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19855099-DS-20 | 19,855,099 | 23,533,177 | DS | 20 | 2169-11-21 00:00:00 | 2169-11-24 21:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Augmentin / heparin
Attending: ___.
Chief Complaint:
leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o CABG/MVR (___), DMI, dCHF, PVD with nonhealing
left heel ulcer s/p angiography (___), CKD stage IV who
presents with worsening ___ edema x1 week.
She was admitted to vascular surgery on ___ and underwent
angiography and reports receiving IVF during that admission. She
was instructed to take her home dose diuretics for her ___ edema.
However, she has experienced increasing swelling since
discharge. Her ___ visited her earlier today and was instructed
to go to ED for IV diuresis and further evaluation.
In the ED initial vitals were: 0 97.8 58 157/46 16 100% RA
- Labs were significant for Na 134, K 5.9, BUN/Cr 71/2.7
(baseline Cr ~ 2.0), ___ 31398 (same as previous admission)c
WBC WNL, Hct 30.1 at baseline.
- Patient was given insulin and dextrose for hyperkalemia even
though no EKG changes seen.
Vitals prior to transfer were: ___ 145/58 14 97% RA
On the floor, VS are 98.1 153/77 62 20 95% on RA. Pt is in no
acute distress. Endorses orthopnea. No chest pain or
palpitations or cough.
Past Medical History:
PMH:
- CHF
- Afib (following CABG) on coumadin
- DM (complicated by retinopathy, nephropathy, neuropathy,
gastroparesis, endometriosis)
- HTN
- PVD with non-healing L heel ulcer s/p angio (___)
- HLD
- Mitral regurgitation
- orthostatic hypotension secondary to autonomic neuropathy
- CAD
- CKD
- Endometriosis
- Diabetic foot ulcers
- Charcot foot
- Blind in R eye
PSH:
- CABG w/MVR (___)
- Laproscopic procedures for endometriosis
- Tonsillectomy
- Multiple eye surgeries
- Multiple B/L foot debridements (with podiatry)
Social History:
___
Family History:
Mother: HTN, ___
Father: ___, CVA, CAD, MI
No history of malignancy
Physical Exam:
ADMISSION PHYSICAL (___)
PHYSICAL EXAM:
Vitals - 98.1 153/77 62 20 95% on RA
GENERAL: obese female in NAD, becomes dyspneic upon laying flat
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, JVP 10-11cm
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB
ABDOMEN: distended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 3+ pitting edema up to knees, left heel ulcer in
dressing c/i/d
NEURO: CN II-XII intact
DISCHARGE PHYSICAL (___)
PHYSICAL EXAM:
Vitals: T: 98.2 BP: 154/53 P: 62 R: 18 O2: 98 on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: minimal crackles at bases b/l
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur, no rubs or gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly
Ext: ___ edema to the knees, large necrotic ulcer on left heel
bandaged
Pertinent Results:
ADMISSION LABS:
___ 08:20PM BLOOD WBC-10.4 RBC-3.50* Hgb-8.8* Hct-30.1*
MCV-86 MCH-25.2* MCHC-29.2* RDW-17.1* Plt ___
___ 08:20PM BLOOD ___ PTT-36.4 ___
___ 08:20PM BLOOD Glucose-68* UreaN-73* Creat-2.7* Na-134
K-5.9* Cl-102 HCO3-25 AnGap-13
___ 08:20PM BLOOD ___
___ 08:20PM BLOOD Calcium-8.7 Phos-6.7* Mg-2.8*
DISCHARGE LABS:
___ 08:15AM BLOOD WBC-8.4 RBC-3.85* Hgb-9.9* Hct-34.0*
MCV-88 MCH-25.6* MCHC-29.0* RDW-16.9* Plt ___
___ 07:40AM BLOOD Glucose-114* UreaN-55* Creat-2.1* Na-138
K-4.9 Cl-103 HCO3-22 AnGap-18
URINE CULTURE (Final ___: NO GROWTH.
C. DIFF
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
ABI/PVR (___)
IMPRESSION: Significant aortoiliac occlusive disease
bilaterally.
