,
Sulfas, and nitrofurantoin - the patient and daughter were not
certain about the validity of these (felt that they were most
likely rash), but patient tolerated dose of ceftriaxone without
event. Transitioned from ceftriaxone to cephalexin to complete 5
days on discharge.
-- Follow up urine culture, pending at time of discharge
#LUE Weakness: Residual from CVA. ___ be mildly exacerbated in
setting of UTI. Resolved shortly thereafter with treatment of
UTI.
CHRONIC ISSUES:
================
#CVA/TIA s/p CEA:
-Continued ASA
#Hypothyroidism: TSH 4.2 ___
-Continued levothyroxine 88mcg PO daily
#B12 deficiency:
-Continued B12.
#Anemia: Resolved on iron supplementation.
-Continued iron.
TIME ATTESTATION:
=================
35 minutes spent on care coordination, counseling and discharge
planning.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Cyanocobalamin 250 mcg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. Aspirin 81 mg PO DAILY
5. Ferrous Sulfate 325 mg PO 2X/WEEK (MO,FR)
6. Naproxen 250 mg PO Q12H:PRN Pain - Mild
Discharge Medications:
1. Artificial Tear Ointment 1 Appl BOTH EYES QHS
2. Artificial Tears ___ DROP BOTH EYES PRN DRY EYES
3. Cephalexin 250 mg PO Q8H
RX *cephalexin 250 mg 1 capsule(s) by mouth every 8 hours Disp
#*13 Capsule Refills:*0
4. Aspirin 81 mg PO DAILY
5. Cyanocobalamin 250 mcg PO DAILY
6. Ferrous Sulfate 325 mg PO 2X/WEEK (MO,FR)
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Naproxen 250 mg PO Q12H:PRN Pain - Mild
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Urinary tract infection
Weakness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen in the hospital for weakness and found to have a
urinary tract infection.
We treated you with antibiotics and you improved. You were also
seen by the physical therapists, who recommend home ___.
As we discussed, please work on your diet by eating smaller,
more frequent meals. Continue the protein supplementation in
your oatmeal. Please try to add an Ensure or Boost type drink
once to twice per day.
Please follow up with your primary care doctor within 2 weeks of
discharge.
Continue taking the antibiotics until the bottle is empty.
It was a pleasure caring from you. We wish you the very best!
- Your ___ Care Team
Followup Instructions:
___
|
19847377-DS-9
| 19,847,377 | 23,834,262 |
DS
| 9 |
2183-12-27 00:00:00
|
2183-12-27 20:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ___
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with EtOH use disorder, HTN who presents to ED with syncope
via EMS. Pt was at a grocery store, felt lightheaded, blurry
vision, and diaphoretic, like he was going to faint, and then
did syncopize. Had those preceding symptoms for about a minute
or two before fainting. He denies any chest pain, shortness of
breath, or palpitations. He was caught by a bystander. No head
strike or loss of consciousness. He is not sure how long he was
out for but believes less than a minute. He was brought to a
chair, and per patient, it took him some time to get back to
normal. Had a cup of cream of wheat and some tea all day before
going to the grocery store at 5pm.
No alcohol on day of admission. He states he has cut back on his
alcohol use although did take a shot of gin and one Guinness the
day before today. Is on HCTZ but is not a new medication but
only recently started taking it again in ___. Has been on
25mg from the start, did not ever have to cut pill in half
before.
___ years ago, had a similar fainting spell. It was summer time
and he felt like he was very dehydrated at that time. He was
outside at that time and had a few drinks and a few drags from a
joint. At that time, he felt dizzy and sweaty and needed to sit
down.
Denies: personal history of heart disease, family history of
early ACS or sudden death.
In the ED, - Initial vitals: T 97.3, HR 84, BP 102/74, RR 18,
SpO2 100%
- Labs notable for: glucose 37 -> 36 -> 391. Cr 1.5, H/H
11.6/34.0. Negative serum tox (alcohol included). TSH wnl.
- Imaging notable for: CXR WNL but with aortic arch possibly
mildly dilated
- Pt given: acetaminophen, IVF, thiamine, multivitamin, and
folic acid
- Cardiology consulted to evaluate tele strip: appears to be AT
vs AFL. ECG shows SR with PAC. No other clinical questions were
posed.
- Vitals prior to transfer: T 98.3, HR 87, BP 108/60, RR 18,
SpO2 96% RA. Orthostatics were unremarkable but were
unfortunately done hours after receiving IVF. On the floor,
denies: dizziness, lightheadedness, vision changes, chest pain,
sob, abdominal pain, cough, weakness, sensation changes. Is very
hungry however. He states he felt much better after getting IVF.
Past Medical History:
EtOH use disorder
Hypertension
Social History:
___
Family History:
No history of early ACS, no history of sudden death
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITALS: reviewed in ___
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops. No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: No spinous process tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation.
DISCHARGE PHYSICAL EXAM:
=========================
VITALS: ___ ___ Temp: 98.6 PO BP: 119/88 HR: 57 RR: 18 O2
sat: 100% O2 delivery: Ra
GENERAL: Alert, older man in NAD
HEENT: Sclera anicteric, MMM
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: CTAB - No wheezes, rhonchi or rales.
ABDOMEN: +BS, NT, ND
EXTREMITIES: No clubbing, cyanosis, or edema
NEUROLOGIC: No facial asymmetry, no dysarthria
PSYCH: Good eye contact, mildly dysthymic mood (however improved
from prior), denies SI/HI
Pertinent Results:
ADMISSION LABS:
===============
___ 06:10PM BLOOD WBC-4.8 RBC-3.24* Hgb-11.6* Hct-34.0*
MCV-105* MCH-35.8* MCHC-34.1 RDW-13.2 RDWSD-51.0* Plt ___
___ 06:10PM BLOOD Neuts-58.3 ___ Monos-3.1*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-2.82 AbsLymp-1.83
AbsMono-0.15* AbsEos-0.01* AbsBaso-0.01
___ 06:10PM BLOOD Glucose-391* UreaN-14 Creat-1.5* Na-135
K-3.4 Cl-93* HCO3-29 AnGap-13
___ 06:10PM BLOOD ALT-20 AST-43* AlkPhos-41 TotBili-0.6
___ 06:10PM BLOOD Calcium-9.2 Phos-3.4 Mg-1.8
___ 06:10PM BLOOD TSH-1.8
___ 06:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
OTHER PERTINENT LABS:
====================
___ 06:18AM BLOOD VitB12-678 Folate-13
IMAGING:
========
___ CXR IMPRESSION:
No acute cardiopulmonary process. Aortic arch may be mildly
prominent/dilated, although this appearance could relate to the
course of the aorta. This could be further assessed on
nonurgent chest CT.
DISCHARGE LABS:
===============
___ 06:41AM BLOOD WBC-4.0 RBC-2.91* Hgb-10.3* Hct-30.8*
MCV-106* MCH-35.4* MCHC-33.4 RDW-13.1 RDWSD-50.6* Plt ___
___ 06:41AM BLOOD ___ PTT-29.2 ___
___ 06:41AM BLOOD Glucose-90 UreaN-12 Creat-1.4* Na-140
K-3.8 Cl-103 HCO3-27 AnGap-10
___ 06:41AM BLOOD ALT-15 AST-30 LD(LDH)-136 AlkPhos-44
TotBili-0.6
___ 06:41AM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.2 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ with HTN and h/o EtOH use disorder who was
admitted for syncope - likely vasovagal in etiology, and
subsequently found to have atrial tachycardia.
ACUTE ISSUES:
=============
#Syncope: Most likely represents vasovagal syncope given
prodrome (tunnel vision, diaphoresis, and lightheadedness).
Orthostatics negative after receiving IVF. Of note, Cardiology
was
consulted in the ED to evaluate for arrhythmia - thought to be
most concerning for atrial tachycardia. Was continued on
telemetry and was found to have multiple intermittent episodes
of tachycardia in the HR 150s (see below) throughout his
hospitalization, however asymptomatic and thus thought less
likely to have resulted in his syncope. His home HCTZ was
initially held given concern for hypovolemia, and was ultimately
transitioned to Metoprolol for additional HR control, as per
below. Pt was encouraged to increase his PO intake, and to
follow up with his PCP for likely depression given endorsed
symptoms of decreased appetite, increased sleep, and decreased
energy since ___ after he had a break up.
#Atrial Tachycardia: Discussed case with Cardiology, who
believes this is likely atrial tachycardia based on the
telemetry. Was started on low dose Metoprolol 25mg daily and was
continued on telemetry. Patient tolerated the transition to
Metoprolol well, however was noted to have HRs in the ___
(asymptomatic) and thus titrated down to Metoprolol 12.5mg
daily. He was advised to call his PCP if he felt lightheaded.
___: Most recent baseline Cr appears to be 1.1-1.2. Found to
have a Cr of 1.5 on admission, improved to 1.4 after IVF thus
suspect pre-renal in the setting of poor PO intake. His home
HCTZ was held, and ultimately transitioned to Metoprolol for
atrial tachycardia and hypertension co-management. On discharge,
his Creatinine was 1.4. He was encouraged to increase his PO
intake. He is to have close follow up with his PCP for follow up
BMP. In addition, his home naproxen was held.
#H/o EtOH use disorder: per patient used to drink at least 10
drinks/day easily, however has cut back to ___ drinks a week
since after the superbowl. Denies withdrawal symptoms. AST/ALT
ratio 2:1. Was continued on Thiamine, Folate, and a MVI. SW was
consulted, however the patient was not interested in further
resources. He was maintained on a CIWA scale and did not score
during his admission.
#Macrocytic anemia: Likely due to former heavy alcohol use. His
Folate was 13 and B12 was 678, both within normal limits. He was
continued on folic acid supplementation.
#Thrombocytopenia: Likely due to former heavy alcohol use. His
Plts were 131 on admission, and 141 on discharge.
CHRONIC ISSUES:
===============
#HTN: Held home HCTZ given syncope was likely ___ hypovolemia in
setting of poor PO intake. Was instead transitioned to
Metoprolol 12.5mg daily for additional HR control given atrial
tachycardia.
#GERD: Continued home omeprazole 20mg BID
TRANSITIONAL ISSUES:
====================
[ ] Monitor BPs and HRs given transition from HCTZ to Metoprolol
[ ] Please repeat BMP on next PCP visit, to evaluate for
resolution ___
[ ] Evaluate and consider treatment for depression given pt
endorsement of depressed mood, decreased appetite, decreased
energy, and increased sleep since ___ after going
through a break up.
[ ] Consider non-urgent chest CT to evaluate for mildly
prominent and dilated aortic arch seen on CXR
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Thiamine 100 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. Naproxen 500 mg PO Q12H:PRN Pain - Mild
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 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
daily Disp #*15 Tablet Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Omeprazole 20 mg PO BID
5. Thiamine 100 mg PO DAILY
6. HELD- Naproxen 500 mg PO Q12H:PRN Pain - Mild This
medication was held. Do not restart Naproxen until told to
restart this ___ by your PCP
___:
Home
Discharge Diagnosis:
PRIMARY:
Vasovagal Syncope
Atrial tachycardia
Acute kidney injury
Depression
SECONDARY:
Hypertension
History of alcohol abuse
Thrombocytopenia
Macrocytic anemia
Gastoresophageal reflux disease
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 after passing out in a grocery
store. We think this was most likely because you had not eaten
much and were dehydrated. You were also found to have a
periodically fast heart rate, which may have contributed to you
passing out - we started a low dose medication to try and slow
this heart rate.
WHAT TO DO AFTER DISCHARGE:
-Please attend all of your appointments as scheduled
-Please take all of your medications as prescribed
-Please talk to your PCP about you feeling down and not eating
much since your breakup
-Please try to increase how much you are eating and drinking
during the day
-Please call your PCP if you feel lightheaded, as this may be an
effect from the medication we started
Followup Instructions:
___
|
19847462-DS-3
| 19,847,462 | 26,732,997 |
DS
| 3 |
2135-01-03 00:00:00
|
2135-01-03 15:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Prozac / Penicillins / Neurontin
Attending: ___
Chief Complaint:
Altered mental status/Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with a history of
schizoaffective disorder and polysubstance use with overdose in
the past who presents with unresponsiveness. He reports taking
an unknown white substance intranasally. By report, he was found
by his friends inside his house the morning of ___. He was
shaking and was put into his bathtube for an unknown period of
time. He continued to shake and EMS was called where they found
the patient shaking and unresponsive. He was given 2mg IN narcan
without response and then given 4mg IV narcan with improved
responsiveness. He was supported with bag valve mask and taken
to ___. He was awake and talkative fluently but
confused about the events leading to his presentation per the
outside ED notes. He denied CP, SOB, diaphoresis, abd pain, leg
swelling. He denied intentional overdose or SI.
EKG was performed with QRS to 160 (from 86 on previous EKG) with
right bundle branch block and right axis deviation. He was given
9 amps sodium bicarbonate at OSH. Bicarbonate gtt was started at
200cc/hr. Repeat EKG with QRS to 153. Labs notable for troponin
I to 0.1. Of note, he has a history of pericarditis and
myocarditis with a positive ___ in ___. Echo performed at
that time with EF 45-50% with inferior and inferolateral
hypokinesis. Repeat TTE in ___ with EF 55%. Cardiac cath
performed in ___ with no abnormalities.
Tox Screen at OSH:
Serum negative for salicylates, acetaminophen, phenytoin,
valproic acid, ethyl alcohol.
Urine POSITIVE for opiates.
Urine negative for buprenorphine, oxycodone, methadone,
barbiturates, TCA, amphetamines, BZD, cocaine, cannabinoids.
CTA chest performed to assess for PE given EKG finding that was
negative for PE but showed that showed evidence of bilateral
aspiration pneumonia with tree and ___ and RML and LUL.
He was transferred from ___ to ___.
In the ___ ED, he was found to have hypoxia and was placed on
facemask. He was found to have urinary retention.
In the ED, initial vitals: 98.8 107 115/69 22 94% face mask
- Exam notable for no clonus, no hyperreflexia.
- Labs were notable for:
Lactate 2
CBC ___
Trop 0.13
Na 149 K 3.1 HCO3 34
ALT 197 AST 73 TB 0.4 Lipase 19 Albumin 3.7
- Imaging: CTA at OSH as above
- Patient was given: Ceftriaxone and 900mg IV clindamycin
- Consults: Toxicology
On arrival to the MICU, the patient is responsive and
cooperative. He states he is very thirsty but otherwise is
having no acute symptoms. He has pain in the central chest that
is reproducible on palpation. He denies shortness of breath,
abdominal pain, fevers, chills.
Past Medical History:
Schizoaffective disorder
Pericarditis in ___
GERD
Hypertension
History of APAP overdose in ___
History of substance abuse
Social History:
___
Family History:
Father with bipolar disorder, grandfather with mental health
problems (committed suicide). Family history of CAD, HTN, COPD
in the father.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: 98.9 85 117/86 16 93%6L
GENERAL: Patient appears nontoxic and in no acute distress. He
is disheveled but responsive to voice.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
dry mucous membranes
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs. Sternum area
tender to palpation.
LUNG: Diffuse rhonchi bilaterally, no wheezes, no crackles, no
use of accessory muscles.
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: 7X5cm patch of erythema over sternum.
DISCHARGE PHYSICAL EXAM
========================
VS: 97.8 111/69 61 18 94% RA (95% ambulatory sats)
Gen: Sitting up in bed, comfortable appearing
Eyes: Sclera anicteric, EOMI
ENT: Oropharynx clear, MMM
Heart: Regular rate and normal rhythm, no m/r/g
Lungs: CTAB, no accessory muscle use
Abd: Soft nontender, normoactive bowel sounds
MSK: No clubbing, cyanosis, or edema. Sternal chest pain
reproducible with palpation.
Skin: No rashes
Vasc: 2+ DP/radial pulses
Neuro: AOx3, moving all extremities
Psych: Appropriate
Pertinent Results:
ADMISSION LABS
==============
___ 07:00PM BLOOD WBC-10.5* RBC-5.02 Hgb-15.0 Hct-44.0
MCV-88 MCH-29.9 MCHC-34.1 RDW-12.8 RDWSD-41.1 Plt ___
___ 07:00PM BLOOD Neuts-89.5* Lymphs-7.1* Monos-2.9*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-9.39* AbsLymp-0.74*
AbsMono-0.30 AbsEos-0.00* AbsBaso-0.02
___ 07:00PM BLOOD Glucose-91 UreaN-13 Creat-0.7 Na-149*
K-3.1* Cl-103 HCO3-34* AnGap-15
___ 07:00PM BLOOD ALT-103* AST-73* CK(CPK)-243 AlkPhos-68
TotBili-0.4
___ 07:00PM BLOOD Lipase-19
___ 07:00PM BLOOD CK-MB-3 cTropnT-0.13*
___ 07:00PM BLOOD Albumin-3.7 Calcium-7.9* Phos-3.4 Mg-1.9
___ 07:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:35PM BLOOD ___ pO2-49* pCO2-52* pH-7.41
calTCO2-34* Base XS-6
___ 07:06PM BLOOD Lactate-2.0
NOTABLE LABS
============
___ 11:21PM BLOOD CK-MB-3 cTropnT-0.02*
___ 03:55AM BLOOD CK-MB-2 cTropnT-<0.01
DISCHARGE LABS
==============
___ 05:50AM BLOOD WBC-8.3 RBC-4.41* Hgb-13.2* Hct-38.6*
MCV-88 MCH-29.9 MCHC-34.2 RDW-12.7 RDWSD-40.8 Plt ___
___ 05:50AM BLOOD Glucose-84 UreaN-12 Creat-0.6 Na-141
K-3.5 Cl-106 HCO3-21* AnGap-18
___ 08:58AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9
MICRO
=====
URINE CULTURE (Final ___: NO GROWTH.
BLOOD CULTURE (___) NO GROWTH TO DATE
IMAGING
========
CXR ___: Compared to chest radiographs ___. Lung
volumes are very low. There may be right lower lobe collapse.
Small bilateral pleural effusions are presumed. Large scale
opacification in the left lower lung suggests severe pneumonia.
Mild cardiomegaly and mediastinal vascular engorgement are
chronic.
TTE ___: The left atrium is elongated. No atrial septal
defect is seen by 2D or color Doppler. The estimated right
atrial pressure is ___ mmHg. Left ventricular wall thicknesses
and cavity size are normal. Regional left ventricular wall
motion is normal. Overall left ventricular systolic function is
low normal (LVEF 50-55%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Physiologic mitral
regurgitation is seen (within normal limits). The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Low normal left ventricular systolic function.
Normal regional left ventricular systolic function.
CXR ___:
Interval resolution of pleural effusions with improvement of
bibasilar
consolidations.
CTA Chest
1. No evidence of pulmonary emboli.
2. There is atelectasis/consolidation of both lower lobes lobes
without evidence of obstruction..
3. There are areas of ___ density in the right middle
lobe and posterior left upper lobe consistent with infectious
airways
disease or aspiration.
4. There is a 16 mm area of nonspecific groundglass density in
the anterior right apex which could also be inflammatory.
Follow-up
CHEST CT in 3 months is recommended to determine whether this
resolves.
Brief Hospital Course:
Mr. ___ is a ___ year old male with past medical history of
polysubstance abuse, schizoaffective disorder, HTN admitted
___ to the ICU with acute encephalopathy and acute hypoxic
respiratory failure in the setting of pneumonia and intoxication
with an unknown substance, thought to be secondary to ingestion
toxidrome, with slowly improving respiratory status.
# Accidental Overdose with Opiate
# Accidental Overdose with unknown substance with toxidrome
# Abnormal EKG
# Acute Toxic Encephalopathy
Patient was brought to ___ unresponsive. He was reported to
be responsive to narcan and his Utox was positive for opiates.
Workup was notable for a wide QRS on EKG, prompting concern for
ingestion and initiation of IV bicarb. He was transferred to
___ MICU with subsequent slow improvement in mental status.
When he woke up he admitted to snorting unknown substance on new
___--likely an opiate contaminated with some
anticholinergic drug. There was also some concern that his
Cogentin contributed to the anticholinergic process also but he
denied taking any extra. Once mental status had returned to
baseline he was restarted on his home dose of Risperdal with
half-dose Cogentin (per discussion with his outpatient
psychiatrist ___ ___. Subsequent EKGs showed
normal QRS.
# Acute Hypoxic Respiratory Failure
# Acute Bacterial Pneumonia secondary to Aspiration
Patient presented with significant hypoxia requiring
non-invasive ventilation, with imaging concerning for pneumonia.
He was started on antibiotics and oxygen was subsequently
weaned. His hypoxia was slow to resolve due to atelectasis and
pleural effusions. With time, ambulation/mobilization, and
incentive spirometry his respiratory status improved so that he
could ambulate without desaturation. He completed a 7d course of
antibiotics prior to discharge. Ambulatory sats on the day prior
to discharge were 95% on room air.
# Hypertension Held nifedipine during this admission given
blood pressures at hoal off of antihypertensive therapy. Could
consider restarting at follow-up
# Schizoaffective Disorder - As above his medications were
restarted. He lives independently with support from ___ (a
___ those with mental illness
and developmental disabilities). His return home was
coordinated with his case worker ___ (___) and his
mother ___ (___). Of note, patient's health
literacy is low and he has poor
short term memory-used simple terms when discussing health
issues and teach back method to ensure his understanding
# Troponinemia: Presented with Troponin elevation to 0.13,
thought to relate to his acute illness without concern for ACS.
Troponin trended to <0.01. and TTE showed low normal left
ventricular systolic function.
# Admitted with transaminitis - Thought to be from above
ingestion and acute illness. Tylenol level negative. It
resolved over several days.
TRANSITIONAL ISSUES
- Discharged home
- CTA Chest at ___ showed "There is a 16 mm area of
nonspecific groundglass density in the anterior right apex which
could also be inflammatory. Follow-up
CHEST CT in 3 months is recommended to determine whether this
resolves."
- Nifedipine held as above due to normal blood pressures
in-house
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benztropine Mesylate 1 mg PO BID
2. Fish Oil (Omega 3) ___ mg PO BID
3. Loratadine 10 mg PO DAILY
4. NIFEdipine CR 30 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Cyanocobalamin 1000 mcg PO DAILY
8. RisperiDONE 4 mg PO QHS
9. melatonin 10 mg oral QHS
10. ProAir HFA (albuterol sulfate) 180 mcg inhalation Q4H:PRN
11. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN eczema
Discharge Medications:
1. Benztropine Mesylate 0.5 mg PO BID
RX *benztropine 0.5 mg 1 tablet(s) by mouth twice daily Disp
#*30 Tablet Refills:*0
2. Cyanocobalamin 1000 mcg PO DAILY
3. Fish Oil (Omega 3) ___ mg PO BID
4. FoLIC Acid 1 mg PO DAILY
5. Loratadine 10 mg PO DAILY
6. melatonin 10 mg oral QHS
7. Omeprazole 20 mg PO DAILY
8. ProAir HFA (albuterol sulfate) 180 mcg inhalation Q4H:PRN
9. RisperiDONE 4 mg PO QHS
10. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN eczema
Discharge Disposition:
Home
Discharge Diagnosis:
# Accidental Overdose with Opiate
# Accidental Overdose with unknown substance with toxidrome
# Abnormal EKG
# Acute Toxic Encephalopathy
# Acute Hypoxic Respiratory Failure
# Acute Bacterial Pneumonia secondary to Aspiration
# Hypertension
# Schizoaffective Disorder
# Troponinemia
# Transaminitis
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
with an unresponsive episode after snorting an unknown drug.
You were found to have a severe pneumonia. You were treated
with antibiotics and you improved.
You should have a repeat CAT scan of your CHEST 3 months to make
sure your lungs completely heal. We have communicated this to
your primary care doctor. Please make sure to discuss it with
him.
Followup Instructions:
___
|
19848164-DS-3
| 19,848,164 | 25,763,771 |
DS
| 3 |
2157-11-02 00:00:00
|
2157-11-02 11:57:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
lidocaine
Attending: ___
Chief Complaint:
Lightheadedness, gait difficulty, emesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ woman with history of hepatitis C
status
post treatment, poorly controlled hypertension secondary to
medication noncompliance who presents with lightheadedness
associated with emesis and gait difficulty.
Briefly, patient reports she was in her usual state of health
until around noon ___. States she just got back home from
meeting with family when she laid down to get some rest. She
said she felt exhausted because she has not eaten all day. When
she was trying to get up from her nap she had a sudden onset of
lightheadedness. She describes the lightheadedness as "feeling
like I am about to pass out". She denies any vertigo, no focal
weakness, no paresthesias, no difficulty for speech, no diplopia
and no emesis at that time. She called her daughter and told
her
that she did not feel well. Her daughter came over to the house
and noticed that her mother appeared unsteady on her feet. She
denies swaying to any particular side. The patient herself says
was due to the lightheadedness. She said this never happened to
her before. Her blood pressure was 163/83, heart rate 89. CBC
and chemistry unremarkable. Patient noted to be orthostatic and
was started on normal saline IVF. She reports feeling somewhat
better not to her baseline. Denies any fevers, or sick
contacts,
abdominal pain having eaten unusual food.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
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. Diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
___ Stroke Scale score was 0:
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
Past Medical History:
HEPATITIS C
HYPERTENSION
Social History:
Lives alone, has 5 children the ___ area, and 6
grandchildren.
She emigrated from ___ in ___. She
denies etoh, tobacco, hx of ivdu, hx of transfusions.
- Modified Rankin Scale:
[x] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
One of ___, 3 sisters and 2 brothers alive and well. One
brother died of colon ca at age ___. Mother died at ___, unknown
cause of death. No known history of breast ca.
Physical Exam:
==============================
ADMISSION PHYSICAL EXAM
==============================
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple
Pulmonary: no increased work of breathing
Cardiac: RRR, nl.
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Speech was not dysarthric. Able to follow both
midline and appendicular commands. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
- Motor - Normal bulk and tone. No drift.
[Delt] [Bic] [Tri] [ECR] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
-DTRs:
[Bic] [Tri] [___] [Quad]
L 2+ 2+ 2+ 2+
R 2+ 2+ 2+ 2+
Plantar response flexor bilaterally.
-Sensory: No deficits to light touch throughout. No extinction
to
DSS.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally.
-Gait: Deferred patient did not feel comfortable walking
==============================
DISCHARGE PHYSICAL EXAM
==============================
Patient able to stand up independently and ambulate in an
independent manner. Neurological exam non-focal.
Pertinent Results:
=======
LABS
=======
___ 10:45PM BLOOD WBC-5.5 RBC-4.20 Hgb-13.3 Hct-38.1 MCV-91
MCH-31.7 MCHC-34.9 RDW-12.6 RDWSD-41.3 Plt ___
___ 11:00PM BLOOD ___ PTT-29.5 ___
___ 10:45PM BLOOD Glucose-123* UreaN-18 Creat-0.7 Na-137
K-3.1* Cl-98 HCO3-28 AnGap-14
___ 10:45PM BLOOD ALT-12 AST-21 AlkPhos-65 TotBili-0.4
___ 10:45PM BLOOD Lipase-19
___ 10:45PM BLOOD cTropnT-<0.01
___ 10:45PM BLOOD Albumin-4.6 Cholest-161
___ 10:40PM BLOOD %HbA1c-5.4 eAG-108
___ 10:45PM BLOOD Triglyc-43 HDL-63 CHOL/HD-2.6 LDLcalc-89
___ 10:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:45AM URINE Color-Straw Appear-Clear Sp ___
___ 12:45AM URINE UCG-NEGATIVE
===========
IMAGING
===========
CTA HEAD AND NECK ___, WET READ):
Patent circle of ___ and its major tributaries. No evidence
of aneurysm. Patent dural venous sinuses. Patent neck vessels
without critical narrowing by NASCET criteria.
NCHCT (___):
There is no evidence of acute intracranial process or
hemorrhage.
CXR (___):
No acute cardiopulmonary process.
Brief Hospital Course:
Patient is a ___ woman with history of hepatitis C
status post treatment and poorly controlled hypertension
secondary to medication noncompliance who presented ___ with
lightheadedness associated with emesis and gait difficulty. She
was admitted to the stroke service given her gait difficulty.
During her hospital stay, her neurological exam remained normal.
Her symptoms also improved with IVF and sounded positional; she
also reported increasing stress at home and decreased sleep and
PO intake over ~3 days. Therefore, MRI was deferred given low
concern for stroke. Patient clinically improved by time of
discharge; physical therapy cleared her for discharge home, as
she was able to walk independently. She did not have orthostatic
changes on examination. She was discharged on her home
medications.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. candesartan-hydrochlorothiazid ___ mg oral DAILY
Discharge Medications:
1. candesartan-hydrochlorothiazid ___ mg oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Lightheadedness, presyncope
Secondary diagnosis:
Hepatitis C
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You presented to the hospital with positional lightheadedness
and nausea/vomiting. Your symptoms improved with fluids. This
may be related to your ongoing stress and decreased dietary
intake over the past couple of days. Please ensure you drink
about ___ litres of water daily and also eat adequate salt. Your
head CT was reassuring and did not show any abnormalities.
We wish you all the best!
Followup Instructions:
___
|
19848401-DS-12
| 19,848,401 | 29,820,206 |
DS
| 12 |
2160-03-27 00:00:00
|
2160-03-27 15:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
bendamustine
Attending: ___.
Chief Complaint:
Rash on left neck
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ CLL (s/p recent initiation of Venetoclax and on monthly
Rituximab), HTN/HLD, pAFIB (no a/c) who presented with 4 days of
left-sided neck discomfort and rash. He was in USOH until ___
days prior to admission, when he noticed an "aggravating"
stiffness on the left side of his neck. ___ days later, he
noticed a small rash over the region. The morning of admission,
he found the rash grew in area to cover most of the left side of
his neck. He therefore
presented to the ED for further evaluation.
He denied any pain or burning sensation over the rash. He denies
any other symptoms including hearing pain, ear pain, vision
changes. No fevers/chills, SOB, abdominal pain, N/V/D. He
reports he had chicken pox as a child (around age
___. He has never received shingles vaccine.
Past Medical History:
Chronic lymphocytic leukemia diagnosed ___, s/p treatment with
6 cycles of Rituxan/Fludaribine, then Bendamustine ___ x 3
cycles, then Ibrutinib ___, Chlorambucil ___, and started
Venetoclax ___
HTN
HLD
GERD
Previous EtOH Abuse per records
Colonic adenoma
Fracture of cervical vertebrae
Erectile dysfunction
pAFIB (not on anticoagulation due to prior intracranial
hemorrhage)
CLL as above
Intracranial hemorrhage/stroke due to ibrutinib
Social History:
___
Family History:
No known history of hematologic malignancy
Maternal uncle with prostate cancer
Physical Exam:
General: Well appearing elderly gentleman. Resting in bed
comfortably
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:
___ handgrip bilaterally
___ plantar and dorsiflexion
Sensation intact to light touch over UE and ___
Alert and oriented x 3
HEENT: Oropharynx clear, no lesions. Sclera anicteric, no
conjunctival irritation. No rashes involving the ear
Cardiovascular: bradycardic, regular, soft systolic murmur best
appreciated at RUSB
Chest/Pulmonary: Clear to auscultation bilaterally
Abdomen: Soft, nontender, nondistended
Extr/MSK: No peripheral edema, no rashes
Skin: Multiple crusted over lesions over the left neck
predominantly in C3
dermatome but extending into C2 and C4 regions. Not draining,
nontender to palpation.
Access: R POC site is c/d/I and nontender to palpation
Pertinent Results:
ADMISSION LABS:
___ 10:20AM GLUCOSE-101* UREA N-10 CREAT-1.0 SODIUM-143
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12
___ 10:20AM ALT(SGPT)-19 AST(SGOT)-23 CK(CPK)-61 ALK
PHOS-90 TOT BILI-0.3
___ 10:20AM WBC-19.1* RBC-4.12* HGB-12.1* HCT-37.3*
MCV-91 MCH-29.4 MCHC-32.4 RDW-12.5 RDWSD-41.4
___ 10:20AM NEUTS-7* BANDS-0 LYMPHS-89* MONOS-3* EOS-1
BASOS-0 ___ MYELOS-0 AbsNeut-1.34* AbsLymp-17.00*
AbsMono-0.57 AbsEos-0.19 AbsBaso-0.00*
DISCHARGE LABS:
___ 05:04AM BLOOD WBC-20.8* RBC-4.03* Hgb-11.8* Hct-35.6*
MCV-88 MCH-29.3 MCHC-33.1 RDW-12.4 RDWSD-39.8 Plt ___
___ 05:04AM BLOOD Neuts-18* Bands-0 Lymphs-74* Monos-8
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-3.74
AbsLymp-15.39* AbsMono-1.66* AbsEos-0.00* AbsBaso-0.00*
___ 05:04AM BLOOD Glucose-114* UreaN-10 Creat-0.9 Na-142
K-4.2 Cl-104 HCO3-24 AnGap-14
___ 6:04 pm DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS
DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final
___:
Reported to and read back by ___ ___ 11:13AM.
POSITIVE FOR VARICELLA ZOSTER.
Viral antigen identified by immunofluorescence.
IMAGING:
CT Neck w/ and w/o contrast (___):
1. Extensive left cervical lymphadenopathy - may be reactive in
etiology or secondary to patient's neoplasm. Continue clinical
follow up is recommended.
2. Patent bilateral internal jugular veins.
3. 1 cm hypodense right thyroid nodule.
4. Fracture of the right lamina of C5, of uncertain chronicity.
5. Approximately 4 mm left upper lobe pulmonary nodule.
Brief Hospital Course:
#C3 dermatome Herpes zoster:
Mr. ___ developed herpes zoster due to his
immunocompromised state. There was no evidence of cranial nerve
or organ involvement. He tested positive for VZV by ___. He was
treated with IV acyclovir 800 mg q8. He will complete a total 14
days, which was switched to PO Valtrex on d/c.
#Superimposed Skin an Soft tissue infection, cellulitis
While hospitalized, Mr. ___ had low grade temperatures of
100.6-100.8. Infectious work-up revealed a cellulitis in the
posterior C3 dermatome. He was started on IV vancomycin which
was narrowed to PO doxycycline at the time of discharge 100mg
BID to complete a total 7 day course (ending on ___ for
presumed superinfection with either staph or strep.
Unfortunately at time of d/c no culture result positive, final
culture and MRSA swab pending at time of d/c.
#CLL - He was continued on his home Venetoclax and allopurinol.
Rituximab infusions on hold until infection is cleared. To be
determined after f/u with heme/onc.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cialis (tadalafil) 20 mg oral DAILY:PRN
2. Pantoprazole 40 mg PO Q24H
3. Allopurinol ___ mg PO DAILY
4. Venetoclax 400 mg PO DAILY
5. Gemfibrozil 600 mg PO BID
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H Duration: 2 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice daily
Disp #*3 Tablet Refills:*0
2. ValACYclovir 1000 mg PO Q8H Duration: 8 Days
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth three times daily
Disp #*25 Tablet Refills:*0
3. Allopurinol ___ mg PO DAILY
4. Cialis (tadalafil) 20 mg oral DAILY:PRN
5. Gemfibrozil 600 mg PO BID
6. Pantoprazole 40 mg PO Q24H
7. Venetoclax 400 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Herpes zoster infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with left-sided neck pain and were
found to have a shingles infection. You were treated with
intravenous acyclovir while in the hospital. You also developed
a cellulitis (bacterial skin infection) over the area where the
zoster was. For this, you were treated with an intravenous
antibiotic.
At discharge, continue taking acyclovir pills for total of 14
days days (including time in the hospital). Please also take
doxycycline for total of 7 days of antibiotics (including time
in the hospital). Please follow-up with your primary care
doctor as below.
Please do not take rituximab until you are cleared from your
current infection.
Followup Instructions:
___
|
19848478-DS-4
| 19,848,478 | 26,102,225 |
DS
| 4 |
2142-05-23 00:00:00
|
2142-05-28 20:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Aricept / ibuprofen
Attending: ___.
Chief Complaint:
abdominal distension
Major Surgical or Invasive Procedure:
___ ex-lap, end ileostomy, closure
___ ex-lap, washout, proctectomy, open abdomen
___ ex-lap, sigmoid resection, open abdomen
___ ex-lap, completion colectomy, open abdomen
Dobhoff feeding tube placed
History of Present Illness:
Mr. ___ is a ___ year-old male with Downs Syndrome, non-verbal
at baseline who presents with abdominal distention and apparent
abdominal pain. Pt in non-communicative and history is
limited, however per report he was not acting himself today and
appeared in pain. He was then noted to have significant
abdominal distention and was transferred from his group home to
the ED. In the ED, the patient is in apparent distress but
unable to communicate.
Past Medical History:
PMH:
-DEMENTIA
-DOWNS SYNDROME
-EDENTULOUS
-IRON DEFICIENCY ANEMIA
-RENAL INSUFFICIENCY
-H/O HEMORRHOIDS
-H/O CONSTIPATION
-H/O PERNICIOUS ANEMIA
-H/O BENIGN PROSTATIC HYPERTROPHY
-H/O VITAMIN B12 DEFIC
-H/O BACK PAIN
PSH:
-Appendectomy
Social History:
___
Family History:
- Mother d bladder cancer
- Brother d lymphosarcoma
- Father d myelodysplastic syndrome (but had "significant
radiation exposure"
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.5 95 124/88 22 96% RA
General: unable to communicate but in obvious distress
HEENT: NC/AT, EOMI, dry mucous membranes
Resp: mildly tachypneic but stable on room air
CV: mildly tachycardic
Abd: Abdomen significantly distended and firm. Exam difficult
but
abdomen appears tender w/ some guarding to palpation
Ext: well-perfused
DISCHARGE PHYSICAL EXAM:
VS: 97.9 80 ___ 99% RA
General: unable to verbalize but tracking with eyes and playful
facial expressions NAD
HEENT: NC/AT, EOMI, moist mucus membranes, dobhoff bridle safely
secured in right nostril
Resp: mild tachypneic but stable on room air
CV: mildly tachycardic
Abd: Abdomen soft, non-distended; ostomy bag with liquid brown
stool and gas.
vertical incision with light pink edges, non-erythematous, non
purulent; wet to dry dressing in place.
GU: condom cath secured.
Ext: well-perfused, positive muscle tone, no joint effusion.
Pertinent Results:
___ 04:55AM BLOOD WBC-5.1 RBC-3.29* Hgb-10.4* Hct-32.7*
MCV-99* MCH-31.6 MCHC-31.8* RDW-15.8* RDWSD-56.6* Plt ___
___ 09:20AM BLOOD WBC-4.6 RBC-3.43* Hgb-10.7* Hct-33.3*
MCV-97 MCH-31.2 MCHC-32.1 RDW-15.9* RDWSD-55.8* Plt ___
___ 10:40AM BLOOD WBC-4.7 RBC-3.20* Hgb-10.0* Hct-30.6*
MCV-96 MCH-31.3 MCHC-32.7 RDW-15.7* RDWSD-52.5* Plt ___
___ 05:08AM BLOOD WBC-7.8 RBC-3.08* Hgb-9.9* Hct-29.1*
MCV-95 MCH-32.1* MCHC-34.0 RDW-14.5 RDWSD-48.9* Plt ___
___ 11:17AM BLOOD WBC-13.1*# RBC-4.65 Hgb-15.1 Hct-45.3
MCV-97# MCH-32.5*# MCHC-33.3 RDW-14.6 RDWSD-52.6* Plt ___
___ 03:35AM BLOOD Neuts-91* Bands-4 Lymphs-3* Monos-0 Eos-0
Baso-0 Atyps-2* ___ Myelos-0 AbsNeut-13.02* AbsLymp-0.69*
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 04:55AM BLOOD Plt ___
___ 03:35AM BLOOD ___ PTT-40.3* ___
___ 04:55AM BLOOD Glucose-137* UreaN-14 Creat-1.1 Na-138
K-4.6 Cl-100 HCO3-32 AnGap-11
___ 04:55AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.4
___ 02:17PM BLOOD TSH-4.6*
___ 10:15PM BLOOD freeCa-1.20
___: chest x-ray:
Lucency in the midline and left sub-diaphragmatic region likely
represents
intraluminal air, but extra-luminal air cannot be definitively
excluded.
Consider left lateral decubitus radiographs for further
evaluation.
___: cat scan abd. and pelvis:
1. Diffuse colonic dilatation measuring up to 6.7 cm in the
transverse colon
with a large amount of fecal loading. No evidence of
perforation or
pneumatosis. Mesenteric edema and small amount of ascites may
be associted, underlying ischemia not excluded.
2. Mild rectal wall thickening and perirectal fat stranding
could reflect
stercoral colitis.
3. Bibasilar consolidation likely reflects atelectasis, but
superimposed
aspiration pneumonitis cannot be excluded.
___: cat scan abdomen and pelvis:
. No evidence of obstruction.
2. Small bilateral pleural effusions.
___: chest x-ray:
3 successive frontal chest radiographs show advancement of the
feeding tube
from the upper esophagus to the mid stomach to the distal
stomach. Wire
stylet is withdrawn several cm from the tip.
Small right pleural effusion is decreased since ___. Lungs
clear. Heart size normal.
___ 12:31 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
OXACILLIN Sensitivity testing confirmed by Sensititre.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- 2 R
TETRACYCLINE---------- 8 I
VANCOMYCIN------------ 1 S
PATHOLOGIC DIAGNOSIS:
1) Colon, sigmoid, partial colectomy:
- Diffuse mucosal and submucosal ischemia with transmural acute
inflammation extending to
specimen margins.
2) Colon, partial colectomy:
- Patchy mucosal and submucosal ischemia with transmural acute
inflammation extending to one
specimen margin.
- Mucosal and submucosal ischemia with transmural inflammation
and pseudomembranes; see note.
- Ischemic changes extend to both specimen margins.
- Three lymph nodes with no malignancy identified (___).
Note: Pseudomembrane formation can be seen in ischemic colitis;
other causes, such as C. difficile
infection cannot be excluded.
Brief Hospital Course:
The patient was found to have an acute abdomen and taken to the
OR emergently for ex-lap and sigmoid resection. He was left with
an open abdomen. He was admitted to the ICU post-operatively.
ICU Course:
Immediately post-op, the patient's pressor requirement began to
decrease. He was started on broad-spectrum antibiotics. However,
the night of POD0, his pressor requirement significantly
increased and abdomen became more distended. He was taken
emergently back to the operating room and underwent completion
colectomy and again left with an open abdomen. His pressors
again were weaned post-operatively.
Throughout POD1, the patient was resuscitated throughout the
day. He was continued on broad spectrum antibiotics and his
pressors were weaned. On POD2, he was again brought to the OR
and underwent resection of his rectal stump. He continued to
removed post-operatively. On POD___, he was weaned off pressors
and remained hemodynamically stable with an improving abdominal
exam. The following day he was brought to the OR and underwent
end ileostomy and abdominal closure. A VAC dressing was placed
to facilitate wound closure.
On ___, the patient was successfully extubated. His NGT was
kept in and his antibiotics were continued. He remained
hemodynamicallys table once extubated and was transferred to the
floor.
The patient was transferred to the surgical floor on ___. His
___ tube and foley catheter were removed and the
patient was voiding without difficulty. His antibiotics were
discontinued. His vital signs were stable and he resumed a
regular diet on ___. His appetite remained diminished despite
resuming the patient's favorite foods. Along with the
diminished appetite, the patient was noted to have decreased
ostomy output. An x-ray of the abdomen was done which showed no
abnormally dilated loops of large or small bowel. To provide
nutrition to the patient, a Dobhoff tube was placed and tube
feedings started. The vac dressing was discontinued on ___
after the wound was reported to be decreasing in size. Moist to
dry dressings were applied.
In preparation for discharge, the patient was evaluated by
physical therapy and recommendations made for discharge to
rehabilitation facility because of the patient's current nursing
needs which are unable to be met in the group home.
The patient was discharged on ___ in stable condition. His
vital signs were stable and he was afebrile. He was tolerating
cyclic tube feedings via a Dobhoff as well as regular diet. He
was voiding via a condom catheter. Ostomy output was still
somewhat diminished. Please monitor ostomy output, patient has
been placed on Colace. Appointments for follow-up were made
with the Acute care clinic.
*********Rehabilitation stay expected to be less than 30
days*************
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
2. Memantine 10 mg PO DAILY
3. Carbamide Peroxide 6.5% 4 DROP AD 1X/WEEK (___)
4. Tamsulosin 0.8 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO QHS
7. Docusate Sodium 50 mg PO QHS
8. Cyanocobalamin 1000 mcg PO DAILY
9. Loratadine 10 mg PO DAILY
10. Psyllium Powder 1 PKT PO TID
11. Mupirocin Ointment 2% 1 Appl TP TID:PRN rash
12. GuaiFENesin 5 mL PO Q4H:PRN cough
13. Bisacodyl 10 mg PR QHS:PRN constipation
14. Finasteride 5 mg PO DAILY
15. Carbidopa-Levodopa CR (50-200) 1 TAB PO TID
Discharge Medications:
1. Carbamide Peroxide 6.5% 4 DROP AD 1X/WEEK (___)
2. Carbidopa-Levodopa CR (50-200) 1 TAB PO TID
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
4. Finasteride 5 mg PO DAILY
5. GuaiFENesin 5 mL PO Q4H:PRN cough
6. Memantine 10 mg PO DAILY
7. Tamsulosin 0.8 mg PO DAILY
8. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
9. Artificial Tear Ointment 1 Appl BOTH EYES PRN eye care
10. Famotidine 20 mg PO DAILY
11. Heparin 5000 UNIT SC BID
12. Miconazole Powder 2% 1 Appl TP QID:PRN bothersome rash
13. Cyanocobalamin 1000 mcg PO DAILY
14. Loratadine 10 mg PO DAILY
15. Mupirocin Ointment 2% 1 Appl TP TID:PRN rash
16. Docusate Sodium 50 mg PO QHS
monitor stool output: call if ostomy output >1200 or < 500
cc....
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Ischemic bowel
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Downs: non-verbal at baseline
Discharge Instructions:
You were admitted to the hospital with abdominal distention and
an elevated white blood cell count. You were taken to the
operating room for an exploratory laparotomy on ___ and
subsequent
reoperation later on the ___ and then again on the ___ for
ischemic bowel. You returned to the operating room on ___ for
an ex-lap, end ileostomy, and closure of abdomen. You were
monitored in the intensive care unit for blood pressure
management, fluid resuscitation, and intubation. After your
vital signs stabilized and the breathing tube was removed, you
were transferred to the surgical floor. Your vital signs have
been stable. You had a Dobhoff feeding tube placed to provide
you with nutrition until your appetite improved. Your VAC
dressing has been removed, since your wound is decreasing in
size. You have been screened for a ___ facility to
continue with the Dobhoff feedings. You are being discharged
with the following instructions:
You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please notify ___ clinic/surgeon, Dr. ___ ostomy output
greater than 1500cc or less than 50 cc/day ( ___
Followup Instructions:
___
|
19848478-DS-5
| 19,848,478 | 22,224,852 |
DS
| 5 |
2142-09-25 00:00:00
|
2142-09-25 16:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Aricept / ibuprofen
Attending: ___
Chief Complaint:
Altered mental status and concern for seizure episode
Major Surgical or Invasive Procedure:
PEG placement
History of Present Illness:
___ is a ___ with PMHx significant for Downs Syndrome
with advanced
Alzheimer's, impaired bowel motility now with ileostomy who at
baseline is awake, non-verbal, has not walked in ~6 months, but
is able to be fed by the staff at his group ___ (no G Tube) who
now presents with 36 hours of worsening AMS followed by an event
observed at ___ concerning for a seizure. He has no known
history of seizures and has never been on any anti-seizure meds
but has had observed myoclonic jerking for several years now. In
fact, an outpatient EEG was recommended after a neurology clinic
visit last year, but this was never performed. Usually, he is
able to sit in his wheelchair and participates in activities at
his day program and at the group ___ although this is rather
limited. Starting yesterday evening, he had no interest in
eating
(usually his favorite nurse can always get him to eat with full
assistance). He went to bed around ___. This morning at
6:30am, he was put into his chair but was very sleepy and not
his
usual self. The nurses at his group ___ tried to feed him at
12pm but he would not wake up. This was very odd for him so he
was taken to ___ for evaluation. Of note, he has not had
any evidence of fever or infection and has not appeared in any
pain or discomfort lately. At ___, routine labs were
unrevealing. ___ showed marked ventriculomegally and atrophy
but no acute mass, hemorrhage, or infarction. One of the workers
at the ___ ___ was sitting with him at ___ when he had
a seizure event where
his whole body went tense followed by some shaking (she thinks
it
was both arms and legs at the same time and his eyes appeared
crossed, not to one direction or the other). This lasted about
30
seconds. He was given Ativan 1mg + 1000g fosphenytoin (per the
outside records) and was transferred to ___ for further
evaluation.
Unable to obtain ROS as the patient is non-verbal.
IMAGING:
___: (my review) marked ventriculomegaly and atrophy, no
hemorrhage, no large hypodensity or midline shift
CTA H/N
1. Atrophy with no evidence of mass, hemorrhage or infarction.
2. 2 mm infundibulum or aneurysm arising from the supraclinoid
segment of the
right internal carotid artery.
3. Otherwise normal head and neck CTA.
Past Medical History:
DEMENTIA (ALZHEIMERS)
DOWNS SYNDROME
BOWEL IMOTILITY S/P ILEOSTOMY
EDENTULOUS
EYEGLASSES
IRON DEFICIENCY ANEMIA
RENAL INSUFFICIENCY
NON VERBAL
H/O HEMORRHOIDS
H/O CONSTIPATION
H/O PERNICIOUS ANEMIA
H/O BENIGN PROSTATIC HYPERTROPHY
H/O VITAMIN B12 DEFIC
H/O BACK PAIN
Social History:
___
Family History:
Relative Status Age Problem Comments
Mother ___ ___ BLADDER CANCER
Father ___ HYPERTENSION
DIABETES MELLITUS
HYPOTHYROIDISM
MYELODYSPLASTIC radiation exposure
SYNDROME
Sister Living ACOUSTIC NEUROMA
HYPERTENSION
Brother LYMPHOSARCOMA
Comments: 1b, 2sisters
Physical Exam:
===ADMISSION EXAM===
GENERAL EXAM:
- Vitals: 68 102/49 20 99%RA
- General: eyes closed, spontaneously moves non-purposefully,
Non-toxic appearing, no obvious distress
- HEENT: NC/AT
- Neck: increased axial tone
- Pulmonary: CTABL
- Cardiac: RRR
- Abdomen: soft, nondistended, not rigid, no guarding, ++BS
- Extremities: pressure sore on left heel
NEURO EXAM:
Eyes closed, does not open them to verbal or noxious stimulation
but will resist eye opening, no commands, non verbal.
Spontaneously moves his arms and legs in the plane of the bed
but this appears non-purposeful. Pupils: R 1.5mm left 3mm,
minimally reactive. Left eye esotropia. +VOR of both eyes but
they are
disconjugate and will not VOR to end gaze in either direction
except left eye at baseline fully adducted. + brisk corneals
bilaterally. Will grimace to noxious with no obvious droop.
Yawns occasionally with occasional mouth chewing movements
accompanied but intermittent mouth jerks. Increase tone and
rigidity
throughout. +strong grasp bilaterally. +glabellar, +suckle. When
testing grasp, will hold arms antigravity for ~3 seconds before
letting them fall back to the bed. Myoclonic jerking observed in
the L>R upper extremities with spontaneous movements. BLE with
brisk withdraw to tickle in the plane of the bed but almost make
it fully antigravity for brief periods. Reflexes difficult to
elicit secondary to diffused increased tone throughout but no
clonus and toes up bilaterally.
===DISCHARGE EXAM===
GENERAL EXAM:
- Vitals (24hr): Tmax/Tcurrent 99.7/97.8 BP 95-130/56-77 HR
72-100 RR ___ RA
- General: NAD
- HEENT: NC/AT
- Neck: increased axial tone
- Pulmonary: Breathing comfortably on RA
- Cardiac: No pallor, no diaphoresis
- Abdomen: No tenderness to palpation
- Extremities: healing pressure sore on left heel. Symmetric, no
edema.
NEURO EXAM:
Arouses to voice and exhibits sustained eye opening.
Spontaneously moves his arms and legs in the plane of the bed
with some purposeful movements (guarding face, yawning). Pupils:
R 1.5mm left 3mm, minimally
reactive. Left eye esotropia. +VOR of both eyes but they are
disconjugate and will not VOR to end gaze in either direction
except left eye at baseline fully adducted. + brisk corneals
bilaterally. Will grimace to noxious with no obvious droop.
Yawns
occasionally with occasional mouth chewing movements accompanied
but intermittent mouth jerks. Increase tone and rigidity
throughout. +strong grasp bilaterally. +glabellar, +suckle. When
testing grasp, will hold arms antigravity for ~3 seconds before
letting them fall back to the bed. At least full strength in
biceps. Occasional myoclonic jerking observed in upper
extremities with spontaneous movements. BLE with brisk withdraw
to tickle in the plane of the bed but almost make
it fully antigravity for brief periods. Reflexes difficult to
elicit secondary to diffused increased tone throughout but no
clonus and toes up bilaterally.
Pertinent Results:
ON ADMISSION:
___ 08:15PM BLOOD WBC-8.0# RBC-4.62# Hgb-13.1*# Hct-42.9#
MCV-93 MCH-28.4# MCHC-30.5* RDW-16.4* RDWSD-55.7* Plt ___
___ 08:15PM BLOOD Neuts-69.1 Lymphs-17.9* Monos-10.6
Eos-0.8* Baso-1.0 Im ___ AbsNeut-5.50# AbsLymp-1.42
AbsMono-0.84* AbsEos-0.06 AbsBaso-0.08
___ 08:15PM BLOOD Plt ___
___ 08:15PM BLOOD Glucose-108* UreaN-19 Creat-1.2 Na-139
K-4.4 Cl-101 HCO3-24 AnGap-18
___ 08:15PM BLOOD ALT-20 AST-24 LD(LDH)-227 AlkPhos-94
TotBili-0.5
___ 08:15PM BLOOD cTropnT-<0.01
___ 08:15PM BLOOD Albumin-3.6 Calcium-8.6 Phos-4.0 Mg-2.1
___ 08:15PM BLOOD Phenyto-15.9
___ 09:13AM URINE Color-Straw Appear-Hazy Sp ___
___ 09:13AM URINE RBC-4* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ BLOOD CULTURES SHOW NO GROWTH
CTA HEAD AND NECK
1. Atrophy with no evidence of mass, hemorrhage or infarction.
2. 2 mm infundibulum or aneurysm arising from the supraclinoid
segment of the
right internal carotid artery.
3. Otherwise normal head and neck CTA.
---
OTHER:
___ 04:47AM BLOOD WBC-13.8*# RBC-4.30* Hgb-12.6* Hct-38.7*
MCV-90 MCH-29.3 MCHC-32.6 RDW-16.2* RDWSD-53.1* Plt ___
___ 04:55AM BLOOD WBC-11.2* RBC-4.35* Hgb-13.0* Hct-39.8*
MCV-92 MCH-29.9 MCHC-32.7 RDW-17.0* RDWSD-56.2* Plt ___
___ 07:05PM BLOOD WBC-13.0* RBC-4.59* Hgb-13.3* Hct-41.2
MCV-90 MCH-29.0 MCHC-32.3 RDW-16.5* RDWSD-54.3* Plt ___
___ 05:08AM BLOOD WBC-10.5* RBC-4.48* Hgb-12.9* Hct-41.4
MCV-92 MCH-28.8 MCHC-31.2* RDW-16.9* RDWSD-56.9* Plt ___
___ 05:13AM BLOOD WBC-9.2 RBC-4.42* Hgb-12.8* Hct-39.8*
MCV-90 MCH-29.0 MCHC-32.2 RDW-16.6* RDWSD-54.9* Plt ___
___ 05:16AM BLOOD WBC-10.7* RBC-4.62 Hgb-13.2* Hct-41.4
MCV-90 MCH-28.6 MCHC-31.9* RDW-16.4* RDWSD-53.6* Plt ___
___ 04:55AM BLOOD Neuts-79.5* Lymphs-12.3* Monos-6.3
Eos-0.9* Baso-0.4 Im ___ AbsNeut-8.89*# AbsLymp-1.37
AbsMono-0.70 AbsEos-0.10 AbsBaso-0.05
___ 07:05PM BLOOD Neuts-84.4* Lymphs-8.0* Monos-6.4
Eos-0.2* Baso-0.4 Im ___ AbsNeut-10.94* AbsLymp-1.04*
AbsMono-0.83* AbsEos-0.03* AbsBaso-0.05
___ 06:46AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.8
___ 05:08AM BLOOD Phos-3.6 Mg-2.1
___ 05:21AM BLOOD Phenyto-17.0
___ 04:47AM BLOOD Phenyto-11.4
___ 04:55AM BLOOD Phenyto-11.1
___ 05:08AM BLOOD Phenyto-9.0*
___ 05:13AM BLOOD Phenyto-7.8*
___ 05:16AM BLOOD Phenyto-8.1*
URINE
___ 09:30PM URINE RBC-2 WBC-7* Bacteri-FEW Yeast-NONE
Epi-<1
___ 09:30PM URINE Color-Straw Appear-Clear Sp ___
OTHER IMAGING/TESTS
EEG
This is an abnormal continuous EMU study because of sharp wave
discharges in the bilateral frontal regions, more common on the
left,
indicative of an underlying region of cortical irritability.
There are
independent, generalized sharp waves which occur with a
triphasic
morphophlogy, in addition to generalized slowing and
disorganization of the
background, both of which are indicative of a moderate
encephalopathy which is nonspecific with regards to etiology.
There are no pushbutton activations.
Brief Hospital Course:
Mr. ___ is a ___ with a history of Down Syndrome,
advanced Alzheimer's dementia , and gastric dysmotility
complicated by bowel ischemia status-post ileostomy (___)
who presented with altered mental status and an episode
concerning for a seizure. cvEEG monitoring showed epileptiform
discharges, which are occasionally periodic, without
electrographic seizure. Seizure with prolonged post-ictal state
remains most likely etiology. His history of Down Syndrome and
Alzheimer's dementia predispose him to development of epilepsy,
and these same conditions, along with his benzodiazepine
administration upon presenting in the ER at ___, predict a
prolonged post-ictal state. Unremarkable infectious workup and
negative imaging make infection, tumor, trauma, or stroke less
likely. Patient's HCP, ___, declined lumbar
puncture to further work up encephalitides. Patient's alertness
and myoclonic jerking has improved over admission on Phenytoin,
though still below baseline according to sister and group ___
aides. In light of aspiration risk and somnolence, patient has
been NPO during admission and underwent primary PEG procedure on
___ for nutrition following consent from ___.
Procedure was successful and patient began feeding and receiving
medications via gastric tube on ___.
On recent neurologic exam, arouses to voice and exhibits
sustained eye opening, but does not respond to commands.
Slightly improved myoclonus in upper extremities since
admission. At rest eyes closed and resist eye opening. L>R
anisocoria, +corneals, L esodeviation (finding noted in ___ by
outpatient neurologist Dr. ___, does not cross midline even
with VOR, no obvious droop with grimace, moving all extremities
in the plane of the bed with no marked asymmetry to noxious
stimuli. Upper extremity strength is at least anti-gravity. He
does have occasional myoclonic jerks in the arms. Toes up.
Case Management has arranged for discharge to The ___ in
___ for further rehabilitation and supervision. HCP and
sister ___ has agreed to this arrangement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbamide Peroxide 6.5% 4 DROP AD 1X/WEEK (___)
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
3. Finasteride 5 mg PO DAILY
4. GuaiFENesin 5 mL PO Q4H:PRN cough
5. Tamsulosin 0.8 mg PO DAILY
6. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
7. Cyanocobalamin 1000 mcg PO DAILY
8. Loratadine 10 mg PO DAILY
9. Mupirocin Ointment 2% 1 Appl TP TID:PRN rash
10. Carbidopa-Levodopa CR (50-200) 1 TAB PO TID
11. Famotidine 20 mg PO DAILY
12. Silver Sulfadiazine 1% Cream 1 Appl TP PRN Apply small
amount to skin break down on coccyx (tail bone) as needed.
13. Miconazole Powder 2% 1 Appl TP BID:PRN For bothersome red
rash.
Discharge Medications:
1. Multiple Vitamins Liq. 5 mL PO DAILY
2. Phenytoin Infatab 100 mg PO TID
3. Simethicone 80 mg PO QID:PRN abdominal discomfort or
distention
4. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
5. Bisacodyl 10 mg PR QHS:PRN no bowel movement x 3d
6. Carbamide Peroxide 6.5% 4 DROP AD 1X/WEEK (___)
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
8. Cyanocobalamin 1000 mcg PO DAILY
9. Famotidine 20 mg PO DAILY
10. Finasteride 5 mg PO DAILY
11. GuaiFENesin 5 mL PO Q4H:PRN cough
12. Loratadine 10 mg PO DAILY
13. Mupirocin Ointment 2% 1 Appl TP TID:PRN rash
14. Polyethylene Glycol 17 g PO DAILY
15. psyllium husk 1.04 gm oral QHS:PRN chronic constipation
16. Senna with Docusate Sodium (sennosides-docusate sodium)
8.6-50 mg oral QHS
17. Tamsulosin 0.8 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizure
prolonged post-ictal period
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
___,
You were admitted with confusion, and were seen to have a
seizure at the other hospital. Your confusion slowly improved,
but did not fully improve. Your swallow was not safe and to help
prevent pneumonia, we placed a feeding tube in your stomach.
Placement in a living facility, the ___ in ___,
was arranged for further rehabilitation and your sister agreed
with this plan.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19848570-DS-7
| 19,848,570 | 20,927,038 |
DS
| 7 |
2120-12-13 00:00:00
|
2120-12-13 11:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
grass pollen
Attending: ___.
Chief Complaint:
Weakness and tingling of left upper extremity
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with the past medical
history of Stage IV rectal cancer with metastatic disease to the
liver and lung previously treated
with surgical resection and chemotherapy, with cessation of
chemo
in ___ for lack of response, presenting from ___
with new intracranial right frontal lobe lesion. He noted that
over the past week, he has had weakness of his left shoulder and
hand, mild initially, characterized by having messier
handwriting, progressive, and associated with parasthesias of
his
left forearm. He noted that he was bumping into doors, and on
the day of presentation, had difficulty walking in the grocery
store, so his neighbor brought him to ___. He denies
having any headaches, nausea, vomiting, vision changes, speech
changes, constipation, diarrhea. He does note a non-productive
cough over weeks to months but no associated fevers or
rhinorrhea.
At ___ of the head notable for metastasis of brain
with extensive vasogenic edema with mild midline shift of 1-2
mm,
effacement of sulci, no herniation on CT.
Lab work notable for white blood cell count 5.7 hemoglobin 11.9
hematocrit 34.6 MCV 84.6 platelets 22 segmented neutrophils 70%
sodium 139 potassium 4.1 chloride 102 bicarb 27 anion gap 10
glucose 110 BUN 23 creatinine 1.0 GFR greater than 60 calcium
9.3
magnesium 2.2. Urinalysis clear yellow specific gravity 1.015 pH
6.0 negative bile albumin glucose ketones blood to be C esterase
nitrate 0 WBCs RBCs.
Vitals in the ___ ER: 98.2 85 114/72 18 95% RA
There, the patient received:
___ 02:55 IV Dexamethasone 4 mg
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative
Past Medical History:
Lower GI bleed, s/p embolization of ___ ___
Rectal cancer (CMS/HCC) [C20] ___ - Present
Secondary malignant neoplasm of liver (CMS/HCC) [C78.7]
___ - Present
Seasonal allergies [J30.2]
Iron deficiency anemia due to chronic blood loss; Diarrhea;
Enlarged prostate with lower urinary tract symptoms (LUTS);
Secondary malignant neoplasm of liver and intrahepatic bile
duct;
Drug-induced polyneuropathy (CMS/HCC); Anemia in neoplastic
disease; Neutropenia (CMS/HCC); Other secondary
thrombocytopenia**
Dupuytren contracture surgery on his left hand, abdominoperineal
resection on ___ for rectal cancer
Asthma
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
97.6
PO 103 / 64 66 18 96 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM. Colostomy stoma c/d/i
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities
PSYCH: pleasant, appropriate affect
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time. Ambulating in room without difficulty.
CRANIAL NERVES: II-XII intact grossly. Facies symmetric.
STRENGTH: Bilateral ___ grip strength.
SENSATION: to light touch fingertips to elbows bilaterally they
are symmetric.
COORDINATION: Normal gait. FTN intact bilaterally.
Pertinent Results:
___ 05:02AM BLOOD WBC-5.6 RBC-4.00* Hgb-11.8* Hct-35.1*
MCV-88 MCH-29.5 MCHC-33.6 RDW-12.9 RDWSD-41.1 Plt ___
___ 05:02AM BLOOD Glucose-135* UreaN-23* Creat-0.9 Na-141
K-4.3 Cl-101 HCO3-30 AnGap-10
___ 06:30AM BLOOD ALT-14 AST-26 AlkPhos-105 TotBili-0.4
___ 06:30AM BLOOD Albumin-3.7 Calcium-8.9 Phos-2.6* Mg-2.1
___:
EXAMINATION: CT scan of the abdomen pelvis with intravenous
contrast
INDICATION: ___ year old man with stage IV rectal ca mets to
lung/liver//
staging; had the last CT torso via ___ on ___
TECHNIQUE: Oncology 2 phase: Multidetector CT of the abdomen
and pelvis was
done as part of CT torso with IV contrast. A single bolus of IV
contrast was
injected and the abdomen and pelvis were scanned in the portal
venous phase,
followed by scan of the abdomen in equilibrium (3-min delay)
phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy
(Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 10.8 s, 0.2 cm; CTDIvol = 144.5 mGy
(Body) DLP =
28.9 mGy-cm.
3) Spiral Acquisition 10.5 s, 68.4 cm; CTDIvol = 6.7 mGy
(Body) DLP = 455.7
mGy-cm.
4) Spiral Acquisition 3.8 s, 24.9 cm; CTDIvol = 6.9 mGy
(Body) DLP = 167.1
mGy-cm.
Total DLP (Body) = 653 mGy-cm.
COMPARISON: CT scan of the torso dated ___. MRI
of the abdomen
dated ___. Please note that the most recent comparison
CT from outside
hospital dated ___ is not available for review at time
of this
dictation.
FINDINGS:
LOWER THORAX: Multiple pulmonary metastases. Please refer to
the separate
report of CT chest performed on the same day for description of
the thoracic
findings.
HEPATOBILIARY: Previously visualized 38 mm segment 6 hepatic
lesion is no
longer identified, and has been previously treated with Y 90.
There is a new
segment 6 segment 6 hypodense lesion measuring 22 mm (axial
series 4, image
60). 9 mm hypodense lesion within segment 8 (axial series 4,
image 49) is
also new from previous. Multiple subcentimeter hypodense
lesions are too
small to characterize, likely representing small cysts or
hamartomas, the
majority of which appear unchanged dating back to MRI from ___. 15 mm
low-attenuation lesion (axial series 4, image 59) along the
posterior surface
of the right hepatic lobe may represent a small cyst, less
likely a capsular
deposit. No biliary ductal dilatation. Unremarkable
gallbladder.
PANCREAS: Unremarkable.
SPLEEN: The spleen measures 13.4 cm in maximal ___,
previously 13.4 cm.
ADRENALS: The adrenal glands are normal in size and morphology.
URINARY: The kidneys are unremarkable. Left-sided extrarenal
pelvis. No
hydronephrosis. Unremarkable bladder.
GASTROINTESTINAL: Soft tissue thickening at the level of the
gastroesophageal
junction appears stable dating back to ___. Small
bowel loops are
normal in caliber. There are several nonobstructed small bowel
loops which
are contained within a right-sided inguinal hernia. Patient is
status post
APR, with diverting left lower quadrant colostomy.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are
unremarkable.
LYMPH NODES: No retroperitoneal or mesenteric adenopathy. No
pelvic or
inguinal adenopathy.
PERITONEUM, RETROPERITONEUM, MESENTERY: Persistent plaque-like
thickening
within the presacral space (axial series 4, image 108). No
discrete soft
tissue mass.
VASCULAR: No abdominal aortic aneurysm. Mild atherosclerotic
calcification.
BONES: Degenerative changes of the thoracolumbar spine, worst at
T12-L1 and
L4-L5. Rounded area of sclerosis in the L3 vertebral body,
vaguely present on
the prior examination and unchanged in size.
SOFT TISSUES: Left lower quadrant colostomy. Right-sided
inguinal hernia
containing a nonobstructed loop of small bowel. Right-sided
hydrocele,
partially imaged.
IMPRESSION:
Please note that the most recent outside examination dated
___ is not
available for comparison at the time of this dictation.
Comparison is made to
___.
1. Previously treated segment 6 hepatic lesion is no longer
identified. 2 new
lesions within segments 6 and 8 are suspicious for new hepatic
metastases.
2. Stable presacral soft tissue thickening is nonspecific and
may represent
post treatment change. Attention on follow-up is recommended.
3. Persistent soft tissue thickening at the level of the
gastroesophageal
junction is stable from previous and may represent thickening of
the
diaphragm, however attention on follow-up is recommended.
4. Right-sided inguinal hernia containing a nonobstructed loop
of small bowel.
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: Indications: Staging; had the last CT torso via ___
___ on
___.
___ year old man with stage IV rectal ca mets to lung/liver
TECHNIQUE: Multi detector helical scanning of the chest was
coordinated with
intravenous infusion of nonionic iodinated contrast agent and
reconstructed as
5 and 1.25 mm thick axial, 5 mm thick coronal and parasagittal,
and 8 mm MIP
axial images. All images were reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy
(Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 10.8 s, 0.2 cm; CTDIvol = 144.5 mGy
(Body) DLP =
28.9 mGy-cm.
3) Spiral Acquisition 10.5 s, 68.4 cm; CTDIvol = 6.7 mGy
(Body) DLP = 455.7
mGy-cm.
4) Spiral Acquisition 3.8 s, 24.9 cm; CTDIvol = 6.9 mGy
(Body) DLP = 167.1
mGy-cm.
Total DLP (Body) = 653 mGy-cm.
** Note: This radiation dose report was copied from CLIP
___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: The chest ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: In the left
supraclavicular station
0.7 cm lymph nodes, not pathologically enlarged (05:26). There
is no axillary
lymphadenopathy. There are no soft tissue metastatic deposits
in the chest
wall.
CHEST CAGE: Multilevel mild-to-moderate degenerative changes of
the mid and
lower thoracic vertebra but there is no evidence of lytic or
sclerotic osseous
destructive metastatic lesions at the level of the ribs,
vertebra or sternum.
UPPER ABDOMEN: Please see separately dictated CT of the abdomen
and pelvis for
complete description of subdiaphragmatic findings.
MEDIASTINUM: There is extensive mediastinal and hilar
lymphadenopathy,
essentially new since ___, including the right
upper paratracheal
station 4 x 3.3 cm conglomerate and subcarinal 5 x 1.8 cm
conglomerate. The
SVC is patent, and there is no significant compression of the
carina and
central bronchi.
HILA: The there is extensive hilar lymphadenopathy. Lingular 7
cm metastatic
deposit continuous within the left hilus, obstructing the
subsegmental bronchi
(5:143). In the right hilus 6 by 3.5 cm mass extends into the
right upper
lobe narrowing and displacing the right upper lobe bronchi which
remain
patent.
HEART and PERICARDIUM: Heart is normal in size. Multiple
metastatic deposits
located in the lingula and right lower lobe for example abut the
pericardium,
but there is no pericardial effusion or clear evidence of
pericardial
invasion.
Right Port-A-Cath terminates in the right atrium. Sub optimal
opacification
of pulmonary vasculature is no filling defects in the in the
main pulmonary
arteries or central branches. Some of the metastatic deposits
exert
mass-effect on pulmonary arteries and veins (5:156 for example).
LUNG and PLEURA: Tracheo bronchial tree is patent centrally. As
mentioned
above the lingular perihilar mass obstructs subsegmental
bronchus with no
significant atelectasis. Other are subsegmental obstruction in
the right
lower lobe (5:159). There are numerous large metastatic
deposits involving
both lungs which are essentially new in comparison to ___. Examples
include the right lower lobe 5 x 4 cm mass (5:159), left lower
lobe 4.3 x 2.5
cm mass (5:193).
There is no pleural effusion. Biapical pleuroparenchymal
scarring is stable.
IMPRESSION:
Extensive metastatic disease in the thorax involve the lungs,
mediastinum and
hila, essentially new in comparison to ___.
EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with metastatic rectal cancer and
new right
frontal brain mass with surrounding edema// please further
characterize, and
for planning for possible XRT.
TECHNIQUE: Sagittal and axial T1 weighted imaging were
performed. After
administration of 7 mL of Gadavist intravenous contrast, axial
imaging was
performed with gradient echo, FLAIR, diffusion, and T1
technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and
coronal
orientations.
COMPARISON: CT head ___
FINDINGS:
There is a 3 cm lesion with peripheral and internal enhancement
within the
right superior. The lesion and associated vasogenic edema
result in local
mass effect with leftward displacement of the falx, inferior
displacement of
the body of the corpus callosum, and narrowing of the right
lateral ventricle.
The basilar cisterns are patent.
There is a 3 mm inferiorly directed aneurysm from the
supraclinoid segment of
the left ICA, likely a superior hypophyseal artery aneurysm
(image 3, series
16).
No other enhancing lesions are identified.
No acute infarction is identified.
The orbits are unremarkable.
IMPRESSION:
1. 3 cm enhancing lesion within the right superior frontal gyrus
with marked
vasogenic edema and trace blood products. Mass effect with
leftward
displacement of the falx, inferior displacement of the body of
the corpus
callosum, and narrowing of the right lateral ventricle. The
basilar cisterns
are patent. Given the clinical history, this lesion is highly
suspicious for
metastatic disease.
2. No other enhancing lesions are identified.
3. 3 mm left superior hypophyseal artery aneurysm.
Brief Hospital Course:
___ gentleman with stage IV rectal cancer with mets to
liver and lung s/p chemoradiation followed by abdominoperineal
resection who presents with LUE weakness and clumsiness,
tingling.
#LUE focal weakness/clumsiness, tingling.
#Right frontal brain metastasis with vasogenic edema
#History of stage IV rectal cancer with mets to liver and lung
s/p
chemoradiation followed by abdominoperineal resection which did
reveal residual disease and FOLFOX completing 12 cycles with
progression of his liver metastasis and stable very small lung
mets. Underwent Y90 to his liver lesion on ___ with evidence
of response on CT scan but unfortunately had progression with
new
lung mets. Currently s/p 19 cycles of FOLFIRI with progression
of
disease now s/p 2 cycles of Lonsurf.
On ___ we were able to get in touch with the primary
oncologist Dr. ___ ___ (unreachable during the
weekend). She reports the patient has an exceedingly poor
prognosis given the new brain met discovery plus our
CT torso suggesting advancing metatstatic disease,
combined with the fact that he had failed to respond to prior
rounds of treatment, and that she had tried but found that he
was
ineligible for any new clinical trials even at ___. She felt
that
neurosurgery would not be the best treatment approach and rather
radiation may be better ___ for him. The patient was provided
this update and agreed with radiation, preferred to have this
arranged with Dr. ___ at ___.
-He was seen by radonc here. He was then arranged for follow up
with Dr. ___ week of discharge and with Dr. ___
palliative care planning.
-The patient responded very well with IV dexamethasone and he
only had LUE minimal intermittent tingling sensation. His
strength was ___, and coordination in LUE is improved. He is
discharged on oral dexamethasone taper that Dr. ___ will
continue to follow for him.
-He is placed on keppra prophylaxis. He was instructed that he
is not permitted to drive due to risk of seizures of untreated
brain mets.
Greater than 30 minutes was spent on discharge planning and
coordination.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
2. Dexamethasone 4 mg PO Q8H
RX *dexamethasone 2 mg 2 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
3. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Ferrous Sulfate 325 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic rectal cancer with new brain lesion
Increased metastatic burden of liver lesions and lung lesions.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Discharge Instructions:
Instructions: Dear Mr. ___,
It was a pleasure to be a part of your care team at ___
___.
====================================
Why did you come to the hospital?
====================================
-You had left upper extremity coordination problems.
====================================
What happened at the hospital?
====================================
-You were diagnosed with metastatic disease to the brain. It is
most likely due to advanced progression of the metastatic rectal
cancer.
-You also underwent CT scan of the chest and abdomen which
demonstrated further progression of the lung metastatic disease,
compared to your ___ scans. The liver metastatic disease has
also increased, compared to the ___ scans.
-You were seen by the neurosurgeons who recommended
dexamethasone (a steroid that reduces inflammation) and Keppra
(also known as levetiracetam, which helps prevent seizures
because brain metastatic disease increases risk of seizures).
-The dexamethasone reduced the inflammation/swelling in the
brain and helped reduce your symptoms. You will need to continue
taking this medication as recommended.
-Our general medicine team discussed with your oncologist, Dr.
___ the recommended next steps. Although surgery was a
potential option, because of your advanced disease and prognosis
as we discussed, radiation is a better option to help treat the
symptoms from the brain metastasis.
-Our radiation oncology team saw you in the hospital and helped
arrange for your follow up with Dr. ___ at ___.
==================================================
What needs to happen when you leave the hospital?
==================================================
-Unfortunately, due to the risk of seizures from the brain
metastases, you are NOT permitted to drive or operate heavy
machinery unless otherwise permitted by your radiation
oncologist after any treatments.
-Please follow up with Dr. ___ radiation planning as
scheduled.
-Please follow up with Dr. ___ palliative care planning,
as scheduled.
-Please take the dexamethasone and Keppra as prescribed. Take
the dexamethasone at 4mg three times daily for 3 days, then take
4 mg twice daily throughout all radiation treatments, then Dr.
___ recommend to you a further taper from then on.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
19848771-DS-15
| 19,848,771 | 23,349,241 |
DS
| 15 |
2176-01-28 00:00:00
|
2176-01-29 21:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Pegylated interferon / Levofloxacin
Attending: ___.
Chief Complaint:
sleepiness
Major Surgical or Invasive Procedure:
Therapeutic paracentesis
History of Present Illness:
HPI: Read and agree with Nightfloat note. In brief, ___ with HCC
cirrhosis with portal vein thrombus involvement not a transplant
candidate planning on starting sorafinib therapy here with
sleepiness and confusion x 1 day. States yesterday he was
nodding his head a lot, falling asleep, making his wife
concerned. He also notes he was sleeping more yesterday. He
states prior to this he had been taking his medications
regularly including his lactulose twice a day with ___ bowel
movements each day. He notes he did not have any lactulose on
the day of admission due to sleepiness. He is on high doses of
pain medications but those have not changed recently. He was
recently prescribed sorafenib but has not yet started taking
this medication. Denies any fevers, chills, new cough, shortness
of breath, nausea, abdominal pain, dysuria, rashes, diarrhea.
States his belly does feel large and feels he needs a
paracentesis with his last one being almost three weeks ago.
.
ROS: as above, also with 10lbs weight loss since ___
.
In the ED, triage vitals were T97.4, HR52, BP137/98, RR18, O2
sat 96%. On exam, A+O, neuro nonfocal, no asterixis. Labs
notable for INR 1.7, creatinine 1.4 (baseline 0.8-1.0),
bilirubin 4.4 (previously 2.2), trop <0.01. UA bland.
Paracentesis w/ 13 PMN, negative for SBP. CT head with prelim
read as no acute process. CXR with no acute cardiopulmonary
process. Patient has 18G, given 500cc IVF. Given lactulose 30ml
in ED as well as sandwich; tolerated both well. Most recent
vitals: T97.8, HR59, RR16, BP112/87, O2Sat: 97 on 2L
.
Currently, he feels more sleepy than usual but is answering
questions appropriately. Does intermittently fall asleep during
questioning. He had 3BMs overnight.
Past Medical History:
- Hepatitis C, chronic: diagnosed age ___, likely contracted
through IVDA, treated ___ with short course of peg-IFN,
cleared; last VL ND in ___
- Hepatitis B, acute: reportedly cleared
-Cirrhosis (radiographic evidence, no biopsy)
-grade II varices lower third of the esophagus (___)
-infiltrative HCC (no biopsy) involving both lobes of liver,
with infiltration of the portal vein (___)
-ascites
-hepatic encephalopathy
- ETOH abuse (quit ___ - He drank consistently for about ___
years until___ when he was treated for hepatitic C. He was
drinking up to
12 beers per day for about that time.
-porphyria cutanea tarda for which for
years he was having phlebotomies twice a year to keep his iron
level within the normal range.
- Hypertension
- Pulmonary nodules
- ___ Cyst of knee
- Cervical spondylosis s/p cervical laminectomy; has residual
chronic neuropathic pain chiefly affecting LUE (arm and ___ 3
digits of left hand)
- Gallstones
- Tobacco dependence
- Erectile dysfunction
- Nephrolithiasis
- PUD (on EGD in ___
Social History:
___
Family History:
Family history of colon cancer.
Physical Exam:
ADMISSION
VS: 98.4 125/82 71 18 97%RA
GEN: well-appearing, NAD, AOx3
HEENT: mild scleral icterus, o/p with white plaques
CV: RRR, no m/r/g
LUNGS: CTAB, scattered wheezes, good air entry
ABD: distended and somewhat firm, non-tender, tympanic to
percussion, palpable liver with nodular surface, +BS
EXT: 1+ edema to knees b/l
SKIN: palmar erythema and scabs from PCT
NEURO: somewhat sleepy, grossly intact, no asterixis
.
DISCHARGE
GEN: well-appearing, NAD, AOx3, alert and appropriate
HEENT: mild scleral icterus, MMM
CV: RRR, no m/r/g
LUNGS: CTAB, scattered inspiratory wheezes, good air entry
ABD: distended and somewhat firm, non-tender, tympanic to
percussion, palpable liver with nodular surface, +BS
EXT: trace pitting edema to knees b/l
SKIN: palmar erythema and scabs from PCT
NEURO: no asterixis
Pertinent Results:
ADMISSION LABS
___ 12:20PM BLOOD WBC-7.9 RBC-3.64* Hgb-11.4* Hct-37.9*
MCV-104* MCH-31.3 MCHC-30.1* RDW-17.1* Plt ___
___ 12:20PM BLOOD ___ PTT-36.9* ___
___ 12:20PM BLOOD Glucose-96 UreaN-14 Creat-1.4* Na-134
K-3.6 Cl-94* HCO3-26 AnGap-18
___ 12:20PM BLOOD ALT-51* AST-108* AlkPhos-640*
TotBili-4.4*
___ 12:20PM BLOOD Lipase-176*
___ 12:20PM BLOOD cTropnT-<0.01
___ 12:20PM BLOOD Albumin-3.6 Calcium-8.7 Phos-4.1 Mg-2.1
.
DISCHARGE LABS
___ 06:30AM BLOOD WBC-7.3 RBC-3.45* Hgb-10.8* Hct-35.4*
MCV-103* MCH-31.4 MCHC-30.6* RDW-17.7* Plt ___
___ 06:30AM BLOOD ___ PTT-35.2 ___
___ 06:30AM BLOOD Glucose-103* UreaN-17 Creat-1.1 Na-136
K-3.6 Cl-96 HCO3-26 AnGap-18
___ 06:30AM BLOOD ALT-40 AST-111* LD(LDH)-232 AlkPhos-484*
TotBili-5.0*
___ 06:30AM BLOOD Albumin-4.5 Calcium-9.0 Phos-2.5* Mg-2.3
.
MICRO
Blood cx ___ no growth to date
Peritoneal cxs ___ and ___ no growth
.
IMAGING
Head CT: No acute intracranial process.
.
Liver Doppler U/S: IMPRESSION:
1. Coarsened nodular liver, compatible with known cirrhosis
with HCC.
2. Extensive thrombus again seen expanding the portal veins and
extending
into the superior mesenteric veins.
3. Patent hepatic artery and hepatic veins.
4. Moderate ascites and borderline splenomegaly.
5. Cholelithiasis without cholecystitis.
.
U/S Guided Paracentesis
Ultrasound-guided therapeutic and diagnostic paracentesis with
removal of 1.3L of clear, straw-colored fluid.
Brief Hospital Course:
___ year old male with hx of hepatitis B and C status post
clearance following interferon treatment, recent admission for
new decompensated cirrhosis, found to have unresectable
hepatocellar carcinoma with portal vein involvement now admitted
with altered mental status.
.
# HEPATIC ENCEPHALOPATHY: Admitted w/ mild encephalpathy and
somnolence for one day. He was oriented and appropriate but
sleepy on exam. Patient reports compliance with his lactulose as
an outpatient so etiology unclear but possibly due to
hepatocellular carcinoma precipitating decompensated liver
disease and high dose of sedating narcotics/neurontin in setting
of reduced renal function. There were no signs of infection as
he had a negative UA, CXR, and diagnostic tap. RUQ ultrasound
with dopplers showed stable portal vein thrombus. Patient was
placed on q2h lactulose and cleared by hospital day #2. By the
time of discharge he was menally back at baseline. He was
discharged on lactulose four times a day and home rifaximin
dose. His narcotic dose was also decreased significantly to
oxycontin 80mg TID and renally dosed neurontin with no adverse
effects on overall pain control
.
#CIRRHOSIS: Patient with recent admission for new diagnosis of
cirrhosis, presumed secondary to chronic hepatitis B/C and
alcohol abuse. MELD score 21, ___ Score class III. He
noted some abdominal distention so a therapeutic paracentesis
was performed prior to discharge with removal of ~1L of fluid.
He was continued on rifaximin, lactulose, and nadolol.
.
#ACUTE RENAL FAILURE: Patient with baseline creatinine of
0.8-1.0 with creatinine of 1.4 on admission. Urine lytes
consistent with prerenal etiology. Improved with 72 hours of
albumin to 1.1. Diuretics were also held at discharge with plan
to resume on an outpatient basis.
.
#HEPATOCELLULAR CARCINOMA: Clinical characteristics, imaging and
serologies (tumor markers) most consistent with HCC although not
biopsy proven. He does not meet ___ and is thus
non-resectable or transplantable. The patient was supposed to
start on palliative Sorafenib on ___ to make his tumor
burden more amenable to cyberknife but had not yet started
taking this medication yet. Per Hem/Onc, he can resume this
medication on discharge. He was seen by Palliative Care and
outpatient services were offered to him.
.
STABLE ISSUES
#MACROCYTIC ANEMIA: Stable, possibly due to poor nutrition.
.
#QTC PROLONGATION: Stable
.
#HYPERTENSION: Stable. Continued on amlodipine for now but it
should be clarified if patient needs this medication in the
future.
.
#Peptic ulcer disease: Continued PPI
.
#CHRONIC NEUROPATHIC PAIN: High doses of narcotics were felt to
be contributting to patient's somnolence so his oxycontin was
decreased to 80mg TID from 240mg TID and gabapentin was renally
dosed. He was continued on baclofen and oxycodone as needed. He
reported adequate pain control at discharge.
TRANSITIONAL:
1. Lasix and spironolactone were stopped as creatinine was not
at baseline at discharge and it is possible that overdiuresis
contributed to acute renal failure. Would reassess volume status
at outpatient appointment to reconsider starting low dose
diuretics or arranging large volume paracentesis.
2. Evaluate pain control and adjust pain regimen as needed
3. Evaluate need for amlodipine as part of patient's blood
pressure regimen
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Pharmacy.
1. Lactulose 30 mL PO TID
2. Nadolol 20 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Spironolactone 50 mg PO DAILY
5. Rifaximin 550 mg PO BID
6. Sorafenib 400 mg PO DAILY
7. Amlodipine 5 mg PO DAILY
8. Baclofen 20 mg PO QID:PRN pain
9. Gabapentin 1600 mg PO TID
10. Pantoprazole 40 mg PO Q12H
11. Prazosin 5 mg PO BID
12. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
13. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
14. Oxycodone SR (OxyconTIN) 240 mg PO Q8H
15. Senna 2 TAB PO BID
Discharge Medications:
1. Sorafenib 400 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Baclofen 20 mg PO QID:PRN pain
4. Gabapentin 300 mg PO Q12H
hold for sedation
5. Lactulose 30 mL PO QID titrate to four bowel movements daily
6. Oxycodone SR (OxyconTIN) 80 mg PO Q8H
hold for sedation, rr<12
7. Pantoprazole 40 mg PO Q12H
8. Prazosin 5 mg PO BID
9. Rifaximin 550 mg PO BID
10. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
11. Nadolol 20 mg PO DAILY
12. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN severe
pain
Hold for sedation, RR<12
13. Senna 1 TAB PO BID constipation
hold for loose stools
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatic encephatlopathy
Cirrhosis
Hepatocellular carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care. You were admitted
with lethargy and confusion. This was likely due to a
combination of liver dysfunction and medication side effects.
You were given lactulose to remove sedating toxins that can
build up when the liver is not working properly. Your pain
medication dosage was changed. Your condition improved.
Your kidney function was reduced from your baseline level. You
were given intravenous fluids and your kidney function improved.
The doses of several of your medications were changed to reflect
the change in kidney function. Your lasix and spironolactone
were stopped.
You were seen by palliative care to discuss resources available
to keep you comfortable moving forward.
We reduced the dose of your pain medication. Please talk to your
pain clinic provider about the medication changes that were
made.
We spoke to your oncologist, who recommended that you start
taking sorafenib.
Please continue your home medications with the following
changes:
1. Lower the dose of oxycodone
2. Lower the dose of gabapentin (neurontin)
3. Stop taking furosemide (lasix)
4. Stop taking spironolactone
Followup Instructions:
___
|
19848806-DS-21
| 19,848,806 | 26,175,751 |
DS
| 21 |
2130-11-17 00:00:00
|
2130-11-17 13:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Cephalexin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic cholecystectomy and umbilical hernia repair
History of Present Illness:
___ yo F, ___ speaking, presenting with right upper quadrant
pain. It started last night after dinner. She describes this
pain as a pressure in RUQ which radiates all over her abdomen.
___ in pain scales. Denies nausea, vomiting, fever, diarrhea or
any other symptoms. She had this pain in the past, about 5
moths before, but now it's much severe and intense.RUQ us showed
cholelithiasis.
Past Medical History:
- " Palpitations "
- Umbilical Hernia
- Cholelithiasis
Social History:
___
Family History:
NC
Physical Exam:
Vitals: Temp: 98.0 HR: 68 BP: 133/83 Resp: 14 O(2)Sat: 99
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses, reducible
umbilical
hernia. RUQ pain has resolved.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 06:07AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 06:07AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:07AM URINE UCG-NEGATIVE
___ 06:07AM URINE HOURS-RANDOM
___ 06:50AM PLT COUNT-226
___ 06:50AM ___ PTT-28.8 ___
___ 06:50AM NEUTS-53.8 ___ MONOS-3.8 EOS-1.9
BASOS-0.5
___ 06:50AM WBC-5.2 RBC-4.76 HGB-13.3 HCT-39.3 MCV-83
MCH-27.8 MCHC-33.7 RDW-13.6
___ 06:50AM ALBUMIN-4.2
___ 06:50AM LIPASE-41
___ 06:50AM ALT(SGPT)-19 AST(SGOT)-33 ALK PHOS-47 TOT
BILI-0.1
___ 06:50AM estGFR-Using this
___ 06:50AM GLUCOSE-101* UREA N-13 CREAT-0.6 SODIUM-138
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-21* ANION GAP-16
___ 10:51AM LACTATE-1.3
CHEST (PA & LAT) Study Date of ___ 11:24 AM
IMPRESSION: Normal chest radiographs.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
7:21 AM
IMPRESSION:
Edematous though not thickened and minimally distended
gallbladder with large gallstones, one of which is located in
the gallbladder neck. Findings suggest early cholecystitis in
the appropriate clinical presentation.
Brief Hospital Course:
Ms. ___ was admitted to the acute care surgery service on
___ for management of her symptomatic cholelithiasis. She
had a Right upper quadrant ultrasound in the emergency
department which showed cholelithiasis without cholecystitis.
She did not have a leukocytosis and her laboratory values were
otherwise unremarkable.
She was taken to the OR on ___ and a laparoscopic
cholecystectomy and umbilical hernia repair was performed
without issue. She was monitored overnight, with stable vital
signs, and pain was well controlled with oral pain medication.
She voided without difficulty.
She had a brief presyncopal episode in the morning of ___,
with some mild right sided chest pain. EKG was sinus rhythm and
electrolytes and cbc were unremarkable. Orthostatics were
negative. Pt's symptoms resolved after 10 minutes. She states
she has had similar episodes in the past when she has been
anxious.
At time of discharge on ___ patient was tolerating a regular
diet, ambulating without difficulty, vital signs remained stable
and pain continued to be well controlled.
Medications on Admission:
Ibuprofen prn
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
symptomatic cholelithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for evaluation of your
abdominal pain. You had an ultrasound of your gallbladder which
showed gallstones and you were brought to the operating room to
have your gallbladder removed. You also had a small umbilical
hernia which was repaired. We watched you overnight and you are
now being discharged home.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may become constipated while taking these pain
medications and should take Colace and Senna to keep your bowel
movements regular while taking this medication.
You may also take acetaminophen (Tylenol) as directed, but do
not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*You may remove the outer bandage tomorrow. Do not take off the
steri-strips (white pieces of tape) as they will fall off on
their own.
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
19848838-DS-10
| 19,848,838 | 26,818,922 |
DS
| 10 |
2177-04-04 00:00:00
|
2177-04-29 12:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Episode of vertigo
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ yo ___ speaking F with a PMHx of L MCA
ischemic stroke ___ with residual right sided weakness), L
common carotid artery occlusion, and HTN who presents to ___
ED with a transient episode of vertigo. History is obtained with
the assistance of pt's son as an ___.
Pt was in her usual state of health until 18:00 on ___. She was
having a BM when she suddenly felt dizzy. This worsened with
standing. She tried to walk to get water but continued to feel
dizzy so had to sit down on the floor. The symptoms persisted
for 30 minutes. These symptoms persisted while she was sitting
on the floor just waxed and waned. While focusing on the floor,
she felt the floor was spinning counterclockwise. She also felt
nauseous and like she was seeing "blue colors". These specific
symptoms had never happened before. She denied any numbness,
weakness, diplopia or speech difficulty. Because she was worried
she was having a stroke, her husband called EMS. Symptoms
resolved after about 30 minutes.