Brief Hospital Course:
The patient is a ___ with CHF, CAD s/p CABG/MVR, T1DM, PVD with
non-healing L heel ulcer, and CKD who presented with volume
overload and a UA concerning for urinary tract infection after
recently being discharged for a LLE angiogram on ___.
S Volume status was She had ___ which improved with
diuresis. She received 3 days of IV ceftriaxone for her presumed
UTI. Her urine culture did not grow anything.
#Acute on Chronic Heart Failure. On admission patient with
evidence of volume overload with bilateral lower extremity
edema. She was initially managed first IV furosemide and then
with PO torsemide with a goal of -1L per day which she met.
Prior to discharge edema had improved. Patient was encouraged to
remain in house for continued diuresis and monitoring however
she advocated for discharge with plan to continue daily
Torsemide 40mg with close cardiology follow-up (double home
dose). Discussion ensued over patient's compliance. Patient was
educated that at this time diuretics necessary to maintain
volume status and failure to consistently take medication could
result in repeat hospitalization and medical compromised (edema,
shortness of breath).
[] Continue PO Torsemide
[] Monitor weight; instructed to call cardiology if weight
increases by ___
#Acute on Chronic Renal insufficiency. Thought secondary to
heart failure exacerbation. Improved to baseline with diuresis
[] Monitor CMP with plan to repeat labs ___
# Peripheral Vascular Disease complicated by L heel ulcer. She
was seen by vascular surgery in the ED who requested b/l ABI/PVR
which demonstrated severe PVD. No changes were made in medical
management (ASA, Statin) and patient was discharged with plan to
follow-up with vascular surgery on ___
# +UA. Patient with pyria on admission UA which was initially
treated however when culture returned negative antibiotics were
stopped.
[ ] Consider repeat UA at next PCP ___
# Atrial Fibrillation. Continued on metoprolol for rate control
and coumadin for anticoagulation.
[] Follow-up INR on ___
# Functional Status. Patient will limited mobility in house.
Seen by physical therapy who recommended continued ___. Patient
declined ___ rehabilitation in favor of home ___, however
she may need more intensive ___ to regain some of her old
functional status
[] Home ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Bethanechol 50 mg PO TID
5. Cetirizine 10 mg oral Daily
6. Cyanocobalamin 500 mcg PO DAILY
7. Ezetimibe 10 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO HS
9. Nephrocaps 1 CAP PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Torsemide 20 mg PO DAILY
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
13. LOPERamide 2 mg PO QID:PRN diarrhea
14. ammonium lactate ___ % topical daily
15. honey 80% gel topical every other day
16. lactobacillus acidophilus 1 billion cell oral daily
17. Minerin (mineral oil-isopropyl myristat;<br>white
petrolatum-mineral oil) 0 TOPICAL DAILY
18. Warfarin 4 mg PO DAILY16
19. Gabapentin 300 mg PO DAILY
20. HumaLOG (insulin lispro) per sliding scale subcutaneous 4
times daily
21. HumuLIN N (NPH insulin human recomb) 30 units subcutaneous
qam
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Bethanechol 50 mg PO TID
5. Cyanocobalamin 500 mcg PO DAILY
6. Ezetimibe 10 mg PO DAILY
7. Gabapentin 300 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO HS
9. Nephrocaps 1 CAP PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Torsemide 40 mg PO DAILY
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
13. Warfarin 4 mg PO DAILY16
14. ammonium lactate ___ % topical daily
15. Cetirizine 10 mg oral Daily
16. honey 80% gel topical every other day
17. HumaLOG (insulin lispro) 0 0 SUBCUTANEOUS 4 TIMES DAILY
18. HumuLIN N (NPH insulin human recomb) 30 units subcutaneous
qam
19. lactobacillus acidophilus 1 billion cell oral daily
20. Minerin (mineral oil-isopropyl myristat;<br>white
petrolatum-mineral oil) 0 TOPICAL DAILY
21. LOPERamide 2 mg PO QID:PRN diarrhea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Fluid overload, UTI
Secondary: CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you. You were admitted for
lower extremity edema, likely caused by volume overload from
your heart failure. You were treated with IV furosemide and then
torsemide by mouth to remove excess fluid. We were also
concerned you had a urinary tract infection and treated you with
3 days of IV ceftriaxone.