Upon presentation to the ___ ED, pt was HD stable. NCHCT was
unremarkable. At the time of my assessment, pt reported ongoing
bilateral posterior neck pain described as dull. This pain is
chronic but worse than is typical for pt. Pt denies any recent
trauma or falls. Of note, at baseline, pt walks with a cane due
to her right sided weakness.
Otherwise, pt's prior stroke was in ___, prior note
states:
"The patient was apparently at home taking care of her
grandchildren when she fell to the floor. The time of onset
from talking to family was between 12:00 - 4:00 ___. She was
unable to speak but called her husband on the phone. Eventually
she was found and taken to ___ where she was found to
have right face weakness, flaccid right arm, and difficulty
producing language."
On neurologic review of systems, the patient reports chronic R
sided weakness. Pt denies lightheadedness or confusion. Denies
difficulty with producing or comprehending speech. Denies loss
of vision, blurred vision, diplopia, vertigo, tinnitus, hearing
difficulty, dysarthria, or dysphagia. Denies focal numbness,
parasthesia. Denies loss of sensation. Denies bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the patient denies fevers, chest
pain, palpitations, cough, nausea, vomiting, diarrhea,
constipation, abdominal pain, dysuria or rash.
Past Medical History:
L MCA ischemic stroke ___ CTA showed a L M2 segment cutoff
and pt received both IV and IA tPA) with residual right leg
circumduction
Left common carotid artery occlusion
HTN
GERD
Osteoporosis
per family ovary or possibly uterus removed for cancer (per OMR)
Social History:
___
Family History:
Brother: ___
Physical ___:
Vitals: 98.9 76 114/62 18 98% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions
Neck: Supple, paraspinal muscle tenderness appreciated in the
cervical region
___: RRR
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Attention to examiner easily maintained. Recalls a
coherent
history. Speech is fluent with full sentences and intact verbal
comprehension. Normal prosody. No dysarthria. No evidence of
hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 2->1 brisk. VF full to number counting.
EOMI, no nystagmus. +saccadic intrusions. V1-V3 without deficits
to light touch bilaterally. Subtle R NLFF. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
*Per Dr. ___ ___:
"Facial sensation and movements are intact except for very
subtle
flattening of the right nasolabial fold."
- Motor - Normal bulk and tone. 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 4+ 5 4+ ___ ___ 4+ 5 5 5
*Per Dr. ___ ___:
"She has normal tone and muscle strength throughout except for
mild right-sided hemiparesis in the range of ___. Deep tendon
reflexes are 2+ throughout with slight right-sided
hyperreflexia."
- Sensory - No deficits to pin bilaterally.
-DTRs:
___ ___ Pat Ach
L 3 3 3 2
R 3 3 3 2
Plantar response extensor R, flexor L.
- Coordination - No dysmetria with finger to nose testing
bilaterally. +clumsiness with rapid alternating movements on the
R.
*Per Dr. ___ ___:
"Cerebellar functions are intact except for slowed rapid
alternating movement of the right hand."
- Gait - Normal initiation. Ambulates independently but takes
slow, hesitant steps. +circumducts R leg.
On discharge: Some R sided UMN pattern weakness in UE and ___
from old ischemic stroke. Speech is fluent and language is
intact.
Pertinent Results:
___ 11:30PM GLUCOSE-124* UREA N-17 CREAT-1.4* SODIUM-139
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
___ 11:30PM WBC-7.1 RBC-3.20* HGB-9.2* HCT-29.5* MCV-92
MCH-28.8 MCHC-31.2* RDW-14.8 RDWSD-50.1*
___ 11:30PM NEUTS-67.3 ___ MONOS-9.3 EOS-0.7*
BASOS-0.4 IM ___ AbsNeut-4.78 AbsLymp-1.56 AbsMono-0.66
AbsEos-0.05 AbsBaso-0.03
___:30PM PLT COUNT-186
___ 11:30PM ___ PTT-28.5 ___
___ 11:30PM cTropnT-<0.01
___ 11:30PM CALCIUM-9.7 PHOSPHATE-3.8 MAGNESIUM-2.6
___ 11:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:32AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 09:32AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:32AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 06:28AM GLUCOSE-90 UREA N-14 CREAT-1.0 SODIUM-140
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14
___ 06:28AM cTropnT-<0.01
___ 06:28AM %HbA1c-5.7 eAG-117
___ 06:28AM WBC-5.2 RBC-3.05* HGB-8.7* HCT-28.5* MCV-93
MCH-28.5 MCHC-30.5* RDW-15.3 RDWSD-51.6*
___ 06:28AM PLT COUNT-171
___ 04:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 04:45AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 04:45AM URINE RBC-3* WBC-44* BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-1
___ 04:45AM URINE HYALINE-21*
___ 04:45AM URINE MUCOUS-MANY
Brief Hospital Course:
Ms. ___ is a ___ yo ___ speaking female with a PMHx of L
MCA ischemic stroke in ___, L common carotid artery occlusion
and HTN who presented to the ___ ED with a 30 minute episode
of vertigo. In the ED the patient was hemodynamically stable.
Given the concern for a stroke or bleed, non-contrast head CT
was performed, which showed no evidence for a hemorrhage, but
there were hypodensities most consistent with old ischemic
strokes.
On the stroke service, MRI and MRA of the brain was performed to
assess for acute strokes, and no acute process was found. A TTE
was also performed, which revealed no thrombus, normal global
and regional biventricular systolic function, and no atrial
septal defect (PFO/ASD already excluded on prior study with use
of aerated saline contrast). Laboratory tests were also sent for
risk factors for stroke. Her HbA1c and blood glucose were
normal.
As the patient's workup of stroke was negative and the patient's
dizziness resolved, she was discharged with the plan to
follow-up with her primary care physician and ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Dizziness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Neuro: Some R sided UMN pattern weakness in UE and ___ from old
ischemic stroke. Speech is fluent and language is intact.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized with symptoms that were concerning for a
stroke. However, after imaging your brain with a CT, and MRI we
found no evidence that you had a stroke or bleed. We performed
an ultrasound of your heart which showed no change from your
previous in ___. We checked bloodwork, your glucose levels were
normal, cholesterol and thyroid levels are pending, these should
be followed by your primay care doctor. You were seen by
physical therapy and they determined you did not need outpatient
therapy. We recommend:
1. Please continue to take all of your medications as directed
by this document.
2. Please keep all your follow up appointments as below.
3. You should see your primary care in ___ weeks for follow up.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19849045-DS-12
| 19,849,045 | 25,247,690 |
DS
| 12 |
2150-10-29 00:00:00
|
2150-10-31 16:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right toe wound
Major Surgical or Invasive Procedure:
****
Selective iliac angiogram.
Right lower extremity angiogram.
History of Present Illness:
Mr. ___ is a ___ male with a PMH of type II diabetes,
who is presenting with a right toe wound.
History from patient is somewhat limited. He is upset that he is
in the solarium and being asked the same questions multiple
times. He cannot get any sleep. He states that he first had
problems with his right big toe several months ago, and that it
has progressively been getting worse. He states that he sees a
podiatrist for his toe and that he has been trying antibiotics,
but the toe has been getting worse. He reports no pain, fevers
or
chills. All of his other toes are fine. Per podiatry note,
patient first noticed a blister in early ___. He was seen by
his
endocrinologist and referred to podiatry. He has recently
completed a course of clindamycin. He was sent here today from
his ___ clinic.
He does not remember all of his medications, but does state that
he takes medications for his diabetes, for his heart, and for
high blood pressure. He states that his heart rate is normally
in
the ___ because of the medication he takes.
Past Medical History:
- type II diabetes
- hypertension
- coronary artery disease s/p MI ___
- s/p cardiac cath ___
Social History:
___
Family History:
-DM and CAD.
-Father: heart disease, multiple MI's and bypass
-Mother: dementia, DM
Physical Exam:
At Discharge:
Temp: 99.0 (Tm 99.0), BP: 150/77 (142-162/77-86), HR: 73
(55-80), RR: 18, O2 sat: 97% (94-98), O2 delivery: RA
General: awake, alert, no acute distress
CV: regular rate and rhythm
Pulm: normal respiratory effort
Abdomen: soft, non-distended, non-tender
Extremities: wwp,
Pulses: R: p//d/d, L: p//d/d
Pertinent Results:
ADMISSION:
___ 02:15PM BLOOD WBC-11.9* RBC-4.90 Hgb-15.2 Hct-44.3
MCV-90 MCH-31.0 MCHC-34.3 RDW-12.9 RDWSD-41.8 Plt ___
___ 02:15PM BLOOD Glucose-148* UreaN-19 Creat-1.1 Na-141
K-4.3 Cl-103 HCO3-22 AnGap-16
Right foot plain film:
Soft tissue ulceration along the medial aspect of the great toe
with subjacent area of cortical indistinctness involving the
medial distal aspect of the proximal phalanx of the great toe
concerning for osteomyelitis.
DISCHARGE:
___ 04:36AM BLOOD WBC-8.3 RBC-4.30* Hgb-13.0* Hct-40.0
MCV-93 MCH-30.2 MCHC-32.5 RDW-12.7 RDWSD-43.1 Plt ___
___ 04:36AM BLOOD Glucose-125* UreaN-9 Creat-0.9 Na-145
K-4.4 Cl-109* HCO3-23 AnGap-13
___ 04:36AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0
Brief Hospital Course:
TRANSITIONAL ISSUES:
- consider lowering doses of nodal agents based on observed
brady on telemetry
- Will Return likely on ___ for RLE bypass
HOSPITAL COURSE:
# Right Great Toe dry gangrene:
Pt presenting with right great toe gangrene/necrosis for several
months. No
surrounding erythema, fevers or chills, or other signs of
systemic infection.No pain. Had completed clinda course prior.
Pods saw pt in ED; wanted abx; on vanc/cefepime/flagyll. Per
podiatry, the patient requires amputation of his right great toe
(which is unsalvageable). However, the patient's non-invasive
studies show a toe pressure of 32 on the right, which is not
sufficient to heal this amputation. As such, a right lower
extremity angiogram was performed to evaluate flow on ___.
Which found: SFA occlusion measured 12 cm; Occlusion in the
popliteal artery (mid segment) measures 6 cm. The findings were
amenable to a bypass and a bypass was planned for early in the
following week (likely ___ for revascularization. As such
amputation by podiatry will occur following revascularization
procedure. The patient was sent home on oral antibiotics, and
will return next week for the procedure.
#Bradycardia: pt, especially during sleep with HR dropping to
high ___ with pauses interrupted by PAC. Did not occur while
awake. PR borderline long at around 200. Also with EKG evidence
of old ___ infarct with Q in V2-6, as well as inferior
Q's. Held metop and dilt initially. Vascular medicine evaluated
the patient and recommended Discontinue diltiazem given no
indication for it and to Restart metoprolol at decreased dose of
50mg succinate daily due to bradycardia.
CHRONIC/STABLE PROBLEMS:
#Coronary artery disease s/p MI: cont asa, statin; hold metop
#Type II diabetes: HISS
#HTN: continued home hydralazine (confirmed takes only once
daily), as pt was planned for OR/vascular initially holding
losartan, dilt, metop at present.
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:
The Preadmission Medication list is accurate and complete.
1. Clindamycin 300 mg PO Q6H
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Losartan Potassium 100 mg PO DAILY
4. Diltiazem Extended-Release 180 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. HydrALAZINE 25 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*2
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Clindamycin 300 mg PO Q6H
Please continue taking this medication until you return for your
surgery
5. FoLIC Acid 1 mg PO DAILY
6. HydrALAZINE 25 mg PO DAILY
7. Losartan Potassium 100 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Right toe gangrene
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at ___
___.
You were admitted for gangrene of your right great toe due to
severely limited blood flow to this area. This was managed with
Betadine dressing, and antibiotics.
You will also underwent a peripheral angiogram for evaluation of
your vasculature. To do the test, a small puncture was made in
one of your arteries. The puncture site heals on its own: there
are no stitches to remove. You tolerated the procedure well
and are now ready to be discharged from the hospital. Please
follow the recommendations below to ensure a speedy and
uneventful recovery.
Peripheral Angiography
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.
Medications:
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
For Problems or Questions:
Call ___ in an emergency such as:
Sudden, brisk bleeding or swelling at the groin puncture site
that does not stop after applying pressure for ___ minutes
Bleeding that is associated with nausea, weakness, or
fainting.
Call the vascular surgery office (___) right away if
you have any of the following. (Please note that someone is
available 24 hours a day, 7 days a week)
Swelling, bleeding, drainage, or discomfort at the puncture
site that is new or increasing since discharge from the hospital
Any change in sensation or temperature in your legs
Fever of 101 or greater
Any questions or concerns about recovery from your angiogram
You are expected to return next week (likely ___ for
another procedure. You will be contacted with the office with
the exact date and time to present to the hospital.
Please continue to use Daily betadine dressing to right great
toe; and take the antibiotics prescribed.
Followup Instructions:
___
|
19849045-DS-14
| 19,849,045 | 22,665,068 |
DS
| 14 |
2150-12-09 00:00:00
|
2150-12-09 18:18:00
|
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:
___ R metatarsal amputation
attach
Pertinent Results:
Admission Labs
___ 03:15PM BLOOD WBC-10.4* RBC-4.05* Hgb-12.1* Hct-37.2*
MCV-92 MCH-29.9 MCHC-32.5 RDW-12.6 RDWSD-42.0 Plt ___
___ 03:15PM BLOOD Neuts-61.5 ___ Monos-8.0 Eos-5.6
Baso-0.9 Im ___ AbsNeut-6.39* AbsLymp-2.39 AbsMono-0.83*
AbsEos-0.58* AbsBaso-0.09*
___ 03:15PM BLOOD ___ PTT-29.3 ___
___ 03:15PM BLOOD Glucose-227* UreaN-12 Creat-1.0 Na-139
K-4.9 Cl-101 HCO3-20* AnGap-18
___ 02:30AM BLOOD ALT-48* AST-34 AlkPhos-98 TotBili-0.2
___ 07:25AM BLOOD Calcium-9.5 Phos-3.8 Mg-1.5*
Reports
Foot XR ___
In comparison with the study of ___, the immediate
postsurgical
changes have resolved following resection of the phalanges of
the first digit.
The cortical margins of the head of the first metatarsal are not
clearly seen
at this time. Also, the medial margin of the head of the second
metacarpal is
irregular with the cortex not clearly seen.
This constellation of findings is worrisome for worsening
osteomyelitis.
Brief Hospital Course:
Mr. ___ is a ___ year-old man with HTN, CAD s/p MI in
___, DM, PAD s/p recent R femoral-peroneal bypass and R hallux
amp in ___, who presented from ___ clinic with wound
dehiscence, now s/p repeat amputation notable for osteomyelitis.
TRANSITIONAL ISSUES
===================
[ ] Per podiatry, should continue Cipro for 10d course.
[ ] Patient should be completely non-weight-bearing on R foot.
[ ] Patient declining rivaroxaban; continue to discuss with
patient and encourage to take it going forward due to bypass.
ACTIVE ISSUES
=============
# R Hallux Amp c/b Wound Dehiscence
# Klebsiella Osteomyelitis
# PAD
Presented from ___ clinic w/ dehisced wound and exposed
bone. Treated empirically with antibiotics. Podiatry & Vascular
consulted. ___ repeat amputation with micro resulting w/
klebsiella and negative margins. Transitioned from IV Vanc/CTX
to Ciprofloxacin for 10 further day course. Recommended
rivaroxaban given bypass but patient declined. Recommended
discharge to rehab but patient declined. Recommended crutches
and/or wheelchair but patient declined and stated he would use a
walker.
CHRONIC ISSUES
==============
# T2DM
Held metformin here, started on Lantus/ISS.
# HTN
Continued hydralazine and Losartan.
# CAD
Continued ASA and metoprolol.
Greater than 30 minutes spent on discharge planning and
coordination of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. HydrALAZINE 25 mg PO QAM
3. Losartan Potassium 100 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Aspirin EC 81 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*20 Tablet Refills:*0
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. HydrALAZINE 25 mg PO QAM
5. Losartan Potassium 100 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Metoprolol Succinate XL 50 mg PO DAILY
8.Rolling Walker
Dx: osteomyelitis M86.171
Px: good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Dehisced R foot amputation site
R foot osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- Your foot amputation came open and needed to be re-operated
upon
What did you receive in the hospital?
- The podiatry team did another amputation.
- You were treated with antibiotics.
- The physical therapy team worked with you.
What should you do once you leave the hospital?
- You should not put any weight on your right leg.
- Please take your medications as prescribed and go to your
future appointments which are listed below.
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
19849930-DS-20
| 19,849,930 | 24,971,949 |
DS
| 20 |
2165-06-26 00:00:00
|
2165-06-27 19:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Mevacor / Adhesive Tape
Attending: ___
Chief Complaint:
Left hand tingling
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a pleasant ___ year old male with a history of s/p
CABG (___) with CABG revision and bioprosthetic MVR (___),
paroxysmal AF (exercise-induced), possible TIA symptoms who
presents with left hand tingling. He apparently was carrying
heavy luggage with his left hand at the onset of these symptoms.
There was no associated chest pain, palpitations, or
lightheadedness. It resolved after one tablet of nitroglycerin.
He was concerned since he felt that these symptoms were similar
to those he experienced in ___ prior to getting his first CABG.
On further questioning, Mr. ___ reports that in ___ he
experienced total left arm numbness, as opposed to the left hand
parasthesias he experienced just prior to this admission. He
denies any recent history of any chest pain, exertional or
otherwise.
He saw his cardiologist Dr. ___ on ___ and his EKG on
this date demonstrated new EKG changes including a more
prominent RBBB, new RAD, and a prolongation of the PR interval
to 300 ms for which it was recommended he undergo an EP study
and an echocardiogram. Mr. ___ went on vacation after this
appointment and was unable to schedule his EP study and
echocardiogram.
Past Medical History:
- Coronary artery disease status post CABG ___ with follow up
stenting in ___ and ___.
- ___, stress echocardiogram that showed
exercise-induced
atrial fibrillation on Coumadin, cardiac surgery consultation
for mitral valve surgery.
- Hospitalized at ___ ___ with transient unsteady gait
after
having stopped his Coumadin for 2 days prior to a dental
procedure with negative MRI/MRA brain
- redo CABG / Mechanical MVR ___ at ___
___
- Post-op atrial fibrillation
Social History:
___
Family History:
Mother died at ___ in childbirth. Father died at ___ of CAD.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION (___):
VITALS - T 97.8 BP 158/65 RR 18 HR 45 OSsat 97% on RA
GENERAL - Well-appearing ___ yo M/F who appears comfortable,
appropriate and in NAD
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - Lungs are clear to ausculatation bilaterally, moving air
well and symmetrically, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, mechanical mitral valve closure
heard. No rubs or gallops.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric.
DISCHARGE PHYSICAL EXAMINATION (___):
VITAL SIGNS - T 97.7 HR 76 RR 18 BP 125/75 O2Sat 100% on RA
GENERAL - Well appearing elderly gentleman who is appropriate
and in NAD.
CARDIOVASCULAR - Bradycardic. Mechanical mitral valve sounds
heard. No rubs or gallops. PMI nondisplaced.
PULMONARY - CTAB, moving air well with no acessory muscle use.
NEUROLOGICAL - Alert & oriented x 3. Neurological examination
unchanged.
Pertinent Results:
ROUTINE LABS:
___ 07:15AM BLOOD WBC-5.1 RBC-4.76 Hgb-13.0* Hct-41.0
MCV-86 MCH-27.3 MCHC-31.7 RDW-14.5 Plt ___
___ 07:15AM BLOOD Glucose-101* UreaN-17 Creat-0.9 Na-140
K-4.7 Cl-103 HCO3-30 AnGap-12
COAGULATION STUDIES:
___ 04:30PM BLOOD ___ PTT-40.2* ___
CARDIAC ENZYMES:
___ 01:30PM BLOOD CK(CPK)-317
___ 07:15AM BLOOD CK-MB-6 cTropnT-<0.01
STRESS TEST (___):
INTERPRETATION: ___ year old man with history of CAD status post
CABG
and stents, hypertension, hyperlipidemia, who presented for
evaluation
of left hand parasthesias. Serial EKGs and troponins were
negative for
ischemia. He performed a modified ___ protocol exercise test
to 7
minutes, stopping for fatigue, reaching peak METS of 4.9
representing an
average functional capacity for his age. Baseline EKG showed
non-specific ST segment and T waves in the setting of RBBB
morphology
which were more pronounced in V1 with peak exercise with no
other
significant changes . His rhythm was sinus with first degree AV
block,
RBBB, and LPFB with occasional isolated APBs and VPBs with 1
ventricular
couplet. He had a mildly blunted blood pressure response to
exercise
and recovery.
IMPRESSION: No angina, significant ischemic changes, or
conduction
system abnormalities throughout the study. Echo report sent
separately.
STRESS ECHOCARDIOGRAM (___):
The patient exercised for 7 minutes and 0 seconds according to a
Modified ___ treadmill protocol ___ METS) reaching a peak
heart rate of 144 bpm and a peak blood pressure of 160/70 mmHg.
The test was stopped because of fatigue. This level of exercise
represents an average exercise tolerance for age. In response to
stress, the ECG showed no diagnostic ST-T wave changes (see
exercise report for details). The blood pressure response to
stress was blunted. There was a normal heart rate response to
exercise.
Resting images were acquired at a heart rate of 56 bpm and a
blood pressure of 132/70 mmHg. These demonstrated normal
regional and global left ventricular systolic function. Right
ventricular free wall motion is normal. There is no pericardial
effusion. Doppler demonstrated trace aortic regurgitation with
no aortic stenosis or significant mitral regurgitation or
resting LVOT gradient.
Echo images were acquired within 46 seconds after peak stress at
heart rates of 143-116 bpm. These demonstrated appropriate
augmentation of all left ventricular segments. There was
augmentation of right ventricular free wall motion.
IMPRESSION: Average functional exercise capacity. No ECG or 2D
echocardiographic evidence of inducible ischemia to achieved
workload. Abnormal hemodynamic response (mildly blunted blood
pressure) to physiologic stress. Trivial aortic regurgitation at
rest.
Brief Hospital Course:
==================================
PRIMARY REASON FOR HOSPITALIZATION
==================================
___ year old male with extensive coronary history presented with
left hand tingling and recent EKG changes. He saw his
cardiologist Dr. ___ on ___ and his EKG on this date
demonstrated new EKG changes including a more prominent RBBB,
new RAD, and a prolongation of the PR interval to 300 ms for
which it was recommended he undergo an EP study and an
echocardiogram. Mr. ___ went on vacation after this
appointment and was unable to schedule his EP study and
echocardiogram at this time.
ACUTE PROBLEMS:
===============
#) LEFT HAND TINGLING: Patinet had high index of suspicion that
this was an anginal equivalent since a similar symptomatology
was present prior to his CABG in ___. ON further questioning,
however, he stated that his anginal symptoms in ___ were really
complete left arm numbness, not left hand tingling. The patient
was carrying heavy luggage in his left hand prior to to
experiencing the tingling, and since he had a negative ischemic
workup here (no ischemic EKG changes, no ischemia seen on stress
test, negative cardiac enzymes), his tingling is more likely to
be musculoskeletal.
#) CARDIAC CONDUCTION ABNORMALITIES
* BRADYCARDIA: Has been in bradycardia to ___ while awake on
telemetry but has been totally asymptomatic. Cardiology agreed
with watchful waiting since he seemed to tolerate this well.
Despite bradycardia, elected to continue metoprolol at half
previous dose. Now on 12.5mg metoprolol succinate qd.
* FIRST DEGREE AV HEART BLOCK: Per Dr. ___ Dr.
___ will likely need EP study to evaluate the
arrhythmia and need for pacemaker placement.
CHRONIC PROBLEMS
================
#) DYSEQUILIBRIUM: Chronic cerebellar microhemorrhages vs. TIAs.
He has been experiencing dysequilibrium for approximately ___
year which occurs about every two weeks. He describes the
episodes as "needing to catch his balance for a few seconds."
He denies any associated lightheadedness, palpitations, chest
pain, or syncope, and reports that he has not fallen. He has
previously been seen in the ED in ___, and ___ for
similar complaints with workup negative for any acute
cerebrovascular ischemic event. Just prior to his ___
admission he had stopped his coumadin for two days for a dental
procedure. At that time, MRI brain was negative for any acute
infarct, but positive for "Scattered chronic cerebral and
cerebellar microhemorrhages, likely related to known
hypertension." He did not experience any dysequilibrium
associated with his left arm tingling or during this admission.
#) ATRIAL FIBRILLATION, PAROXYSMAL: Was not in atrial
fibrillation during this admission. Continue with home dose of
warfarin 10mg daily. INR on day of discharge (___) was
therapeutic at 2.4.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Aspirin 81 mg PO DAILY
2. Lisinopril 20 mg PO DAILY hypertension
Hold if SBP < 90
3. Finasteride 5 mg PO DAILY
4. Rosuvastatin Calcium 10 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
Hold if SBP < 90
Hold if HR < 40
6. Tamsulosin 0.4 mg PO HS BPH
7. Warfarin 10 mg PO DAILY16
8. lactobacillus acidophilus *NF* Dose is Unknown Oral Unknown
9. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) Dose is
Unknown Oral Unknown
10. Oxybutynin Dose is Unknown PO TID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Lisinopril 20 mg PO DAILY hypertension
Hold if SBP < 90
4. Metoprolol Succinate XL 12.5 mg PO DAILY
Hold if SBP < 90
Hold if HR < 40
5. Oxybutynin 5 mg PO QHS
6. Rosuvastatin Calcium 10 mg PO DAILY
7. Tamsulosin 0.4 mg PO HS BPH
8. Warfarin 10 mg PO DAILY16
9. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 1 tab ORAL
Frequency is Unknown
10. lactobacillus acidophilus *NF* 0 tab ORAL Frequency is
Unknown
Discharge Disposition:
Home
Discharge Diagnosis:
Primary-
Left hand tingling
Right axis deviation
Bradycardia
Right bundle branch block
1st degree AV heart block
Secondary diagnoses
Coronary artery disease
Paroxysmal atrial fibrillation
BPH
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for left hand tingling.
There was some concern that this may have been due to your
heart, but you underwent a stress test which was within normal
limits. You should follow-up with your cardiologist after going
home.
We made the following changes to your medications:
- Change metoprolol succinate XL dose to 12.5mg daily
Followup Instructions:
___
|
19849930-DS-24
| 19,849,930 | 22,474,638 |
DS
| 24 |
2171-11-06 00:00:00
|
2171-11-06 15:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Mevacor / Adhesive Tape
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Coronary angiogram ___
History of Present Illness:
Mr. ___ is an ___ with H/O CAD s/p 4 vessel CABG ___
(LIMA-LAD, SVG-D1, SVG-OM1, SVG-PDA), s/p PCI on ___ during
which the SVG-D1 and SVG-PDA were noted to be occluded and
during which the RCA was treated with overlapping Cypher stents
of 3.5 x 13, 3.0 x 33, and 2.5 x 28 mm, redo CABG (SVG-PDA) and
29 mm ___ bioMVR ___ at ___ (Dr. ___ pre-op
coronary angiography showed patent stented LMCA, LAD proximal
90%, D1 ostial 80%, CX ostial chronic total occlusion, RCA
ostial 50%, SVG-PDA ostial chronic ___ occlusion, patent
LIMA-LAD, patent SVG-OM1; presumed occluded SVG-D not seen on
aortography), HFrEF with LVEF ___, paroxysmal atrial
fibrillation on warfarin with H/O possible TIA, hypertension,
hyperlipidemia, conduction system disease with RBBB s/p dual
chamber pacemaker ___, and CKD presenting with chest pain.
He started having chest pain at 9 pm on the night prior to
admission and went to sleep. He awoke at 23:45 and took SL NTG
because he was still having chest pain at rest. Chest pain did
not resolve with nitroglycerin, prompting patient to go to the
ED. Patient described his chest pain as a dull aching sensation
in his left chest, occurring at rest with some associated
shortness of breath. Patient also had chest pain a week ago that
self-resolved in under an hour. Patient endorsed dyspnea on
exertion and lower extremity edema, unchanged from his baseline.
At baseline, he has slight limitation of his physical activity
with shortness of breath but is comfortable at rest. He denied
palpitations, nausea, vomiting, diaphoresis, recent fevers or
chills, headache, cough and abdominal pain. He has been taking
his medications as prescribed with no recent changes in diet.
Past Medical History:
-CAD, S/P CABG in ___ and redo ___ at ___ (see above)
-PCIs in ___ and ___.
-S/P bioprosthetic MVR in ___ with his redo CABG,
-paroxysmal atrial fibrillation,
-conduction system disease (manifest with RBBB and alternating
left anterior/posterior hemiblock with a long PR interval and a
HV interval of 89 ms on EP study), S/P ___
dual-chamber pacemaker on ___ - mostly V-paced with
a wide paced QRS of about 180ms.
-Systolic CHF (LVEF 35-40%)
-possible history of TIA
-Hypertension
-Hyperlipidemia
-Diverticulosis
-BPH
-H/O GI bleeding
-H/O pancreatitis
-Hemorrhoids
-S/P cholecystectomy
-S/P appendctomy
-S/P bilateral inguinal hernia repair
-Recent hemorrhoidectomy, subsequent urinary retention with
indwelling urinary catheter placement
Social History:
___
Family History:
Mother died at ___ in childbirth. Father died at ___ of CAD.
Physical Exam:
On admission
GENERAL: Well-developed, well-nourished elderly white man in
NAD. Mood, affect
appropriate.
VITALS: T 97.4F, BO 117/71, HR 70, RR 18, SaO2 98% on RA
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with elevated JVP.
CARDIAC: RRR, normal S1, S2. Systolic murmur at LLSB. No
thrills, lifts
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, not distended. No HSM or tenderness.
EXTREMITIES: No clubbing, cyanosis or edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
At discharge
GENERAL: Well-developed, well-nourished, in NAD.
VITALS: T 97.6F, BP 111/68, HR 72, RR 18, SaO2 98% on RA
HEENT: NCAT. Sclera anicteric.
NECK: Supple with flat neck veins.
CARDIAC: RRR, normal S1, S2. Systolic murmur at LLSB.
LUNGS: No chest wall deformities, no tenderness to palpation of
chest wall. Resp were unlabored, no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, not distended. No rebound or
guarding.
EXTREMITIES: No clubbing or cyanosis. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric. Trace pitting
edema of both lower extremities
Pertinent Results:
___ 01:50AM BLOOD WBC-4.7 RBC-3.32* Hgb-10.3* Hct-33.1*
MCV-100* MCH-31.0 MCHC-31.1* RDW-13.8 RDWSD-50.0* Plt ___
___ 01:50AM BLOOD ___ PTT-30.8 ___
___ 01:50AM BLOOD Glucose-127* UreaN-37* Creat-1.7* Na-141
K-5.3 Cl-104 HCO3-25 AnGap-12
___ 01:50AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.4
___ 01:50AM BLOOD CK-MB-6 proBNP-___*
___ 01:50AM BLOOD cTropnT-0.06*
___ 05:34AM BLOOD CK-MB-5 cTropnT-0.06*
___ 08:43AM BLOOD CK-MB-6 cTropnT-0.05*
___ 01:15PM BLOOD VitB12-1323* Folate->20 Hapto-83
___ 06:30AM BLOOD ALT-28 AST-29 LD(LDH)-321* AlkPhos-52
TotBili-0.6 DirBili-<0.2 IndBili-0.6
CXR ___xpanded. Stable mild cardiomegaly. Hila and
mediastinal contours unremarkable. Mild pulmonary edema. No
evidence of pneumonia. Small left pleural effusion. No evidence
of pneumothorax . Left-sided pacemaker has leads which project
over the right atrium and right ventricle. Sternal wires are
intact. Surgical clips overlie the mediastinum. Visualized
osseous structures are unchanged when compared to most recent
prior chest radiograph.
IMPRESSION:
1. Mild pulmonary edema. No evidence of pneumonia.
2. Small left pleural effusion.
3. Stable mild cardiomegaly.
Exercise Nuclear Stress Test ___: The patient exercised
for 2.5 minutes of a Gervino protocol and was stopped for a
progressive drop in systolic BP 120/68->104/68->90/60. The
estimated peak MET capacity was 2.3 which represents a poor
functional capacity for his age. No arm, neck, back or chest
discomfort was reported by the patient throughout the study. The
ST segments are uninterpretable for ischemia in the setting of
the baseline IVCD. The rhythm was sinus with 2 isolated apbs.
Abnormal BP response to exercise with an appropriate increase in
HR.
IMPRESSION: Absence of anginal symptoms with uninterpretable ST
segments. Poor functional capacity with decline in SBP with
exertion.
IMAGING: Left ventricular cavity size is dilated at 242 ml
(normal to 110 ml). Resting and stress perfusion images reveal
moderately decreased tracer uptake in the inferior wall and apex
as well as the anteroseptal wall. Gated images reveal global
hypokinesis. The calculated left ventricular ejection fraction
is 22%. No prior study for comparison.
IMPRESSION: Dilated ventricular cavity with global hypokinesis
and an ejection fraction of 22%. No reversible perfusion
defects.
Coronary Angiogram ___:
The coronary circulation is right dominant.
LM: The Left Main, arising from the left cusp, is a large
caliber vessel. This vessel bifurcates into the Left Anterior
Descending and Left Circumflex systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. There is a 60% stenosis in the
proximal segment. There is a 100% stenosis in the proximal
segment. The Septal Perforator, arising from the proximal
segment, is a small caliber vessel. The Diagonal, arising from
the proximal segment, is a medium caliber vessel. There is a 60%
stenosis in the proximal segment.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel. There is a 100% stenosis in the proximal
segment.
The ___ Obtuse Marginal, arising from the proximal segment, is a
medium caliber vessel. The ___ Obtuse Marginal, arising from the
mid segment, is a medium caliber vessel.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel. There is a 50% stenosis in the ostium.
The Acute Marginal, arising from the proximal segment, is a
small caliber vessel. The Right Posterolateral Artery, arising
from the distal segment, is a medium caliber vessel. The Right
posterolateral of the RPLA, arising from the proximal segment,
is a medium caliber vessel. The Right Posterior Descending
Artery, arising from the distal segment, is a medium caliber
vessel.
Bypass Grafts:
LIMA: A medium caliber arterial LIMA graft connects to the mid
segment of the LAD. This graft is patent.
SVG: A medium caliber saphenous vein graft connects to the
proximal segment of the Diag. This graft is patent. A medium
caliber saphenous vein graft jump segment to to the proximal
segment of the ___ OM. This graft is also patent.
SVG: A medium caliber saphenous vein graft connects to the
proximal segment of the RPDA. This graft is patent.
DISCHARGE LABS:
___ 07:15AM BLOOD WBC-5.9 RBC-3.48* Hgb-10.7* Hct-34.7*
MCV-100* MCH-30.7 MCHC-30.8* RDW-13.5 RDWSD-49.1* Plt ___
___ 08:50AM BLOOD ___ PTT-27.2 ___
___ 06:45AM BLOOD Glucose-103* UreaN-24* Creat-1.3* Na-143
K-4.9 Cl-106 HCO3-24 AnGap-13
___ 06:45AM BLOOD Phos-2.8 Mg-2.2
Brief Hospital Course:
Mr. ___ is an ___ with H/O CAD s/p 4 vessel CABG ___
(LIMA-LAD, SVG-D1, SVG-OM1,
SVG-PDA), s/p PCI on ___ during which the SVG-D1 and
SVG-PDA were noted to be occluded and during which the RCA was
treated with overlapping Cypher stents of 3.5 x 13, 3.0 x 33,
and 2.5 x 28 mm; redo CABG and 29 mm ___ bioMVR
___
(SVG-PDA) at ___ (Dr. ___ pre-op patent ___, patent
SVG-OM1; presumed occluded SVG-D not seen on aortography), HFrEF
LVEF ___, paroxysmal atrial fibrillation on warfarin,
hypertension, hyperlipidemia, conduction system disease with
RBBB s/p dual chamber pacemaker ___ and CKD who presented with
chest pain. CK-MB normal, troponin-T flat at 0.06 to 0.05 with
eGFR 38. He exercised to ___ METs without symptoms, but with
decline in SBP during exercise concerning for ischemia. Coronary
angiogram on ___ revealed stable coronary disease (patent
LIMA-LAD, patent SVG-RPDA, patent SVG-Diag-OM2). His chest pain
did not recur during his admission. He was continued on home
aspirin 81 mg, and carvedilol 3.125 mg BID as well as home
ezetimibe and rosuvastatin. Clopidogrel was deferred given
ongoing oral anticoagulation.
Other issues:
# Chronic systolic heart failure: LVEF 30% (___). ___
functional class I-II. He was continued on home epleronone,
torsemide, and Entresto.
# Paroxysmal atrial fibrillation, conduction Disease s/p PPM:
Recent pacemaker interrogation with several episodes of NSVT,
asymptomatic and infrequent short, self terminating episodes of
atrial fibrillation. He was treated with heparin prior to his
coronary angiogram and was restarted on warfarin without bridge
afterwards.
# Thrombocytopenia: New since ___, stable.
# Macrocytic Anemia" Iron studies were normal, hemolysis labs
were normal. He had elevated B12 and normal folate. Reticulocyte
count inappropriately normal.
# CKD: Cr at baseline ~1.6-1.7.
# Hypertension: continued carvedilol, torsemide, epleronone
# Hyperlpidemia: Continued ezetimibe and rosuvastatin
# BPH: Held finesteride and tamsulosin in setting of low BPs
TRANSITIONAL ISSUES:
[] DISCHARGE WEIGHT: 86.3 kg (190.26 lb)
[] DISCHARGE CREATININE: 1.5
[] DISCHARGE INR: 1.2
[] DISCHARGE DIURESIS: torsemide 60 mg daily
[] Please continue to monitor exercise tolerance; patient had
hypotensive although asymptomatic response to exercise
[] Please consider if patient needs to continue B12 supplements
given high B12 serum levels during this admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Torsemide 60 mg PO DAILY
2. Tamsulosin 0.4 mg PO BID
3. Eplerenone 25 mg PO DAILY
4. Ezetimibe 10 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. FoLIC Acid 2.5 mg PO DAILY
___ MD to order daily dose PO DAILY16
9. Sacubitril-Valsartan (49mg-51mg) 1 TAB PO BID
10. CARVedilol 3.125 mg PO BID
11. Pyridoxine 50 mg PO DAILY
12. Rosuvastatin Calcium 20 mg PO QPM
13. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. CARVedilol 3.125 mg PO BID
3. Cyanocobalamin 1000 mcg PO DAILY
4. Eplerenone 25 mg PO DAILY
5. Ezetimibe 10 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. FoLIC Acid 2.5 mg PO DAILY
8. Pyridoxine 50 mg PO DAILY
9. Rosuvastatin Calcium 20 mg PO QPM
10. Sacubitril-Valsartan (49mg-51mg) 1 TAB PO BID
11. Tamsulosin 0.4 mg PO BID
12. Torsemide 60 mg PO DAILY
13. ___ MD to order daily dose PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
-Coronary artery disease, native and bypass graft
-Unstable angina with elevated troponin-T in setting of
-Stage 3 chronic kidney disease
-Chronic left ventricular systolic heart failure
-Paroxysmal atrial fibrillation
-Long term use of anticoagulants
-Prior pacemaker implantation
-Prior bioprosthetic mitral valve replacement
-Hypertension
-Hypotension
-Hyperlipidemia
-Benign prostatic hypertrophy
-Anemia, macrocytic
-Thrombocytopenia, chronic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had chest pain.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You had a stress test and your blood pressure was low.
- You had a coronary angiogram, which is a test to look at the
blood vessels in your heart, and they were all open.
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 ___!
Your ___ Care Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19849930-DS-29
| 19,849,930 | 24,306,897 |
DS
| 29 |
2172-03-04 00:00:00
|
2172-03-05 07:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Mevacor / Adhesive Tape
Attending: ___.
Chief Complaint:
"I feel light/unsteady"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ y/o male with HFrEF (EF 25%), paroxysmal afib,
His-Purkinje system conduction disease s/p dual chamber PPM
placement, BPH, CAD (s/p 4VCABG ___, re-do 1v CABG +
bioprosthetic MVR ___ and CKD recently admitted for
symptomatic
orthostatic hypotension, now re-presenting with weakness and
lightheadedness.
He was discharged 2 days ago following an overnight
hospitalization for lightheadedness and nocturnal symptomatic
orthostasis, thought to be due to new Tamsulosin. PPM was
interrogated by EP, device found to be functioning normally with
no arrhythmia events identified. He had no significant events
on
telemetry. On the floor his orthostatics resolved and he
reported feeling back to baseline. He was advised to hold
tamsulosin and weigh himself daily upon discharge.
Today he re-presents stating that his symptoms have worsened.
Reports that he feels "light/unsteady" at night, when he wakes
___ per night for nocturnal micturition. Denies dizziness,
changes in vision or hearing, or diaphoresis a/w these events.
States that these episodes never occur during the day, and he is
able to ambulate 0.5 miles each morning without sx. Endorses
that these sx occurred twice while lying down, once yesterday
and
once ___, not a/w dyspnea, CP or palpitations.
He did stop taking tamsulosin following his recent dicharge but
restarted it the next evening as he had difficulty urinating.
Endorses chronic SOB close to his baseline, denies CP, N/V, f/c,
dysuria, and changes in bowel or bladder habits. Endorses
chronic ___ swelling but no changes from baseline.
In the ED:
- Initial vital signs were notable for: T96.7, HR70, BP96/55,
RR16, O2Sat97%RA
- Exam notable for: RRR, normal S1 and S2, 1+ pitting edema to
his knees
- Labs were notable for: cTropnT: 0.10* proBNP: 6760*
Glucose: 107* UreaN: 37* Creat: 2.4* HCO3: 22 AnGap: 19*
Hgb: 10.4* Hct: 34.5* Plt Ct: 137* ___: 2.5*
- Studies performed include: UCx (pending), ECG (see below)
- Patient was given: no medications in the ED
- Consults: none
Vitals on transfer:
T 97.7, BP 95/59, HR 67, RR 20, O2Sat 98% RA
Orthostatics: 91/59 lying, 96/58 sitting, 95/53 standing
Upon arrival to the floor, Mr. ___ states that he is
comfortable
and his symptoms have not recurred, as they only occur at night.
Past Medical History:
HFrEF (EF 25%)
His-Purkinje system conduction disease s/p dual chamber PPM
placement (RBBB, LPFB, LAFB)
Paroxysmal afib
CAD (s/p 4VCABG ___, re-do 1v CABG + bioprosthetic MVR ___
BPH
HTN
CKD
Dyslipidemia
Eczema
Hearing loss
Cataracts
Pre-diabetes
Social History:
___
Family History:
Mother died at ___ in childbirth.
Father died at ___ of CAD.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 97.7, BP 95/59, HR 67, RR 20, O2Sat 98% RA
GENERAL: Well-appearing, lying comfortably in bed, in no acute
distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD appreciated.
CHEST: +PPM left chest
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Early
systolic murmur ___ heard at ___.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowel sounds, non-distended, non-tender to
palpation in all four quadrants. No organomegaly.
EXTREMITIES: WWP, no clubbing, cyanosis, compression stockings
in
place with 1+ edema present bilaterally up to the knee, at
baseline per pt
SKIN: Warm. Cap refill <2s. No rash, diffuse bruising b/l UE
NEUROLOGIC: Grossly normal strength and sensation
DISCHARGE PHYSICAL EXAM
GENERAL: Well-appearing, lying comfortably in bed, in no acute
distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD appreciated.
CHEST: +PPM left chest
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. III/VI
early systolic murmur ___ heard at ___.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowel sounds, non-distended, non-tender to
palpation in all four quadrants. No organomegaly.
EXTREMITIES: WWP, no clubbing, cyanosis, compression stockings
in
place with 1+ edema present bilaterally up to the knee, at
baseline per pt
SKIN: Warm. Cap refill <2s. No rash, diffuse bruising b/l UE
NEUROLOGIC: Grossly normal strength and sensation
Pertinent Results:
ADMISSION
___ 07:43AM BLOOD WBC-5.3 RBC-3.48* Hgb-10.4* Hct-34.5*
MCV-99* MCH-29.9 MCHC-30.1* RDW-14.5 RDWSD-53.3* Plt ___
___ 07:43AM BLOOD Neuts-86.3* Lymphs-4.7* Monos-7.1 Eos-1.1
Baso-0.4 Im ___ AbsNeut-4.61 AbsLymp-0.25* AbsMono-0.38
AbsEos-0.06 AbsBaso-0.02
___ 07:43AM BLOOD ___ PTT-32.2 ___
___ 07:43AM BLOOD Glucose-107* UreaN-37* Creat-2.4* Na-144
K-5.0 Cl-103 HCO3-22 AnGap-19*
___ 07:43AM BLOOD ALT-19 AST-28 AlkPhos-56 TotBili-0.4
___ 07:43AM BLOOD proBNP-6760*
___ 07:43AM BLOOD cTropnT-0.10*
___ 07:43AM BLOOD Lipase-31
___ 07:43AM BLOOD Albumin-4.1 Calcium-9.0 Phos-3.4 Mg-2.3
DISCHARGE
___ 07:46AM BLOOD WBC-4.6 RBC-3.63* Hgb-10.7* Hct-36.2*
MCV-100* MCH-29.5 MCHC-29.6* RDW-14.4 RDWSD-53.0* Plt ___
___ 07:35AM BLOOD Glucose-95 UreaN-40* Creat-2.1* Na-141
K-4.8 Cl-103 HCO3-25 AnGap-13
___ 07:35AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.4
REPORTS
___ Imaging CHEST (PA & LAT)
1. Significant improvement in pulmonary edema. Retrocardiac
opacity suggests
atelectasis in the left lower lobe.
2. Mild cardiomegaly, unchanged.
Brief Hospital Course:
This an ___ year old male with past medical history systolic CHF
paroxysmal atrial fibrillation, His-Purkinje system conduction
disease s/p dual chamber pacemaker placement, BPH, CAD, and CKD
stage IV, with recent admission ___ for presyncope
thought ot be secondary to orthostatic hypotension for which
his tamsulosin was stopped, readmitted ___ with recurrent
symptoms after self-restarting Tamsulosin at home, without
symptoms after holding Tamsulosin for 2 nights, able to be
discharged home
# Presyncope
# Medication induced orthostatic hypotension
Patient with recent hospital stay for lightheadedness
attributed to tamsulosin use, for which he was recommended to
discontinue this medication, but who self-restarted it and
represented with recurrence of symptoms. Felt to be
medication-related again. Discontinued tamsulosin on
admission. Additional workup without signs of cardiac or
neurologic process, dehydration or other acute process.
Pacemaker had been interrogated during prior admission; during
this admission telemetry without notable issues. Patient
monitored for 2 nights off of tamsulosin and symptoms did not
recur. Discharged with instructions not to restart tamsulosin.
See below re: BPH management
# BPH with urinary symptoms
Patient reported he had restarted tamsulosin at home because of
difficulty with stream initiation at night. He presented with
symptoms attributed to tamsulosin as above. Tamsulosin stopped
and patient monitored for recurrent of symptoms, as well as
signs of worsening urinary retention.
No subjective symptoms and bladder scan only showed retention
of 100cc urine. Given that he developed urinary symptoms
previously while off of tamsulosin, team also provided patient
education on straight catheterization, and instructions to
perform this if he should develop urinary symptoms at home.
Continued finasteride 5mg daily.
#Chronic systolic heart failure (EF 26%)
#Heart block s/p PPM in ___
Pt was euvolemic on exam, at his dry weight of 183lb.
Continued home torsemide, metop, eplerenone,
Sacubitril-Valsartan. ___ for CRT upgrade in ___.
#CAD
#HLD
Continued ASA, rosuvatatin, ezetimibe
# Paroxysmal A Fib
# Bioprosthetic MVR:
INR at goal (___).. Continued warfarin 5mg daily. Continue
metop as above. Continue amiodarone.
# Macrocytic Anemia:
Pt with chronic h/o macrocytic anemia, previously found to be
due to B12 deficiency. Continue pyridoxine, cyanocobalamin.
Transitional issues
- Discharged home
- Discontinued Tamsulosin; given associated symptoms, would not
recommend restarting this unless patient hemodynamics improve
- Follow up with urologist, Dr. ___, on ___ for
management of urinary retention.
> 30 minutes spent on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Eplerenone 25 mg PO DAILY
4. Ezetimibe 10 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. FoLIC Acid 2.5 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Pyridoxine 50 mg PO DAILY
9. Rosuvastatin Calcium 20 mg PO QPM
10. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
11. Torsemide 30 mg PO DAILY
12. Warfarin 5 mg PO DAILY16
13. Aspirin 81 mg PO DAILY
14. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Eplerenone 25 mg PO DAILY
5. Ezetimibe 10 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. FoLIC Acid 2.5 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Pyridoxine 50 mg PO DAILY
10. Rosuvastatin Calcium 20 mg PO QPM
11. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
12. Torsemide 30 mg PO DAILY
13. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Presyncope secondary to
# Medication induced orthostatic hypotension
# BPH with urinary symptoms
#Chronic systolic heart failure (EF 26%)
#Heart block s/p PPM in ___
#CAD
#HLD
# Paroxysmal A Fib
# Bioprosthetic MVR:
# Macrocytic Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came into the hospital because you were feeling light and
unsteady at nighttime. We suspect the Tamsulosin you restarted
was likely causing this sensation, and it did not recur in the
hospital after we stopped this medication.
When you leave the hospital you should:
- Take all of your medications as prescribed.
- Attend all scheduled clinic appointments.
- If you are unable to void for more than 6 hours, you should
catheterize yourself.
- Do not take Tamsulosin unless instructed to do so by your
urologist.
- Please continue to weigh yourself everyday, and call your
cardiologist if your weight goes up more than 3 pounds in one
day or 7 pounds in one week.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
19849930-DS-30
| 19,849,930 | 28,028,210 |
DS
| 30 |
2172-04-22 00:00:00
|
2172-04-22 21:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Mevacor / Adhesive Tape / Aldactone
Attending: ___.
Chief Complaint:
Unsteady gait
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is an ___ old male with a history of HFrEF (EF
25%), paroxysmal afib, His-Purkinje system conduction disease
s/p
dual chamber PPM placement, BPH, CAD (s/p 4VCABG ___, re-do 1v
CABG + bioprosthetic MVR ___ and CKD recently admitted for
symptomatic orthostatic hypotension presenting with vertigo and
gait instability.
The patient has difficulty characterizing his symptoms
completely, but notes that for "some time" he has had occasional
"disequilibrium" that disrupts his gait. This sensation seems to
come on randomly at times but will reliably occur when he lies
back in bed. He thinks it is like vertigo. No hearing changes,
tinnitus, visual changes, headache, weakness in arms or legs,
nausea/vomiting. Denies lightheadedness or feeling like he is
going to pass out. He decided to come to the ED after the
sensation was particularly bad last night, requiring him to hold
on the wall while walking in his home.
He does have a history of 2 admissions for orthostasis that were
attributed to medication effect from tamsulosin, but states that
that sensation was different from this one. He has baseline
dyspnea with exertion that is unchanged, and continues to walk
0.5 miles daily. He does weigh himself daily but reports that
his
weight is not different from baseline and that it fluctuates
around 185 lbs. He has had no chest pain or palpitations.
Recent
medication changes significant for recent decrease of torsemide
to 20 mg daily by his cardiologist Dr. ___. Of note, when he
saw
Dr. ___, he reports that he was concerned about
progressive aortic stenosis, and was going to be set up to see
Dr. ___ consideration of non-surgical repair.
In the ED, initial vitals: T 97.8 HR 70 BP 105/45 RR 18 O2 sat
100% RA. Orthostatic vital signs were unremarkable.
- Exam notable for "baseline edema", fatigueable left-beating
nystagmus.
- Labs notable for baseline anemia and renal disease, trop to
0.09 (stable), BNP >8000 (stable), unremarkable UA, INR 2.4.
- Imaging notable for CXR with pulmonary vascular congestion, CT
head without acute process, shoulder x-ray without fracture.
- Patient was given aspirin, eplerenone, amiodarone, and
metoprolol prior to transfer.
On arrival to the floor, the patient reports his symptoms have
resolved. Prior to evaluation by the examiner, he had been
ambulating up and down the hall without symptoms.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative less otherwise noted in the HPI.
Past Medical History:
HFrEF (EF 25%)
His-Purkinje system conduction disease s/p dual chamber PPM
placement (RBBB, LPFB, LAFB)
Paroxysmal afib
CAD (s/p 4VCABG ___, re-do 1v CABG + bioprosthetic MVR ___
BPH
HTN
CKD
Dyslipidemia
Eczema
Hearing loss
Cataracts
Pre-diabetes
Social History:
___
Family History:
Mother died at ___ in childbirth. Father died at ___ of CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.1 BP 93/54 HR 70 RR 18 O2 sat 99% Ra
GENERAL: Pleasant, lying in bed comfortably
HEENT: Sclera anicteric. Moist mucus membranes.
CARDIAC: Regular rate and rhythm. ___ systolic murmur heard
across the precordium. JVP 10 cm.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, mildly distended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused. ___ pitting edema to bilateral shins
under compression stockings.
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact. No nystagmus.
___ not performed, though lying down elicits vertigo
sensation without observed nystagmus. Motor strength ___ in
upper
and lower extremities. No dysmetria.
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 857)
Temp: 97.4 (Tm 98.1), BP: 100/63 (94-105/56-68), HR: 70
(70-79), RR: 18 (___), O2 sat: 97% (97-100), O2 delivery: Ra,
Wt: 182.98 lb/83 kg
GENERAL: Pleasant, lying in bed comfortably
HEENT: Sclera anicteric. Moist mucus membranes.
CARDIAC: Regular rate and rhythm. ___ systolic murmur heard
across the precordium. JVP not elevated
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, mildly distended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused. trace to 1+ pitting edema to bilateral
shins under compression stockings.
NEURO: Alert, oriented. No nystagmus. Moving all extremities. No
dysmetria.
SKIN: No significant rashes
Pertinent Results:
LABS:
___ 07:45AM BLOOD WBC-5.3 RBC-3.76* Hgb-11.0* Hct-37.0*
MCV-98 MCH-29.3 MCHC-29.7* RDW-15.1 RDWSD-54.7* Plt ___
___ 05:06AM BLOOD WBC-4.2 RBC-3.35* Hgb-9.8* Hct-32.4*
MCV-97 MCH-29.3 MCHC-30.2* RDW-14.7 RDWSD-51.8* Plt ___
___ 07:45AM BLOOD Neuts-86.3* Lymphs-5.1* Monos-7.1
Eos-0.7* Baso-0.4 Im ___ AbsNeut-4.61 AbsLymp-0.27*
AbsMono-0.38 AbsEos-0.04 AbsBaso-0.02
___ 08:58AM BLOOD ___ PTT-33.3 ___
___ 05:06AM BLOOD ___ PTT-32.6 ___
___ 07:45AM BLOOD Glucose-114* UreaN-35* Creat-2.5* Na-141
K-5.0 Cl-104 HCO3-24 AnGap-13
___ 05:06AM BLOOD Glucose-94 UreaN-33* Creat-2.1* Na-139
K-4.6 Cl-102 HCO3-25 AnGap-12
___ 07:45AM BLOOD cTropnT-0.09*
___ 05:20AM BLOOD cTropnT-0.10*
___ 05:06AM BLOOD cTropnT-0.09*
___ 07:45AM BLOOD proBNP-8291*
___ 05:06AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1
___ 07:45AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.3
IMAGING:
CT HEAD W/O CONTRASTStudy Date of ___ 8:37 AM
There is no evidence of hemorrhage, edema, masses, mass effect
or infarction. There is enlargement of the ventricles and sulci
within the range expected for age. The left lens has been
resected. There is minimal mucosal thickening in the ethmoid
air cells. Otherwise, the paranasal sinuses and mastoid air
cells appear normal.
IMPRESSION:
No evidence of mass, hemorrhage or infarction. Minimal paranasal
sinus inflammatory changes.
CHEST (PA & LAT)Study Date of ___ 8:09 AM
Pulmonary vascular congestion, tiny right pleural effusion,
unchanged left basal opacity, may represent chronic pleural
thickening, difficult to exclude small effusion.
SHOULDER ___ VIEWS NON TRAUMA LEFTStudy Date of ___ 8:10
AM
Three views of the left shoulder. Chronic deformity of the left
clavicle reflect old healed injury. High-riding left humeral
head likely reflects chronic rotator cuff disease. No acute
fracture is seen. Left AC joint arthropathy is moderate with
bony hypertrophy and loss of joint space. No worrisome
calcifications.
IMPRESSION:
Degenerative disease as stated. No acute fracture.
___ 11:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Brief Hospital Course:
___ old male with a history of HFrEF (EF 25%), paroxysmal
afib, His-Purkinje system conduction disease s/p dual chamber
PPM placement, BPH, CAD (s/p 4VCABG ___, re-do 1v CABG +
bioprosthetic MVR ___ and CKD recently admitted for
symptomatic orthostatic hypotension presenting with vertigo and
gait instability. Orthostatic vital signs were normal. Symptoms
were thought to be not consistent with symptomatic aortic
stenosis or arrhythmia. Recent outpatient pacemaker
interrogation was normal. He was continued on his home heart
failure regimen and discharged with plan for outpatient
vestibular physical therapy.
TRANSITIONAL ISSUES:
====================
#PCP:
[]Patient should have outpatient vestibular ___ evaluation for
BPPV
[]Will need continued monitoring of volume status and renal
function and titration of diuresis
[]Continued on home warfarin dosing while inpatient, please
ensure proper anticoagulation follow up
#CARDIOLOGY:
[]Consider outpatient evaluation for low-flow low-gradient
aortic stenosis
[]Will need continued titration of heart failure medications
#AT DISCHARGE:
[]Weight: 83 kg (182.98 lb)
[]Cr: 2.1
#CODE: full (presumed)
#CONTACT: ___
Relationship: son
Phone number: ___
======================
PROBLEM-BASED SUMMARY:
======================
ACUTE ISSUES:
=============
#Vertigo:
#Unstable gait:
History of recurrent paroxysmal vertigo associated with supine
position sounds most consistent with BPPV. Rapid complete
resolution and normal CT are reassuring against central vertigo,
though this remains in the differential. Doubt orthostasis given
sensation is different from prior episodes, and orthostatic
vital signs negative x2. Vertigo sensation also seems
inconsistent with presyncope from aortic stenosis or arrhythmia,
though he does report his outpatient cardiologist was concerned
about progressive valve disease. The patient did not experience
any exertional symptoms with walking and reported sporadic
symptoms including at rest. Outside TTE with stable AS gradients
makes AS less likely culprit per cardiology curbside. Defered
PPM interrogation given atypical symptoms and recent normal
interrogation. Monitored on telemetry without any notable
events. Per ___, should have outpatient ___ including vestibular
evaluation.
#Chronic HFrEF:
Recently s/p failed upgrade to CRT-P. Appeared mildly volume up
on exam on admission and weight is increased ~6 lbs from prior
discharge, though exam appears stable with those documented when
patient was dry, and denies symptoms of heart failure
exacerbation. BNP elevated at baseline.
-Preload: continued home torsemide
-Afterload: Continued home Entresto
-NHBK: Continued home metoprolol, eplerenone
#Troponinemia
Low level troponin elevations chronically likely iso HF and CKD,
on admission 0.09 and trended to peak of 0.10. Given otherwise
asx, no c/f ACS currently.
CHRONIC ISSUES:
===============
#CKD: Attributed to chronic hypertension. Cr at baseline.
-Monitored BMP
-Continued home calcitriol
#Normocytic anemia: Likely in the setting of chronic kidney
disease.
-Continued to monitor CBC
#Atrial fibrillation:
-Continued home metoprolol
-Continued home warfarin, trend INR
#CAD:
-Continued home ASA, metoprolol, rosuvastatin
.
.
.
.
Attending addendum
Greater than 30 minutes were spent providing and coordinating
care for this patient on day of discharge.
___ MD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Eplerenone 25 mg PO DAILY
5. Ezetimibe 10 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. FoLIC Acid 2.5 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Pyridoxine 50 mg PO DAILY
10. Rosuvastatin Calcium 20 mg PO QPM
11. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
12. Torsemide 20 mg PO DAILY
13. Warfarin 5 mg PO DAILY16
14. Calcitriol 0.25 mcg PO EVERY OTHER DAY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO EVERY OTHER DAY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Eplerenone 25 mg PO DAILY
6. Ezetimibe 10 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. FoLIC Acid 2.5 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Pyridoxine 50 mg PO DAILY
11. Rosuvastatin Calcium 20 mg PO QPM
12. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
13. Torsemide 20 mg PO DAILY
14. Warfarin 5 mg PO DAILY16
15.Outpatient Physical Therapy
ICD: H81.10
Outpatient physical therapy including vestibular physical
therapy evaluation and treatment. Up to 12 sessions with
additional as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Vertigo
Unsteady gait
Secondary diagnoses:
Heart failure with reduced ejection fraction
Chronic kidney disease
Anemia
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
================================================
Discharge Worksheet
================================================
Dear Mr. ___
WHY WERE YOU ADMITTED?
-You came to ___ because you were feeling dizzy and unsteady
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
-You had tests done to evaluate for a cause of your dizziness
that were ultimately unrevealing
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please be sure to attend your follow up appointments (see
below)
- Please take all of your medications as prescribed (see below).
- Please check your weight daily. If you gain 3 lbs in 2 days or
5 lbs in 3 days, please call your cardiologist.
It was a pleasure participating in your care. We wish you the
___!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19849930-DS-31
| 19,849,930 | 21,530,025 |
DS
| 31 |
2172-06-16 00:00:00
|
2172-06-16 21:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Adhesive Tape
Attending: ___.
Chief Complaint:
dyspnea and leg swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o HFrEF (EF 25%), paroxysmal afib, His-purkinje system
conduction disease ___ dual PPM, BPH, CAD ___ 4v CABG +
bioprosthetic MVR and CKD presenting with worsening exertional
dyspnea.
Patient describes DOE for the past few weeks and endorses 7
pound
weight gain over the past month. Denies PND, orthopnea, f/c,
n/v/d, CP, palpitations, dizziness, syncope, and diaphoresis.
Denies pain or tingling in arms, hands, or jaw associated with
symptoms. States that this morning he couldn't catch his breath
and it took him hours to shower due to DOE and fatigue.
He is followed by Dr. ___ in Cardiology and has been having
weekly echocardiograms; he is scheduled for a nuclear stress
echo
on ___. His medication regimen changed about two weeks ago
at which time, Entresto was discontinued and eplerenone was
halved. He is ___ failed CRT upgrade in ___ of this year due
to
L subclavian occlusion with Dr. ___ he was continued on
medical management for the time being.
Past Medical History:
Heart Failure with reduced ejection fraction
His-Purkinje system conduction disease status post dual chamber
PPM
placement
Paroxysmal atrial fibrillation
Coronary artery disease
Mitral valve replacement with bioprosthetic valve
Benign prostatic hypertrophy
Hypertension
Chronic kidney disease
Dyslipidemia
Eczema
Hearing loss
Cataracts
Pre-diabetes
Social History:
___
Family History:
Mother died at ___ in childbirth. Father died at ___ of CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: 98.1 70 ___ 97% RA
24 HR Data (last updated ___ @ 1658)
Temp: 97.5 (Tm 97.5), BP: 122/77, HR: 70, RR: 20, O2 sat:
100%, O2 delivery: RA
Admission weight: 88.0 kg (194 lb)
Dry weight: 184 lbs (per patient)
Last Discharge weight: 83 kg (182.98 lb)
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: JVP around 11 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. ___ systolic
murmur
___ heard at ___. No rubs or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles or rhonchi.
+Diffuse end expiratory wheezes.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing or cyanosis. 2+
pitting peripheral edema up to thighs
SKIN: +stuck-on warty plaques
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM
======================
Gen: Well-appearing elderly gentleman in no acute distress.
CV: JVP 10, RRR, grade III/VI systolic murmur ___ heard at
___.
PULM: Mild inspiratory/expiratory wheezes on left.
ABD: Soft, non-tender, non-distended.
EXT: Warm. B/l 1+ edema to midshin, compression stockings in
place
NEURO: Alert, oriented, attentive. Normal gait.
Pertinent Results:
ADMISSION LABS:
=============
___ 01:55PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:55PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 01:55PM URINE HYALINE-20*
___ 01:55PM URINE MUCOUS-RARE*
___ 10:07AM LACTATE-1.4
___ 10:00AM GLUCOSE-118* UREA N-59* CREAT-3.5* SODIUM-142
POTASSIUM-5.1 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15
___ 10:00AM estGFR-Using this
___ 10:00AM CK(CPK)-218
___ 10:00AM cTropnT-0.16*
___ 10:00AM CK-MB-7 ___
___ 10:00AM CALCIUM-9.1 PHOSPHATE-4.7* MAGNESIUM-2.6
___ 10:00AM WBC-7.4 RBC-3.43* HGB-10.1* HCT-33.5* MCV-98
MCH-29.4 MCHC-30.1* RDW-15.5 RDWSD-55.5*
___ 10:00AM NEUTS-87.9* LYMPHS-3.9* MONOS-7.2 EOS-0.3*
BASOS-0.3 IM ___ AbsNeut-6.48* AbsLymp-0.29* AbsMono-0.53
AbsEos-0.02* AbsBaso-0.02
___ 10:00AM PLT COUNT-156
___ 10:00AM ___ PTT-36.7* ___
TTE- ___
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
moderate cavity size
dilation and severe global hypokinesis. Severe low flow, low
gradient aortic stenosis. Moderate pulmonary artery systolic
hypertension. Moderate tricuspid regurgitation. Well seated,
normal functioning bioprosthetic mitral valve prosthesis with
normal gradient and no mitral regurgitation. In the absence of
prominent ECG voltage for LVH, an infiltrative process should be
considered.
Dobutamine Stress Echo- ___
CONCLUSION: Uninterpretable ECG with to dobutamine stress. Mild
mitral regurgitation at rest. Moderate tricuspid regurgitration
at rest. Mild aortic stenosis with slightly increase in aortic
velocity with with progressive dobutamine but no change in
calculated aortic valve area. Moderately increased pulmonary
artery systolic pressure at rest. Normal resting blood pressure
with a hypotensive response and a blunted heart rate response to
dobutamine stress.
DISCHARGE LABS
=============
___ 07:55AM BLOOD WBC-6.2 RBC-3.55* Hgb-10.5* Hct-34.4*
MCV-97 MCH-29.6 MCHC-30.5* RDW-15.9* RDWSD-55.5* Plt ___
___ 07:55AM BLOOD Glucose-142* UreaN-52* Creat-2.7* Na-140
K-3.9 Cl-95* HCO3-31 AnGap-14
___ 07:55AM BLOOD ALT-32 AST-38 LD(LDH)-402* AlkPhos-89
TotBili-0.8
Brief Hospital Course:
SUMMARY
===============
Mr. ___ is a ___ with h/o ischemic cardiomyopathy (EF 25%),
CABG, bioMVR, AS, paroxysmal AF/VT ___ dual PPM (failed CRT
upgrade), admitted for gradually progressive dyspnea and edema,
thought to be due to worsening AS. Patient was aggressively
diuresed and once euvolemic underwent a dobutamine stress test
that showed only mild AS and therefore not a candidate for TAVR.
TRANSITIONAL ISSUES
=====================
[] Metoprolol initially held during admission given concern that
patient had low flow low gradient on TTE. This was restarted
after dobutamine stress echo demonstrated only mild AS with good
flow. Patient discharged on 12.5mg metoprolol XL. Recommend
further uptitration as tolerated as outpatient. No evidence for
alternate etiology for decompensation (pacemaker interrogation
negative, no s/sx of ischemia, adherent to meds/diet).
[] Eplerenone held during admission due to ___ on CKD. Patient's
Cr continued to improve throughout admission iso aggressive
diuresis. Recommend checking lytes on ___.
[] On TTE, patient noted to have thickened aortic valve. At
discharge, SPEP/UPEP/kappa/lambda light chains tests all
pending.
[] For afterload reduction could consider initiation of
isordil/hydralazine to optimize his heart failure regimen if he
is able to tolerate.
[] Patient not on ___ because of renal function.
ACTIVE ISSUES:
==============
# Acute on chronic HFrEF
# Aortic stenosis
Presented with gradually progressive edema and dyspnea, thought
likely
due to progressive aortic stenosis. No evidence for increased
arrhythmia burden, new ischemia, or alternate etiology. Patient
was aggressively diuresed with a Lasix gtt to euvolemia. Once
euvolemic he had a dobutamine stress. The dobutamine stress
showed he did not have low flow low gradient and rather that he
was able to augment with dobutamine and was not limited by his
aortic valve stenosis.
While he was in the hospital, his eplerenone was held due to an
___. This should be restarted if tolerated as an outpatient. His
metoprolol was also held initially given concern that patient
had low flow on TTE. However, this was restarted at a lower dose
with plans to uptitrate as outpatient after dobutamine stress
showed patient with good flow and mild aortic stenosis. Patient
was discharged on torsemide 40mg daily.
# History of paroxysmal AF and VT ___ dual-chamber PPM.
To rule out that decompensated heart failure occurred in the
setting of PPM dysfunction, his device was interrogated which
was unrevealing. He was continued on Amiodarone daily.
Metoprolol decreased as above. Warfarin continued. Please see
warfarin worksheet.
# CAD ___ CABG:
Trop mildly elevated on admission with flat MB, demand ischemia
from HF vs decreased renal clearance. No s/sx to suggest new
ischemia requiring intervention. Continued on home aspirin,
rosuvastatin. Metoprolol decreased as above.
# ___ on CKD:
Cardiorenal, improving with diuresis. At discharge, Cr improved
to 2.7 from initial peak of 3.5. Continued on home calcitriol.
#Wheezing/Shortness of breath. Patient improved with
intermittent nebulizer treatments.
CHRONIC ISSUES:
==============
#Normocytic anemia:
Likely due to CKD. Iron studies were wnl. B12 was normal at
1862.
# CODE: full (confirmed)
# CONTACT: ___
Relationship: son
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO 3X/WEEK (___)
4. Cyanocobalamin 1000 mcg PO DAILY
5. Eplerenone 12.5 mg PO DAILY
6. Ezetimibe 10 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. FoLIC Acid 2.5 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Pyridoxine 50 mg PO DAILY
11. Rosuvastatin Calcium 20 mg PO QPM
12. Torsemide 20 mg PO DAILY
13. Warfarin 5 mg PO DAILY16
14. Senna 8.6 mg PO QHS
15. Acidophilus (Lactobacillus acidophilus) oral DAILY
Discharge Medications:
1. 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
2. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
3. ___ MD to order daily dose PO DAILY16
4. Acidophilus (Lactobacillus acidophilus) oral DAILY
5. Amiodarone 200 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Calcitriol 0.25 mcg PO 3X/WEEK (___)
8. Cyanocobalamin 1000 mcg PO DAILY
9. Ezetimibe 10 mg PO DAILY
10. Finasteride 5 mg PO DAILY
11. FoLIC Acid 2.5 mg PO DAILY
12. Pyridoxine 50 mg PO DAILY
13. Rosuvastatin Calcium 20 mg PO QPM
14. Senna 8.6 mg PO QHS
15. HELD- Eplerenone 12.5 mg PO DAILY This medication was held.
Do not restart Eplerenone until instructed to restart by your
doctor.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
====================
# Acute on chronic heart failure with reduced ejection fraction
# Aortic stenosis
# paroxysmal atrial fibrillation
# Acute kidney injury on chronic kidney disease
SECONDAY DIAGNOSES
Normocytic anemia
coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were feeling short of breath because you had fluid in your
lungs. This was caused by a condition called heart failure,
where your heart does not pump hard enough and fluid backs up
into your lungs.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
You were medications to help get the fluid out. Your breathing
got better and were ready to leave the hospital. You also had a
stress test to see if your aortic valve was causing your fluid
overload.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning. Your weight on discharge is
###. Call your doctor if your weight goes up more than 3 pounds
(increases to a weight of ###).
- Call you doctor if you notice any of the "danger signs"
below.
We wish you the ___!
Your ___ Care Team
Followup Instructions:
___
|
19851369-DS-20
| 19,851,369 | 25,029,380 |
DS
| 20 |
2113-04-05 00:00:00
|
2113-04-05 16:44:00
|
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 intertrochanteric femur fracture
Major Surgical or Invasive Procedure:
placement of left short trochanteric femoral nail on ___
History of Present Illness:
___ male presents with the above fracture s/p mechanical
fall. Pt was hiking in ___ when he slipped on ice at 1600
this afternoon and fell onto his left hip. He states he knew
immediately something was wrong. He was unable to walk due to
the
pain. Ambulance was called and he was brought out on a ATV
stretcher. He went to ___ and was found to have a
left comminuted Intertrochanteric fracture and transferred here.
He denies previous injury to that leg. Normal state of health
prior to fall.
Past Medical History:
RIGHT DISTAL BICEPS RUPTURE
Social History:
___
Family History:
NC
Physical Exam:
Upon Admission:
General: Well-appearing male in no acute distress.
Right lower extremity:
- Skin intact
- leg is held in external rotation at the hip, flexed at the
knee
and shortened.
- Soft, TTP over the anterior hip.
- Will not range the hip due to pain. minimal range of the knee
due to hip pain. Full ROM of the ankle
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Upon discharge:
General: Well-appearing male in no acute distress.
Right lower extremity:
- Incision c/d/I
- Soft and compressible thigh and calf
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Pertinent Results:
___ 06:40AM BLOOD Hct-37.5*
___ 05:35AM BLOOD Hct-37.9*
___ 08:13AM BLOOD WBC-7.9 RBC-3.90* Hgb-12.2* Hct-35.9*
MCV-92 MCH-31.3 MCHC-34.0 RDW-13.0 RDWSD-43.4 Plt ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left intertrochanteric femur fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for placement of short trochanteric
femoral nail, which the patient tolerated well. For full details
of the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the left lower extremity, and
will be discharged on lovenox 40mg daily x 4 weeks 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:
ACETAZOLAMIDE - acetazolamide 250 mg tablet. 1 tablet(s) by
mouth
daily
ONDANSETRON HCL - ondansetron HCl 4 mg tablet. 1 tablet(s) by
mouth Q8hrs as needed for nausea
OXYCODONE - oxycodone 5 mg tablet. 1 to 2 tablet(s) by mouth
every four to six hours as needed for pain Do not drive while
taking this medication. Do not take with alcohol.
Medications - OTC
DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s)
by
mouth Q12 hrs as needed for for constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times daily
Disp #*60 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl [Correctol] 5 mg 1 to 2 tablet(s) by mouth daily
Disp #*50 Tablet Refills:*0
3. Calcium Carbonate 1250 mg PO TID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*50 Tablet Refills:*0
5. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe
Refills:*0
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Mild
RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4)
hours Disp #*34 Tablet Refills:*0
7. Senna 8.6 mg PO DAILY
RX *sennosides [senna] 8.6 mg 1 tab by mouth daily Disp #*50
Tablet Refills:*0
8. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left intertrochanteric femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated to the left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40 mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- If you have a splint, it must be left on until follow up
appointment unless otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
weight bearing as tolerated to the left lower extremity
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Please remain in the splint until follow-up appointment. Please
keep your splint dry. If you have concerns regarding your
splint, please call the clinic at the number provided.
Call your surgeon's office with any questions.
Followup Instructions:
___
|
19851620-DS-19
| 19,851,620 | 24,849,809 |
DS
| 19 |
2181-04-09 00:00:00
|
2181-04-09 17:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
clindamycin / Levaquin
Attending: ___
Chief Complaint:
cardiac arrest
Major Surgical or Invasive Procedure:
Intubation at ___ ___
History of Present Illness:
___ year old w/ hx of myasthenia ___, progressive supranuclear
palsy, spinal stenosis, HLD, HTN presenting s/p cardiac arrest.
Per family, patient was relatively healthy until ___ years ago
when he was hospitalized for the first time for bilateral knee
replacements. He continued to decline when he was diagnosed with
myasthenia ___ in ___ and progressive supranuclear palsy
with parkinsonian features in ___. Since then, he has had
issues with drooling and managing secretions. Mr. ___ has
maintained cognitive function and is able to balance checkbooks
but has difficulty with manual function and requires physical
assistance for ADL including bathing, writing, ambulating. He
typically walks with a rollator with the assistance of two
people.
He lives with both his wife ___ and his daughter. His daughter
recall that around 9:50 p.m., he had finished watching t.v. and
taking his medication. She walked him up the stairs to his
bedroom and then as he was walking to the bathroom, his knees
suddenly buckled. He had no prodrome or complaints prior to
this event though he did c/o of intermittent left calf pain over
the week which would occur at night and improve with massage.
His daughter did note that he was holding his breath as he was
walking up the stairs - he often does this to prevent himself
from drooling. His daughter was able to catch him before he fell
- ___ did not suffer from headstrike. He had a vacant look as
he fell, with no associated rhythmic movements. He did not grab
his chest or have complaints of shortness of breath. His family
tells me that he rarely ever has any falls. His daughter slowly
lowered him to the floor and noticed shallow breathing. She
began chest compressions and gave him half a tab of aspirin as
her mother called ___.
BLS arrived initially, found patient pulseless and initiated
CPR. Initial rhythm is unknown. No shock was advised on AED.
Patient had ROSC ___ min later. He was transported to ___
___ and noted to have spontaneous breathing. He was intubated
(#7.5, 23cm @lip. CMV 500x14 100% +5 PEEP) with etomidate and
rocuronium and sedated with fent/versed. Vitals were HR64
BP114/52. His initial labs showed chem7:
145/5.2/105/2.6/38/1.4/175, Ca 8.5 with WBC 11.7, h/h ___,
lactic acid 4.3 and trop T 0.03 (nl ___.
Today's vitals BI-ED 00:07 T34C 96.6 55 128/60 20 100% RA
Physical exam in ED notable for occasional non-purposeful
movement. No response to painful stimuli. Pupils 3mm
non-reactive. Bilateral BS. RRR.
Labs were notable for: h/h ___ (unk baseline), creat 1.3,
lactate 1.4, urine/serum tox positive for benzos received at OSH
EKG showed: Sinus rhythm HR50. PVCs, QRS 124.
CT head showed: no acute intracranial process
CXR showed: mild cardiomegaly with R hilar
adenopathy/consolidation, and possible retrocardiac opacity
Bedside TTE showed: no evidence of effusion but did suggest
depressed EF.
Patient was started on fent/midaz gtt and given 4.5g zosyn and
1g vanc.
On arrival to the MICU, patient was intubated and sedated.
Review of systems:
(+) Per HPI
(-) per wife/daughter - negative for fevers, chills, chest pain,
shortness of breath, nausea, vomiting, abd pain, dysuria.
Past Medical History:
Myasthenia ___
Progressive supranuclear palsy
Spinal stenosis
HLD
HTN
B/L knee repair
BPH
Bradycardia
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM
Vitals: T:33.9 BP:122/91 P:45 R:14 O2: 100% on CMV PEEP5 FIO2
40% TV500 ___
GENERAL: elderly male, sedated, puffy eyelids
HEENT: Sclera anicteric, dry MM, ETT in place
NECK: large neck
LUNGS: R bronchial breath sounds, otherwise clear
CV: bradycardic, regular, normal S1 S2, no murmurs, rubs,
gallops
ABD: obese, soft non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
Groin: large palpable hernia
EXT: cool, 1+ pulses, 2+ pitting edema up b/l legs, no clubbing
or cyanosis; RA changes of b/l hands
Neuro: pupils 3mm, minimally reactive, symmetric, no withdrawal
to pain
DISCHARGE EXAM
Vitals: not checked, CMO
GENERAL: thin, quiet, breathing unlabored, in no distress
EXTREMITIES: warm
Pertinent Results:
ADMISSION LABS
============================
___ 01:00AM BLOOD WBC-7.4 RBC-2.49* Hgb-8.4* Hct-28.0*
MCV-112* MCH-33.7* MCHC-30.0* RDW-14.7 RDWSD-60.8* Plt ___
___ 01:00AM BLOOD Neuts-76.8* Lymphs-8.2* Monos-9.7 Eos-3.0
Baso-0.4 Im ___ AbsNeut-5.70 AbsLymp-0.61* AbsMono-0.72
AbsEos-0.22 AbsBaso-0.03
___ 01:00AM BLOOD ___ PTT-24.7* ___
___ 01:00AM BLOOD Glucose-126* UreaN-41* Creat-1.3* Na-145
K-4.6 Cl-108 HCO3-26 AnGap-16
___ 01:00AM BLOOD cTropnT-0.03*
___ 01:00AM BLOOD Albumin-3.2* Calcium-8.3* Phos-3.6 Mg-2.4
Iron-34*
___ 01:00AM BLOOD calTIBC-234* Ferritn-138 TRF-180*
___ 02:49PM BLOOD Triglyc-96 HDL-36 CHOL/HD-3.1 LDLcalc-57
___ 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS* Barbitr-NEG Tricycl-NEG
___ 05:18AM BLOOD ___ pO2-22* pCO2-62* pH-7.31*
calTCO2-33* Base XS-1
___ 01:23AM BLOOD Lactate-1.4
___ 03:07PM BLOOD freeCa-1.07*
DISCHARGE LABS
============================
___ 03:16AM BLOOD WBC-6.1 RBC-2.63* Hgb-8.9* Hct-29.4*
MCV-112* MCH-33.8* MCHC-30.3* RDW-13.5 RDWSD-55.0* Plt ___
___ 03:16AM BLOOD Glucose-98 UreaN-56* Creat-1.1 Na-149*
K-4.5 Cl-111* HCO3-24 AnGap-19
___ 03:16AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.9*
MICRO
============================
___ BLOOD CX: negative
___ URINE CX: negative
___ SPUTUM CX: yeast
___ SPUTUM CX: negative
IMAGING
============================
ECHO ___
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
There is an inferobasal left ventricular aneurysm. Overall left
ventricular systolic function is severely depressed (LVEF= 25 %)
secondary to inferior, posterior, and apical akinesis, and
hypokinesis of the rest of the left ventricle. A left
ventricular mass/thrombus cannot be excluded. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Doppler parameters are most consistent with Grade
II (moderate) left ventricular diastolic dysfunction. The right
ventricular free wall thickness is normal. Right ventricular
chamber size is normal with severe global free wall hypokinesis.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. An eccentric,
posteriorly directed jet of moderate (2+) mitral regurgitation
is seen. Due to the eccentric nature of the regurgitant jet, its
severity may be significantly underestimated (Coanda effect).
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
CT HEAD ___. There is loss of gray-white differentiation of the apparent
right post
central gyrus and right anterior insula with associated mild
sulcal effacement and white matter hypodensity of the right
corona radiata, concerning for acute infarcts given the clinical
history. MRI would be more sensitive, if there Are no
contraindications, for more subtle findings.
2. No acute intracranial hemorrhage.
MRI BRAIN ___. No evidence for acute infarction in the right postcentral
gyrus, right
frontal operculum, or right anterior insula, where edema was
suspected on the preceding noncontrast head CT.
2. Signal abnormality on diffusion tracer sequence and ADC map
in the right inferior parietal lobe, where there is extensive
high T2/FLAIR signal, is most consistent with T2 shine through
related to chronic small vessel ischemic disease. Subacute
infarction older than 10 days is less likely, given the
patient's presentation. However, comparison with prior studies
would be helpful in this regard.
3. Global parenchymal volume loss with disproportionate
involvement of the
superior parietal lobes along the postcentral sulci.
4. Technically limited neck MRA demonstrates bilateral carotid
bulb
irregularity, presumably atherosclerotic, with mild, less than
40% stenosis by NASCET criteria on the right, and no evidence
for stenosis by NASCET criteria on the left.
5. Right vertebral artery origin is suboptimally visualized, and
mild stenosis cannot be excluded. Left vertebral artery origin
is not included on the images.
6. Motion limited brain MRA demonstrates no evidence for
flow-limiting
stenosis or large aneurysm in the major intracranial arteries.
CXR ___. Left lower lobe atelectasis is unchanged.
2. Moderate pulmonary venous channel edema and moderate
cardiomegaly is
unchanged.
3. Small left pleural effusion is minimally changed.
Brief Hospital Course:
___ year old w/ hx of myasthenia ___, progressive supranuclear
palsy, spinal stenosis, HLD and HTN presenting s/p cardiac
arrest.
ACTIVE ISSUES
# CARDIAC ARREST: Unclear precipitating event. This may have
been true cardiac arrest, or respiratory arrest (perhaps
aspiration leading to PEA), or primary stroke. Acute MI is less
likely given indeterminant troponins and underwhelming EKG, with
EF near baseline and clean coronaries per PCP. No DVTs on ___.
He was treated with broad spectrum antibiotics, and cultures
showed no growth. He was cooled under the cooling protocol. He
was weaned off all pressors.
# HYPERCARBIC RESPIRATORY FAILURE: Patient's ongoing respiratory
failure was likely multifactorial, and caused by weakness and
neuromuscular failure from myasthenia ___, as well as
critical illness. Bronch ___ without evidence of mucous
plugging and therefore not likely LLL collapse. Neuromuscular
radiology was consulted, and patient received IV Ig for 5 days,
Prednisone 40mg daily, and pyridostigmine. After a family
meeting (see ___ Metavision note), family and patient decided
that trach would not be within goals of care. Patient was
extubated to a trial of BiPap, and code status was DNR/DNI at
that time. He was discharged on hospice with pyridostigmine for
symptoms.
# ANEMIA: Patient remained anemic throughout hospitalization, no
evidence of hemolysis or bleeding .
# ___: Unknown baseline, likely elevated in the setting of acute
insult from cardiac arrest. Maintained good UOP during
hospitalization.
# PARKINSONISM: on Sinemet at home. Stopped, per hospice care.
# HTN: Held home BP meds in the ICU.
# BPH: meds were held during cooling, then restarted
TRANSITIONAL ISSUES:
====================
[ ] Swallow evaluation, has issues at baseline
[ ] Resume home BP meds
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa CR (50-200) 1 TAB PO BID
2. Carbidopa-Levodopa CR (___) 1 TAB PO QAM
3. AzaTHIOprine 75 mg PO BID
4. AzaTHIOprine 50 mg PO QAM
5. Lisinopril 5 mg PO DAILY
6. Carvedilol 6.25 mg PO BID
7. Simvastatin 20 mg PO QPM
8. Finasteride 5 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. Amoxicillin ___ mg PO PREOP 1 hr prior to dds appt
11. Naproxen 220 mg PO Q12H
12. Aspirin 81 mg PO QPM
13. GuaiFENesin ER 600 mg PO QAM
14. Multivitamins 1 tab Other DAILY
15. Fergon (ferrous gluconate) 240 mg (27 mg iron) oral DAILY
16. Ascorbic Acid ___ mg PO DAILY
17. Cetirizine 10 mg PO DAILY
18. Artificial Tears Preserv. Free ___ DROP BOTH EYES DAILY
Discharge Medications:
1. Bisacodyl 10 mg PR QHS:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*12
Suppository Refills:*0
2. LORazepam 1 mg PO Q4H:PRN ANXIETY
RX *lorazepam 2 mg/mL 0.5 (One half) mL by mouth every 4 hours
Refills:*0
3. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 4 mg
SL Q2H:PRN Pain - Moderate
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.2 mL by mouth
every 2 hours Disp ___ Milliliter Milliliter Refills:*0
4. OLANZapine (Disintegrating Tablet) 5 mg PO QHS
RX *olanzapine 5 mg 1 tablet(s) by mouth at bed Disp #*30 Tablet
Refills:*0
5. Pyridostigmine Bromide Syrup 60 mg PO TID
RX *pyridostigmine bromide [Mestinon] 60 mg/5 mL 5 mL by mouth
three times daily Refills:*0
6. Pyridostigmine Bromide 60 mg PO TID
RX *pyridostigmine bromide 60 mg 1 tablet(s) by mouth three
times daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses: cardiac arrest, myasthenic crisis, pneumonia
Secondary diagnoses: systolic heart failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
You were at ___ after your
heart stopped. You were resuscitated, but your course was
complicated by worsening myasthenia ___ and pneumonia. You
remained in the ICU with life support, and made small
improvements.
You are being discharged home in the care of hospice and your
family.
It was a pleasure caring for you.
We wish you the very best,
Your care teams at ___
Followup Instructions:
___
|
19851669-DS-23
| 19,851,669 | 23,347,897 |
DS
| 23 |
2188-12-16 00:00:00
|
2188-12-16 19:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ibuprofen / Lamisil / Biaxin
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Open reduction internal fixation of distal right humerus
fracture ___
History of Present Illness:
___ year-old female with a history of hypertension,
hyperlipidemia and peripheral vascular disease s/p bilateral
iliac stents (___) who presents after a mechanical fall from
bed resulting in a right humeral fracture requiring operative
management; we are called to comment upon pre-operative risk
stratification and optimization as well as ___ transfer.
The night prior to admission Mrs. ___ underwent a fall from
her bed when she rolled over and subsequently sustained injury
to her face and right arm. She denies losing consciousness at
any moment. She had significant pain in her forehead and the
area surrounding her left eye as well as difficulty moving her
right shoulder and elbow.
Past Medical History:
1. Hyperlipidemia.
2. Tobacco abuse, ongoing.
3. Hypertension.
4. Peripheral vascular disease, status post aortoiliac
reconstruction under the care of Dr. ___, currently
with ___ class 2 claudication.
5. Agenesis of left kidney
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her father had a CABG at age ___, sister ___
died from renal CA.
Physical Exam:
ADMISSION PHYSICAL EXAM
==============================
Vitals: 97.8 75 162/71 16 94% RA
General: A&Ox3, NAD
CAM/MINICOG: Negative
Heart: Regular rate and rhythm peripherally
Lungs: Breathing comfortably on room air.
Right upper extremity:
- Skin intact
- Large ecchymosis & effusion over right elbow
- TTP over elbow. Soft, shoudler, wrist and digits
- Full, painless active/passive ROM of wrist, and digits. Unable
to range elbow secondary to pain.
- EPL/FPL/DIO (index) fire
- Sensation intact to light touch in radial/median/ulnar nerve
distributions
- 2+ radial pulse, fingers warm and well perfused
Left upper extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless active/passive ROM of shoulder, elbow, wrist,
and digits
- EPL/FPL/DIO (index) fire
- Sensation intact to light touch in
axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse, fingers warm and well perfused
DISCHARGE PHYSICAL EXAM
=============================
Vitals: Tm98.6 HR100-121 BP147-180 (most 150s-170s)/ 70s O298 RA
General: Alert, oriented, no acute distress; lying in bed;
appears comfortable.
HEENT: Sclera anicteric, MMM, oropharynx clear; left eye with
surrounding dark purple bruise, somewhat improved.
Neck: supple, JVP not elevated, no LAD.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi; breathing on room air.
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur at
RUSB and LUSB radiating to carotids, II/VI, no thrill,
unchanged.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly.
Ext: Warm, well perfused, 1+ left dorsal pulse, did not palpate
right dorsal pulse; no edema; bilateral mid lower leg scratches,
uncovered and no new wounds
Neuro: alert and oriented x3; no focal deficits.
Pertinent Results:
ADMISSION LABS
============================
___ 07:25PM BLOOD WBC-5.5 RBC-2.93* Hgb-10.6* Hct-28.5*
MCV-97# MCH-36.2* MCHC-37.2* RDW-11.8 RDWSD-41.6 Plt ___
___ 07:25PM BLOOD Neuts-81.6* Lymphs-8.2* Monos-9.6
Eos-0.0* Baso-0.2 Im ___ AbsNeut-4.50 AbsLymp-0.45*
AbsMono-0.53 AbsEos-0.00* AbsBaso-0.01
___ 07:25PM BLOOD ___ PTT-26.5 ___
___ 07:25PM BLOOD Glucose-144* UreaN-18 Creat-1.3* Na-121*
K-3.8 Cl-78* HCO3-27 AnGap-20
DISCHARGE AND PERTINENT LABS
============================
___ 06:10AM BLOOD WBC-4.1 RBC-2.61* Hgb-8.9* Hct-27.1*
MCV-104* MCH-34.1* MCHC-32.8 RDW-15.6* RDWSD-58.2* Plt ___
___ 06:10AM BLOOD Glucose-106* UreaN-10 Creat-1.2* Na-132*
K-3.9 Cl-90* HCO3-21* AnGap-25*
___ 10:30AM BLOOD LD(LDH)-209 TotBili-0.5
___ 06:10AM BLOOD Calcium-9.6 Phos-2.9 Mg-1.9
___ 10:30AM BLOOD calTIBC-291 VitB12-291 Folate-GREATER TH
Hapto-212* Ferritn-189* TRF-224
___ 08:09AM URINE Hours-RANDOM Creat-23 Na-82 K-5 Cl-82
___ 06:41AM URINE Hours-RANDOM Na-25 K-48 Cl-20 Calcium-0.7
HCO3-LESS THAN
___ 08:09AM URINE Osmolal-231
___ 06:41AM URINE Osmolal-297
___ 10:30AM BLOOD Ret Aut-4.1* Abs Ret-0.08
___ 09:30AM BLOOD Osmolal-261*
IMAGING AND DIAGNOSTICS
===========================
CXR ___:
IMPRESSION:
Possible very minimal interstitial edema versus chronic lung
disease. No focal consolidation.
CT head+spine ___:
IMPRESSION:
No acute intracranial process.
IMPRESSION:
1. No acute fracture. Minimal retrolisthesis of C5 over C6 is
of
indeterminate age, but likely degenerative. Degenerative
changes.Partially
imaged thyroid gland appears mildly prominent but not fully
imaged or well
assessed on this study, correlate with thyroid function tests
non urgently.
No discrete thyroid nodule is identified
EKG ___:
Normal sinus rhythm. Normal ECG. No significant change compared
to the previous tracing of ___.
CT upper ext ___:
IMPRESSION:
1. Transverse impacted fracture of the distal humerus
metadiaphysis with posterior displacement of the distal end of
the proximal fracture fragment. The fracture plane extends
through the lateral epicondyle and the superior aspect of the
medial epidcondyle. There is suggestion of areas of sclerosis
along the fracture edges that raises the possibility of a
subacute or chronic
fracture.