We recommended that you stay in the hospital for management of
your fluid overload, however you wished to return home. In order
to manage your fluid overload at home, you will have to closely
monitor your weight and communicate with your PCP or
cardiologist. Weigh yourself every morning, or watch the amount
of swelling of your legs if you cannot weigh yourself, and call
your doctor if weight goes up more than 3 lbs or you notice any
changes in your leg swelling.
The physical therapists here thought that your best chance to
regain functional status was to go to a rehabilitation program,
however you declined, preferring to do home ___.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19855099-DS-21 | 19,855,099 | 25,117,801 | DS | 21 | 2169-12-21 00:00:00 | 2169-12-23 17:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Augmentin / heparin
Attending: ___.
Chief Complaint:
Dyspnea, leg swelling
Major Surgical or Invasive Procedure:
___: right heart catheterization
History of Present Illness:
___ F w/ PMHx s/f CHF (echo ___ showed 50-55% EF), DMI c/b
neuropathy/nephropathy, CABG ___ complicated by papillary
rupture causing acute MVR s/p bioprosthetic repair, CKD stage
IV, and PVD s/p angio (___) presenting with complaint of SOB.
Patient reports that she has been having bilateral ___ swelling
for last few days. Contacted her doctor on ___ and was told
to come to hospital. However, she elected to delay coming in due
to family circumstances. This morning ___, she woke up with SOB
and came in to be treated. She denies any chest pain, asymmetric
leg swelling, or recent illnesses. She has a cough that is not
productive of sputum. Endorses having chills and subjective
fever. She denies urinary problems.
Of note, pt recently hospitalized at ___ ___ for fluid
overload and was diuresed and given ceftriaxone for presumed
UTI, discharged on torsemide 20 mg BID. She states that she has
been occasionally skipping the afternoon dose of her torsemide
because it interfered with her job. She says that she is still
above her dry weight (160 lb) and is about 200 lbs. She does not
weigh herself regularly.
In the ED, initial vitals were 99.3 63 198/59 18 98% 2L Nasal
Cannula. She desaturated to 91 with walking and endorsed SOB on
exertion.
ED labs significant for: K 5.8, Na 132, Cr 2.2, blood glc 475,
ALT: 77 AST: 203 AP: 359 Tbili: 0.3 Alb: 3.4; H/H 8.___.4,
proBNP: <5
In ED, given furosemide 40 mg IV, Insulin regular, and nitro.
On the floor, VS: T 98.1 BP 148/47 HR 59 R 20 SpO2 100% 3LNC, BG
303
Past Medical History:
PMH:
- CHF
- Afib (following CABG) on coumadin
- DM (complicated by retinopathy, nephropathy, neuropathy,
gastroparesis, endometriosis)
- HTN
- PVD with non-healing L heel ulcer s/p angio (___)
- HLD
- Mitral regurgitation
- orthostatic hypotension secondary to autonomic neuropathy
- CAD
- CKD
- Endometriosis
- Diabetic foot ulcers
- Charcot foot
- Blind in R eye
PSH:
- CABG w/MVR (___)
- Laproscopic procedures for endometriosis
- Tonsillectomy
- Multiple eye surgeries
- Multiple B/L foot debridements (with podiatry)
Social History:
___
Family History:
Mother: HTN, ___
Father: ___, CVA, CAD, MI
No history of malignancy
Physical Exam:
Exam on Admission:
VS: T 98.1 BP 148/47 HR 59 R 20 SpO2 100% 3LNC, BG 303
General: ___ laying in bed in NAD, cooperative
HEENT: NC/AT, left eye PERRL, right eye nonreactive (blind in
right eye), sclerae anicteric, MMM
Neck: Supple, no appreciable JVD due to habitus
CV: RRR, S1+S2, no murmurs, rubs, or gallops
Lungs: Moderate rales in bases bilaterally, no wheezes
Abdomen: Soft, nontender, nondistended, no organomegaly or
masses
GU: Foley in place
Ext: ___ pitting edema to thighs bilaterally. There is a left
hyperkerotic foot lesion on the plantar aspect of the left heel
with a 4x4 area of black eschar. Extremities are warm and
well-perfused bilaterally
Exam on Discharge:
PHYSICAL EXAM:
VS: Tc: 97.8 BP: 136/50(110-140s/50-60s) HR: 50(50-60s) SaO2:
93-98%on RA.