2. Surrounding soft tissue edema, hematoma, and joint effusion
noted.
3. The radio capitellar and ulnar trochlear articulations
remain congruent, as does the proximal radioulnar joint. .
CXR ___:
IMPRESSION:
As compared to the previous radiograph, no relevant change is
seen. Mild
overinflation. Borderline size of the cardiac silhouette
without pulmonary edema. Mild bilateral apical thickening. No
pleural effusions. No pneumonia, no pulmonary edema.
V/Q Scan ___:
IMPRESSION: Normal VQ scan. A normal V/Q scan rules out
recent pulmonary embolism.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with past medical history of
congenital single kidney, hypertension, hyperlipidemia, and
peripheral vascular disease s/p bilateral stents in ___, who
presented ___ after a mechanical fall. She underwent an open
reduction internal fixation of the distal right humerus on ___.
She was found to be hyponatremic and with an increasing
creatinine level, and was transferred to medicine on ___.
#Distal right humerus fracture: S/p ORIF ___ by orthopedic
surgery. Pain was controlled with oxycodone.
#Hyponatremia: Patient was asymptomatic. Serum Na was 121 at
admission, and improved to 125 by time of transfer, after
receiving ___ L over two days. Her serum osmolality was 261,
urine sodium 25, and urine osm 297. She appeared clinically dry
on exam. She was bolused with 1 L normal saline x2 on ___ and
___, and sodium improved to 132 upon discharge. She had been
taking hydrochlorothiazide at home, which likely contributed to
her hyponatremia. She was advised to avoid diuretics in the
future, unless otherwise instructed by a health care provider
familiar with her history, and only with close monitoring.
___: Patient was admitted with a creatinine of 1.3, and this
increased to 1.8 over 1 day. This appeared to be prerenal ___.
After bolusing the patient with IVF as above, creatinine
returned to 1.2 prior to discharge. We do not have a baseline to
compare to as patient has not had follow-up in primary care for
years. This should be followed and worked up appropriately on an
outpatient basis.
#Anemia: on ___ patient was found to have hemoglobin/hematocrit
6.9/20.7 down from ___ on ___, and 10.6/28.5 upon admission.
She was transfused with 1 unit of PRBCs and hemoglobin increased
appropriately to 8.6. Anemia studies were sent, and looked to be
a mixed picture of iron deficiency anemia and anemia of chronic
disease vs inflammation after surgery. Per orthopedic surgery,
it is normal for patients to lose blood after surgeries, and she
was having no other source of blood loss, so this is the likely
cause of her acute drop. Patient was not started back on home
plavix during hospitalization in the setting of recent bleed.
#HTN and tachycardia: Patient initially told the team she was
not taking any medications at home. After further investiation,
we found that prescriptions were being refilled in her name. On
further discussion, it became clear that she was taking these
medications, although she had been reluctant to share this
information given that she did not have a PCP managing these
medications. Home meds were atenolol, hydrochlorothiazide and
lisinopril. She appears to have developed rebound tachycardia
and hypertension in the setting of these medications being held
perioperatively. Prior to learning that she was taking these
medications, we started her on amlodipine. Blood pressures only
mildly improved over a 1.5 day period on amlodipine, not enough
time to see a full effect. Heart rates peaked in 110s-120s, and
SBPs 150s-180s. We sent patient for a V/Q scan to rule out
pulmonary embolism in the setting of recent surgery,
tachycardia, and t wave inversions in III and flatening in V3 in
an EKG showing sinus tachycardia. V/Q scan was reported as low
probabily for PE. She was discharged with home atenolol and
lisinopril, and the amlodipine started while hospitalized. She
was not continued on hydrochlorothiazide as explained above.
#O2 requirement: upon transfer, occupational therapy was working
with the patient and she was found to be desatting with
ambulation on RA to mid ___. She was not complaining of
shortness of breath, and we do not have a baseline level of
activity or oxygen requirements for her. Her chest X-ray and
lung exam were both non concerning for acute pulmonary process
or pulmonary edema. OT recommended patient attend rehab after
discharge. She is an active smoker, and should likely undergo
formal PFT testing as outpatient.
#Bilateral lower leg scratches: Patient noticed to have
significant self-induced scabs and scratches on both of her
legs. She says she gets dry skin and scratches her legs. We
ordered aquafor for skin hydration and changing of the bandages
covering the legs, with excellent effect.
#Hyperlipidemia: Continued Atorvastatin 20 po nightly
TRANSITIONAL ISSUES
#Restart plavix
#Outpatient lung CT scan in smoker
#Outpatient PFTs
#Smoking cessation counseling
#Echo to evaluate systolic heart murmur (last done ___ years
ago)
#Medication management and prescription management
#F/u with orthopedic surgery
#DEXA Scan
#F/u H/H, anemia workup
#Continue to trend creatinine
#Continue to trend sodium, avoid diuretics if possible, as
patient becomes hypovolemic and then hyponatremic
#Code status: FULL
#CONTACT: ___, Brother, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
2. Aquaphor Ointment 1 Appl TP QID:PRN scabs on legs/dryness
RX *white petrolatum [Advanced Healing (Petrolatum)] 41 % apply
as needed as needed Refills:*0
3. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth at night Disp #*30
Tablet Refills:*1
4. 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
5. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
RX *oxycodone 15 mg 1 tablet(s) by mouth q4h prn pain Disp #*20
Tablet Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [___] 8.6 mg 1 by mouth twice a day Disp
#*30 Tablet Refills:*0
7. Vitamin D 400 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*1
8. Calcium Carbonate 500 mg PO TID
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1
tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0
9. Atenolol 100 mg PO DAILY
RX *atenolol 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
10. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
11. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
12. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
13. Milk of Magnesia 30 ml PO BID Constipation
RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 ml by
mouth daily Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
==================
Distal right humerus fracture
Hyponatremia
Acute kidney injury
Anemia
Secondary Diagnoses
==================
Hypertension
Peripheral vascular disease
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You presented to the
hospital after a fall. You were found to have a fracture of your
arm, and this was corrected by surgery with the orthopedic
surgery team. While you were hospitalized, you were noticed to
have a low sodium value and decreased renal function, and you
were transferred to the general medicine team. The reason your
sodium was low and your renal function was decreased was that
you did not have enough fluids in your system. This is likely
because you were taking a diuretic medication called
hydrochlorothiazide. We gave you IV fluids, and these problems
corrected. We recommend not using diuretics in the future as
this may worsen this problem.
In addition, you were found to have a low red blood cell level,
or anemia, during your hospitalization. The likely cause of the
acute drop in blood was your surgery. However, your blood levels
are low at your baseline, and you should follow this up with
your primary care physician. Furthermore, your blood pressures
were high during hospitalization. We started you on a medication
called amlodipine, and your blood pressures improved.
Also while you were hospitalized, you were found to have a high
heart rate in the 100-110 range. This is likely because you were
not continued on home dose of atenolol, because there was
miscommunication of the medications you were or were not taking.
We are discharging you with your home dose of atenolol.
We did not restart your plavix during hospitalization because of
the acute blood loss after surgery, we recommend you speak with
your primary care physician about restarting this post
discharge.
Please take all the medications as prescribed to you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19851671-DS-18
| 19,851,671 | 28,006,224 |
DS
| 18 |
2154-09-25 00:00:00
|
2154-09-25 15:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
adhesive / dicloxacillin
Attending: ___
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ sp CABG 4 ___ discharged yesterday to rehab was sent to
___ from his rehab facility for hypotension.
Initially there was a question of seizure but the pt speaks
___ only and denies loss of conciousness when asked via his
daughter who is present. He endorses temporary confusion however
which has since resolved. He responded to at least 2 L
crystalloid for a SBP in the ___ and currently his SBP is 110.
He
has never been tachycardic and is 98% on RA. He denies SOB,
chest
pain, cough, fevers or any other symptoms. His post op course
was notable for mild pancreatitis but his lipase, amylase and
LFTs are stable; he also denies abdominal pain/N/V.
Past Medical History:
Coronary Artery Disease s/p revascularization
postop atrial fibrillation ___
Secondary:
- Syncope ___ (occurred while traveling to ___ ___
___ after drinking a small amount of wine. ___ hypotension
other similar incidents which occurred while just before or
- Vasovagal
- DVT and PE ___ (following right knee replacement)
- Diabetes
- Hypertension
- Cervical radiculopathy (severe DJD with neuroforaminal
encroachment especially at C4-C5, C5-C6, and C6-C7)
- Osteoarthritis
- Hyperlipidemia
- Carpal tunnel syndrome
- Colon polyps
- Sleep apnea (compliant with CPAP)
- Lentigo Maligna s/p resection ___ at ___, with additional
resection in ___
Past Surgical History:
- Lentigo Maligna s/p resection ___, w/ additional resection in
Social History:
___
Family History:
Mother had MI
and died in her ___. Father had MI later in life.
Physical Exam:
Time Pain Temp HR BP RR Pox Glucose
+ Triage 02:10 0 98.0 89 101/55 18 98% RA glc 112
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[]
Extremities: Warm [x], well-perfused [x] Edema [x] _none____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses: normal BLE
Pertinent Results:
Chest Film: ___
There is left basilar atelectasis and slight blunting of the
left costophrenic angle. Aeration of the left lower lobe is
improved. Platelike atelectasis is again seen at the level of
the left hila. The heart remains enlarged. The aorta is
tortuous. There is no pneumothorax. Median sternotomy wires
are intact. The right internal jugular central venous line has
been removed over the interval.
IMPRESSION:
Improved aeration of left lower lobe, with mild persistent
atelectasis and blunting of the left costophrenic angle.
___ WBC-8.0 RBC-3.22* Hgb-9.8* Hct-30.4* MCV-94 MCH-30.4
MCHC-32.2 RDW-13.3 RDWSD-46.1 Plt ___
___ WBC-8.8 RBC-3.02* Hgb-9.0* Hct-29.0* MCV-96 MCH-29.8
MCHC-31.0* RDW-13.5 RDWSD-47.8* Plt ___
___ WBC-6.8 RBC-3.32* Hgb-9.9* Hct-31.8* MCV-96 MCH-29.8
MCHC-31.1* RDW-13.4 RDWSD-47.1* Plt ___
___ ___
___ ___ PTT-30.7 ___
___ Glucose-138* UreaN-30* Creat-1.3* Na-135 K-5.1 Cl-101
HCO3-22
___ Glucose-126* UreaN-27* Creat-1.2 Na-135 K-4.6 Cl-104
HCO3-18*
___ Glucose-126* UreaN-18 Creat-1.2 Na-134 K-4.9 Cl-100
HCO3-23
___ Lipase-610*
___ Lipase-670*
___ Amylase-246*
___ ALT-26 AST-22 AlkPhos-70 TotBili-0.3
___ ALT-31 AST-31 AlkPhos-77 Amylase-348*
___ 07:00AM BLOOD WBC-6.8 RBC-3.32* Hgb-9.9* Hct-31.8*
MCV-96 MCH-29.8 MCHC-31.1* RDW-13.4 RDWSD-47.1* Plt ___
___ 06:55AM BLOOD ___
___ 06:55AM BLOOD Amylase-322*
Brief Hospital Course:
Mr. ___ was admitted on ___ for hypotension which
responded to volume. His beta blockade dose was decreased. His
amylase and lipase were elevated but began to resolve. He was
placed on a full liquid diet initially but was asymptomatic with
a benign abdominal exam and tolerated advancement of his diet.
His amiodarone and metformin were stopped. He remained in sinus
rhythm on lopressor. Anticoagulation continued for history of
postoperative atrial fibrillation. By hospital day two he was
ready for transfer back to ___ and Rehab.
Medications on Admission:
1. Aspirin EC 81 mg PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. Acetaminophen 650 mg PO Q4H:PRN pain/fever
6. Amiodarone 200 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO TID
8. Warfarin 2 mg PO DAILY16
dose to change daily for goal INR ___, dx: AFib
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 8.6 mg PO BID
11. Ferrous Sulfate 325 mg PO DAILY
12. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 8.6 mg PO BID
8. Simvastatin 20 mg PO QPM
___ MD to order daily dose PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Readmit for hypotension
Coronary Artery Disease s/p revascularization
postop atrial fibrillation ___
Secondary:
- Syncope ___ (occurred while traveling to ___ ___
___ after drinking a small amount of wine. ___ hypotension
other similar incidents which occurred while just before or
- Vasovagal
- DVT and PE ___ (following right knee replacement)
- Diabetes
- Hypertension
- Cervical radiculopathy (severe DJD with neuroforaminal
encroachment especially at C4-C5, C5-C6, and C6-C7)
- Osteoarthritis
- Hyperlipidemia
- Carpal tunnel syndrome
- Colon polyps
- Sleep apnea (compliant with CPAP)
- Lentigo Maligna s/p resection ___ at ___, with additional
resection in ___
Past Surgical History:
- ___ s/p resection ___, w/ additional resection in
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulates with a walker
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: none
Discharge Instructions:
1. Please shower daily including washing incisions gently with
mild soap, no baths or swimming, and look at your incisions
2). Please NO lotions, cream, powder, or ointments to incisions
3). Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4). No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
5). 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**
Followup Instructions:
___
|
19852063-DS-14
| 19,852,063 | 23,192,942 |
DS
| 14 |
2142-03-08 00:00:00
|
2142-03-08 08:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
atorvastatin
Attending: ___.
Chief Complaint:
L ankle pain
Major Surgical or Invasive Procedure:
ORIF L ankle fracture
History of Present Illness:
HPI:
Ms. ___ is an ___ F who presents from ___ ED
after mechanical fall with twisting injury early this AM with
immediate left foot pain, deformity, and inability to ambulate.
She denies HS/LOC/other injuries.
At time of examination she denies any numbness/tingling
distally.
She denies any recent CP/SOB/F/C/N/V
Past Medical History:
HTN
HLD
Social History:
___
Family History:
NC
Physical Exam:
AVSS
NAD, A&Ox3
LLE
Incision well approximated. Fires
___. SITLT s/s/dp/sp/tibial
distributions. 1+ DP pulse, wwp distally.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L ankle fracture-dislocation and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF L ankle fracture, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touch down weight bearing in the left lower extremity, and will
be discharged on for DVT prophylaxis. The patient will follow up
with ___ routine. A thorough discussion was had with
the patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Pravastatin 40 mg PO QPM
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY as needed
4. raloxifene 60 mg oral DAILY
5. turmeric root extract unknown strength oral ___ tablet BID
6. Aspirin 81 mg PO EVERY OTHER DAY
7. Calcium Carbonate 300 mg PO QAM
8. Vitamin D ___ UNIT PO DAILY
9. Multivitamins ___ TAB PO BID
10. Fish Oil (Omega 3) Dose is Unknown PO EVERY OTHER DAY on
non-Aspirin days only
11. Calcium Carbonate 1000 mg PO DAILY:PRN heartburn
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 30 mg SC QHS
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 30 mg/0.3 mL 1 syringe SC every evening Disp #*12
Syringe Refills:*0
5. Senna 8.6 mg PO BID
6. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg ___ tablet(s) by mouth every four to six
hours Disp #*50 Tablet Refills:*0
7. Fish Oil (Omega 3) 1000 mg PO EVERY OTHER DAY on non-Aspirin
days only
8. Aspirin 81 mg PO EVERY OTHER DAY
9. Calcium Carbonate 300 mg PO QAM
10. Calcium Carbonate 1000 mg PO DAILY:PRN heartburn
11. Fluticasone Propionate NASAL 1 SPRY NU DAILY as needed
12. Lisinopril 5 mg PO DAILY
13. Multivitamins ___ TAB PO BID
14. Pravastatin 40 mg PO QPM
15. raloxifene 60 mg oral DAILY
16. turmeric root extract unknown oral ___ TABLET BID
17. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
L ankle fracture-dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- touch down weight bearing left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Physical Therapy:
- touchdown weight bearing LLE
- ROMAT L hip, knee
- splint in place until follow up
Treatments Frequency:
- splint to remain on until follow up
Followup Instructions:
___
|
19852063-DS-15
| 19,852,063 | 28,632,177 |
DS
| 15 |
2142-10-12 00:00:00
|
2142-10-12 11:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
atorvastatin
Attending: ___.
Chief Complaint:
recurrent lateral cellulitis and sinus tract
Major Surgical or Invasive Procedure:
left tibia/fibula irrigation and excisional debridement of bone
for infection, removal of hardware, application of negative
pressure dressing ___, ___
left ankle I&D, removal of hardware ___, ___
History of Present Illness:
___ yo female with history of ORIF L ankle fracture by Dr.
___. She has had multiple clinic visits for slow
recovery including one course of Keflex given in ___. Over
the last week she has had worsening pain, erythema and drainage
from her left lateral malleolus, the pain has become so severe
with walking that she is now using a walker. She denies any
fevers or other systemic symptoms. She was seen at urgent care
and referred in for evaluation by orthopedics.
Past Medical History:
BENIGN NEOPLASM OF THE PANCREAS
OSTEOPENIA
SEBORRHEIC KERATOSIS
OSTEOARTHRITIS OF HANDS
RIGHT BUNION AND HAMMER TOE
SUI
HYPERTENSION
HYPERLIPIDEMIA
L ANKLE FX
Social History:
___
Family History:
NC
Physical Exam:
Exam on discharge:
Exam:
Vitals: AVSS
General: Well-appearing, breathing comfortably on RA.
MSK:
Left lower extremity:
-Incision clean, dry intact
-Fires ___
-SILT s/s/sp/dp/t nerve distributions distally
-Foot WWP
Pertinent Results:
please see OMR
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have recurrent left ankle lateral cellulitis and sinus tract
and was admitted to the orthopedic surgery service. The patient
was taken to the operating room on ___ for left tibia/fibula
irrigation and excisional debridement of bone of infection,
removal of hardware, application of negative pressure dressing,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. ID was consulted. Please see their
note for full details. Per their recommendations, the patient
was started on Vancomycin pending sensitivities. The patient was
taken back to the OR on ___ for left ankle I&D, removal of
hardware. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications. The patient was given ___ antibiotics
and anticoagulation per routine. The patient's home medications
were continued throughout this hospitalization. The patient was
switched to IV Cefazolin on ___ per ID's recommendations. The
patient received a PICC line. The patient is weight-bearing as
tolerated in an air cast boot in the left lower extremity, and
will be discharged on Aspirin for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. The patient
worked with ___ and in combination with case management,
discharge to rehab was deemed appropriate. Patient stay at rehab
expected to be less than 30 days. The ___ hospital course
was otherwise unremarkable. The patient expressed readiness for
discharge.
Medications on Admission:
Vitamin D ___ UNIT PO DAILY
Fish Oil (Omega 3) 1000 mg PO DAILY
Fluticasone Propionate NASAL 1 SPRY NU DAILY
Lisinopril 5 mg PO DAILY
Multivitamins 1 TAB PO DAILY
Omeprazole 20 mg PO DAILY
Pravastatin 40 mg PO QPM
raloxifene 60 mg oral QAM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY Duration: 4 Weeks
3. Calcium Carbonate 500 mg PO TID
4. CeFAZolin 2 g IV Q8H Duration: 6 Weeks
___ to ___
5. Docusate Sodium 100 mg PO BID
hold for loose stools
6. Heparin Flush (10 units/ml) 2 mL IV ONCE MR1 For PICC
insertion Duration: 1 Dose
7. TraMADol ___ mg PO Q4H:PRN pain
RX *tramadol 50 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
8. Vitamin D ___ UNIT PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Lisinopril 5 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Pravastatin 40 mg PO QPM
15. raloxifene 60 mg oral QAM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
recurrent left ankle lateral cellulitis and sinus tract
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated in the air cast boot
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 ASA 81mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Physical Therapy:
Activity: Left lower extremity: Full weight bearing
Needs air cast boot.
Followup Instructions:
___
|
19852548-DS-7
| 19,852,548 | 23,871,885 |
DS
| 7 |
2132-06-21 00:00:00
|
2132-06-21 17:47:00
|
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
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ gentleman with a history of
HIV but not on any antiretroviral medication who presented to
the emergency room today with dyspnea, cough and diarrhea over a
3 month period. Diarrhea reported to be non ___ had
previously been in ___ and only recently returned to the
___. He was evaluated by his PCP ___ for cough
and diarrhea and at that time CD4 level checked and was 160, ID
consult was placed as an outpatient however he did not make it
to that visit due to the current hospitalization.
In ED initial VS: HR: 104 BP: 101/65, RR: 24 94% on RA
ED Course: ___ started on steroids and IV Bactrim. CXR
demonstrated diffuse groundglass opacities concerning for PCP
___ started on broad spectrum antibiotics
Vanc/Cefepime as well as TMP/Sulfa and Methylpred for PCP
___ became increasing hypotensive and was started
on Levophed. He received 3L of fluid in the ED and became
hypoxic requiring a non rebreather mask. ABG initially notable
for respiratory alkalosis which on repeat ABG corrected.
___ was given: Vanc, Cefepime,TMP-Sulfa, Methylprednisone
125mg
Imaging notable for: CXR concerning for PCP pneumonia
VS prior to transfer: HR: 67 BP: 83/45, RR: 38
Past Medical History:
Herpes simplex (oral)
HIV Infection
Syphillis with neuro involvement
Social History:
___
Family History:
Noncontributory to current illness
Physical Exam:
FICU Admission Exam:
VITALS: Reviewed in Metavision
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonch. Decreased inspiratory effort.
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No obvious lesions
NEURO: CN ___ in place , ___ strengths in all extremities. No
focal deficits noted
Discharge Exam:
Vitals: Temperature 97.4-98.3, systolic blood pressure 94-107,
pulse 77-91, respiratory rate 18, 94-98% on 2 L
Gen: Pleasant, no acute distress, somewhat thin.
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Diminished breath sounds at the bases, no clear
expiratory crackles, no egophony, no wheezes, clear in the upper
lung fields
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities
Psychiatric: pleasant, appropriate affect
Pertinent Results:
Pertinent FICU Admission Labs:
___ 05:12PM BLOOD WBC-6.1 RBC-3.60* Hgb-8.9* Hct-27.5*
MCV-76* MCH-24.7* MCHC-32.4 RDW-17.0* RDWSD-46.5* Plt ___
___ 05:36PM BLOOD ___ PTT-31.2 ___
___ 06:07PM BLOOD Glucose-170* UreaN-14 Creat-0.6 Na-135
K-3.9 Cl-101 HCO3-22 AnGap-12
___:35AM BLOOD calTIBC-181* Ferritn-1132* TRF-139*
___ 07:15PM BLOOD Type-ART pO2-78* pCO2-32* pH-7.51*
calTCO2-26 Base XS-2
Pertinent Imaging:
CXR ___: Bilateral ground-glass pulmonary opacities raise
concern for pneumonia, specifically PCP pneumonia given clinical
history.
CT Chest ___:
1. Diffuse ground-glass opacities in bilateral lobes with dense
consolidations in bilateral lower lobes most concerning for
Pneumocystis jiroveci pneumonia in given ___ history.
Ferritin 132, TIBC 181, transferrin 139
Cryptococcal antigen negative
Blood culture, ___: Pending
Serum RPR: Reactive, 1:2 titer
Flu A/B: Negative
Respiratory viral panel, ___: Negative
MRSA screen, ___: Negative
Sputum ___, 3:09 ___: Test canceled due to contamination
Sputum ___, 10:10 AM: Pending
Sputum ___, 12:09 AM: Test canceled due to extensive
contamination
HIV-1 viral load 4.8 log 10 copies per mL
HIV 1 Genotyping: Pending
Strongyloides IgG negative
Aspergillus galactomannan antigen negative
Beta glucan >500
QuantiFERON gold indeterminate
Urinary strep antigen negative
Legionella urinary antigen negative
UA less than 1 WBC, negative leuks, negative nitrite
Urine sodium less than 20
Brief Hospital Course:
FICU Course ___
___ yo male with hx of untreated HIV with a CD4 count of 74 who
was admitted to the FICU for initial hypoxic respiratory
failure.
# Septic Shock
# PCP pneumonia
___ initially had SBP's in high 60's in the ED. He received
3L of fluid and was started on Levophed pressor. ___ blood
pressure stabilized following fluid resuscitation and he was
weaned off of Levophed on ___. CXR and CT findings
consistent with PCP pneumonia and ___ was started on
TMP/Sulfa and Methylprednisolone on ___. He was
simultaneously treated for CAP with IV Ceftriaxone and
Azithromycin. He was briefly on Vancomycin, discontinued on
___. He was seen by the Infectious Disease service and an
extensive ID workup was performed. Notable results are outlined
below:
Positive:
- Beta glucan >500
- HIV-1 viral load 4.8 log 10 copies per mL
- Serum RPR: Reactive, 1:2 titer
Negative:
- MTB NAAT on sputum sample
- Cryptococcal antigen
- Blood culture, ___
- Flu A/B
- Respiratory viral panel, ___
- MRSA screen, ___
- Strongyloides IgG
- Aspergillus galactomannan antigen
- Urinary strep antigen
- Legionella urinary antigen
Indeterminate:
QuantiFERON gold (likely d/t Anergy)
Pending:
- HIV 1 Genotyping
Additionally, his CD4 count was found to be 74. He was weaned
from pressors and transferred to the medical floors on 2L NC on
___. Over the next several days he was maintained on
broad-spectrum antimicrobial therapy to cover for both
pneumocystis and community-acquired pneumonia. Serial sputums
were tested for pneumocystis, but were indeterminate. MTB NAAT
sputum testing returned negative on ___, and he was
subsequently taken off of negative pressure precautions. At this
time he was also fully weaned off of oxygen. Beta glucan testing
was sent, and on ___ finally returned >500, highly suggestive
of a pneumocystis infection. At this time he was taken off of
treatment for CAP (though he essentially completed a full 7 day
course for this during his admission), and was converted to oral
high-dose Bactrim and prednisone at dosing to cover
pneumocystis. On discharge he will complete 14 more days of
active therapy for pneumocystis, then will take Bactrim DS once
daily for pneumocystis prophylaxis.
His HIV genotyping remains pending at this time, and thus he was
not started on ART at the time of discharge, but he will follow
up with his HIV doctor, ___, within the next week
and will likely start ART therapy at that time.
#Diarrhea: Present for 3 months, possibly related to
malnutritional status or could be related to an opportunistic
infection. Oddly, he had no episodes of diarrhea during his
stay, and thus we were unable to fully evaluate him for
potential etiologies such as CMV, Cryptosporidium, O/P, etc.
Strongyloides antibody was negative.
# Anemia: He has a very high ferritin, slightly low iron, low
TIBC, with a normal transferrin saturation. This all is
consistent with anemia of chronic disease, likely both from an
active HIV as well as active pulmonary infection. No evidence
suspicious for bleeding. Once he resolves from his current
infection, and his HIV is under better control, he should have a
follow-up CBC as well as follow-up iron studies performed.
#History of neurosyphilis: His serum RPR was positive with a
titer of 1:2, which is very low, and could be related to his
prior history of infection.
Medications on Admission:
None
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily PRN Disp #*30 Packet Refills:*2
2. PredniSONE 40 mg PO DAILY Duration: 5 Doses
This is dose # 1 of 2 tapered doses
RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*5 Tablet
Refills:*0
3. PredniSONE 20 mg PO DAILY Duration: 11 Doses
This is dose # 2 of 2 tapered doses
RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*11 Tablet
Refills:*0
4. Sulfameth/Trimethoprim DS 2 TAB PO TID Duration: 14 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2
tablet(s) by mouth three times a day Disp #*84 Tablet Refills:*0
5. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
START ON ___, AFTER FINISHING COURSE OF TREATMENT FOR
PNEUMOCYSTIS
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumocystis Jirovecii Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
- Take 2 Bactrim DS tablets 3 times daily for the next ___ days
___ - ___. After this, take 1 Bactrim DS daily (starting
___, to prevent recurrent Pneumocystis infection
- Take 40mg of prednisone daily for 5 days ___ - ___,
then decrease your dose to 20mg daily starting on ___.
Continue this for 11 days total, then stop
Followup Instructions:
___
|
19852995-DS-7
| 19,852,995 | 22,346,613 |
DS
| 7 |
2172-08-09 00:00:00
|
2172-08-09 21:11:00
|
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 Pain
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy (EGD) x 2 with banding
TACE
Flexible sigmoidoscopy
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: Mr. ___ is a ___ w/PMH of
active Hepatitis B, HIV/AIDS (not yet on ART, last CD4 158),
cirrhosis with HCC with portal vein thrombosis (all newly
diagnosed ___ who presented to the ED with 4 days of
intermittent abdominal pain and rectal pain x 4 days. Patient
has been having loose stools (is on lactulose) but due to
worsening rectal pain stopped lactulose yesterday. He has noted
tenesmus as well as sharp nonradiating lower abdominal pain for
the past four days, with one episode of vomiting 5 days ago. He
denies new abdominal distension. He denies fever but has had
chills. He denies any back pain or urinary symptoms.
Of note, he stopped taking his warfarin 4 days ago because he
thought they were causing him cramps. He restarted two days ago
but then was told to stop on day of admission due to preparation
for TACE planned for ___.
In the ED, initial vitals were: 99.7 93 117/76 18 100% RA
Exam was notable for tenderness on rectal exam but no mass. LLQ
was tender with mild distension but soft.
Labs were notable for:
WBC 3.2 (ANC 1696; 1 atypical) H/H 11.3/33.2 Plt 72
Chemistry panel unremarkable (Cr 0.9)
ALT 85 AST 198 AP 122 T bili 3.7 Lipase 76 Alb 2.5
INR 1.9
Lactate 2.9
U/A showed few bacteria, moderate blood, 10 WBCs, 10 RBCs, neg
leuks, neg nitrites
CT Abd/Pelvis w/contrast showed:
Focal wall thickening and adjacent inflammatory changes
surrounding the rectum, suggestive of proctitis, as well as
proximal small bowel wall thickening (may be reactive to ascites
but cannot r/o superimposed enteritis); hepatic cirrhosis with
numerous ill-defined lesions c/w known HCC,splenomageal and
esophageal/perianal varices and large volume ascites.
CXR showed no acute process.
A bedsound ultrasound was done which showed no tappable
ascites.
Patient was given: 1L NS bolus, 1g CTX and 500 mg IV
metronidazole.
Currently, the patient denies fevers, nausea, dysuria, CP, SOB,
arthralgias.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
PAST MEDICAL HISTORY:
#HIV infection.
-Diagnosed: ___
-Nadir CD4 count: 158 and 21% in ___
-Opportunistic infections: None known
-Other HIV-related complications: None
-History of antiretroviral therapy: None
GERD.
H. pylori.
History of alcohol abuse.
Hepatitis B. Active.
Hepatocellular carcinoma.
Portal vein thrombosis.
Social History:
___
Family History:
FAMILY HISTORY: His mother is in her mid ___. He has three
brothers and two sisters. He reports no family history of
malignancy.
Physical Exam:
ADMISISON PHYSICAL EXAM
VS: 97.6 121/71 89 20 100%RA
Wt 81.3 kg
General: Slightly somnolent ___ gentleman laying
in bed in NAD, nontoxic appearing
HEENT: NC/AT, MMM, no oropharyngeal ulcerations
Neck: Supple, no JVD
CV: RRR S1+S2 no M/R/G
Chest: Gyencomastia noted L > R
Lungs: CTAB
Abdomen: Distended but soft, minimally TTP in lower quadrants
and RUQ, ne rebound or guarding. No palpable HSM.
Rectal: Tender rectal exam
Ext: No edema
Neuro: AAOx2 (unsure of place), no asterixis
Skin: No rashes
DISCHARGE PHYSICAL EXAM
Vitals: 98.6, BP 100/58 HR=75, RR=20, Spo2=99% RA
General: AOx3, sleeping, appears in mild distress
HEENT: NC/AT, MMM, no oropharyngeal ulcerations or exudates,
eyes jaundiced, underside of tongue jaundiced
Neck: Supple, no JVD
CV: RRR S1+S2 no M/R/G
Lungs: No increased work of breathing, decreased inspiratory
effort, no wheezes, rales, or ronchi.
Abdomen: Increasing distention, soft but tense, moderate
tenderness to palpation diffusely, +BS, no rebound or guarding,
superficial veins evident
Ext: Mild asterixis, 1+ nonpitting edema lower extremity
Neuro: AOx3, alert, moving all extremities appropriately.
Skin: No notable rashes or skin breakdown
Pertinent Results:
ADMISSION LABS
___ 01:55PM HAV Ab-POSITIVE
___ 01:55PM TRIGLYCER-51 HDL CHOL-21 CHOL/HDL-7.1
LDL(CALC)-119
___ 01:55PM CHOLEST-150
___ 02:23PM PLT SMR-VERY LOW PLT COUNT-72*
___ 02:23PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 02:23PM HOS-AVAILABLE
___ 02:23PM NEUTS-53 BANDS-0 ___ MONOS-9 EOS-4
BASOS-0 ATYPS-1* ___ MYELOS-0 AbsNeut-1.70 AbsLymp-1.09*
AbsMono-0.29 AbsEos-0.13 AbsBaso-0.00*
___ 02:23PM WBC-3.2* RBC-3.51* HGB-11.3* HCT-33.2* MCV-95
MCH-32.2* MCHC-34.0 RDW-19.0* RDWSD-65.0*
___ 02:23PM ALBUMIN-2.5*
___ 02:23PM LIPASE-76*
___ 02:23PM ALT(SGPT)-85* AST(SGOT)-198* ALK PHOS-122 TOT
BILI-3.7*
___ 02:23PM estGFR-Using this
___ 02:23PM GLUCOSE-93 UREA N-16 CREAT-0.9 SODIUM-134
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-24 ANION GAP-12
___ 02:31PM ___ PTT-32.5 ___
___ 04:32PM LACTATE-2.9*
DISCHAGRE LABS
___ 05:38AM BLOOD WBC-10.5* RBC-3.33* Hgb-11.5* Hct-34.1*
MCV-102* MCH-34.5* MCHC-33.7 RDW-21.6* RDWSD-78.2* Plt ___
___ 05:38AM BLOOD Plt ___
___ 05:38AM BLOOD Glucose-77 UreaN-27* Creat-1.0 Na-130*
K-4.9 Cl-92* HCO3-28 AnGap-15
___ 05:38AM BLOOD ALT-178* AST-436* AlkPhos-228*
TotBili-12.9*
PERTINENT LABS DURING ADMISSION
HIV-1 Viral Load/Ultrasensitive (Final ___: 3,030
copies/ml.
RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE.
C. difficile DNA amplification assay (Final ___: Positive
for toxigenic C. difficile by the Illumigene DNA amplification.
CMV Viral Load (Final ___: CMV DNA not detected.
GRAM STAIN (Final ___: 1+ (<1 per 1000X
FIELD):POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
HTLV I/II ANTIBODY, WITH Nonreactive
ENTAMOEBA HISTOLYTICA IGG NEGATIVE
HIV 1 GENOTYPE
HIV Subtype: B
___________________________________________________________
Antiretroviral drugs Resistance Mutations Detected
Predicted
___________________________________________________________
! !
NRTIs ! !
ZDV (zidovudine or Retrovir) ! NO!
ABC (abacavir or Ziagen) ! NO!
ddI (didanosine or Videx) ! NO!
3TC (lamivudine or Epivir) ! NO!
FTC (emtricitabine or Emtriva) ! NO!
d4T (stavudine or Zerit) ! NO!
TDF (tenofovir or Viread) ! NO!
________________________________!___!______________________
! !
NNRTIs ! !
ETR (etravirine or Intelence) ! NO!
EFV (efavirenz or Sustiva) ! NO!
NVP (nevirapine or Viramune) ! NO!
RPV (rilpivirine or Edurant) ! NO!
________________________________!___!______________________
! !
PIs ! !
FPV (fos-amprenavir or Lexiva) ! NO!
IDV (indinavir or Crixivan) ! NO!
NFV (nelfinavir or Viracept) ! NO!
SQV (saquinavir or Invirase) ! NO!
LPV (lopinavir or Kaletra) ! NO!
ATV (atazanavir or Reyataz) ! NO!
TPV (tipranavir or Aptivus) ! NO!
DRV (darunavir or Prezista) ! NO!
! !
________________________________!___!__________
MICRO
GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML.
CMV Viral Load (Final ___: CMV DNA not detected.
HIV-1 Viral Load/Ultrasensitive (Final ___: 3,030
copies/ml.
TOXOPLASMA IgG ANTIBODY (Final ___: NEGATIVE FOR
TOXOPLASMA IgG ANTIBODY BY EIA.
STUDIES
RUQ US ___. Coarsened and nodular liver echotexture consistent with
cirrhosis and known multifocal HCC. Findings are consistent
with tumor thrombus in the main portal vein extending to right
and left branches of portal vein, which is
unchanged from prior CT of ___.
2. Patent hepatic veins and hepatic arteries.
3. Splenomegaly and moderate ascites.
CXR ___
There are opacities at the right and left lung bases. No
pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are unremarkable.
IMPRESSION:
Bilateral lower lobe pneumonia.
EGD ___
Esophageal varices 3 cords of grade II. Needs lowered INR for
EGD with MAC. Food in the stomach. Mosaic appearance in the
whole stomach compatible with portal hypertensive gastropathy.
Otherwise normal EGD to third part of the duodenum
CT abdomen/pelvis ___. Focal wall thickening and adjacent inflammatory changes
surrounding the rectum, is suggestive of proctitis given the
patient's presentation.
2. Proximal small bowel wall thickening may be secondary to
underdistention and reactive changes from the surrounding
ascites. However, superimposed
enteritis is difficult to exclude.
3. Hepatic cirrhosis with numerous ill-defined hepatic lesions,
compatible with known hepatocellular carcinoma.
4. Splenomegaly, esophageal/perianal variceal formation,
recannulized umbilical vein, and large volume ascites, all of
which are likely secondary to
third spacing in the setting of portal hypertension.
5. Persistent portal venous thrombosis.
___ Flex sigmoidoscopy
Contiguous friable, erythematous mucosa from the rectum to 30cm
into the sigmoid, most prominent in the rectum. (biopsy. Rectal
varices. Otherwise normal sigmoidoscopy to splenic flexure
CT Abdomen ___. Cirrhosis, with numerous ill-defined hepatic lesions,
compatible with the patient's history of hepatocellular
carcinoma. The dominant lesion in segment VII appears hypodense
on this study, and contains two punctate foci of gas. While this
may relate to post-TACE changes, superimposed infection cannot
be completely excluded. Extent of disease burden cannot be
evaluated on single-phase examination.
2. Extensive portal venous tumor thrombus.
3. Sequela of portal hypertension including splenomegaly,
varices, and
interval increase in the amount of ascites.
4. Slight interval decrease in rectal wall thickening,
suggesting improving proctitis.
CT Abdomen ___. Cirrhosis, with numerous ill-defined hepatic lesions,
compatible with the patient's history of hepatocellular
carcinoma. The dominant lesion in the inferior right hepatic
lobe appears hypodense in this study, likely related to
posttreatment change. The previously described punctate foci of
gas within this lesion are no longer identified. Extent of
disease burden cannot be evaluated on this single-phase
examination.
2. Extensive portal vein tumor thrombus. Interval increase in
probable bland thrombus within the superior mesenteric vein.
3. Sequela of portal hypertension including splenomegaly,
varices, and large amount of simple ascites. If there is
concern for SBP, recommend further evaluation with diagnostic
paracentesis.
Brief Hospital Course:
Mr. ___ is a ___ man with HIV, HBV, cirrhosis, and
Hepatocellular carcinoma, all diagnosed in ___, who
presented to the ED with abdominal and rectal pain, found to
have proctitis on CT scan with stool culture positive for C
Diff. He was also treated for HCC with TACE and had his varices
banded as inpatient.
# C. Diff Colitis: Patient presented with rectal and lower
abdominal pain, found to have proctitis and possible concomitant
enteritis on CT scan, with perihepatic ascites yet nothing
amenable to paracentesis. Lactate in the ED was 2.9. Patient was
given 1g CTX and 1L NS in the ED and another gram of CTX on the
floor for empiric treatment of SBP. Infectious work up was done
which found that he was C Diff positive on ___. He was treated
empirically first for intestinal infections with IV flagyl, and
was switched to oral flagyl for C. Diff and doxycycline to cover
for chlamydia proctitis, although patient denies any recent anal
intercourse. He was switched to PO vancomycin/doxycycline. He
also had a flex sig conducted, which showed contiguous friable,
erythematous mucosa from the rectum to 30cm into the sigmoid,
most prominent in the rectum. He completed a 7 day course of
doxycycline and was continued on PO Vancomycin for 2 weeks after
all other antibiotics were discontinued. PO Vancomycin will be
completed ___ after completion of ___iprofloxacin
for UTI.
# HIV/AIDS: CD4 count was 158 ___. Current VL ___: 3,000.
Patient follows with Dr. ___ as an outpatient. Per last
outpt note, patient was not on ART on admission but was on
entecavir for HBV. On overview of outpatient records, was put on
atovaquone for possibility of less interaction with warfarin (tx
for PVT) versus bactrim. OI work up negative to date (including
CMV viral load although CMV IgG positive). HIV genotype B.
Truvada/Raltegravir initiated ___ and entecavir discontinued.
# HCC/cirrhosis: By imaging this is Stage IIIb or T1IIbN0
disease. AFP was elevated at ___. He received TACE on ___.
EGD done in the last 4 months, and redone on this admission.
Shown to have 3 cords of varices, with two grade II varices that
were banded. Nadolol 20 mg daily was also initiated in light of
grade II varices. On OSH records, H. Pylori was positive, portal
hypertensive gastropathy and non bleeding ulcer were ntoed.
Patient has uptrending TBili and WBC s/p Tace as well. Blood Cx,
Urine Cx, CXR and RUQ US were done in setting of increased T
bili and WBC. Lactulose was restarted and rifaximin was
initiated in setting of fatigue and somnolence. Patient was
always arousable and oriented however. Encephalopathy may have
been secondary to sensitivity to opioids used intermittently for
pain control, rather than hepatic. Home doses of Lasix and
spironolactone were withheld in the setting of infection. His
LFTs continued to show decompensation with ___ peak at 13.3.
A CT scan showed foci concerning for superinfection at the site
of TACE, for which he was started on Zosyn. His abdominal exam
was concering for peritonitis and Vancomycin IV was started.
Additional CT of the abdomen and diagnostic paracentesis did not
show growth, did not demonstrate SBP, and showed resolution of
the foci of possible infection at the site of TACE. Both Zosyn
and Vancomycin were discontinued. The patient remained afebrile.
With regards to his ascites, he required therapeutic
paracentesis ___ with ___ drained for symptomatic relief.
He was discharged with f/u in ___ clinic (paracentesis
every ___ and ___.
# Portal vein thrombosis: diagnosed ___, seen on CT on ___
admission as well. Patient was initially started on lovenox as
outpatient but then was transitioned to warfarin ___ expense of
lovenox. He stopped taking warfarin ___ perceived side effects
and in preparation for TACE procedure for ___ which was done on
___. Warfarin was withheld in the setting of elevated INR and
multiple inpatient procedures. INR uptrended to a peak of 2.8
and was 1.8 on discharge.
# Hepatitis B: Patient admitted on entecavir. HDV coinfection
negative. HIV treatment naïve. As per ID recs, he was started on
Truvada/raltegravir and discontinued entecavir ___ as
Truvada/Raltegravir can be used to co-treat HBV infection. VL of
HBV: 130,000 ___. HBV genotype A. HbeAg negative, HbeAb
positive.
# Pancytopenia: Most likely secondary to a combination of
cirrhosis and HIV. This was monitored during admission without
acute intervention.
#Urinary tract infection: Close to the time of discharge, pt had
increased WBC count and urine growing GNRs. He expressed a
preference for comfort focused care and care outside of the
hospital setting. However, he wanted to treat reversible
infections. Therefore, he was discharged with PO ciprofloxacin
to treat his urinary tract infection.
#Goals of care: Multiple discussions were held between the
patient, his brother, and the liver team. Mr. ___ understands
that there is nothing more that can be done to treat his cancer.
Given this, he prefers a comfort focused approach to his care.
He would like to treat infections with medications by mouth but
strongly prefers not to be in the hospital. He signed a MOLST
form indicating DNR/DNI, Do not rehospitalize. His goals are to
spend the remainder of his life living outside of the hospital
and to spend time with his brother, with the goal of traveling
to ___ and ___ if possible. Given continued pain
on the day of discharge, he was discharged with an additional
prescription for morphine to be used prn for severe pain and
comfort. He was discharged to the ___, where
he is to be evaluated for hospice services.
TRANSITIONAL ISSUES
===================
- Pt will continue with therapeutic paracentesis twice per week
___ and ___ for symptomatic relief.
- Pain control with PO Oxycodone ___ po q4h:Prn pain. ___
require uptitration.
- Pt is being discharged with ciprofloxacin 500mg po q12h x 5
days for treatment of UTI. Please follow-up final speciation and
sensitivities.
- Stopped home lasix and spirnolactone on discharge for Na <130
- PO Vancomycin is to be completed on ___
- Started rifaximin and lactulose
#CODE: DNR/DNI, Do not rehospitalize
#CONTACT: Patient, girlfriend ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atovaquone Suspension 1500 mg PO DAILY
2. Entecavir 0.5 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Lactulose 30 mL PO BID
5. Pantoprazole 40 mg PO Q12H
6. Spironolactone 100 mg PO DAILY
7. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Atovaquone Suspension 1500 mg PO DAILY
2. Pantoprazole 40 mg PO Q12H
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. Raltegravir 400 mg PO BID
5. Rifaximin 550 mg PO BID
6. Vancomycin Oral Liquid ___ mg PO Q6H
To be completed ___. Docusate Sodium 100 mg PO BID
8. Simethicone 40-80 mg PO QID:PRN bloating
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Senna 8.6 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY
12. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h:prn Disp #*90
Tablet Refills:*0
14. Lactulose 30 mL PO TID
15. Morphine Sulfate (Concentrated Oral Soln) 5 mg PO Q3H:PRN
severe pain
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 1.25 mL by mouth
q3hrs Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Clostridium Difficile Colitis
SECONDARY DIAGNOSIS
===================
AIDS
Hepatitis B virus
Cirrhosis
Hepatocellular carcinoma
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
rectal and abdominal pain. While you were here, you were treated
for an infection in your intestines by the bacteria "Clostridium
Difficile."
While you were here, you were also treated for the cancer in
your liver with a "TACE" procedure. You also received treatment
for enlarged veins found in your throat to prevent them from
bleeding. You had the fluid in your abdomen drained ___ times
per week and you will continue to have this done with our
Interventional Radiologists as an outpatient.
The infectious disease team was following you throughout your
hospital stay, and recommended placing you on medical therapy
for your HIV and hepatitis B infection which you started. You
are now taking Truvada and Raltegravir for both infections.
Unfortunately, the cancer that you have is not curable or
treatable. Given this, you wanted to be with your brother rather
than here in the hospital, and wanted care to focus primarily on
comfort.
Please find information below regarding any upcoming
appointments and discharge medications.
It was a pleasure taking part in your care!
Your ___ Team
Followup Instructions:
___
|
19853093-DS-10
| 19,853,093 | 20,752,130 |
DS
| 10 |
2167-10-26 00:00:00
|
2167-10-26 19:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Mr. ___ is a ___ man with DMII (on insulin) c/b diabetic
nephropathy s/p LRRT (___), pAfib (on warfarin), neurogenic
bladder s/p neobladder (___) who was sent to the ED from ___
for
severe hypoglycemia and is admitted for management of recurrent
hypoglycemia.
The patient went to an appointment at ___ for a scheduled wound
check. During check-in vitals, the patient developed altered
mental status and somnolence. A code blue was called and he was
found to have a FSBG of 24. He received oral glucose and IV D50
25gm given with increase in FSBG to 220s. The patient's mental
status returned to his baseline and he was transferred to the ED
for management of severe hypoglycemia.
Of note, the patient had a similar episode of hypoglycemia in
___ for which he was evaluated in the ED by ___ and
subsequently sent home with outpatient follow-up.
In the ED, initial vitals were: 97.6, HR102, BP175/68, RR20, 97%
RA
FSBG: 120 -> 45 on presentation
- Exam notable for:
LUNGS: expiratory wheezes at bases bilaterally
ABD: suprapubic catheter in place, NDNT
EXT: 2+ b/l ___ edema, 2cm clean based ulcer on left lateral
distal shin without purulence or drainage (see OMR for picture)
- Labs notable for:
WBC: 8.7, Hgb 13.0, Plt: 153
Serum Glucose: 66
Electrolytes: WNL, Cr 0.6
INR: 2.2
UA: Lg leuk, Nitr Pos, WBC 61, Bact mod, Epi 0
FSBG: 120 on arrival, down to 45 within 2 hours, returned to
___ oral glucose but again dropped to 35 during ED observation
requiring 1 amp IV dextrose
- Imaging was notable for:
CXR: Left basilar atelectasis. Mild pulmonary vascular
congestion
- Patient was given:
Duonebs
Insulin 9u
CTX for pos UA
Home meds
- Consults:
___ was consulted and recommended a 20% decrease in lantus
and
50% decrease in Humalog SS and to follow-up with ___ in 1
week.
Upon arrival to the floor, patient reports that he feels well
and
has no acute complaints. He says that on ___ morning he took
his sugar and it was 160 so he gave himself 10u as he usually
does in the morning. He had cereal and milk for breakfast and
then went to the doctor's office. He had no preceding symptoms
prior to the episode. He denies any recent fevers.
Past Medical History:
Lt calcaneal fracture
renal failure s/p renal transplant (live-donor kidney transplant
from his daughter on ___
dilated cardiomyopathy, EF 55% in ___
mitral regurgitation, s/p repair (Carbomedics annuloplasty ring
placement on ___
osteoporosis
Paroxysmal atrial fibrillation
neurogenic bladder status post right colon augmentation to his
bladder in ___ with a Mitrofanoff segment to his umbilicus
neo-bladder through which he straights catheterizes himself 6x/d
through umbilicus
SBO
Social History:
___
Family History:
Father had MI at ___. No family history of diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: 97.9F, 155/80, HR90, RR18, 97%Ra
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, ___ SEM at base and ___ holosystolic murmur at
apex. JVP not elevated
PULM: Crackles at the bases bilaterally
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, lateral to umbilicus is
neo-bladder exit without any evidence of purulence, erythema
EXTREMITIES: ___ edema in bilateral feet, but not erythematous
or tender. Burn on LLE wrapped and not examined (picture in OMR.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1624)
Temp: 98.0 (Tm 98.5), BP: 141/67 (107-150/58-72), HR: 87
(82-92), RR: 18, O2 sat: 93% (93-97), O2 delivery: Ra
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, ___ systolic murmur at right upper sternal
border. JVP not elevated
PULM: Decreased breath sounds b/l with faint L basilar crackles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, lateral to umbilicus is
neo-bladder exit without any evidence of purulence, erythema
EXTREMITIES: ___ edema in bilateral feet, but not erythematous
or tender. Burn on LLE wrapped and not examined (picture in OMR.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Renal: LLQ kidney transplant site without tenderness
Vascular: LUE HD graft with +burit/thrill
Pertinent Results:
ADMISSION LABS
___ 02:04PM BLOOD WBC-8.7 RBC-4.07* Hgb-13.0* Hct-39.8*
MCV-98 MCH-31.9 MCHC-32.7 RDW-13.2 RDWSD-47.0* Plt ___
___ 02:04PM BLOOD Neuts-87.3* Lymphs-6.1* Monos-5.9
Eos-0.3* Baso-0.1 Im ___ AbsNeut-7.60* AbsLymp-0.53*
AbsMono-0.51 AbsEos-0.03* AbsBaso-0.01
___ 02:04PM BLOOD ___ PTT-43.5* ___
___ 02:04PM BLOOD Glucose-66* UreaN-18 Creat-0.8 Na-143
K-4.6 Cl-103 HCO3-28 AnGap-12
___ 02:04PM BLOOD Calcium-9.4 Phos-2.9 Mg-2.1
DISCHARGE LABS
___ 06:57AM BLOOD WBC-7.8 RBC-3.77* Hgb-12.0* Hct-36.7*
MCV-97 MCH-31.8 MCHC-32.7 RDW-13.0 RDWSD-46.2 Plt ___
___ 06:57AM BLOOD ___
___ 06:57AM BLOOD Glucose-155* UreaN-28* Creat-0.7 Na-143
K-4.4 Cl-107 HCO3-24 AnGap-12
___ 06:57AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.9
OTHER PERTINENT LABS
___ 10:03AM BLOOD Cyclspr-116
___ 06:57AM BLOOD Cyclspr-135
MICRO
___ 12:40 pm URINE
URINE CULTURE (Preliminary):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
KLEBSIELLA OXYTOCA. >100,000 CFU/mL.
PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING/STUDIES
___ CHEST (PA & LAT)
IMPRESSION:
Left basilar atelectasis. Mild pulmonary vascular congestion.
Brief Hospital Course:
Mr. ___ is a ___ year old male with history of Type II DM,
complicated by diabetic nephropathy s/p LRRT (___),
ileo-neobladder (___), dilated cardiomyopathy, paroxysmal afib
on warfarin, who initially presented from clinic after code blue
was called for unresponsiveness. Was found to have finger stick
in the ___ with subsequent improvement in mental status after IV
dextrose administration. Hypoglycemia was ultimately attributed
to incorrect administration of Humalog, where patient endorsed
administered 10 units Humalog for all ___ >100 prior to meals.
Was seen by ___ during hospitalization, lantus was decreased
from 25 units QHS to 15 units QAM. Sliding scale insulin was
also down-titrated and patient had stable fasting glucose and
fingersticks prior to discharge.
ACTIVE ISSUES:
===================
#Hypoglycemia
#Toxic metabolic encephalopathy
- Patient with type II DM, presented from clinic after code blue
was called for unresponsiveness. Patient was found to have
finger stick in the ___, received IV and oral dextrose with
subsequent improvement in mental status. Was evaluated by ___
during hospitalization. Was found to be administering fast
acting insulin incorrectly as he would administer 10 units
Humalog for any finger stick >100. Home insulin was decreased
from 25 units QHS to 15 units QAM. Sliding scale was also dose
reduced to less aggressive regimen Humalog: BG 110-150 3u;
150-200 5u; 200-250 7u; 250-300 9u. Patient received DM
education from ___ educator prior to discharge. Was arranged
for follow-up with ___ on ___ prior to discharge.
#Pyuria - With history of neo-bladder (___) through which he
straight catheterizes himself around 6x per day. Received
ceftriaxone in the ER for possible UTI. Patient has had many
positive urine cultures in the past. On further review of record
his
nephrologist Dr. ___ has not treated positive cultures in
the past unless he has had systemic symptoms, fevers, abdominal
or back pain. Urine culture speciated as KLEBSIELLA OXYTOCA,
however given patient was asymptomatic, antibiotics were
deferred.
#pAF - Supratherapeutic INR 3.4 on admission and warfarin was
initially held. He was subsequently re-started on home regimen
3mg 1x/week and 2mg 6x/week. Continued home metoprolol tartrate
50mg BID.
#Cough with sputum - Patient complained of cough with sputum for
10 days prior to admission. Reports no fevers, shortness of
breath, chest pain. Chest x-ray was unremarkable with low
suspicion for PNA antibiotics were deferred. Given Tessalon
Perles and Mucinex for relief.
CHRONIC ISSUES
====================
#s/p Kidney transplant
#Immunosuppression - History of diabetic nephropathy s/p LRRT
(___). Was continued on immunosuppression Cyclosporine 75mg
q12h, MMF 500mg BID, and prednisone 5mg daily cyclosporine
levels at goal as per recommendations from the transplant team.
#Left lower extremity burn - Areas of both superficial and deep
partial thickness burn, in setting of hot pack directly on skin
to treat pain related to recent gout flare. There was no
evidence of infection and based on patients description, never
had purulence or cellulitis. Patient did not complain of pain
during admission. Continued Silver Sulfadiazine 1% Cream 1 Appl
TP daily.
#Gout - Continued home allopurinol
#HTN - Continued home lisinopril and amlodipine
#Chronic HFpEF - Continued home Lasix
#HLD - Continued home statin
Transitional issues:
===============
[ ] NEW/CHANGED MEDICATIONS
- Lantus changed from 25 units QHS to 15 units QAM
Unclear insulin regimen at home, but patient was discharged
with ISS regimen below:
AC: Humalog: BG 100-150 3u; 150-200 5u; 200-250 7u; 250-300 9u
HS: Humalog: 200-250 3u; 250-300 5u
[ ] ___ follow-up appointment arranged on ___ at 3PM
with Dr. ___
[ ] Ongoing outpatient diabetes education and insulin safety
administration
[ ] Patient found to have pyuria growing KLEBSIELLA OXYTOCA.
Antibiotics deferred per outpatient transplant nephrology prior
recommendations given he was asymptomatic and afebrile. Continue
close interval monitoring for signs and symptoms of infection
#CODE: Full (confirmed)
#CONTACT: daughter ___ ___
>30 minutes were spent in discharge planning and coordination of
patient care on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Famotidine 20 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. amLODIPine 5 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Vitamin D 1000 UNIT PO DAILY
6. PredniSONE 5 mg PO DAILY
7. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain
- Moderate
8. Mycophenolate Mofetil 500 mg PO BID
9. Warfarin 3 mg PO 1X/WEEK (___)
10. Warfarin 2 mg PO 6X/WEEK (___)
11. Silver Sulfadiazine 1% Cream 1 Appl TP DAILY
12. Allopurinol ___ mg PO DAILY
13. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
14. Furosemide 40 mg PO DAILY
15. Lisinopril 40 mg PO DAILY
16. Gabapentin 200 mg PO QHS
17. Glargine 25 Units Bedtime
Insulin SC Sliding Scale using Aspart Insulin
18. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
19. Ascorbic Acid ___ mg PO DAILY
20. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using novolog Insulin
2. Allopurinol ___ mg PO DAILY
3. amLODIPine 5 mg PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
7. Famotidine 20 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Gabapentin 200 mg PO QHS
10. Lisinopril 40 mg PO DAILY
11. Metoprolol Tartrate 50 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Mycophenolate Mofetil 500 mg PO BID
14. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
15. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN
Pain - Moderate
16. PredniSONE 5 mg PO DAILY
17. Silver Sulfadiazine 1% Cream 1 Appl TP DAILY
18. Vitamin D 1000 UNIT PO DAILY
19. Warfarin 3 mg PO 1X/WEEK (___)
20. Warfarin 2 mg PO 6X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
=============
Hypoglycemia
Toxic metabolic encephalopathy
Type II diabetes mellitus
Paroxysmal atrial fibrillation
Secondary diagnoses:
==============
Status post kidney transplant on immunosuppression
Left lower extremity burn
Hypertension
Chronic heart failure with preserved ejection fraction
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
-You were admitted to the hospital because your blood sugar was
low.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Because your blood sugar was low, we adjusted your inuslin
regimen
- You were evaluated by the ___ doctors and were arranged for
a follow-up appointment with them
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications as prescribed
and follow-up with your appointments as listed below.
- Return to the Emergency Department if you experience worsening
lightheadedness or confusion
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19853114-DS-17
| 19,853,114 | 28,694,563 |
DS
| 17 |
2155-07-27 00:00:00
|
2155-07-27 15:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
fentanyl / levofloxacin / omeprazole
Attending: ___.
Chief Complaint:
feeling "off"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PRIMARY DIAGNOSIS: Metastatic Breast Cancer
PRIMARY ONCOLOGIST: Dr ___ COMPLAINT: Pain
HISTORY OF PRESENT ILLNESS:
Ms. ___ is a pleasant ___ w/ breast ca c/b extensive vertebral
mets, currently on weekly taxol and Xgeva, who c/b recent fecal
incontinence. It was over a week ago and was transient. An
outpatient C-spine MRI was done on ___ which revealed
cerebellar
mets. The next day an MRI of the head was done which
unfortunately revealed new "Innumerable supratentorial,
infratentorial brain metastases, bone metastases, scalp
metastases." Reassuringly no cord compression. She was referred
to the ED for admission. She received 8 mg IV Dex and admitted.
She admits to fatigue but no focal weakness. Admits to low back
pain for the past few months and managed w/ apap, iburpofen, and
no narcotics. Also has coccyx pain recently but attributed it
from not having enough tissue around it and sitting alot for
medical visits this week. Has low grade nausea w/ the chemo
which she chews on ginger w/ some benefit. She has an "ocean"
sound in her ear for which she saw audiology (or ENT) and
dentist
and diagnosed with TMJ. No headaches. She's noticed a new lump
on
her scalp. No other rashes. No difficulty walking.
REVIEW OF SYSTEMS:
12 point ROS reviewed in detail and negative except for what is
mentioned above in HPI
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
This now ___ postmenopausal female was
diagnosed in ___ with 1.8-cm and 1.6-cm grade 2 infiltrating
lobular carcinomas with mucinous differentiation of the left
breast with one of 16 axillary nodes containing a 0.7-cm
metastasis, ER positive, PR negative, HER2 negative, Oncotype DX
score 36. She received four cycles of
cyclophosphamide-docetaxel, then radiation therapy to the left
breast and letrozole.
Ms. ___ developed back pain in early ___. Bone scan on ___ showed uptake in the L2 lamina corresponding with a
mixed lytic-sclerotic lesion on CT, without other sites of
disease. She began Faslodex. Ms. ___ developed increasing
pain
discomfort in late ___. Bone scan on ___ showed
uptake in the L2 and L4 vertebral bodies and the left
acetabulum.
MRI of the lumbar spine on ___, showed lesions in
L1, L2 and L3 consistent with metastases. On ___,
CT-guided biopsy of the left L2 transverse process revealed
metastatic carcinoma consistent with breast origin, ER positive,
PR negative, and HER-2 negative. She underwent radiation
therapy
to the L1-L4 vertebral bodies inclusive from ___, to ___ (20 Gy in 5 fractions).
Ms. ___ began capecitabine following completion of radiation.
She was switched to palbociclib and Bazedoxifene in ___
after progression and then to exemestane and Afinitor in ___.
Bone scan on ___ showed uptake in multiple thoracic
vertebral bodies, multiple lumbar vertebral bodies similar to
before, the left ilium which on my review includes the entire
ilium but not the sacrum, the right lateral sixth rib, and the
superior left scapula. MRI of the lumbosacral spine on the same
date showed diffuse involvement of the vertebral bodies, the
sacrum, both ilia, and degenerative changes, with the cauda
equine ending at L1-2. Torso CT on the same date showed lung
changes consistent with bronchial inflammatory disease, an
increase in disease in the T10 vertebral body, and increased
sclerosis of the left ilium, with the spine lesions looking
approximately the same. She has a history of left sciatic
discomfort which recently substantially increased,
pain in the left buttock with sitting, discomfort in the left
groin, and pain in the right lower back. Examination showed
discomfort to palpation just to the right of the spine at about
the level of the L5 vertebral body, the right and left
sacrum, left ilium, and the left hip.
PAST MEDICAL HISTORY (per OMR):
1. Laparoscopic ___ colposuspension, uterosacral ligament
suspension, and perivaginal repair performed by Dr. ___ on ___, for a cystocele, incontinence,
and vaginal wall prolapse. On ___, she underwent
laparoscopic sacral colpopexy with mesh and lysis of adhesions
for recurrent vaginal prolapse. On ___, she underwent
fulguration of granulation tissue in her vagina and Monarc
transobturator suburethral sling with cystoscopy with Dr.
___ continued stress incontinence. On ___, she underwent excision of the vaginal mesh following
erosion. On ___, she underwent robotic lysis of
adhesions and excision of her mesh/Gore-Tex foreign body with
Dr.
___ vaginal bleeding.
2. Gastroesophageal reflux.
3. Chronic constipation.
4. Bilateral cataract surgery and the most recent on the right
side in ___.
Social History:
___
Family History:
FAMILY HISTORY (per OMR):
The patient's father died at age ___ of lung
cancer that was thought to be related to his work as a ___.
Her twin brother was recently diagnosed with prostate cancer and
has undergone brachytherapy treatment. She is of ___ ethnic
descent.
Physical Exam:
VITAL SIGNS: 97.9PO 127 / 75 79 18 98 RA
General: NAD, Resting in bed comfortably
HEENT: MMM, no OP lesions
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no peritoneal signs
LIMBS: WWP, no ___, no tremors
SKIN: No notable rashes on trunk nor extremities but she has
indurated scalp lesion on left side which is pink, non-tender
(likely scalp met per MRI)
NEURO: CN III-XII intact, no dysmetria, no dysdiadochokinesia,
gait in room intact (seen walking in hallway as well and was
independent), can stand up rather quickly and robustly
independently from bed without using her arms, negative Romberg
but she does sway and states it is baseline from her vertigo
PSYCH: Thought process logical, linear, future oriented
ACCESS: Chest port site intact w/o overlying erythema, accessed
and dressing C/D/I
Moter strength out of 5:
- shoulder abd: 5 b/l
- shoulder add: 5 b/l
- elbow flex: 5 b/l
- elbow ext: 5 b/l
- wrist flex: 5 b/l
- wrist ext: 5 b/l
- finger flex: 5 b/l
- finger ext: 5 b/l
- finger abd: 5 b/l
- thumb abd: 5 b/l
Lower ext strength out of 5:
- hip flexion: 5 R, ___ L
- hip extension: 5 b/l
- hip adduction: 5 b/l
- hip abduction: 5 b/l
- knee extension: 5 b/l
- knee flexion: 5 b/l
- plantar flexion: 5 b/l
- dorsiflexion: 5 b/l
- ___. longus: 5 b/l
Tone:
- rectal: deferred
Sensation to crude touch:
Upper and lower ext: intact
Pertinent Results:
___ 02:30PM BLOOD WBC-6.1 RBC-2.81* Hgb-8.0* Hct-25.0*
MCV-89 MCH-28.5 MCHC-32.0 RDW-15.9* RDWSD-52.4* Plt ___
___ 02:30PM BLOOD Neuts-88.0* Lymphs-2.8* Monos-7.2 Eos-1.0
Baso-0.2 Im ___ AbsNeut-5.39 AbsLymp-0.17* AbsMono-0.44
AbsEos-0.06 AbsBaso-0.01
___ 06:20AM BLOOD ___ PTT-34.5 ___
___ 02:30PM BLOOD Glucose-97 UreaN-20 Creat-0.5 Na-140
K-3.9 Cl-103 HCO3-24 AnGap-13
___ 06:20AM BLOOD ALT-9 AST-14 LD(LDH)-261* AlkPhos-93
TotBili-0.2
___ 06:20AM BLOOD Albumin-3.3* Calcium-8.5 Phos-2.8 Mg-2.1
MRI BRAIN:
IMPRESSION:
1. Innumerable supratentorial, infratentorial brain metastases,
bone
metastases, scalp metastases. Findings consistent with
leptomeningeal
metastases; infectious, inflammatory processes could have
similar appearance.
2. Findings consistent with small areas of subacute
microhemorrhage within few
parenchymal metastases. Melanoma could have similar appearance.
MRI C SPINE:
IMPRESSION:
1. Multiple small rounded lesions measuring up to 7 mm noted in
the posterior
fossa including the left pons and right inferior cerebellar
hemisphere
compatible with metastatic disease.
2. 5 mm likely extramedullary peripheral enhancing lesion along
the right
dorsal aspect of the C6 cord with associated abnormal cord
signal spanning C5
through C7.
3. Enhancing STIR hyperintense signal along the dorsal T4
epidural space
compatible with soft tissue extension of osseous lesion.
4. Mild degenerative changes without high-grade spinal canal or
neural
foraminal narrowing.
Brief Hospital Course:
___ woman with metastatic breast ca c/b extensive vertebral/bone
mets, recent fecal incontinence, s/p several unsuccessful
treatment attempts, presents with new innumerable
supratentorial, infratentorial brain metastases, bone
metastases, and scalp metastases in addition to a C spine
lesion.
Metastatic Breast cancer to spine, bone, brain with
leptomeningeal spread:
Patient now with significant metastatic disease most recently
found to have brain mets and a C spine lesion. Clinically she
has a non focal exam. She is at high risk for neurologic
decline. Treatment will consist of radiation, steroids, and
consideration for systemic treatment given her good functional
status, though it is unclear if any such options remain.
- Radiation oncology consulted, started radiation of brain,
Cspine lesion on ___ for 5 treatments to resume next week
- Continue decadron 4mg q6
- frequent neuro checks
- neuro onc consulted they will follow up with her next week
- I reviewed the case with her primary oncologist as well
- Tylenol prn
Fecal Incontinence:
Her symptom of fecal incontinence, which has improved, was c/f
cauda equina but this was not seen on her MRI L/T spine. In
addition, no cord compression was seen in cervical spine though
she does have signal changes. Colonsocopy with bx was
essentially negative. For now will monitor clinically.
PPI Allergy
Pt states she has no recollection of ever having a reaction to
omeprazole, which is listed as an allergy.
- discharged with famotidine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Dexamethasone 4 mg PO Q6H
RX *dexamethasone 2 mg 2 tablet(s) by mouth every six (6) hours
Disp #*112 Tablet Refills:*1
2. Famotidine 20 mg PO Q12H while on dexamethasone
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Lidocaine 5% Patch 2 PTCH TD QAM
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. HELD- Ibuprofen 400 mg PO Q8H:PRN Pain - Mild This
medication was held. Do not restart Ibuprofen until you see your
doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic breast cancer to brain, spine, bone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation of new cancer areas in your
brain and spine. You started radiation treatments on ___ and
will have 5 total sessions as scheduled. You were also started
on steroids to decrease swelling in these areas.
Please continue these steroids and return for your radiation
sessions next week. Please follow up closely with Dr. ___
ongoing care. You will also see Dr. ___ in clinic next week.
They will call you with an appointment
Followup Instructions:
___
|
19853278-DS-20
| 19,853,278 | 28,377,536 |
DS
| 20 |
2181-04-28 00:00:00
|
2181-04-29 08:01:00
|
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:
Post-partum fever
Major Surgical or Invasive Procedure:
Dilation and curettage
History of Present Illness:
Ms. ___ is a ___ yo ___ s/p uncomplicated SVD on ___ who
presents to ED with ?mastitis. Post-partum course c/b HA
requiring trip to ED on ___ with negative work-up including
neurology consult.
For several days she notes fevers to 103 with associated chills
and sweats. Denies localizing symptoms other than HA as above
until earlier today when she notes right breast pain worse with
breastfeeding. No dysuria. No visual changes or RUQ pain. HA
has been improving. No CP, SOB.
Past Medical History:
POBHx: TAB x1, SVD x 1 on ___
PGynHx: Denies STDs or abnl paps
PMH: migraines (new diagnosis 2 days ago)
PSH: None
Social History:
___
Family History:
Non-contributory
Physical Exam:
VS: 99.8 -> 102.4 77 155/85 16 98% RA
Gen: NAD
Card: Regular, ___ SEM
Resp: Clear bilaterally
Breasts: +erythema and mild induration in right lower outer
quadrant, no mass felt
Abd: Soft, NT, fundus well below umbilicus
Ext: NT, NE
Pertinent Results:
Admission Labs (___):
WBC-10.3 Hgb-10.5* Hct-33.6* MCV-82 MCH-25.8* MCHC-31.3
RDW-18.7* Plt ___ Neuts-82.2* Lymphs-12.5* Monos-3.5 Eos-1.5
Baso-0.3
Glucose-73 UreaN-20 Creat-0.7 Na-141 K-3.1* Cl-105 HCO3-24
AnGap-15
K: 3.1 -> 3.0 -> 2.8 -> 3.6 -> 3.8
ALT-31 AST-23 AlkPhos-110* TotBili-0.3
Albumin-3.5
Calcium-8.2* Phos-4.0 Mg-1.8 UricAcd-5.2
___ cTropnT-0.02* -> <0.01 -> <0.01 -> <0.01
URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-80
Bilirub-NEG Urobiln-2* pH-6.5 Leuks-MOD URINE RBC-11* WBC-45*
Bacteri-FEW Yeast-NONE Epi-0
Pertinent Labs during admission:
___ BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-OCCASIONAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Schisto-1+ Burr-1+
___ LD(___)-288* -> 288
___ Hapto-384* -> 386
___ Random Urine: Creat-191 Na-114 K-50 Cl-186 TotProt-87
Prot/Cr-0.5*
___ 24 hour urine CATECHOLAMINES, METANEPHRINES,
FRACTIONATED = Pending
Radiology:
Breast U/S (___): No drainable fluid collection. Mild skin
thickening could represent mastitis. 6-mm hypoechoic structure
at the 9 o'clock position of the right breast, most likely cyst.
TEE (___): Small secundum ASD seen.
Renal U/S (___): No sonographic evidence of renal stones or
hydronephrosis. No evidence of renal artery stenosis or renal
vein thrombosis. Suggestion of a left duplex kidney.
Pelvic U/S (___): There is a 2 centimeter area of
vascularized retained products of conception arising from the
posterior endometrial wall.
Microbiology/Path:
UCx (___): No growth
Blood Cx ___, 30): Pending
Path from OR (___): Pending
Brief Hospital Course:
___ year old ___ s/p uncomplicated vaginal delivery on ___
presented with fever and elevated blood pressures and was found
to have mastitis and retained products of conception, as well as
hypertension complicated by hypokalemia.
1. Mastitis: On admission, patient's fevers up to 102.4, and she
had a U/A concerning for a UTI, as well as tender and indurated
right breast. A breast ultrasound was consistent with mastitis
without any abscess, and she was treated with IV Kefzol
initially and transitioned to IV Vancomycin on HD3, given
concern for recurrent fevers and possibility for MRSA mastitis.
Patient afebrile since HD3, and thus was transitioned to PO
Bactrim. Her urine and blood cultures showed no growth, and by
discharge, patient's breast exam was much improved. Breast milk
cultures were pending at the time of discharge.
2. Retained products of conception: Pelvic ultrasound was
performed on HD4, which was concerning for retained products of
conception. Patient taken urgently to the OR for D&C on HD4.
Intra-op findings significant for small amount of likely
retained POC, with pathology pending at time of discharge.
3. Hypertension: Patient developed elevated blood pressures to
170s-180s/90s-100s on HD1. Nephrology was consulted on HD2, who
felt her elevated BP was related to pain/NSAID use and
recommended outpatient follow-up. She had a renal ultrasound
negative for renal artery stenosis or kidney stones, and urine
catecholamines/metanephrines were pending at the time of
discharge. Maternal fetal medicine was also consulted, who felt
her hypertension was unlikely related to pre-eclampsia, given
negative labs. The patient was briefly placed on Magnesium on
HD2 for severely elevated BPs to 180s/100s and headache, but
this was stopped in favor of lisinopril 10mg, per ___
recommendations. The patient's blood pressure continued to be
elevated on HD3 and 4, and she responded to prn dosing of
nifedipine 10mg PO. By HD5, her blood pressures were reasonably
controlled and she was discharged on 20mg lisinopril daily. She
is scheduled for follow-up with nephrology.
4. Hypokalemia: Patient was hypokalemic to 2.8 on HD1, which
responded appropriately to potassium replacement. She remained
with a normal potassium level without need for replacement for
the rest of her hospital stay. Nutrition was consulted re:
concern for high salt diet as contributory factor for
hypokalemia.
5. Positive troponins: A bedside ultrasound revealed
questionable pericardial effusion and troponins were mildly
elevated. Repeat measurements showed negative troponin. A TTE
was performed which revealed a small ASD and no other
abnormalities.
Medications on Admission:
Prenatal Vitamins
Acetaminophen
Motrin
Discharge Medications:
1. Ibuprofen 600 mg PO Q6H:PRN Pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
2. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 2 Weeks
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*28 Tablet Refills:*0
4. Clotrimazole Cream 1 Appl TP BID rash
RX *clotrimazole 1 % apply to affected area twice a day Disp #*1
Tube Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Mastitis
Urinary Tract Infection
Hypertension
Retained products of conception
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 hospital with mastitis, urinary tract
infection, and high blood pressure. Your mastitis and urinary
tract infection were treated with IV antibiotics, and you are
being discharged on oral antibiotics. Please continue to pump
breast milk until your mastitis is cleared.
You were seen by nephrology (kidney doctors) for your high blood
pressure and were started on lisinopril for your high blood
pressure. You have a follow up appointment with them in two
weeks.
You were also found to have retained products of conception and
you underwent a dilation and curettage.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* Nothing in the vagina (no tampons, no douching, no sex), no
heavy lifting of objects >10lbs for 2 weeks.
* You may eat a regular diet
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Call your doctor for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
Followup Instructions:
___
|
19853481-DS-5
| 19,853,481 | 27,529,179 |
DS
| 5 |
2148-08-17 00:00:00
|
2148-08-20 22:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
neck/throat pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HOSPITAL MEDICINE ADMISSION NOTE
Time patient seen and examined today: ___
CC:
HPI:
___ y.o F with recent wisdom teeth extraction (x4) last week
presented to OSH with increasing neck/throat pain and associated
shortness of breath, originally presented to ___,
with a CT scan concerning for possible mediastinal, transferred
to ___ for further evaluation. She reports that
approximately two days She endorses fever. CT scan showed
possible mediastinitis.
She received IV fluid, pain control and IV unasyn at ___
___, and was transferred here for ___ evaluation and due
to concern for mediastinitis.
In the ED, initial VS were 99.8112 126/70 18 98% RA
She received IV morphine 2 mg x 2, IV ketorolac 15 mg x 1, IV
clindamycin 600 mg x 1, and 650 mg PO acetaminophen.
Labs showed a WBC of 12.7, H/H of 10.6, 32.8, Plt 187. BMP with
BUN/Cr of ___. Lactate 1.9.
She was monitored in the ED without significant airway
compromise.
She was subsequently admitted to medicine for IV antibiotics.
She was seen by ___ who recommended continuation of IV unasyn
and admission to medicine.
She was seen by ENT with a upper airway scope that showed no
edema or erythema.
Upon arrival to the floor, the patient appears well. She reports
that she had her wisdom teeth out on ___. On ___, she
had a significant amount of swelling, which she thought was
normal postoperatively. Her pain was controlled on Percocet and
ibuprofen. She had some nausea and vomiting which she attributed
to the Percocet. On the day of admission, she woke up with
swelling around her anterior neck and difficulty swallowing,
feeling that her throat was tight. She first presented to
___ and ___ came here for evaluation. She denies shortness
of breath, chest pain. She denies a sensation of choking. She
endorses headache and some associated lightheadedness. She
reports nausea and vomiting.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
PAST MEDICAL/SURGICAL HISTORY:
- Surgical extraction of wisdom teeth on ___
SOCIAL HISTORY: ___
FAMILY HISTORY: No history of autoimmune disorders.
ALLERGIES/ADR: NKDA
PREADMISSION MEDICATIONS:
The Preadmission Medication list is accurate and complete
1. Ibuprofen 600-800 mg PO Q6H:PRN Pain - Moderate
2. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Severe
EXAM
VITALS: 98.3 PO 100 / 62 L Lying ___ RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Lower facial swelling with significant swelling, R>L, with
overlying tenderness R>L.
Neck: Fullness and swelling bilaterally, without erythema, no
obvious lymphaneopathy or overling cellulitis
JAW: No clicking, popping, crepitis
CV: Heart tachycardiac, but regular, no murmur, no S3, no S4.
No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation.
MSK: Neck supple, moves all extremities
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
DATA: I have reviewed the relevant labs, radiology studies,
tracings, medical records, and they are notable for:
CT Head/Neck with contrast (OSH)
FINDINGS:
- Deep parapharyngeal space and fat appear preserved without
inflammatory change.
- Multiple foci of air are noted adjacent to the right mandible
as
well as soft tissue standing and trace fluid.
IMPRESSION:
- Bilateral superficial subcutaneous and deeper facial standing
and fluid especially adjacent to the mandible at the region of
the bilateral wisdom teeth. No drainable fluid collection.
Although some of these finding could be seen with recent
procedure, the extent of these findings is worrisome for
infection/phlegmon. Clinical correlation is recommended.
- Nonspecific fluid seen adjacent to the aortic arch. Clinical
correlation is recommended. This could be seen with spread of
infection to the mediastinum causing mediastinitis.
LABS:
___ 10:55AM BLOOD WBC:12.7* RBC:3.81* Hgb:10.6* Hct:32.8*
MCV:86 MCH:27.8 MCHC:32.3 RDW:14.8 RDWSD:46.8* Plt Ct:187
___ 10:55AM BLOOD Neuts:80* Bands:14* Lymphs:2* Monos:2*
Eos:2 Baso:0 ___ Myelos:0 AbsNeut:11.94*
AbsLymp:0.25* AbsMono:0.25 AbsEos:0.25 AbsBaso:0.00*
___ 10:55AM BLOOD Glucose:91 UreaN:14 Creat:0.9 Na:137
K:4.0 Cl:103 HCO3:19* AnGap:15
___ 10:55AM BLOOD Calcium:7.5* Phos:3.3 Mg:1.3*
SUMMARY/ASSESSMENT:
___ year old female presents with facial swelling, trismus,
post-op infection after wisdom teeth (#1,16,17,32) extractions 2
days ago, without evidence of airway compromise, admitted to
receive IV unasyn.
ACUTE/ACTIVE PROBLEMS:
# Sespis
# Post dental extraction infection without abscess: Patient with
right sided dental infection with significant swelling, fever,
leukocytosis, tachycardia and drainage of pus from the surgical
site. She was evaluated by ENT with a fiberoptic exam without
any evidence of airway compromise. Original CT scan at OSH read
for possible mediastinitis, however, per the ___ note, our
radiologists thought that the nonspecific fluid in the aortic
arch most likely represents normal anatomic finding. Patient
appears clinically well.
- Continue IV Unasyn (d1 ___
- Pain management with acetaminophen and IV ketorolac, with
addition of opiates if necessary
- Will t/b with radiology regarding official reread of CT scan
- Remain NPO
- Appreciate OMFS recommendations
- Appreciate ENT recommendations
- ___ CT scan reread per our radiology department
Past Medical History:
Surgical extraction of wisdom teeth on ___
Social History:
___
Family History:
No history of autoimmune disorders.
Physical Exam:
ADMISSION PHYSICAL:
VITALS: 99.3 98 138/95 12 95%
GENERAL: Alert, oriented, no acute distress
HEENT: Peripheral swelling visualized externally, uvula remains
centered at midline, palatal elevation symmetric
NECK: Supple, no JVD, no tracheal deviation
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops appreciated
ABD: +BS, soft, mildly tender diffusely, non-distended, no
rebound tenderness or guarding, no organomegaly appreciated
EXT: Pedal pulses and edema unable to assess due to stockings,
very slight R leg fullness relative to L
SKIN: No active lesions
NEURO: No motor/sensory deficits elicited
ACCESS: PIV
DISCHARGE PHYSICAL:
Vitals: afebrile, SBPs 130, P 70, RR 16, 98 RA
Very pleasant female who appears in no acute distress.
Right-sided lower facial swelling has essentially resolved.
Area is still TTP
Unable to appreciate any purulent discharge from the #32
extraction site
Right side of her neck is minimally tender to palpation
No erythema within the outlined areas of her neck/chest
improving voice
CV: RRR, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation.
MSK: Neck supple, moves all extremities
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 12:00AM WBC-8.0 RBC-3.48* HGB-9.8* HCT-29.7* MCV-85
MCH-28.2 MCHC-33.0 RDW-15.0 RDWSD-47.2*
___ 12:00AM NEUTS-71 BANDS-22* LYMPHS-3* MONOS-0 EOS-4
BASOS-0 ___ MYELOS-0 AbsNeut-7.44* AbsLymp-0.24*
AbsMono-0.00* AbsEos-0.32 AbsBaso-0.00*
___ 12:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 12:00AM PLT SMR-LOW* PLT COUNT-128*
___ 11:02AM LACTATE-1.9
___ 10:55AM GLUCOSE-91 UREA N-14 CREAT-0.9 SODIUM-137
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-19* ANION GAP-15
___ 10:55AM estGFR-Using this
___ 10:55AM CALCIUM-7.5* PHOSPHATE-3.3 MAGNESIUM-1.3*
___ 10:55AM WBC-12.7* RBC-3.81* HGB-10.6* HCT-32.8*
MCV-86 MCH-27.8 MCHC-32.3 RDW-14.8 RDWSD-46.8*
___ 10:55AM NEUTS-80* BANDS-14* LYMPHS-2* MONOS-2* EOS-2
BASOS-0 ___ MYELOS-0 AbsNeut-11.94* AbsLymp-0.25*
AbsMono-0.25 AbsEos-0.25 AbsBaso-0.00*
___ 10:55AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL
___ 10:55AM PLT SMR-NORMAL PLT COUNT-187
DISCHARGE LABS:
ALT 81, AST 74, Alk phos 145, TBili 0.5
Lipase 66
Retic 0.8%
Milfod Blood cultures: NGTD
Pending studies:
-Blood cultures ×2, ___
-MRSA screen, ___
Iron ___
Ferritin 67
Haptoglobin 268
TIBC 259
IMAGING:
___ opinion CT Neuro ___:
1. Extensive swelling of the neck and face bilaterally with
cervical
lymphadenopathy. Within the mediastinum there is a portion of
the mediastinal
fat that appears somewhat higher in density, which raises
concern for
infection given the patient's clinical diagnosis. Recommend
follow-up imaging
with either contrast-enhanced CT or MR of the chest.
2. The visualized portion of the brain appears grossly normal.
CT Neck w/con ___: IMPRESSION:
1. New symmetric thickening and edema of the glottis and
supraglottic larynx
extending into the aryepiglottic folds,, without epiglottic
involvement, may
be reactive or inflammatory/infectious.
2. Neck edema, stranding has overall mildly improved.
Enhancement of the
superficial lobes of the parotid glands is similar, may be
reactive or from
parotitis.
3. There is mild increase in fat stranding at the superior
margin of the
clavicles, that appears slightly worse compared to prior CT
neck.
4. Small areas fluid and air adjacent to the lateral mandibles,
may represent
postoperative change or phlegmon, without definite evidence of
well-defined
abscess.
5. New consolidation in the dependent portion right lower lobe,
with nodular
components, partially seen, worrisome for pneumonia or
aspiration. Small
pleural effusions. Refer to chest CT report.
CTA Chest (gated) ___: IMPRESSION:
-Small pericardial effusion.
-Abnormal thickening and enhancement of the anterior superior
portion of the
pericardium may be reactive to an infectious process in the
mediastinum,
however no mediastinal fluid collection or definite mediastinal
stranding is
identified to provide direct evidence of mediastinitis.
-Bibasilar consolidations, right greater than left, are
concerning for
pneumonia.
-Scattered small mediastinal nodes are nonspecific, may be
reactive to either
a process in the mediastinum or the lungs.
-Small bilateral pleural effusions and mild pulmonary edema.
Abd XRAy no intraperitoneal free air
RUQ US: trace perihepatic ascites. Hepatic parenchyma WNL. NO
biliary dilation. Pancreas normal (tail not visualized). Sludge
in gallbladder with no cholelithiasis or cholecystitis.
+Splenomegaly
Brief Hospital Course:
Ms. ___ is a ___ female s/p recent wisdom teeth
extraction who was admitted to ___ on ___ ___nd
throat pain due to a right masticator space infection following
a wisdom tooth extraction. She was transferred from ___
___ due to imaging findings concerning for mediastinitis.
# Postoperative Infection Follow Wisdom Tooth Extraction
# Right Masticator Space Infection
# Concern for Mediastinitis
On arrival she was evaluated by ___, as well as ENT in the ED.
ENT for fiberoptic evaluation, which showed no concern for
airway compromise. ___ felt this was consistent with a right
masticator space infection, but that she needed further
evaluation to rule out mediastinitis. Gated chest CT showed
several inconclusive findings, including "abnormal thickening
and enhancement of the anterior superior portion of the
pericardium which may be reactive to infectious process in the
mediastinum, however, no mediastinal fluid collection or
definite mediastinal staining is identified to provide direct
evidence of mediastinitis". She was evaluated by Thoracic
surgery and infectious disease services. Thoracic surgery felt
that she was very unlikely to have mediastinitis based on
clinical grounds, as she appeared well overall and never
complained of chest pain or pleuritic symptoms in particular.
She was treated with broad-spectrum IV antibiotics, including IV
vancomycin/Zosyn initially, and was later narrowed to IV Unasyn
when multiple cultures (between ___ and ___
returned with no growth to date. Additionally, a MRSA swab was
negative. Overnight on ___ she developed progressive dysphonia,
bruising concern for laryngeal edema prompting transfer to the
ICU for continuous O2 monitoring. She ended up being fine, with
no signs of airway compromise, and repeat ENT fiberoptic
evaluation at that time showed no signs of airway concerns, and
she was transferred back to the floors the following day.
Eventually her back and tooth pain gradually improved, and she
was able to start eating a regular (soft food) diet. By ___
she was feeling much better and was medically cleared to return
home. At the recommendation of the infectious disease service,
she will go home to complete 9 more days of oral Augmentin
therapy for 14 days of antibiotics total. She will follow-up in
the ___ clinic on discharge (exact date and time still to be
determined, ___ will reach out to patient to coordinate)
# Aspiration Pneumonia: Chest demonstrated signs of bibasilar
infiltrates consistent with aspiration pneumonia. She will be
fully treated for this with the oral Augmentin therapy as
described above.
# Abd pain: developed during the final few days of her hospital
stay, likely due to gastritis, as her symptoms improved with IV
Pepcid. A workup for other causes was notable for mildly
elevated LFTs (ALT 81, AST 74, Alk phos 145, TBili 0.5). Right
upper quadrant ultrasound showed some sludge in the gallbladder
with no Cholelithiasis or cholecystitis. Mild splenomegaly to
13 cm is also noted. These findings may have been due to
prolonged n.p.o. status for mild cholestasis secondary to
antibiotic therapy. These findings were discussed with her PCP,
___ patient ___ go for repeat LFTs next week. She
will continue famotidine p.o. twice daily on discharge
# Anemia: DIC panel negative. Retic 0.8%. Hemolytic workup
negative, with a normal LDH and T bili. Found to be mildly iron
deficient - Iron 22, Ferritin 67, Transferrin saturation 8%.
Noted to have mild splenomegaly on RUQUS, of unclear
significance. Inherited disorders such as Hereditary
spherocytosis could be considered. These findings were discussed
with her PCP, who will follow up with patient in clinic next
week to determine if further evaluation is warranted.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 600-800 mg PO Q6H:PRN Pain - Moderate
2. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Severe
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
Take three times daily for 2 weeks, then as needed
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*1
2. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H
RX *amoxicillin-pot clavulanate 250 mg-62.5 mg/5 mL 500 mg by
mouth three times a day Disp #*270 Milliliter Refills:*0
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
Take twice daily for 2 more weeks
RX *chlorhexidine gluconate 0.12 % 15ml - swish and spit twice a
day Refills:*0
4. Famotidine 20 mg PO BID
Take twice daily for the next two weeks, then as needed
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*2
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN BREAKTHROUGH PAIN
take as needed for breakthrough pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth q4h PRN Disp
#*14 Tablet Refills:*0
6. Naproxen 250 mg PO BID
Take twice daily with meals. ___ cause stomach upset
RX *naproxen 250 mg 1 tablet(s) by mouth twice a day Disp #*28
Tablet Refills:*1
7. Ondansetron ODT 4 mg PO Q8H:PRN Nausea
Take as needed for Nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q6h PRN Disp #*30
Tablet Refills:*1
8.Outpatient Lab Work
Labs needed: BMP, Hepatic Function Panel, and CBC with
Differential
ICD-9: 528.3
Forward to PCP ___
___ Disposition:
Home
Discharge Diagnosis:
Right masticator space infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you. As you know, you were admitted
to ___ for evaluation and management of an oral
infection following a wisdom tooth extraction. You made a good
initial response to anbitiotics. Unfortunately, a CT scan of
your neck raised concerns for a condition called Mediastinitis,
which is an infection of the Mediastinum (the space in your
chest between your lungs and heart). You were evaluated by
multiple specialists, and we obtained specialized imaging of
your chest to evaluate for this condition. Based on imaging we
were unable to completely rule this out; however, the consensus
amongst all of the doctors involved in your care was that
Mediastinitis was highly unlikely based on your overall
excellent clinical condition.
You were briefly monitored in the Intensive Care Unit after
developing worsening voice hoarseness. Thankfully your condition
remained stable, and you were transferred back to the floors the
following day.
By ___ your infection had improved significantly and you were
cleared for discharge back to home.
Your instructions:
- Take all of your medications as prescribed (specific
instructions included on the prescriptions)
- Please get repeat bloodwork done next ___.
Please have these done at least 2 hours prior to your
appointment with Dr. ___ that she can review them with you
at the time of your appointment
- Continue a soft diet as tolerated. Once your pain
improves/resolves you can resume a normal diet
Followup Instructions:
___
|
19853875-DS-7
| 19,853,875 | 27,076,018 |
DS
| 7 |
2145-01-25 00:00:00
|
2145-01-26 19:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
diabetic ketoacidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ is a ___ with insulin-dependent diabetes on an
insulin pump, as well as ankylosing spondylitis, who presents
with elevated blood sugars since ___ to the 400s-500s, coupled
with nausea, vomiting, and diarrhea, found to have elevated
blood sugar with anion gap metabolic acidosis.
She reports that she typically has a novolog insulin pump and
continuous glucose monitor (changed q10d) but did not have a
continuous monitor this past week and was using finger-sticks to
monitor her sugars. On ___ mid-day she had poor
control on the pump, with sugars as high as the 500s; she
removed the pump and used 12u Tresiba (around noon) with novolog
correction
every ___ hours (ratio of 1:50, usually ___ units). Her sugars
bounced between 300-400 since then. In the evening, she
developed nausea primarily with eating but did have one episode
w/o provocation; she had chills with vomiting. She also starting
having diarrhea; the first was soft but then she had frequent
liquid stools, last ___ at ___ pm. This was accompanied by
crampy abdominal pain. She was unable to keep food down and by
___ was unable to keep water down.
On ___, she also developed dyspnea, which has been
present in prior episodes of DKA. She had myalgias feel like her
existing hyperglycemia, not like the flu (which she has had
before); "it feels like my body is digesting itself." She
reports mild flank pain as well, though no dysuria, increased
urinary frequency; she thinks she was dehydrated. She has a sore
throat
she attributes to vomiting ___ times.
Prior to coming to ED (circa noon ___ she took 12u Tresiba.