Tele: NSR, HR in ___
Wt 81.4 -> 80.4 -> 79.7 -> 80.2 ->80.1 kg
(New dry weight 80kg)
I/O--
24h: 1500/450+ (net +500-900cc)
Since MN: 400/500+ (net -100-200)
General: Lying comfortably in bed in NAD
HEENT: NCAT, left eye PERRL, right eye nonreactive (blind in
right eye), sclerae anicteric, MMM
Neck: Supple, JVP not elevated
CV: RRR, S1+S2, no murmurs, rubs, or gallops
Lungs: clear bilaterally, no murmurs/rubs/gallops
Abdomen: Soft, nontender, nondistended, no organomegaly or
masses
GU: Foley in place draining light yellow urine
Ext: 1+ pitting edema to knees, trace edema in thighs. Feet
wrapped, heel protectors in place. Extremities warm and
well-perfused.
Pertinent Results:
___ 05:20AM ___ PTT-40.1* ___
___ 05:20AM PLT COUNT-323
___ 05:20AM proBNP-<5
___ 05:20AM LIPASE-7
___ 05:20AM ALT(SGPT)-77* AST(SGOT)-203* ALK PHOS-359*
TOT BILI-0.3
___ 05:20AM GLUCOSE-475* UREA N-52* CREAT-2.2*
SODIUM-132* POTASSIUM-5.8* CHLORIDE-102 TOTAL CO2-20* ANION
GAP-16
___ 05:36AM LACTATE-1.6 K+-5.4*
___ 05:36AM ___ COMMENTS-GREEN TOP
___ 04:40PM ___ PTT-57.0* ___ 04:40PM TSH-8.6*
___ 04:40PM CALCIUM-8.2* PHOSPHATE-4.3 MAGNESIUM-2.1
___ 04:40PM GLUCOSE-250* UREA N-52* CREAT-2.2* SODIUM-133
POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-22 ANION GAP-15
Right heart cath ___:
There was elevation of right and left-sided pressures with mean
RA 23, RV 66/27, PA 66/36/42, and mean PCW 33 mm Hg. The cardiac
index was preserved at 4.2 L/min/m2 using an assumed oxygen
consumption.
1. Biventricular diastolic heart failure.
2. Mild-moderate pulmonary hypertension.
3. No oxymetric evidence of significant right-to-left or
left-to-right shunting on repeat fuller examination.
TTE ___:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). The right ventricular
cavity is mildly dilated with normal free wall contractility.
There is abnormal diastolic septal motion/position consistent
with right ventricular volume overload. The diameters of aorta
at the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. A
bioprosthetic mitral valve prosthesis is present. The gradients
are high normal for this type of prosthesis. No mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. There
is no pericardial effusion.
IMPRESSION: Well seated bioprosthetic mitral prosthesis with
high normal gradient. Mild symmetric left ventricular
hypertrophy with preserved regional and global systolic
function. Pulmonary artery hypertension. Right venticular cavity
dilation with preserved free wall motion.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
TTE (___):
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF=55%). The right ventricular cavity is mildly
dilated with mild global free wall hypokinesis. There is
abnormal septal motion/position. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. A bioprosthetic
mitral valve prosthesis is present. The motion of the mitral
valve prosthetic leaflets appears normal. The gradients are
higher than expected for this type of prosthesis. Mild (1+)
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 borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved left ventricular systolic function. Mildly dilated,
mildy hypokinetic right ventricle. Mitral valve bioprosthesis
with mildly elevated transmitral mean pressure gradient. Mild
mitral regurgitation. Borderline pulmonary artery systolic
pressure.
Liver/GB ultrasound (___): 1. Cholelithiasis without evidence
of cholecystitis. 2. Small right pleural effusion. 3. Pulsatile
flow of the main portal vein is likely secondary to patient's
heart failure.
CXR (___):
(Preliminary report):
IMPRESSION: Evidence of heart failure with interval increase in
mild--to-moderate pulmonary edema and small bilateral pleural
effusions.
CXR (___):
The heart is mildly enlarged. The patient is post CABG. There
is central pulmonary vascular congestion with mild pulmonary
edema, slightly worsened since ___, with increased
small bilateral pleural effusions. There is no pneumothorax.
IMPRESSION:
Central pulmonary vascular congestion with mild pulmonary edema
and small bilateral pleural effusions have slightly worsened
since ___.
FOOT AP,LAT & OBL LEFT Study Date of ___
IMPRESSION:
In comparison with the study of ___, there is again
evidence of severe neuropathy involving the tarsal bones, talus,
and anterior portion of the calcaneus. Extensive vascular
calcification indicates diapedesis the underlying cause. The
mineralization is seen at the metatarsophalangeal joints. On
the oblique view, there is the suggestion gas in soft tissues
laterally at the tarsal level.
Although no discrete erosions are appreciated, if there is
serious clinical concern for osteomyelitis, MRI could be
obtained.
___:
Sinus rhythm. Incomplete right bundle-branch block. Delayed R
wave
progression. Small inferior Q waves. Inferior and lateral minor
ST-T wave
abnormalities. Compared to the previous tracing of ___ no
diagnostic
change.
discharge labs:
___ 05:10AM BLOOD WBC-7.5 RBC-3.27* Hgb-7.9* Hct-26.2*
MCV-80* MCH-24.0* MCHC-30.0* RDW-17.8* Plt ___
___ 05:20AM BLOOD Neuts-75.3* Lymphs-11.1* Monos-11.2*
Eos-1.6 Baso-0.9
___ 12:40PM BLOOD Glucose-28* UreaN-107* Creat-2.7* Na-130*
K-3.6 Cl-82* HCO3-34* AnGap-18
___ 05:35AM BLOOD ALT-37 AST-38 LD(LDH)-196 AlkPhos-316*
TotBili-0.2
___ 12:40PM BLOOD Calcium-9.1 Phos-4.9* Mg-2.6
Brief Hospital Course:
The patient is a ___ with diastoic CHF (EF 55%), CAD s/p CABG x2
with emergent MVR due to papillary muscle rupture (___)
complicated by ___ requiring temporary CRRT, T1DM, PVD, and CKD
who presented with SOB, ___ swelling, BG of 475 and hyperkalemia.
Right heart catheterization showed elevated right heart
pressures. She was successfully diuresed with lasix gtt and
metolazone and transitioned to PO torsemide and metolazone. Her
BGs and lytes have resolved and she has completed treatment for
HCAP (vanc/zosyn). She has had 2 days with low fingersticks in
___ overnight and 37 ___. We recommended that she stay in
the hospital an additional day to monitor labs and blood
gluocse, especially because blood sugar was 37 this afternoon.
We have discussed this extensively with her and notified her
that she is leaving against medical advice this evening, but you
chose to be discharged anyway.
#Chronic diastolic heart failure (EF 55%):
Last echo ___ with EF 55%. BNP <5. Unclear of dry weight on
last discharge ___, but on earlier ___ admission discharge
weight was 86 kg (dry weight thought to be more like 77 kg). Pt
was admitted ___ with a similar presentation and was
diuresed and discharged on torsemide 40 mg daily; however she
had not been taking this. Pt had initially been diuresing on
lasix gtt and metolazone, however stopped responding and
___ had UOP over 12 hours was 125-150 ccs. Creatinine rose
as well, so stopped lasix gtt and metolazone given renal
function. Right heart catheterization ___ showed elevated right
heart pressures. More aggressive diuresis was started (10mg
metolazone, 200mg IV lasix, 20mg/hr lasix gtt) and patient
responded appropriately, with increasing net negative output.
Transitioned to PO torsemide 80mg bid and metolazone 2.5mg biw
on ___. SW consulted for medication noncompliance and
extensive discussion with patient and PACT team.