She was initially diagnosed with diabetes in ___ when she
presented with DKA. She has had DKA one additional time in the
setting of viral illness or strep. Denies any ingestion,
atypical alcohol, suicide attempt.
She has no known recent sick contacts and her only recent travel
was to ___ on a plane.
SH: no smoking, once a week ___ drinks, no drugs
In the ED,
- Initial Vitals: 97.2 | 122 | 139/84 | 24 | 100% RA | FSG 261
FSG: 238, 216, 249, 267
- Labs notable for:
Leukocytosis 10.1 (84.5% PMNs)
@2140 -
134 | 96 | 17
--------------< 269, AG 26
4.4 | 12 | 1.0
VBG 7.27 | 33 | 23 | 15
@ 0015 -
130 | 99 | 13 Ca 8.7
--------------< 234, AG 18 Mg 1.6
4.4 | 13 | 0.7 Phos 2.8
VBG 7.35 | 28 | 80 | 16
Flu pending
UA pending
Urine HCG negative
- Imaging:
___ CXR: No acute cardiopulmonary process.
- Consults: None
- Interventions: She was started on an insulin gtt at 3
unit/hour which was increased to 4u/hr.
She also received: 2L LR and was started on 150/hr D5NS with
40mEq K, and 4mg ondansetron.
On arrival to the floor, she confirms and clarifies the above
story.
Of note, she was seen at ___ in ___, at which time
her A1c was 10.2%, representing an average blood glucose around
240. Additional ___ labs from ___ include:
133 | 94 | 15
---------------<
4.5 | 25 | 0.59
TSH 1.06, T4 1.18
Alb:Cr 17.30 (up from 8.21)
Urine pH 6.0 glucose 250, Ketones >=80, neg
blood/protein/nitrite/bili, ___ WBC
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
- Ankylosing Spondylitis (HLAB27+)
- Type I DM
- Camylobacter diarrhea
Social History:
Marital status: Significant Other
Children: No
Lives with: Alone
Lives in: Apartment
Work: ___
Multiple partners: ___
___ activity: Present
Sexual orientation: Male
Sexual Abuse: Denies
Domestic violence: Denies
Contraception: Condoms - Male; OCPs
Tobacco use: Never smoker
Alcohol use: Present
drinks per week: ___
Alcohol use Can drink 6 over afternoon/evening on a
comments: weekend day, may have a glass of beer or
wine with dinner other nights
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
Comments: Has a dog (great ___ and a cat.
Family History:
Relative Status Age Problem Onset Comments
Mother FIBROID UTERUS
CHRONIC FATIGUE
HYPOTHYROID
NEUROPATHY
Father PROSTATE CANCER
VALVULAR HEART
DISEASE
MGM Deceased ___ OLD AGE
MGF Deceased ___ OLD AGE
PGM STROKE
Comments: Mother's side of family with numerous autoimmune
thyroiditis
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================================
VS: 117/83, HR 100, SpO2 96%, RR 25
GEN: Nontoxic, no acute distress, appears mildly uncomfortable
EYES: Pupils 3mm and equal and reactive, no injection or sceral
icterus.
HENNT: Dry lips, MMM. No oral lesions.
CV: RRR, tachycardic, no murmurs
RESP: CTAB without adventitious sounds.
GI: Soft, mildly tender/uncomfortable to palpation but not
localizable, nondsitended.
MSK: WWP, no edema.
SKIN: no rashes on face, back, arms, abdomen.
NEURO: face grossly symmetric, no dysarthria, moving all limbs
with purpose against gravity
PSYCH: pleasant, appropriate, somewhat low affect but not
overtly anxious or tearful
.
.
Discharge exam:
===============
Gen: NAD
ENT: MMM, OP clear
CV: RR, tachycardic, no murmurs
Resp: CTAB, normal WOB
GI: soft, not distended, not tender to firm palpation, BS+
Neuro: awake, alert, conversant with clear speech, stable gait
Psych: calm, cooperative, pleasant, good insight
Pertinent Results:
ADMISSION LABS
==================================
___ 09:40PM BLOOD WBC-10.1* RBC-4.77 Hgb-13.8 Hct-43.2
MCV-91 MCH-28.9 MCHC-31.9* RDW-12.4 RDWSD-41.0 Plt ___
___ 09:40PM BLOOD Neuts-84.5* Lymphs-9.8* Monos-4.2*
Eos-0.3* Baso-0.7 Im ___ AbsNeut-8.50* AbsLymp-0.98*
AbsMono-0.42 AbsEos-0.03* AbsBaso-0.07
___ 09:40PM BLOOD Glucose-269* UreaN-16 Creat-1.0 Na-134*
K-4.4 Cl-96 HCO3-12* AnGap-26*
___ 09:40PM BLOOD Calcium-9.8 Phos-4.7* Mg-1.8
___ 09:51PM BLOOD ___ pO2-23* pCO2-33* pH-7.26*
calTCO2-15* Base XS--13
___ 09:51PM BLOOD K-3.8
RELEVANT LABS
==================================
___ 12:44PM BLOOD cTropnT-<0.01 proBNP-328*
___ 12:15AM BLOOD ALT-12 AST-17 AlkPhos-79 TotBili-0.6
___ 02:30AM BLOOD %HbA1c-9.5* eAG-226*
___ 12:15AM BLOOD Osmolal-281
___ 03:27AM BLOOD Lactate-1.2
RELEVANT IMAGING
==================================
___ CXR AP
No acute cardiopulmonary process.
___ RIGHT LOWER EXTREMITY ULTRASOUND
No evidence of deep venous thrombosis in the right lower
extremity veins.
Discharge labs:
================
___ 05:51AM BLOOD WBC-5.8 RBC-3.82* Hgb-11.0* Hct-33.4*
MCV-87 MCH-28.8 MCHC-32.9 RDW-12.6 RDWSD-40.0 Plt ___
___ 05:51AM BLOOD Glucose-253* UreaN-5* Creat-0.5 Na-139
K-4.3 Cl-102 HCO3-25 AnGap-12
___ 05:51AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.0
Brief Hospital Course:
================
PATIENT SUMMARY
================
___ is a ___ female with Ankylosing Spondylitis and
type I DM on an insulin pump who presents with diabetic
ketoacidosis without a clear trigger. Was initially on an
insulin gtt, quickly transitioned onto SC insulin. ___ was
consulted and provided recommendations.
================
ACUTE ISSUES
================
#DIABETIC KETOACIDOSIS
No obvious infectious trigger other than a possible diarrheal
illness vs issues with her pump, but it is unclear whether her
GI symptoms are the cause or result of her evolving DKA. Denies
atypical ingestion or problems with acquiring/administering
insulin. Treated initially on insulin gtt, was quickly
transitioned to subcutaneous insulin. ___ was consulted and
advised resuming her home insulin pump regimen.
___
Pre-renal from DKA-induced hypovolemia. Improved with fluid
resuscitation.
#Shortness of breath
Patient c/o dyspnea. Has associated right leg discomfort and
possible pleuritic-type pain (pain in ___ chest and b/l
subcostal areas). Was not hypoxia. CXR without abnormality.
Right leg ___ without DVT. Trop negative, proBNP very mildly
elevated. Very low suspicion for PE. Discussed with patient the
risks and benefits of radiation exposure from CTA for the time
being, and watching symptoms closely, and patient was amenable
to this. D-dimer was negative. On day of discharge her symptoms
of SOB and pleuritic pain had completely resolved without
interventions other than resolution of DKA.
================
CHRONIC ISSUES
================
#ANKYLOSING SPONDYLITIS:
Held home Celebrex i/s/o ___. APAP for now. At home she mostly
uses acupuncture and takes Celebrex very rarely.
.
.
.
Time in care: >30 minutes in discharge-related activities on the
day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. norgestimate-ethinyl estradiol 0.18/0.215/0.25 mg-25 mcg oral
DAILY
2. Celecoxib 200 mg oral DAILY:PRN pain
3. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Target glucose: 80-180
Discharge Medications:
1. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Target glucose: 80-180
2. Celecoxib 200 mg oral DAILY:PRN pain
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Multivitamins W/minerals Chewable 1 TAB PO DAILY
5. norgestimate-ethinyl estradiol 0.18/0.215/0.25 mg-25 mcg
oral DAILY
6. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
DKA
Type I DM
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 hospital with high blood sugars and
diabetic ketoacidosis. We do not have a clear sense on what
triggered this episode, but it has improved with IV fluids and
an insulin drip in the ICU. Your blood sugar management will
continue to be using your insulin pump and we encourage you to
see your diabetologist in the next ___ weeks to follow-up and
ensure that your regimen is working well for you.
You had symptoms of pleuritic chest pain and shortness of breath
that resolved without treatment.
It was a pleasure caring for you while you were here and we wish
you all the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
19854363-DS-22
| 19,854,363 | 21,228,584 |
DS
| 22 |
2194-12-26 00:00:00
|
2194-12-27 15:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim DS / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
___ Pigtail Catheter Placement
___ Thoracoscopy guided Talc Pleurodesis
History of Present Illness:
___ w/ PMHx emphysema, lung cancer s/p palliative radiation at
___, HFpEF, HTN, TIAs, a-fib on Eliquis presented with R sided
chest pain and SOB. She says she woke up at 6 AM on the morning
of ___ with pain in the R side of her chest that worsened with
inspiration. Also reports progressive worsening of shortness of
breath and fatigue so she came to ED for further evaluation.
Upon initial evaluation in the ED, the patient had stable vital
signs and an unremarkable ECG. She then developed acute onset
SOB and desatted to the ___ on RA. She was placed on NRB w/
improvement in her sats. Portable CXR was obtained which showed
a large R sided PTX w/ some shifting of the mediastinum c/f
tension pneumo. IP was then consulted and placed a pigtail
catheter.
In the ED:
Initial vital signs were notable for:
- 96.9 92 140/79 16 99% RA
Labs were notable for:
- CBC wnl
- Na 135, K 4.1, BUN 23
- Trop neg x1
- Lactate 1.5
- VBG 7.31/62
- ___ 13.7, PTT 29.3, INR 1.3
- proBNP 2554
Studies performed include:
- CXR (___)
- Large right pneumothorax with contralateral shift of the
mediastinal structures, raising the possibility of tension
pneumothorax.
- CXR (___)
- Interval re-expansion of the right lung status post
placement of a right-sided chest tube. There is trace
residual right apical and basilar pneumothorax.
- CXR (___)
- FINDINGS: Right-sided pigtail chest tube is unchanged in
position as compared to most recent chest radiograph.
Previously noted right pneumothorax is no longer seen.
Otherwise no change.
- IMPRESSION: No residual right pneumothorax.
Right chest tube in place.
- CT Chest w/o contrast (___)
1. Difficult to distinguish between presumed interval growth
of a pre-existing right upper lobe pulmonary nodule into
a larger mass and its resulting postobstructive
atelectasis, noting obstruction of the adjacent right
upper lobe posterior segment bronchus. The confluent area
of opacification measures approximately 4.8 cm.
2. A right middle lobe pulmonary nodule has slightly
increased in size and measures 0.7 cm.
3. A small right hydropneumothorax is decreased in size
since radiographs obtained 1 day prior status-post
pigtail pleural drainage catheter placement.
4. Ground-glass opacities in the peripheral left upper lobe
apicoposterior segment could reflect sequela of
aspiration or developing infection.
5. Severe centrilobular and paraseptal pulmonary emphysema.
6. Severe calcified coronary and aortic atherosclerosis.
7. Unchanged main pulmonary artery enlargement suggests
pulmonary hypertension.
- CXR (___)
- Unchanged appearance of the chest since 1.5 hours prior.
The pigtail pleural drainage catheter is unchanged in
position.
Patient was given:
- ___ 08:56 IV Morphine Sulfate 4 mg
- ___ 10:03 IV Fentanyl Citrate 50 mcg
- ___ 10:03 PO Acetaminophen 1000 mg
- ___ 13:12 IV Morphine Sulfate 2 mg
- ___ 18:35 IV Morphine Sulfate 2 mg
- ___ 18:35 PO/NG Apixaban 2.5 mg
- ___ 00:16 IV Morphine Sulfate 2 mg
- ___ 00:17 PO Pravastatin 40 mg
- ___ 05:38 IV Morphine Sulfate 2 mg
Consults:
- IP as above, placed pigtail, PTX improved.
Vitals on transfer: T98.0 BP132/69 HR85 RR16 O2sat 91%RA
Upon arrival to the floor, patient was hemodynamically stable.
She corroborates the above history. She denies current SOB,
chest pain, fevers, chills, abdominal pain, nausea, diaphoresis,
orthopnea, vomiting, diarrhea.
REVIEW OF SYSTEMS: Otherwise negative.
Past Medical History:
PAST MEDICAL HISTORY:
- Emphysema
- FDG avid lung nodule, s/p palliative XRT at ___ in ___
- HFpEF
- HTN
- AFib
- TIA x 2
- HLD
- Hypothyroidism
- Anxiety
- s/p b/l cataract surgery
- Varicose veins
- Dizziness ___ diagnosed with BPPV, resolved
- BSO
- cholecystecomy
- appendectomy
Social History:
___
Family History:
Noncontributory.
Mother: with stroke, DM
Paternal aunt: stroke
Physical ___:
ADMISSION PHYSICAL EXAM:
======================
VITALS: T98.0 BP132/69 HR85 RR16 O2sat 91%RA
GENERAL: lying in bed in NAD
HEENT: NC/AT
NECK: No JVD
CARDIAC: RRR, nl s1/s2, no mrg
LUNGS: CTABL, no increased WOB, no decreased breath sounds over
R lung fields
ABDOMEN: soft, NT/ND, +BS
EXTREMITIES: no edema over BLE
NEUROLOGIC: AOx3
DISCHARGE PHYSICAL EXAM:
=========================
VITALS: T 97.7 PO BP 106 / 57 L Lying HR 74 RR 17 93% RA
GENERAL: pleasant elderly lady, lying in bed in NAD
HEENT: NC/AT, anicteric sclera, PERRL
NECK: supple, no lymphadenopathy
CARDIAC: irregularly irregular, nl s1/s2, no mrg
LUNGS: CTABL, no increased WOB, slightly decreased breath sounds
RLL posteriorly
-- chest tube incision site in right anterio-lateral chest wall,
healing well with no induration or erythema
ABDOMEN: soft, NT/ND, +BS
EXTREMITIES: warm well perfused, 2+ pulses, no edema
NEUROLOGIC: AOx3, CN ___ grossly intact; no focal neurologic
deficits
Pertinent Results:
ADMISSION LABS:
==============
___ 08:03AM BLOOD WBC-5.6 RBC-4.18 Hgb-12.9 Hct-39.6 MCV-95
MCH-30.9 MCHC-32.6 RDW-14.4 RDWSD-50.1* Plt ___
___ 08:03AM BLOOD Neuts-73.3* Lymphs-18.3* Monos-5.9
Eos-1.1 Baso-0.9 Im ___ AbsNeut-4.07 AbsLymp-1.02*
AbsMono-0.33 AbsEos-0.06 AbsBaso-0.05
___ 08:43AM BLOOD ___ PTT-29.3 ___
___ 08:03AM BLOOD Glucose-116* UreaN-23* Creat-0.9 Na-135
K-7.8* Cl-96 HCO3-26 AnGap-13
___ 08:03AM BLOOD ALT-<5 AST-63* AlkPhos-40 TotBili-0.5
___ 08:03AM BLOOD proBNP-2554*
___ 08:03AM BLOOD cTropnT-<0.01
___ 08:16AM BLOOD ___ pO2-30* pCO2-62* pH-7.31*
calTCO2-33* Base XS-2
___ 08:16AM BLOOD Lactate-1.5 K-4.1
PERTINENT LABS:
==============
___ 06:05AM BLOOD CK-MB-1 cTropnT-<0.01
___ 03:54PM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:45AM BLOOD ALT-18 AST-22 LD(LDH)-183 AlkPhos-61
TotBili-0.7
MICROBIOLOGY:
=============
___ 8:03 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:08 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
========
CXR (___)
- IMPRESSION: Large right pneumothorax with contralateral shift
of the mediastinal structures, raising the possibility of
tension pneumothorax.
CXR (___)
- IMPRESSION: Interval re-expansion of the right lung status
post placement of a right-sided chest tube. There is trace
residual right apical and basilar pneumothorax.
CXR (___)
- IMPRESSION: No residual right pneumothorax. Right chest tube
in place.
CT Chest w/o contrast (___)
- IMPRESSION:
-- 1. Difficult to distinguish between presumed interval growth
of a pre-existing right upper lobe pulmonary nodule into a
larger mass and its resulting postobstructive atelectasis,
noting obstruction of the adjacent right upper lobe posterior
segment bronchus. The confluent area of opacification measures
approximately 4.8 cm.
-- 2. A right middle lobe pulmonary nodule has slightly
increased in size and measures 0.7 cm.
-- 3. A small right hydropneumothorax is decreased in size since
radiographs obtained 1 day prior status-post pigtail pleural
drainage catheter placement.
-- 4. Ground-glass opacities in the peripheral left upper lobe
apicoposterior segment could reflect sequela of aspiration or
developing infection.
-- 5. Severe centrilobular and paraseptal pulmonary emphysema.
-- 6. Severe calcified coronary and aortic atherosclerosis.
-- 7. Unchanged main pulmonary artery enlargement suggests
pulmonary hypertension.
Repeat CXRs were conducted daily or more frequently ___,
___ x2, ___ x2, ___ which showed stability.
DISCHARGE CXR (___):
IMPRESSION:
1. Stable subcutaneous emphysema over the right chest wall.
2. Stable right apical pneumothorax.
3. Worsening pulmonary edema.
___ Bilateral ___
- IMPRESSION: No evidence of deep venous thrombosis in the right
or left lower extremity veins.
PROCEDURES:
===========
___ Medical Thoracoscopy, Talc Pleurodesis, Chest Tube
Placement
- A cluster of apical blebs were noted. 4g talc was insufflated.
DISCHARGE LABS:
==============
___ 06:50AM BLOOD WBC-5.6 RBC-3.86* Hgb-11.9 Hct-36.9
MCV-96 MCH-30.8 MCHC-32.2 RDW-14.0 RDWSD-49.1* Plt ___
___ 06:50AM BLOOD Glucose-95 UreaN-16 Creat-0.8 Na-137
K-3.8 Cl-93* HCO3-30 AnGap-14
___ 06:50AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9
Brief Hospital Course:
PATIENT SUMMARY:
====================
Ms. ___ is a ___ year old woman with PMH of severe emphysema,
lung cancer s/p palliative XRT, HFpEF, HTN, TIAs, a-fib on
Eliquis who presented with R sided chest pain and dyspnea and
was found to have a large R sided pneumothorax. A pigtail
catheter was placed by IP with re-expansion of the lung. Patient
then underwent talc pleurodesis to prevent recurrence. Course
complicated by development of UTI which was treated with PO
macrobid (continued through ___.
ACUTE ISSUES:
=============
#Spontaneous Pneumothorax
#Emphysema
As above, Ms. ___ presented with acute R sided chest pain,
SOB, and hypoxemia and was found to have large R sided PTX. It
was felt this was secondary to her underlying severe emphysema.
Interventional Pulmonology placed a pigtail catheter with
complete re-expansion of the lung, then eventually performed a
talc pleurodesis via thoracoscopy ___. Daily CXRs were
performed to assess interval change, which demonstrated
stability. Pre-procedure, her DOAC was held but restarted
uneventfully ___. Her pain was controlled with tylenol and
oxycodone 2.5mg q4hr:PRN (NSAIDs avoided due to interference
with anti-inflammatory response required for successful
pleurodesis -- IVF also avoided for this reason). Follow-up with
interventional pulmonology arranged prior to discharge.
#Atrial fibrillation with rapid ventricular response
CHADS2-VASc 7. During her hospitalization, Ms. ___ developed
new-onset pleuritic chest pain with tachycardia. ECG notable for
atrial fibrillation with rapid ventricular response. ECG with
new TWI but cardiac enzymes persistently negative, so ACS felt
to be unlikely. Some concern for PE as trigger given held
anticoagulation prior to procedure, but LENIs negative and
patient without worsening hypoxemia. Ultimately attributed to
pain post-pleurodesis and resolved with treatment of pain. Home
diltiazem continued. Home apixaban initially held for
pleurodesis, then re-started post-procedure.
#Lung Nodule, malignant
Per review of records here and at ___, Ms. ___ has had
multiple pulmonary nodules seen on CT chest since ___, with
one FDG-avid spiculated nodule. Has received palliative
radiation at ___, but no definitive biopsy in concordance with
patient's wishes. On CT here, possible progression of nodule to
mass. Further conversations with the patient confirmed that she
did not want biopsy.
#Urinary Tract Infection
Patient is followed in ___ clinic and has history of
recurrent UTIs, although per chart review may also be
chronically colonized with E.Coli. She has been taking
prophylactic methenamine +Vitamin C at home. On ___, she
developed urinary frequency and dysuria, with UA showing
multiple WBCs, ___ positive with bacteria. She was started on a 5
day course of Macrobid, and prophylactic methenamine/Vit C was
held. She will finish her course of Macrobid ___, after which
she will resume taking methenamine + Vit C.
CHRONIC & RESOLVED ISSUES:
============================
#HFpEF:
Appeared euvolemic on admission. Continued home furosemide 20mg
daily and diltiazem. Home Lisinopril discontinued due to soft
blood pressures. Discharge weight: 129.9lbs.
TRANSITIONAL ISSUES:
====================
[] Discharge weight: 129.9 lbs.
[] Please ensure patient does not receive anti-inflammatory
medications for several weeks post-pleurodesis.
[] Discharged on 5 day course of Macrobid (___) for
empiric treatment of UTI, urine culture pending at time of
discharge.
[] Methenamine-Ascorbic Acid was held on discharge due to
starting Macrobid 5 day course. Patient can restart
methamine-ascorbic acid on ___ after macrobid course is
complete.
[] Lisinopril was discontinued this hospitalization due to
relatively low blood pressures. Follow-up pressure and consider
re-starting if needed
[] Ensure ongoing goals of care discussions and follow-up
regarding enlarging pulmonary mass
#CODE: DNR/DNI (confirmed); ok to reverse for procedures
#CONTACT: ___
Relationship: Daughter / HCP
Phone number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 40 mg PO QPM
2. Apixaban 2.5 mg PO BID
3. Lisinopril 10 mg PO QPM
4. Levothyroxine Sodium 50 mcg PO QAM
5. Diltiazem Extended-Release 360 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Oxybutynin XL (*NF*) 5 mg Other DAILY
8. Ascorbic Acid ___ mg PO BID
9. Calcium Carbonate 500 mg PO DAILY
10. Vitamin D 400 UNIT PO DAILY
11. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0
2. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5
Days
do not take methenamine + vitamin C with this medication.
RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1
capsule(s) by mouth twice daily Disp #*9 Capsule Refills:*0
3. Apixaban 2.5 mg PO BID
4. Calcium Carbonate 500 mg PO DAILY
5. Diltiazem Extended-Release 360 mg PO DAILY
6. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
7. Furosemide 20 mg PO DAILY
8. Levothyroxine Sodium 50 mcg PO QAM
9. Oxybutynin XL (*NF*) 5 mg Other DAILY
10. Pravastatin 40 mg PO QPM
11. Vitamin D 400 UNIT PO DAILY
12. HELD- Ascorbic Acid ___ mg PO BID This medication was held.
Do not restart Ascorbic Acid until you complete your course of
antibiotics
13. HELD- methenamine hippurate 1 gram oral BID This medication
was held. Do not restart methenamine hippurate until finishing
your antibiotics for your UTI
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary:
----------
Spontaneous pneumothorax
Emphysema
Urinary tract infection
Secondary:
------------
Malignant lung nodule
Afib
HFpEF
Hypothyroidism
Recurrent UTIs (on prophylactic methenamine-vitC)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were having trouble breathing and imaging showed that your
lung had collapsed.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- A chest tube was placed to help your lung re-expand.
- To prevent this from happening again, you had a procedure
called a pleurodesis.
- You were found to have a urinary tract infection and were
started on antibiotics to treat this.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications as prescribed,
including your new antibiotic (macrobid), and follow-up with
your appointments as listed below.
- Do not take non-steroidal anti inflammatory medications to
treat your pain for the next ___ weeks (these include drugs like
Advil, Ibuprofen, Motrin, Naproxen). If you are having pain,
please take Tylenol, or acetaminophen. You can take 1 gram of
Tylenol up to three times a day, as needed for pain.
- Do not take methenamine or vitamin C for the next 5 days while
you are taking Macrobid
- After you finish a 5 day course of Macrobid on ___, you can
start taking methenamine and vitamin c again.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19854363-DS-23
| 19,854,363 | 25,707,020 |
DS
| 23 |
2196-02-21 00:00:00
|
2196-02-23 09:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim DS / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 10:25AM BLOOD WBC-5.1 RBC-3.92 Hgb-12.0 Hct-37.9 MCV-97
MCH-30.6 MCHC-31.7* RDW-13.3 RDWSD-47.1* Plt ___
___ 10:25AM BLOOD Neuts-78.5* Lymphs-13.6* Monos-6.1
Eos-0.4* Baso-1.0 Im ___ AbsNeut-3.97 AbsLymp-0.69*
AbsMono-0.31 AbsEos-0.02* AbsBaso-0.05
___ 10:25AM BLOOD ___ PTT-32.1 ___
___ 10:25AM BLOOD Glucose-94 UreaN-20 Creat-0.8 Na-137
K-4.6 Cl-95* HCO3-28 AnGap-14
___ 10:25AM BLOOD ALT-9 AST-17 AlkPhos-45 TotBili-0.4
___ 10:25AM BLOOD Lipase-21
___ 10:25AM BLOOD cTropnT-<0.01
___ 05:00PM BLOOD cTropnT-<0.01
___ 10:25AM BLOOD Albumin-4.1 Calcium-10.0 Phos-3.1 Mg-1.9
Cholest-200*
___ 10:31AM BLOOD %HbA1c-5.5 eAG-111
___ 10:25AM BLOOD Triglyc-42 HDL-109 CHOL/HD-1.8 LDLcalc-83
IMAGING:
========
CTA HEAD AND CTA NECK ___
IMPRESSION:
1. No acute large territory infarction or hemorrhage. White
matter changes
consistent with mild chronic microangiopathic ischemic disease.
2. Patent circle of ___ without evidence of stenosis,
occlusion, or
aneurysm.
3. Unchanged 2 mm posteromedially oriented outpouching of the
cervical segment
of the right internal carotid artery consistent with a
pseudoaneurysm.
4. Atherosclerosis of the carotid bifurcations with
approximately 40% stenosis
of the right internal carotid artery by NASCET criteria.
5. Patent bilateral cervical vertebral arteries without evidence
of
occlusionor dissection.
6. Slight interval increase in the size of soft tissue
thickening in the right
upper lobe in close proximity to the right hilum. This can
reflect post
radiation change and/or tumor. Consider dedicated chest
imaging.. Severe
centrilobular and paraseptal emphysema in the visualized lung
apices.
7. Stable 1.4 cm hypoattenuating nodule in the left thyroid
lobe. Per ACR
guidelines, no follow up recommended. See recommendations
below.
RECOMMENDATION(S): Absent suspicious imaging features, unless
there is
additional clinical concern, ___ College of Radiology
guidelines do not
recommend further evaluation for incidental thyroid nodules less
than 1.0 cm
in patients under age ___ or less than 1.5 cm in patients age ___
or ___.
MR ___ SPINE W AND WO CONTRAST ___
IMPRESSION:
1. No evidence of spinal cord compression or signal abnormality.
2. Multilevel degenerative changes of the cervical spine, as
above.
STROKE PROTOCOL BRAIN ___
IMPRESSION:
1. No acute intracranial abnormality. No evidence of an acute
infarct,
intracranial mass, or hemorrhage
2. White matter changes of chronic microangiopathy with
age-related
involutional changes. The white matter changes have progressed
since ___.
TTE ___
CONCLUSION:
The left atrial volume index is moderately increased. The right
atrium is markedly enlarged. There is
mild symmetric left ventricular hypertrophy with a normal cavity
size. There is normal regional and
global left ventricular systolic function. There is beat-to-beat
variability in the left ventricular
contractility due to the irregular rhythm. The visually
estimated left ventricular ejection fraction is
55-60%. There is no resting left ventricular outflow tract
gradient. Normal right ventricular cavity size
with normal free wall motion. The aortic sinus diameter is
normal for gender with a mildly dilated
ascending aorta. There is a mildly dilated descending aorta. The
aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. There is mild [1+]
aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral valve prolapse.
There is mild [1+] mitral regurgitation. The
pulmonic valve leaflets are normal. The tricuspid valve leaflets
appear structurally normal. There is mild
[1+] tricuspid regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/
global biventricular systolic function. Mild aortic
regurgitation. Mild mitral regurgitation.
MICROBIOLOGY
============
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
DISCHARGE LABS:
===============
___ 05:55AM BLOOD WBC-5.0 RBC-3.36* Hgb-10.4* Hct-32.9*
MCV-98 MCH-31.0 MCHC-31.6* RDW-13.4 RDWSD-48.5* Plt ___
___ 05:55AM BLOOD Glucose-86 UreaN-20 Creat-0.7 Na-135
K-3.9 Cl-96 HCO3-28 AnGap-11
___ 05:55AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.0
Brief Hospital Course:
========
SUMMARY:
========
___ F w/ history of Afib on apixaban, lung cancer s/p XRT on
surveillance with concern for recurrence, spontaneous
pneumothorax in ___, hx of TIA, hypothyroidism, HTN, HFpEF, who
presented initially with right arm numbness and pain ruled out
for stroke and cord compression, but found with bradycardic AF
with EKG findings suggestive of AV nodal disease as well as
orthostasis. She was given IVF with improvement of her
orthostasis. She was started on a reduced dose of her home
diltiazem with stable heart rates at discharge.
====================
TRANSITIONAL ISSUES:
====================
Discharge Cr: 0.7
Discharge Weight: 121 lb
Discharge Diuretic: PO furosemide 20 daily
[] Her home diltiazem ER was reduced from 180 mg daily to 120mg
daily, which may have been the etiology of her bradycardia.
[] She was discharged with an event monitor for 2 weeks for
extended monitoring of her heart. She will be scheduled for
cardiology follow up.
[] We held her oxybutynin while she was inpatient and did not
restart on discharge given problems with orthostasis. If she
redevelops urinary symptoms can restart.
[] Follow up CBC from ___ for anemia and thrombocytopenia
Contact: ___ (Daughter) ___ Code: Full,
confirmed
ACUTE/ACTIVE PROBLEMS:
======================
#Intermittent Bradycardia
#Atrial Fibrillation/Flutter, with complete heart block
Patient found in the ED to have bradycardia with rates in the
___ with EKG revealing for AF rhythm and evidence of possible
complete heart block. EP was urgently consulted and felt that AV
block pattern was likely due to vagal stimulus (acute arm
pain/discomfort) as the pattern augmented with activity as well
as receiving too high a dose of diltiazem. They recommended
admission for further monitoring on telemetry and optimization
of diltiazem dosing. It was felt that she did not require PPM
placement. TTE showed LVEF of 55-60% with mild LVH, but normal
cavity size and preserved biventricular systolic function. She
was initially given diltiazem fractionated to 30mg q6h, then
consolidated to a reduced dose of diltiazem ER 120 (she was
previously on 180mg at home). Her heart rates were stable on
discharge in the ___. For anticoagulation, she was continued on
apixaban 2.5mg BID.
#R arm numbness/pain
Patient initially presented with ~12 hours of R arm numbness
that became painful to the touch. Neurology was consulted on
presentation to the ED and ruled out stroke or cord compression
with MR ___ and CTA head and neck. Based on the neurology
consult's exam, patient with possible C6 radiculopathy, further
supported by evidence of cervical stenosis on MR ___. The
patient's symptoms resolved without intervention.
#Asymptomatic Bacteuria
#History of Recurrent UTIs
Patient without symptoms suggestive of UTI on admission aside
from dizziness, but does have a history of recurrent
UTI/colonization. On presentation, UA revealing for 31 WBCs and
few bacteria, but with 3 epithelial cells. Urine culture
revealing for E. coli, sensitive to ceftriaxone. She was given 3
doses of ceftriaxone, but this most likely represented chronic
colonization rather than acute infection.
#Orthostasis
On the day of presentation to the ED, patient reported dizziness
that was relieved with lying down. Central neurologic etiology
ruled out with negative CTA head and neck. Patient found to be
positively orthostatic while in the ED and was given IVF. Her
home Lisinopril was held. Repeat orthostatic vitals while on the
floor were negative. She was not feeling symptomatic on day of
discharge, so lisinopril restarted on discharge given BPs in the
150s.
CHRONIC/STABLE PROBLEMS:
========================
#HFpEF
Patient was euvolemic on exam. Of note, patient previously
trialed on metoprolol for AF as above, but this was discontinued
given development of HRs in ___ on low dose 12.5 mg. Her home
furosemide was continued during admission.
#Hypothyroidism
Continued home Synthroid.
#HLD
Continued home pravastatin.
#HTN
Her home Lisinopril was held due to orthostasis, but SBPs on day
of discharge were 140-150s, so this was restarted on discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. Calcium Carbonate 500 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Levothyroxine Sodium 50 mcg PO QAM
5. Pravastatin 40 mg PO QPM
6. Vitamin D 400 UNIT PO DAILY
7. Ascorbic Acid ___ mg PO BID
8. Lisinopril 10 mg PO DAILY
9. estradioL 0.01 % (0.1 mg/gram) vaginal 1X/WEEK
10. methenamine hippurate 1 gram oral BID
11. Diltiazem Extended-Release 180 mg PO DAILY
12. Oxybutynin XL (*NF*) 5 mg Other DAILY
13. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
Discharge Medications:
1. Diltiazem Extended-Release 120 mg PO DAILY
2. Apixaban 2.5 mg PO BID
3. Ascorbic Acid ___ mg PO BID
4. Calcium Carbonate 500 mg PO DAILY
5. Estradiol 0.01 % (0.1 mg/gram) vaginal 1X/WEEK (___)
6. Furosemide 20 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO QAM
8. Lisinopril 10 mg PO DAILY
9. methenamine hippurate 1 gram oral BID
10. Pravastatin 40 mg PO QPM
11. Vitamin D 400 UNIT PO DAILY
12. HELD- Oxybutynin XL (*NF*) 5 mg Other DAILY This
medication was held. Do not restart Oxybutynin XL (*NF*)
until instructed by your primary care doctor, as this can cause
low blood pressures
13.Outpatient Lab Work
D64.9
Obtain complete blood count on ___. Fax results to ___,
___., MD, Fax number: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-bradycardia
-atrial fibrillation
-atrial flutter
-R arm numbness, R arm pain
-orthostatic hypotension
Secondary:
-hypothyroidism
-hyperlipidemia
-chronic diastolic heart failure
-hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
===================================
- You were admitted because you had arm pain/numbness and also
had a slow heart rate.
What happened while I was in the hospital?
==========================================
- You arm pain and numbness got better without intervention.
- The cardiologists (heart doctors) evaluated you for the slow
heart rate. This may have been due to the dose of diltiazem you
were taking at home or a response to the pain you were having in
your arm.
- Your heart was monitored while you were in the hospital and
your heart rates were normal by the time you were going home.
- You had an event monitor placed before you went home to
monitor your heart for 2 weeks, which your cardiologist Dr.
___ will follow up with you about.
What should I do after leaving the hospital?
============================================
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Continue to weight yourself daily and contact your doctor if
your weight goes up by more than 3lb in one day or 5lb in one
week.
- Please have labs drawn on ___.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
19854867-DS-20
| 19,854,867 | 29,718,580 |
DS
| 20 |
2158-05-05 00:00:00
|
2158-05-07 10:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
doxycycline
Attending: ___
Major Surgical or Invasive Procedure:
___ Bone marrow Biopsy
attach
Pertinent Results:
Admission Labs
___ 12:02PM BLOOD WBC-3.2* RBC-4.29* Hgb-12.0* Hct-35.2*
MCV-82 MCH-28.0 MCHC-34.1 RDW-14.7 RDWSD-44.2 Plt Ct-54*
___ 12:02PM BLOOD Neuts-59 Bands-2 ___ Monos-11 Eos-2
___ Metas-1* AbsNeut-1.95 AbsLymp-0.80* AbsMono-0.35
AbsEos-0.06 AbsBaso-0.00*
___ 12:02PM BLOOD ___ PTT-30.4 ___
___ 10:09PM BLOOD ___ 12:02PM BLOOD Glucose-104* UreaN-24* Creat-1.7* Na-126*
K-5.6* Cl-90* HCO3-17* AnGap-19*
___ 12:02PM BLOOD ALT-29 AST-193* AlkPhos-76 TotBili-0.6
___ 12:02PM BLOOD Lipase-66*
___ 12:02PM BLOOD cTropnT-<0.01
___ 12:02PM BLOOD Albumin-3.4* Calcium-8.4 Phos-3.6 Mg-2.3
___ 10:09PM BLOOD calTIBC-157* VitB12-471 Ferritn-4923*
TRF-121*
___ 03:33AM BLOOD Triglyc-227* HDL-<10*
Pertinent & Discharge Labs
___ 07:51AM BLOOD PEP-NO SPECIFI FreeKap-27.9* FreeLam-23.7
Fr K/L-1.2
___ 07:30AM BLOOD CMV VL-NOT DETECT
CD25: 3850
___ 09:42AM BLOOD WBC-5.5 RBC-4.32* Hgb-11.9* Hct-38.0*
MCV-88 MCH-27.5 MCHC-31.3* RDW-15.9* RDWSD-48.0* Plt ___
___ 09:42AM BLOOD Neuts-80* Lymphs-16* Monos-4* Eos-0*
Baso-0 AbsNeut-4.40 AbsLymp-0.88* AbsMono-0.22 AbsEos-0.00*
AbsBaso-0.00*
___ 09:42AM BLOOD ___ PTT-23.7* ___
___ 06:12AM BLOOD ___ 09:42AM BLOOD Glucose-235* UreaN-19 Creat-1.1 Na-136
K-4.5 Cl-97 HCO3-24 AnGap-15
___ 09:42AM BLOOD ALT-34 AST-22 LD(LDH)-320* AlkPhos-75
TotBili-0.7
___ 09:42AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0
___ 09:42AM BLOOD Ferritn-1644*
Reports
PET - No abnormal FDG uptake to suggest malignancy or explain
hemophagocytic lymphohistiocytosis.
BMBX - NORMOCELLULAR BONE MARROW WITH OVERALL CELLULARITY OF
___,
INCREASED MEGAKARYOCYTES, AND FEATURES SUGGESTIVE OF
HEMOPHAGOCYTOSIS.
Flow - No evidence of leukemia or lymphoma
Brief Hospital Course:
Mr. ___ is a ___ year-old man who presented with
splenomegaly, pancytopenia, ___, and hypotension with overall
picture most consistent with HLH. He was treated with a course
of steroids with significant clinical, symptomatic, and
laboratory improvement and is being discharged home with
outpatient hematology follow-up.
TRANSITIONAL ISSUES
===================
[ ] Should continue on dexamethasone 18mg daily until
appointment with Hematology on ___, at which point
may be tapered going forward.
[ ] Started on Bactrim SS for PJP prophylaxis, Ca/Vit D for bone
health, and omeprazole for stomach protection while on steroids.
ACUTE ISSUES
============
# Splenomegaly
# Pancytopenia, improved
# LFT abnormalities, improved
# Hemophagocytic Lymphohistiocytosis
Presented after dizziness and falling at home after recent
discharge from ___ where he underwent thorough workup for
infectious etiologies including tickborne, all of which was
negative, although ferritin and CD25 were both elevated.
Initially hypotensive requiring brief stay in ICU for
norepinephrine which was immediately discontinued. No evidence
of infection. Noted to have pancytopenia. Hematology/Oncology
was consulted and performed a bone marrow biopsy for evaluation
of possible HLH based on inflammatory markers. BM Bx returned
with features consistent with hemophagocytosis. Underwent
thorough malignancy workup with CT Torso, PET scan, SPEP, Free
K/L, and flow cytometry, all of which were negative. Started
empirically on dexamethasone per protocol, with clinical
improvement and normalization of labs. Overall diagnosis
consistent with HLH, unclear trigger. Plan for outpatient
follow-up with hematology. If any worsening of symptoms, may
need etoposide (often normal part of first-line treatment along
with steroids).
# Rib Fracture
Fell ___, noted to have R ___ rib fracture and R 12 rib
fracture on CT. Pain controlled w/ lidocaine & APAP.
CHRONIC ISSUES
==============
# GERD: omeprazole
# HLD: atorvastatin
# Code Status: Full
# Emergency Contact: Wife, ___ (___)
Agree with summary as documented above. 35 minutes spent in
discharge preparation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Baclofen 10 mg PO QHS:PRN Muscle Spasms
3. Calcium Carbonate 1500 mg PO DAILY:PRN heartburn
4. Vitamin D ___ UNIT PO DAILY
5. Magnesium Oxide 250 mg PO DAILY
6. melatonin 5 mg oral QHS:PRN insomnia
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 40 mg PO BID
9. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
10. Ranitidine 300 mg PO BID:PRN heartburn
11. Sildenafil 20 mg PO PRN sexual intercourse
Discharge Medications:
1. Dexamethasone 18 mg PO DAILY
RX *dexamethasone 6 mg 3 tablet(s) by mouth once a day Disp #*21
Tablet Refills:*0
2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY PJP Prophylaxis
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0
3. Atorvastatin 20 mg PO QPM
4. Baclofen 10 mg PO QHS:PRN Muscle Spasms
5. Calcium Carbonate 1500 mg PO DAILY:PRN heartburn
6. Magnesium Oxide 250 mg PO DAILY
7. melatonin 5 mg oral QHS:PRN insomnia
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 40 mg PO BID
10. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
11. Sildenafil 20 mg PO PRN sexual intercourse
12. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: HLH
Secondary Diagnosis:
-HLD
-BPH
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 the ___
___.
Why did I come to the hospital?
- You were confused and had several falls after having low blood
pressure
What happened while I was in the hospital?
- We did a workup to try and determine what the cause of your
symptoms were.
- We did a bone marrow biopsy which showed features suggestive
of hemophagocytic lymphohistiocytosis (HLH), a rare disorder of
macrophages.
- We looked for any possible cause of triggering this disease
(HLH), but did not find any evidence of clear infection,
autoimmune disease, or cancer.
- We started you on steroids, which are a common part of the
treatment for HLH.
- We set you up to see Dr. ___ our hematology team in
clinic.
What should I do once I leave the hospital?
- Take your medications as prescribed and follow up with your
doctor appointments as listed below.
- We started you on a medicine to prevent a type of pneumonia
which can be more likely for patients on steroids.
- We started you on a medicine to protect your stomach from the
steroids, as well as calcium and vitamin D to prevent bone loss.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19854867-DS-21
| 19,854,867 | 26,364,402 |
DS
| 21 |
2158-06-20 00:00:00
|
2158-06-21 17:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
doxycycline
Attending: ___.
Major Surgical or Invasive Procedure:
Bone marrow biopsy (___)
attach
Pertinent Results:
ADMISSION LABS:
=============
___ 02:40PM BLOOD WBC-14.6* RBC-5.08 Hgb-14.8 Hct-44.1
MCV-87 MCH-29.1 MCHC-33.6 RDW-20.6* RDWSD-62.4* Plt Ct-37*
___ 02:40PM BLOOD Neuts-58 Bands-2 ___ Monos-4* Eos-1
___ Metas-1* NRBC-0.2* Other-1* AbsNeut-8.76* AbsLymp-4.82*
AbsMono-0.58 AbsEos-0.15 AbsBaso-0.00*
___ 02:40PM BLOOD Plt Smr-VERY LOW* Plt Ct-37*
___ 04:31PM BLOOD ___ PTT-38.3* ___
___ 04:31PM BLOOD ___ 04:31PM BLOOD Glucose-96 UreaN-28* Creat-1.4* Na-129*
K-5.6* Cl-88* HCO3-20* AnGap-21*
___ 04:31PM BLOOD Lipase-101*
___ 06:30PM BLOOD cTropnT-0.03*
___ 11:56PM BLOOD cTropnT-<0.01
___ 02:40PM BLOOD Albumin-3.0* Calcium-8.8
___ 04:31PM BLOOD Albumin-3.1* Calcium-8.7 Phos-4.0 Mg-1.8
___ 02:40PM BLOOD Ferritn-4434*
___ 04:31PM BLOOD Hapto-264* Ferritn-4710*
___ 02:40PM BLOOD Triglyc-410*
___ 02:40PM BLOOD CRP-29.9*
___ 01:53PM BLOOD ___ pO2-59* pCO2-34* pH-7.39
calTCO2-21 Base XS--3
___ 04:40PM BLOOD Lactate-4.5*
___ 07:44PM BLOOD Lactate-3.9*
___ 12:02AM BLOOD Lactate-3.0*
IMAGING
=======
___ CXR Portable
The heart is normal in size.The mediastinum is grossly
unremarkable.There is
mild left lung basilar atelectasis.There is no
consolidation.There is no
pleural effusionor pneumothorax.The previously described right
fifth, sixth
and twelfth ribs fracture is not well visualized at the current
study.There is
no degenerative change of the thoracic spine.
IMPRESSION:
No acute cardiopulmonary pathology. No evidence of pneumonia.
___ CT Head
There is no evidence of infarction, hemorrhage, edema, or mass
effect. The ventricles and sulci are mildly prominent
consistent with mild involutional
changes. No acute fracture is seen. The paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. No acute
intracranial abnormality.
___ MRI HEAD W+W/OUT CON
1. No acute intracranial abnormalities identified. No evidence
intracranial
enhancement.
2. Hypoenhancing pituitary lesion, incompletely characterized on
this exam
however may be secondary to a microadenoma versus pituitary
cyst. Dedicated
pituitary MRI may be helpful for further characterization.
Recommendations: Dedicated pituitary MRI may be helpful for
further characterization of the pituitary lesion.
___ FDG TUMOR IMAGING PET
No abnormal FDG uptake to suggest malignancy. 2. Moderate
bilateral pleural effusions.
___ TTE
There is normal left ventricular wall thickness with a normal
cavity size. There is normal regional and global left
ventricular systolic function. The visually estimated left
ventricular ejection fraction is >=70%. There is no resting left
ventricular outflow tract gradient. No ventricular septal defect
is seen. Normal right ventricular cavity size with normal free
wall motion. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. There is trace aortic
regurgitation. The mitral valve leaflets are mildly thickened
with
no mitral valve prolapse. There is an eccentric, inferolateral
directed jet of mild to moderate [___] mitral regurgitation.
Due to acoustic shadowing, the severity of mitral regurgitation
could be UNDERestimated. Due to the Coanda effect, the severity
of mitral regurgitation could be UNDERestimated. The pulmonic
valve
leaflets are normal. The tricuspid valve leaflets appear
structurally normal. There is moderate [2+] tricuspid
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion. IMPRESSION:
Preserved biventricular systolic function. Mild to moderate
mitral regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary hypertension.
___ L-SPINE (AP & LAT)
Mild degenerative changes of the lumbar spine.
___ CT CHEST W/CONTRAST
1. Small left and trace right nonhemorrhagic pleural effusions.
2. Mild enlargement of the main pulmonary artery is suggestive
of underlying
pulmonary hypertension.
3. No evidence of lymphadenopathy in the chest.
4. Redemonstration of a moderate-sized hiatal hernia.
5. Please see separately submitted Abdomen and Pelvis CT report
for
subdiaphragmatic findings.
___ CTAP W/CONTRAST
1. Small left and trace right nonhemorrhagic pleural effusions.
2. Mild enlargement of the main pulmonary artery is suggestive
of underlying
pulmonary hypertension.
3. No evidence of lymphadenopathy in the chest.
4. Redemonstration of a moderate-sized hiatal hernia.
5. Please see separately submitted Abdomen and Pelvis CT report
for
subdiaphragmatic findings.
PERTINENT LABS:
=============
___ 12:46PM BLOOD G6PD-NORMAL
___ 04:29AM BLOOD FacVIII-269*
___ 02:20PM BLOOD FacXIII-ABNORMAL
___ 04:29AM BLOOD VWF AG-674* VWF Act->200
___ 02:40PM BLOOD Triglyc-410*
___ 07:30PM BLOOD HIV Ab-NEG
___ 03:07PM BLOOD b2micro-3.0*
___ 02:40PM BLOOD CRP-29.9*
___ 06:00AM BLOOD 25VitD-22*
___ 07:30PM BLOOD CMV VL-2.0*
___ 04:15PM BLOOD CMV VL-DETECTED,
___ 05:43AM BLOOD CMV VL-1.8*
DISCHARGE LABS:
==============
___ 12:00AM BLOOD WBC-16.2* RBC-2.90* Hgb-8.7* Hct-27.4*
MCV-95 MCH-30.0 MCHC-31.8* RDW-19.4* RDWSD-62.0* Plt ___
___ 12:00AM BLOOD Neuts-72* Bands-7* Lymphs-11* Monos-3*
Eos-0* ___ Metas-5* Myelos-2* NRBC-0.5* AbsNeut-12.80*
AbsLymp-1.78 AbsMono-0.49 AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD ___ PTT-22.7* ___
___ 12:00AM BLOOD ___ 12:00AM BLOOD Ret Aut-2.7* Abs Ret-0.08
___ 12:00AM BLOOD Glucose-128* UreaN-37* Creat-1.0 Na-134*
K-5.5* Cl-96 HCO3-24 AnGap-14
___ 12:00AM BLOOD ALT-72* AST-55* LD(LDH)-796* AlkPhos-150*
TotBili-0.6
___ 12:00AM BLOOD Albumin-3.5 Calcium-8.5 Phos-4.8* Mg-2.1
UricAcd-3.8
___ 12:00AM BLOOD ___
MICROBIOLOGY:
============
___ BCx neg x2
___ UCx neg
___ Rapid resp viral screen & culture negative
___ BCx neg x2
___ BCx neg x2
Brief Hospital Course:
TRANSITIONAL ISSUES
===================
[ ] per ___ 94 protocol the patient will have to decrease his
dose of dexamethasone by half (9mg -> ~4mg), patient will have
to decrease his dose of insulin by half as well during that time
[ ] patient will likely need a new prescription of prednisone
once his dose is decreased
BRIEF MICU CORUSE
================
___ year old man with HLD, recently diagnosed with HLH of unknown
trigger (___ ___ treated with dexamethasone. He improved
quickly and was on a steroid taper as per the ___ 94 protocol.
On ___ he presented to his clinic visit for follow-up and was
noted to have malaise and confusion. He was found to have
thrombocytopenia, and elevated inflammatory markers c/f HLH
flare. He was given IV 140 mg methylpred on ___ and first dose
of etoposide overnight ___ and admitted to the FICU. He
had a new O2 requirement but was stable on 4L O2 via nasal
cannula. He had Q6 DIC labs monitored. His mental status and O2
requirement improved so he was transferred to the oncology
service.
BRIEF ___ UNIT COURSE
===================
Mr. ___ is a ___ year old man with hyperlipidemia, recently
diagnosed with HLH (___ ___ treated with dexamethasone who
presented to the ED from clinic ___ due to HLH flare and
started HLH 94 protocol after a brief stay in the ICU (as above)
with no convincing evidence of hematologic malignancy.
ACTIVE ISSUES
=============
#HLH
#Thrombocytopenia
#c/f lymphoma
Pt was diagnosed with HLH on ___ ___. Initially responded
to high dose steroids and transitioned to a taper, later
presenting to clinic in ___ w/worsening
thrombocytopenia, markedly
elevated LDH, high triclycerides, elevated ferritin, CRP and
coags concerning for flare/recurrence of HLH with unclear
trigger and was initiated on etoposide per ___-94 protocol. He
underwent extensive lymphoma work up (MRI head/spine w/out
abnormality; PET ___ without localizing lesion; EBV, HHV8, HIV
negative; negative skin biopsy of pathologic bruises; CT torso
on ___ without LAD and shows persistent splenomegaly; most
recent flow cytometry results without without signs of
hematologic malignancy) without convincing evidence for a
hematologic malignancy. Dexamethasone decreased from 18mg since
___, on 9 mg dexamethasone stably elevated serum ferritin and
LDH. Patient at this time would prefer to continue with ___ 94
protocol in light of no concrete evidence of underlying
lymphoma. Patient declined LP and IT MTX at start of week 3 of
protocol. Received neupogen for profound cytopenias iso
etoposide, counts recovering at discharge. Patient obtained port
___ before discharge for outpatient chemotherapy. Patient
discharged on acyclovir, atovaquone, and fluconazole for
prophylaxis.
- ___ 94 protocol (dex and etoposide w/out IT HD per pt) for 8
weeks; week 3 resumed ___
- week ___: 9mg dex daily with one dose of etoposide ___
- week ___: 9mg dex daily with one dose of etoposide ___
#Steroid-induced diabetes
The patient was on high doses of dexamethasone (___) for >1
month and presented with persistently elevated blood glucose
levels. Patient was seen by ___ service and started on
insulin, down-titrating as needed with decreasing doses of
dexamethasone. ___ service and primary team set up an
appointment for him for next week but the patient declined the
appointment. It is imperative for the patient to have education
regarding decreasing his dose of insulin by his ___, initiated
by provider decreasing dose of dexamethasone. Tapering down
dexamethasone dose to half the current dose will significally
affect his insulin regimen. ___ recommends decreasing his
dose by half from 6 units three times a day before large meals
to 3 units 3 times a day before meals.
#Elevated ALT, AST, LDH
Patient had markedly elevated AST and LDH, with only mildly
elevated ALT 73 and normal bilirubin and alk phos. Likely
consistent with hemophagocytosis in the setting of HLH. No
evidence of hepatomegaly on exam. AST and LDH eventually
downtrended with high dose steroids. Home atorvastatin 10mg was
held in setting of elevated LFTs and
likely ___ liver injury in setting of HLH.
CHRONIC ISSUES
=======================
# Volume overload (resolved)
Patient presented with significant abdominal distention with
bilateral lower extremity pitting edema up to mid thighs.
Likely secondary to combination of high-dose steroids and
current continuous fluids needed for proper volume resuscitation
in setting of HLH. Was diuresed and edema resolved with tapering
of steroids.
# Ecchymoses (resolving)
# potential coagulopathy
Patient with new non-traumatic ecchymoses over right upper
extremity left upper extremity and hips bilaterally. Most
notable was a deep dark purple bruise extending from sacroiliac
region to lateral mid thigh. Findings consistent with
pathological bruising in setting of a normal ___, short PTT,
and low fibrinogen. Platelets remained low but unlikely
that this was secondary to a platelet problem due to pattern of
bruising. There was concern for intravascular lymphoma in this
patient with circulating cells suspicious for lymphoma and large
ecchymosis, however skin biopsies from pathologic bruising did
not reveal neoplastic etiology. Bruises eventually resolved by
discharge.
#AMS/#Toxic Metabolic Encephalopathy (resolved)
Presenting from clinic with worsening confusion, had difficulty
spelling WORLD backwards outpatient. Per last clinic note by Dr.
___, pt at is extremely high functioning often emailing him
literature on HLH. CT Head showed no abnormalities including
signs of infarct/hemorrhage. MRI without gross abnormality, only
small finding in pituitary concerning for likely pituitary cyst.
No abnormal findings on PET-CT.
#GERD
-home omeprazole 20mg increased to BID
#HLD
-held home atorvastatin iso transaminitis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Calcium Carbonate 500 mg PO Frequency is Unknown
3. Dexamethasone 9 mg PO DAILY
4. melatonin 1 mg oral QHS:PRN
5. Omeprazole 20 mg PO DAILY
6. TraZODone 50 mg PO QHS:PRN insomnia
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet by mouth twice a day Disp #*60
Tablet Refills:*0
2. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 ml by mouth once a day Refills:*0
3. Fluconazole 400 mg PO Q24H
Take daily but not the day before etoposide, the day of
etoposide, and the day after etoposide.
4. Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro [Humalog U-100 Insulin] 100 unit/mL AS DIR 6
Units before BRKFST, LNCH, and DINR Disp #*1 Vial Refills:*1
5. Omeprazole 20 mg PO BID
6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Take as needed for pain from the port
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
7. Dexamethasone 9 mg PO DAILY
RX *dexamethasone 6 mg 1.5 tablet(s) by mouth once a day Disp
#*60 Tablet Refills:*0
8. melatonin 1 mg oral QHS:PRN
RX *melatonin 1 mg 1 tablet by mouth at bedtime Disp #*30 Tablet
Refills:*0
9. TraZODone 50 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 1 tablet by mouth at bedtime Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
___
SECONDARY DIAGNOSIS
===================
Steroid induced 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 taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- you were admitted for an ___ flare
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- you were continued on the ___ 94 protocol for your condition
while undergoing an extensive lymphoma work up which did not
yield a definite diagnosis of lymphoma
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19855099-DS-13
| 19,855,099 | 23,924,601 |
DS
| 13 |
2169-03-15 00:00:00
|
2169-03-15 16:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Augmentin / heparin
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___ - CABGx2/MV Replacement(26mm ___ Valve)
___ - Cardiac catheterization and placement of an
Intra-aortic balloon pump
History of Present Illness:
Ms ___ is a ___ with h/o type 1 diabetes, Charcot foot c/b
R ulcer, orthostatic hypotension ___ autonomic neuropathy, HTN,
HLD, gastroparesis, who presents SOB and and hypotensive. She
reports that this AM, she awoke feeling SOB suddenly, w/ some
associated back pain. Then called ambulance and was brought to
hospital. Onset was sudden. She is currently on BiPAP and SOB so
further history is deferred.
Of note, she was admitted at ___ from ___ for R foot
exostectomy with excision and closure of plantar foot ulcer.
Cultures grew group B strep at that time. She has previously
grown group B strep, corynebacterium, pan-sensitive pseudomonas,
and MSSA from this ulcer. She was given a course of abx though
this is not specified in the d/c summary. She was seen by
podiatry on ___, who noted she reported nausea, vomiting, mild
fevers and chills since a few days prior. Exam did not probe to
bone. Believe she was given clindamycin and cipro. She also
called HCA on ___ w/ complaint of N/V and poor PO intake for 5
days.
In the ED, initial vitals were: 96.4 84 ___ 100% ra
(recorded). At some point in ED was in the ___ so placed on
BiPAP. An EKG showed non-specific TWI's. CXR was significant for
pulmonary edema. Labs were significant for trop 0.07, Cr 1.8,
WBC 17. Pressure later dropped to 80's, started on levophed
initially, then later dopamine. She was given nebulizers,
morphine, and zosyn as well (some concern for a heel infection).
A TTE was performed late in the ED course, and was signicant for
severe mitral regurgitation, with some evidence of anterior
leaflet flail and papillary muscle rupture.
Upon presentation to the CCU, she is on BiPAP and SOB, and
appears ill. Able to speak and confirm important aspects of
medical history, and consent for procedures.
A plan was put in place in conjunction w/ CCU team,
Interventional Cards, CT surgery, and anesthesia to intubate,
perform R and L heart, place IABP, and then potentially perform
TEE, then consider moving to the OR for MVR.
Past Medical History:
DM Type 1 - followed by Dr. ___ at ___, c/b retinopathy,
nephropathy, neuropathy, and gastroparesis
Severe orthostatic hypotension from autonomic neuropathy
Endometriosis
Gastroparesis
Hyperlipidemia
Hypertension
Social History:
___
Family History:
+DM, Stroke, HTN
Physical Exam:
Admission exam
97.7 96 110/64 20 99% on BiPAP
General: appears dyspnic, unable to speak in full sentances
HEENT: EOMI, PERRL, MMM
CV: RRR, ___ systolic murmur best heard at ___
Lungs: bilateral rales, speaking in short sentances
Abdomen: BS+, soft, non-tender, no HSM
GU: foley in place
Ext: warm, well perfused, no edema. R midfoot w/ ulcer w/ yellow
base, foul smell though no erythema and no frank pus. L heel w/
similar appearance.
Neuro: A+Ox3, conversational but speaking in short sentances,
CN2-12 grossly intact, strength ___ bilaterally
Skin: lower extremity ulcers per above, otherwise no rashes or
lesions
PULSES: palpable in b/l DP/TP position
Discharge Physical Exam
Pulse: 70, NSR Resp: 14 O2 sat:96% on 3L NC Temp: 98.6F
B/P: 143/58
General:WD female who appears older than stated age, lying in
bed, NAD
Skin: Dry [x] intact:multiple healing skin tears on extremities
bilat [x]
HEENT: R eye opaque, L pupil brisk; NGT in place
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear with decreased bases bilaterally [x],
tunneled HD line c/d/i
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [s], well-perfused [x] Edema: +1 gen anasarca
[x], RUE ___ site c/d/i
Neuro: Grossly intact [x]
Pulses:
DP Right: 1 Left: 1
___ Right: 1 Left: 1
Radial Right: 1 Left: 1
Sternum: stable, well healing incision, c/d/i
Pertinent Results:
Cardiac Catheterization ___:
- ESTIMATED blood loss: <40 cc
- Hemodynamics (see above): Severely elevated left- and right-
sided filling pressures. Moderately elevated pulmonary
arterial pressure. Decreased cardiac output and cardiac
index.
- Coronary angiography: Co-dominant
LMCA: Patent
LAD: 90% focal mid vessel followed by long 50-60%. The
third Diag (large) has ostial 80%.
LCX: Co-dominant. Patent with mild luminal irregularities.
RCA: Smaller vessel but co-dominant. Diffusely diseased.
The distal has tubular 90%. The RPDA has mild luminal
irregularities.
Interventional details
- The RCFA was accessed under US guidance. Aortography showed
patent abdominal aorta and iliofemoral system. A 30 cm IABP was
placed under fluoroscopic guidance. Balloon functioning properly
1:1. The balloon secured in place.
.
Intra-op TEE ___
Conclusions
Pre-CPB:
A left atrial appendage thrombus cannot be excluded.
No atrial septal defect is seen by 2D or color Doppler. The
septum bows to the left indicating very high right sided
pressures.
Overall left ventricular systolic function is low normal (LVEF
50-55%), overestimated because of the MR.
___ is severe global free wall hypokinesis.
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque..
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation.
Severe (4+) mitral regurgitation is seen. There is a ruptured
papillary muscle attached to the anterior leaflet which
prolapses into the atrium and causes a posteriorly directed jet.
There is no pericardial effusion.
Post CPB:
The patient is AV-Paced, on infusions of milrinone and
epinephrine.
There is a prosthetic valve in the mitral position. No leak, no
MR. ___ mean gradient = 6 mmHg.
The LV is mildly depressed with septal hypokinesis.
Improved RV systolic fxn. It is now mildly to moderately
depressed.
No AI. Aorta intact.
The tip of the SGC is at the PA bifurcation.
The IABP is well placed just distal to the left subclavian
artery.
.
LABS:
___ 03:00AM BLOOD WBC-13.1* RBC-2.65* Hgb-8.1* Hct-26.9*
MCV-102* MCH-30.4 MCHC-29.9* RDW-18.9* Plt ___
___ 12:00AM BLOOD WBC-14.6* RBC-2.88* Hgb-8.4* Hct-29.2*
MCV-101* MCH-29.3 MCHC-28.9* RDW-20.1* Plt Ct-98*#
___ 03:00AM BLOOD ___ PTT-26.4 ___
___ 02:22AM BLOOD ___ 10:32PM BLOOD Ret Aut-6.5*
___ 03:00AM BLOOD Glucose-208* UreaN-37* Creat-3.8*# Na-135
K-3.8 Cl-97 HCO3-28 AnGap-14
___ 12:00AM BLOOD Glucose-241* UreaN-20 Creat-2.5*# Na-136
K-4.0 Cl-97 HCO3-28 AnGap-15
___ 04:19AM BLOOD ALT-5 AST-36 AlkPhos-151* Amylase-22
TotBili-1.5
___ 03:14AM BLOOD ALT-6 AST-70* AlkPhos-160* TotBili-1.1
___ 12:00PM BLOOD CK-MB-2 ___
___ 03:00AM BLOOD Albumin-3.2* Calcium-8.4 Phos-4.2 Mg-2.3
___ 06:30PM BLOOD HCV Ab-NEGATIVE
___ 01:54PM BLOOD SEROTONIN RELEASE ASSAY-NEGATIVE
Brief Hospital Course:
Ms ___ is a ___ year old female with history of type 1
diabetes, Charcot foot complicated by ulcers, orthostatic
hypotension ___ autonomic neuropathy, HTN, HLD, gastroparesis,
who presents SOB and and hypotensive. Found on TTE to have flail
anterior mitral valve and acute mitral regurgitation. She was
intubated and diuresis was started. She was taken to the
catheterization lab which revealed two vessel coronary artery
disease and severe mitral regurgitation. An intra-aortic balloon
pump was placed. As she was in cardiogenic shock, her pressor
requirement was increasing on levophed and dobutamine. The
cardiac surgery service was consulted and it was decided to take
her to the operating room. She was worked-up in the usual
manner. Her creatinine was noted to be 1.8 which was her
baseline. Her white blood cell count was elevated at 17 and thus
she was cultured and the podiatry service was consulted to
assist with the management of her foot ulcers. On ___, Ms.
___ was taken to the operating room where she undewent
emergent replacment of her mitral valve and coronary artery
bypass grafting to two vessels. Please see operative note for
details. Postoperatively she was taken to the intensive care
unit for monitoring. On postoperative day one, her balloon pump
was removed without issue. Over the ensueing days the milrinone,
levo and vasopressin were weaned with stable hemodynamics.
___ was consulted for management of her diabetes. She was
slow to wake resulting in prolonged intubation. All narcotics
were d/c'd. Aggressive diuresis was initiated with a lasix drip.
She failed to respond to diuresis with rising BUN/Creat and
devloped ___. Renal was consulted and she ultimately required
CVVHD and the HD. Post-op course was also complicated by
leukocytosis with WBC as high as 40,000. She was treated with
broad spectrum antibiotics and the only positive cultures were
pseudomonas in her heels and yeast in the urine and sputum which
was treated with fluconazole. She was ultimately extubated on
POD# 13 but was very weak and deconditoned. She required a
dobhoff tube for enteral feeds, which was placed in a
post-pyloric position. She failed her speech and swallow and was
made strict NPO on ___ and no improvement on repeat evaluation
___. She should be reassessed at rehab as she regains
strength. Post-operatively she had variable heart rhythm-second
degree mobitz type I, Junctional, Sinus brady, afib. EP was
consulted and felt a pacer was not needed and her rhythm
ultimately returned to sinus. Her post-op course was also
complicated by thrombocytopenia. She was HIT positive and Heme
was consulted. She was started on argatroban and then her SRA
was negative (sent ___ and her argatroban was stopped
(___). Coumadin was started for Afib prophylaxis on ___.
Overall she remains deconditioned but continues to improve and
will require rehab to regain her strength and ultimately
transiton home. She remains on HD and it is yet to be determined
if her renal function will return. Her leukocytosis is resolving
off antibiotics and the infectious disease service signed off.
By post-operative day ___ she was ready for discharge to
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atorvastatin 80 mg PO DAILY
3. Glargine 15 Units Breakfast
Glargine 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Clindamycin 150 mg PO Q6H
5. Furosemide 40 mg PO DAILY
6. TraMADOL (Ultram) 50-100 mg PO Q4H:PRN pain
7. Omeprazole 40 mg PO DAILY
8. Ciprofloxacin HCl 500 mg PO Q12H
9. Aspirin 81 mg PO DAILY
10. Cetirizine 10 mg oral daily
11. Cyanocobalamin 500 mcg PO DAILY
12. Vitamin D 50,000 UNIT PO TWICE MONTHLY
Discharge Medications:
1. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
5. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
6. Docusate Sodium 100 mg PO BID
7. Warfarin 3 mg PO ONCE Duration: 1 Dose
titrate for goal INR of ___ for atrial fibrillation
8. Cyanocobalamin 500 mcg PO DAILY
9. Vitamin D 50,000 UNIT PO TWICE MONTHLY
10. DiphenhydrAMINE 12.5 mg PO Q6H:PRN itching
11. Collagenase Ointment 1 Appl TP BID
12. Sarna Lotion 1 Appl TP QID:PRN itch
13. Omeprazole 40 mg PO DAILY
14. Cetirizine 10 mg oral daily
15. Neomycin-Polymyxin-Bacitracin 1 Appl TP ASDIR
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Coronary artery disease, ruptured papillary muscle, DM Type 1 -
followed by Dr. ___ at ___, c/b retinopathy, nephropathy,
neuropathy, and gastroparesis, Severe orthostatic hypotension
from autonomic neuropathy, Endometriosis, Gastroparesis,
Hyperlipidemia, Hypertension
Post-op AFIB
Post-op acute on chronic renal failure, now requiring HD
Discharge Condition:
Alert and oriented x3 nonfocal
Deconditioned
Incisional pain managed with prn tylenol and ultram
R arm PICC and R HD subclavian catheter
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage.
The left heel is now with 10% red tissue and the remaining
slough
is debriding and moist. There are no signs of infection.
The right foot incision is healing with less depth than
previously - approx 0.6cm ( from 1 cm previously ). There are no
signs of infection.
Edema 1+
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns ___
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Labs: ___ for Coumadin indication afib
Goal INR 2.0-3.0
First draw ___ then every mon, wed and ___ until stable
Results to be managed by rehab medical staff and plaese arrange
Followup Instructions:
___
|
19855099-DS-14
| 19,855,099 | 22,841,434 |
DS
| 14 |
2169-03-27 00:00:00
|
2169-03-27 18:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Augmentin / heparin
Attending: ___.
Chief Complaint:
Vomiting
Major Surgical or Invasive Procedure:
Hemodialysis ___
History of Present Illness:
___ with h/o type 1 diabetes, gastroparesis, CAD s/p recent CABG
and MVR on ___, who presents with 2 episodes of emesis at
rehab, which were concerning for coffee ground emesis. She was
recently discharged after a complicated hospital course during
which she underwent CABG and urgent MVR. Her post-op course was
complicated by acute on chronic renal failure requiring dialysis
as well as CHF. She was doing well at rehab, when this morning
she had 2 episodes of brown emesis. The patient states that she
occasionally has episodes of vomiting related to her
gastroparesis. She descirbes the vomit as brown and no different
than the usual appearance of her vomit. She has had no furthur
episodes of vomiting. She currently denies abdominal pain,
nausea, chest pain, shortness of breath, fevers/chills.
In the ED, initial vitals: 99.1 100 135/77 22 100% 2LNC. Stool
was guaiac negative. Labs were notable for HCT of 27, which is
at her baseline from recent discharge. Sodium was 127 and Cr
2.7. She last had dialysis 1 day prior to admission.
On transfer, vitals were: 99.2 86 129/57 20 100%.
Past Medical History:
DM Type 1 - followed by Dr. ___ at ___, c/b retinopathy,
nephropathy, neuropathy, and gastroparesis
CAD s/p CABG ___
Acute mitral regurgitation s/p MVR w/ bioprosthetic valve on
___
Severe orthostatic hypotension from autonomic neuropathy
Endometriosis
Gastroparesis
Hyperlipidemia
Hypertension
Social History:
___
Family History:
+DM, Stroke, HTN
Physical Exam:
Admission:
Vitals- 98.1 88 141/61 15 98%2L
General- chronically ill-appearing in no acute distress
HEENT- blind in right eye. EOMI. moist MMs
Neck- supple. JVP not elevated
CV- RRR. ___ holosystolic murmur heard best at LUSB w/o
radiation. Healing sternotomy scar
Lungs- bibasilar crackles
Abdomen- obese, soft, NT/ND, +BS
Ext- 1+ pitting edema b/l LEs to mid shins
Neuro- no focal deficits. a&ox3
Discharge:
Vitals T 98.6 HR 73 BP 124/60 RR 14 SpO2 100%/2L
General- chronically ill-appearing in no acute distress
HEENT- blind in right eye. EOMI. moist MMs
Neck- supple. JVP not elevated
CV- RRR. ___ holosystolic murmur heard best at LUSB w/o
radiation. Healing sternotomy scar
Lungs- bibasilar crackles
Abdomen- obese, soft, NT/ND, +BS
Ext- 1+ pitting edema b/l LEs to mid shins
Neuro- no focal deficits. a&ox3
Pertinent Results:
Admission labs:
___ 07:00PM BLOOD WBC-11.8* RBC-2.69* Hgb-7.7* Hct-27.0*
MCV-101* MCH-28.9 MCHC-28.7* RDW-17.0* Plt ___
___ 04:38AM BLOOD WBC-11.6* RBC-2.53* Hgb-7.4* Hct-25.2*
MCV-100* MCH-29.3 MCHC-29.3* RDW-16.9* Plt ___
___ 04:12AM BLOOD WBC-10.7 RBC-2.56* Hgb-7.6* Hct-25.7*
MCV-100* MCH-29.7 MCHC-29.6* RDW-16.9* Plt ___
___ 07:00PM BLOOD ___ PTT-38.6* ___
___ 04:12AM BLOOD ___ PTT-39.6* ___
___ 07:00PM BLOOD Glucose-308* UreaN-37* Creat-2.7*#
Na-127* K-3.9 Cl-93* HCO3-23 AnGap-15
___ 04:38AM BLOOD Glucose-118* UreaN-40* Creat-3.1* Na-131*
K-3.7 Cl-97 HCO3-22 AnGap-16
___ 04:12AM BLOOD Glucose-210* UreaN-48* Creat-3.3* Na-127*
K-4.0 Cl-94* HCO3-21* AnGap-16
___ 07:00PM BLOOD ALT-33 AST-56* AlkPhos-343* TotBili-0.6
___ 04:38AM BLOOD ALT-27 AST-43* LD(LDH)-324* CK(CPK)-18*
AlkPhos-311* TotBili-0.5
___ 07:00PM BLOOD cTropnT-0.26* ___
___ 12:18AM BLOOD CK-MB-3 cTropnT-0.25*
___ 04:38AM BLOOD CK-MB-3 cTropnT-0.27*
___ 04:38AM BLOOD ___ Folate-19.2
Discharge labs:
___ 04:12AM BLOOD WBC-10.7 RBC-2.56* Hgb-7.6* Hct-25.7*
MCV-100* MCH-29.7 MCHC-29.6* RDW-16.9* Plt ___
___ 04:12AM BLOOD ___ PTT-39.6* ___
___ 04:12AM BLOOD Glucose-210* UreaN-48* Creat-3.3* Na-127*
K-4.0 Cl-94* HCO3-21* AnGap-16
___ 04:12AM BLOOD Calcium-8.4 Phos-5.0*# Mg-2.3
=========================================================
IMAGING:
CXR ___:
Interval replacement of right IJ central venous catheter with a
right subclavian dialysis catheter. Persistent cardiomegaly,
pulmonary edema, pleural effusions, left greater than right.
Brief Hospital Course:
___ w/ h/o T1DM c/b gastroparesis and recent CABG / MVR presents
from rehab with two episodes of vomiting, which was concerning
for "coffee-ground" emesis.
#Vomiting/gastroparesis: Patient had 2 episodes of dark colored
vomiting prior to admission, which patient described as
consistent with prior episodes of gastroparesis. Her HCT has
remained at baseline and she had no further vomiting or coffee
ground emesis. She was never hemodynamically unstable. GI was
consulted and felt there was no concern for significant GI
bleed, no endoscopy was performed. ___ have had small
___ tear or irritation from her NG tube as the cause
for dark appearance of her vomit. She was restarted on tube
feeds and was discharged back to rehab. Started on Zofran PRN
for nausea/vomiting.
#CAD s/p recent CABG: Patient presented with elevated troponin
to 0.26. She has no signs or symptoms of ACS. Her EKG shows no
acute ischemic changes. Repeat troponin was 0.25 and MB was 3.
TnT likely elevated in the setting of her renal failure, MB was
normal and this was not felt to be ACS. She was continued on her
home statin, aspirin and was started on metoprolol given recent
CABG.
#Chronic CHF s/p recent bioprosthetic MVR: No evidence of acute
exacerbation. Volume status managed by HD. As above, she was
started on metoprolol.
#T1DM: Continued on home glargine and was placed on sliding
scale insulin.
#CKD: Currently on TuThSa dialysis after her CABG. Last received
HD ___.
#Code status this admission: Full
#Emergency contact: ___ (son) ___
#Transitional issues:
-Determine need for ongoing anticoagulation, developed Afib
post-op from CABG/MVR, has follow-up with cardiac surgery and
cardiology
-Monitor for further dark colored emesis
-Hold warfarin on ___ given INR of 3.2
-Continue to manage vomiting with zofran as needed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
5. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
6. Docusate Sodium 100 mg PO BID
7. Warfarin 3 mg PO ONCE
8. Cyanocobalamin 500 mcg PO DAILY
9. Vitamin D 50,000 UNIT PO TWICE MONTHLY
10. DiphenhydrAMINE 12.5 mg PO Q6H:PRN itching
11. Collagenase Ointment 1 Appl TP BID
12. Sarna Lotion 1 Appl TP QID:PRN itch
13. Omeprazole 40 mg PO DAILY
14. Cetirizine 10 mg oral daily
15. Neomycin-Polymyxin-Bacitracin 1 Appl TP ASDIR
Discharge Medications:
1. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Collagenase Ointment 1 Appl TP BID
5. Cyanocobalamin 500 mcg PO DAILY
6. DiphenhydrAMINE 12.5 mg PO Q6H:PRN itching
7. Docusate Sodium 100 mg PO BID
8. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
9. Neomycin-Polymyxin-Bacitracin 1 Appl TP ASDIR
10. Sarna Lotion 1 Appl TP QID:PRN itch
11. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
12. Warfarin 3 mg PO DAILY16
13. Cetirizine 10 mg oral daily
14. Omeprazole 40 mg PO DAILY
15. Vitamin D 50,000 UNIT PO TWICE MONTHLY
16. Metoprolol Succinate XL 25 mg PO DAILY
17. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Gastroparesis, Vomitting
Secondary Diagnosis:
End Stage Renal Disease on Hemodialysis
Chronic anemia from ESRD
chronic CHF s/p recent MVR, on anticoagulation
CAD s/p recent CABG
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 Ms. ___,
It was a pleasure caring for you at ___
___. You were sent in from ___ with
concerns for bleeding from your upper gastrointestinal tract
(esophagus or stomach). You were monitored in the Intensive Care
Unit and your blood counts were stable without evidence or
bleeding or further vomitting. You are being discharged back to
your rehab for further care.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19855099-DS-15
| 19,855,099 | 21,042,269 |
DS
| 15 |
2169-05-16 00:00:00
|
2169-05-17 11:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Augmentin / heparin
Attending: ___
Chief Complaint:
fevers and leukocytosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a past medical history notable for of
Type I diabetes mellitus, recent CABG and MVR in ___,
recent acute on chronic renal failure requiring dialysis who
presented from rehab with worsening leukocytosis (18 on
___ at rehab) and fevers. The patient states that she she
is also being treated for pneumonia, UTI and right ear infection
with ertapenum. She complains of cough and wheezing however her
SOB has improved and she is no longer requiring oxygen. The
patient injured her knee with physical therapy on ___ and
continues to experience knee pain. She has not orthopedic
hardware.She has multiple foot ulcers as well as a right leg
ulcer which are painless. She denies headache, vision changes,
chest pain, nausea, vomiting, diarrhea and lower extremity
edema.
Regarding her recent renal failure, the patient has not needed
dialysis in >3 weeks. She is a patient of Dr. ___
last creatinine at rehab was 1.4 on ___. Her last INR was
2.4 on ___. She takes warfarin for pAF.
In the ED initial vitals signs were: 97.2 69 119/52 16 93%.
Glucose was found to be 38. The patient was given 1 amp D50 and
improved to 150s. Labs were significant for WBC 16.6, H/H
9.3/30.5, plt 413, Na 141, K 4.1, Cl 102, HCO3 24, BUN 35, Cr
1.6, glucose 118, AG 19 and lactate 1.2. Imaging significant for
CXR with cardiomegaly and bibasilar consolidations. Knee XR with
moderate to large suprapatellar joint effusion and extensive
vascular
calcifications are seen.
The ___ rehab facility (Presentation Rehab) was contacted
in the ED regarding recent cultures. The rehab reported a UA
growing an ESBL. Sensitivities: augmentin 8, imipenum 0.25,
pip-tazo 8, bactrim 20.
On the floor the patient was found to have a BG of 58. She was
given apple juice w/ relief of symptoms. She denied significant
pain. She has not SOB/cough.
Review of Systems:
(+)
(-) 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:
DM Type 1 c/b retinopathy, nephropathy, neuropathy, and
gastroparesis
CAD s/p CABG ___
Acute mitral regurgitation s/p MVR w/ biopros valve on ___
Severe orthostatic hypotension from autonomic neuropathy
Endometriosis
Hyperlipidemia
Hypertension
Social History:
___
Family History:
Mother: HTN, ___
Father: ___, CVA, CAD, MI
No history of malignancy
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- 99.1 136/57 82 22 100% RA
General- AAOx3, no acute distress, appears generally well,
interactive
HEENT- cloudy right cornea w/ loss of vision, irregular left
pupil which is reactive to light, nose clear, OP w/o lesions
Neck- no lymphadenopathy
Lungs- decreased air entry at the bases bilaterally w/
assoicated faint rales, no wheezes/rhonchi
CV- RRR, soft systolic murmur at base, no rubs/gallops
Abdomen- +BS, soft, non-tender, non-distended
GU- not performed
Ext- WWP, trace symmetric ___ edema, right medial thigh ulcer
with fibrinous exudate w/o surrounding erythema, left knee with
mild effusion w/o increased warmth/pain on passive ROM,
decreased sensation of BLE
Neuro- ___ upper and lower extremity strenght bilaterally, other
than above noted left eye blinding CN II-XII intact
Lines- left midline w/o erythema/tenderness, right HD tunneled
catheter without superficial erythema/warmth
DISCHARGE PHYSICAL EXAM
Vitals- 98.5 141/46 74 18 96/RA
General- Alert, oriented, no acute distress
HEENT- cloudy right cornea w/ loss of vision, irregular left
pupil which is reactive to light, nose clear, OP w/o lesions
Neck- no LAD
Lungs- CTAB, no wheezes, rales, ronchi
CV- RRR, normal S1 and S2, no appreciable m/r/g
Abdomen- soft, non-distended, bowel sounds present, no
tenderness to palpation over the suprapubic region
GU- no Foley
Ext- WWP, 2+ pitting edema to thigh on right, 1+ edema to shins
on left, ulcers on R medial thigh, R dorsal foot, L calcaneus
all stable. BLE are sensitive to light palpation R>L
(inconsistent during exam and stable over past several days).
Decreased sensation of BLE.
Neuro- A&Ox3, no asterixis
Pertinent Results:
___ 06:38PM GLUCOSE-118* UREA N-35* CREAT-1.6* SODIUM-141
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-24 ANION GAP-19
___ 06:38PM WBC-16.6* RBC-3.19* HGB-9.3* HCT-30.5* MCV-96
MCH-29.2 MCHC-30.5* RDW-16.3*
___ 06:38PM NEUTS-82.6* LYMPHS-9.0* MONOS-7.5 EOS-0.6
BASOS-0.3
___ 06:38PM PLT COUNT-413
___ 06:24PM LACTATE-1.2
___ 09:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 09:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 09:00PM URINE RBC-25* WBC->182* BACTERIA-FEW
YEAST-MANY EPI-28 RENAL EPI-1
___ 09:00PM URINE HYALINE-7*
___ 09:00PM URINE WBCCLUMP-FEW
___ EKG
Baseline artifact. Sinus rhythm. Low limb lead voltage. RSR'
pattern
in leads V1-V2. Early R wave progression. Non-diagnostic
inferior Q waves. Since the previous tracing of ___ the
rate is slower. Otherwise, no change.
___ CXR
IMPRESSION:
1. Cardiomegaly.
2. Bibasilar opacities on the left could be due to pleural
effusion and
atelectasis, although consolidation due to infection is not
excluded at either lung base.
___ LEFT KNEE X-RAY
Findings: No evidence of acute fracture dislocation is seen.
Tiny posterior patellar spur are noted. No concerning
osteoblastic or lytic lesion is seen. There is a moderate to
large suprapatellar joint effusion. Extensive vascular
calcifications are seen.
IMPRESSION:
Moderate to large suprapatellar joint effusion without
underlying fracture seen.
___ TTE
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). The estimated cardiac index is normal (>=2.5L/min/m2).
The right ventricular cavity is mildly dilated with borderline
normal free wall function. There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload. The aortic valve leaflets (?#) appear structurally
normal with good leaflet excursion. No masses or vegetations are
seen on the aortic valve. There is no aortic valve stenosis. No
aortic regurgitation is seen. A bioprosthetic mitral valve
prosthesis is present. The prosthetic mitral leaflets appear
normal. The motion of the mitral valve prosthetic leaflets
appears normal. The gradients are higher than expected for this
type of prosthesis. No mass or vegetation is seen on the mitral
valve. Trivial 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 mild pulmonary artery systolic
hypertension. No vegetation/mass is seen on the pulmonic valve.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Well seated bioprosthetic mitral valve with mildly
elevated transvalvular gradients. No echocardiographic evidence
of endocarditis. Normal left ventricular cavity sizes with
preserved global and regional systolic function. Borderline
right ventricular systolic function. Mild pulmonary
hypertension.
Compared with the prior study (images reviewed) of ___, a
bioprosthetic mitral valve is present.
___ ART DUP EXT UP BILAT COMP
IMPRESSION: Patent central veins. Bi/triphasic arterial flow
with small
radial arteries and calcifications. The cephalic and basilic
vein diameters as noted.
___ VENOUS DUP UPPER EXT BILATERAL
IMPRESSION: Patent central veins. Bi/triphasic arterial flow
with small
radial arteries and calcifications. The cephalic and basilic
vein diameters as noted.
___ L FOOT X-RAY 1 VIEW
This exam consists of only a single cross-table lateral
radiograph of the left foot. There is prominent bone
destruction involving most or all of the tarsal bones distal to
the talus and calcaneus with associated subluxations or
dislocations particularly of the navicular bone. There is
prominent dorsal soft tissue swelling. Vascular calcifications
with normal bone mineralization (consistent with diabetic
neuropathy). Since previous relatively similar exam ___, the apparent ulceration over the posterior heel pad seen
at that time is less evident and the dorsal soft tissue swelling
is more prominent. No discrete or new focus of bone
destruction.
IMPRESSION: Limited single view with findings typical of
diabetic neuropathic osteoarthropathy.
___ RENAL ULTRASOUND
FINDINGS: The left kidney measures 9.7 cm and there is no
hydronephrosis, stone or mass. The right kidney measures 9.9 cm
and there is no hydronephrosis, stone or mass. The bladder is
collapsed and not well seen. A few hyperechoic foci are seen in
the renal sinuses bilaterally likely representing either renal
sinus fat or vascular calcifications.
IMPRESSION: No evidence of hydronephrosis. No other
abnormality identified. The bladder is collapsed and not well
seen.
___ VENOUS DUP EXT UNI (MAP/DVT) RIGHT
Impression: No evidence of right lower extremity deep vein
thrombosis.
___ 09:25AM BLOOD WBC-8.4 RBC-2.92* Hgb-7.9* Hct-26.5*
MCV-91 MCH-27.1 MCHC-29.9* RDW-16.4* Plt ___
___ 09:25AM BLOOD Glucose-154* UreaN-31* Creat-1.4* Na-136
K-3.9 Cl-101 HCO3-27 AnGap-12
___ 09:25AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0
___ 09:25AM BLOOD ___ PTT-40.7* ___
___ 09:23AM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:23AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 09:23AM URINE RBC->182* WBC-79* Bacteri-FEW Yeast-MOD
Epi-1 TransE-1
*********MICRO**********
___ 1:36 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___. ___ @ 10:52 AM ON
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
___ 11:41 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 ORGANISMS/ML..
___ 9:23 am URINE Source: Catheter.
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML..
Brief Hospital Course:
___ year old female with a PMH of Type I diabetes mellitus,
recent CABG and tissue MVR in ___, recent acute on
chronic renal failure requiring dialysis who presented from
rehab with worsening leukocytosis (18 on ___ at rehab) and
fevers, now with ___.
ACTIVE ISSUES:
# Fevers: Patient was initially treated for UTI with Vanc/Zosyn
given admission UA. She had serial urine cultures, one which
grew yeast (she received 1 dose of fluconazole) and another
which grew out 10,000-100,000 GNRs. However, patient continued
to develop fevers without significant improvement in her
leukocytosis. Because she denied any dysuria symptoms, vanc and
zosyn were stopped on ___. Her HD line was pulled, cath tip
culture was negative. Her multiple ulcers were assessed by
Vascular Surgery and Podiatry, both of whom did not feel her
ulcers were infected. She had imaging of her feet which showed
no areas of new osteomyelitis. At admission she also had a left
knee pleural effusion and later developed pain in her right knee
as well. Given her adequate passive ROM of knee flexion
bilaterally, her exam was not consistent with septic arthritis.
She was seen by ortho who felt this was not a septic joint,
rather inflammation from trauma. She was C.diff positive and
started on PO vancomycin after which her leukocytosis and fevers
resolved. She will continue PO vanc till 1.30.
#Acute on chronic kidney disease: Patient became oliguric and
had Cr rise which peaked at 3.4. Urine sediment showed brown
muddy casts with urine eos, likely ATN vs AIN. Her Cr improved
to baseline (1.4 at time of discharge) and she did not require
HD and her urine output improved. She did become volume
overloaded while she was oliguric and continues to have 1+
pitting edema to her knees bilaterally. She was continued on
her ___ Lasix 40 mg BID to which she has good response. She
also had bilateral upper extremity vein mapping in anticipation
of future need for dialysis. She will have follow-up with her
outpatient nephrologist.
#Lower extremity pain: Edema likely ___ volume overload. Patient
developed some asymmetric pitting edema, R>L, but LENIs were
negative for DVT. She has pain to palpation in her BLE thought
to be ___ volume overload, diabetic neuropathy. Her pain is not
localized strictly in the joints. However, should she develop
localized pain in her knees and passive ROM is completely
limited by pain, would consider checking a uric acid to assess
for gout.
#DMI complicated by critical hypoglycemia, 40s. Patient
evaluated by ___ who recommended Lantus 18u QAM + HISS.
FSBGs well controlled while in-house in the 130s-240 range day
prior to discharge.
___ ulcers: The patient has multiple foot and lower extremity
ulcers with fibrinous exudates. None appeared to be actively
infected. Patient received ongoing wound care. The patient was
evaluated by Vascular Surgery and Podiatry who did not think
surgical debridement was necessary. Patient has follow-up with
Podiatry and Vascular Surgery.
#Paroxysmal atrial fibrillation: Developed post op after CABG/
tissue valve surgery. Rate well controlled on ___ metoprolol.
Patient was continued on her warfarin 2mg from rehab. However,
she became supratherapeutic so her coumadin was held. Her
coumadin was restarted, but then uptitrated to 3 mg qday after
the patient's subtherapeutic INR persisted. INR at discharge
was 2.1.
*****TRANSITIONAL ISSUES*****
- Code: full (confirmed)
- Patient should have INR checked on ___.
- If patient develops localized pain only in knee joint and
passive ROM is completely limited by pain, can consider checking
a uric acid level. For now I would treat symptoms w/ tylenol
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO DAILY
2. Docusate Sodium 200 mg PO DAILY
3. Gabapentin 300 mg PO DAILY
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Metoprolol Succinate XL 12.5 mg PO HS
6. Pantoprazole 40 mg PO Q24H
7. Nephrocaps 1 CAP PO DAILY
8. Cyanocobalamin 500 mcg PO DAILY
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
10. Bethanechol 50 mg PO TID
11. Florastor (saccharomyces boulardii) 250 mg oral BID
12. Levemir 15 Units Breakfast
NPH 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
13. Furosemide 40 mg PO BID
14. Aspirin 81 mg PO DAILY
15. Acetaminophen 650 mg PO Q6H:PRN pain
16. ___ MD to order daily dose PO DAILY16
17. Vitamin D 50,000 UNIT PO 1X Q15DAY
18. Ciprofloxacin 0.3% Ophth Soln 3 DROP RIGHT EAR DAILY
19. TraMADOL (Ultram) 50 mg PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Bethanechol 50 mg PO TID
6. Ciprofloxacin 0.3% Ophth Soln 3 DROP RIGHT EAR DAILY
7. Cyanocobalamin 500 mcg PO DAILY
8. Docusate Sodium 200 mg PO DAILY
9. Furosemide 40 mg PO BID
10. Gabapentin 300 mg PO DAILY
11. Levothyroxine Sodium 25 mcg PO DAILY
12. Metoprolol Succinate XL 12.5 mg PO HS
13. Nephrocaps 1 CAP PO DAILY
14. Pantoprazole 40 mg PO Q24H
15. TraMADOL (Ultram) 50 mg PO TID
Please do not take if very sleepy, with alcohol, or while
driving.
16. Florastor (saccharomyces boulardii) 250 mg oral BID
17. Vitamin D 50,000 UNIT PO 1X Q15DAY
18. Glargine 18 Units Breakfast
Glargine 0 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
19. Warfarin 3 mg PO DAILY16
20. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 8 Days
take till ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
C. diff colitis
acute tubular necrosis/ ___
Secondary:
Diabetic foot ulcer
Right thigh pressure ulcer
Chronic kidney disease stage III
Type 1 diabetes mellitus, uncontrolled with complications
Diabetic neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the ___
for fevers. We initially treated you for a urinary tract
infection with IV antibiotics. Your urine tests later showed
that your infection improved. We later found that you also had
an infection of your colon called C dif. You were treated with
oral antibiotics (oral vancomycin) and your diarrhea improved.
You should continue taking this.
We were also concerned for other sources of infection so your
leg and foot ulcers were evaluated by Podiatry and Vascular
Surgery. They felt your ulcers were looked well and uninfected.
We also removed your tunnelled HD line since it may have been
another source of infection. The catheter tip was cultured and
the culture was negative.
You were also treated for acute kidney injury. We believe your
kidneys were injured because of your recent infections. Your
kidney function has improved.
You were also having significant pain in your legs. We believe
that the pain is due to the fluid in your legs and some
inflammation in your knees related to physical therapy. You had
an ultrasound to see if you have clots in your legs and the
ultrasound was negative.
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.
Followup Instructions:
___
|
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