- 80mg bid PO torsemide
- metolazone 2.5mg biw
- metoprolol 25 hs, imdur 90 daily, hydral 10 q8h
# ___ on CKD: Pts BUN/Cr suggests prerenal etiology, likely
cardiorenal syndrome. Recent acute on chronic renal failure
requiring dialysis in ___ likely secondary to acute MR.
___ alb/cr ratio of 544 ___. Cr on admission 2.2,
baseline 1.7 (___). FeUREA is 25% on ___, showing prerenal
etiology. Cr peaked at 3. and trended down as diuresis tapered.
Renal consulted. Trended BUN, Cr, strict I/Os, daily weights.
Phos binder while on diuresis.
# Mild Hyponatremia: Could be related to CHF or
pseudohyponatremia secondary to elevated blood glucose. Na
stable at 129-130 while diuresing. Urine lytes consistent with
prerenal etiology. Will follow up as outpatient with lab draw by
visiting nurse.
# Afib: Pt has been in NSR this admission, INR therapeutic on
admission, but 1.7 after holding dose for cath. Restarted
warfarin after right heart cath, gave 4mg-8mg daily until INR
therapeutic. Discharged on warfarin 6mg daily.
# New leukocytosis and U/A: RESOLVED. Leukocytosis resolved.
Patient WBC had been elevated to 12.5 ___. Pt remained
asymptomatic and afebrile. Changed foley. Repeat UCx yeast
<100,000. Not consistent with fungal infection. Continued to
monitor for signs of infection.
#HCAP: RESOLVED. CXR concerning for RLL consolidation, pt had
been afebrile since starting empiric HCAP coverage with
vanc/zosyn for pseudomonas/aspiration. Completed 8 day course of
vanc/zosyn on ___. Comfortable on room air, with good O2 sat.
#L heel ulcer: s/p diagnostic LLE angiogram for a nonhealing
left foot ulcer. Pt has had multiple B/L foot debridements (with
podiatry). The angio noted a patent common femoral,
profundafemoris, SFA with a couple of areas of
non-hemodynamically significant stenosis with 2 vessel runoff to
the lower leg and an occluded ___. She is considered to have
non-reconstructable PAD. Podiatry was consulted and believes her
L heel to be stable and unlikely to be a source of infection.
Foot x-rays show no sign of erosions; not likely infectious
source. Followed wound care and podiatry recs.
# Anemia: On presentation pt's H/H 8.4/29.4; likely secondary to
CKD. There are no active signs of bleeding. H/H has been stable.
No signs of hemolysis. Guaiac negative.
# CAD s/p CABG with bioprosthetic MVR: Pt underwent CABG x2
___ complicated by papillary muscle rupture, acute MR, s/p
bioprosthetic MVR with residual mild-to-moderate
patient-prosthesis mismatch (___), with a mean gradient of 10
mmHg across the mitral valve. Her valvular disease could
potentially be contributing to her SOB/pulmonary edema.
Continued aspirin, atorvastatin, warfarin.
#HTN: Pt's BPs 133-144/50s
Changed anti-hypertensives to metoprolol 25 hs, imdur 90 daily,
hydral 10 q8h.
# IDDM: Pt has longstanding type 1 diabetes mellitus with
multiple complications including retinopathy, nephropathy,
neuropathy and gastroparesis; currently uncontrolled (last
HgbA1c ___ was 9.9. Pt reports decreased UOP, likely related
to neurogenic bladder. Pt presents with BG 475, does not have an
anion gap. Was started on regular insulin in the ED. Pt's blood
glucose values have been labile on this admission despite
regular recommendations from ___. She reports that this is
baseline for her. NPH and ISS per ___ recs with out patient
follow up set up.
# URI symptoms: Pt reports nasal congestion and coughing and
wheezing, remains afebrile. She reports that she had used an
albuterol inhaler in rehab in the past when she was recovering
from pneumonia. Albuterol nebs PRN and standing
albuterol/ipratropium nebs as above. Guafenisin / saline nasal
spray.
# Hypothyroidism: Pt has not been taking levothyroxine 25 mcg
daily at home; TSH 8.6. Free T4 normal at 0.98. Restarted home
levothyroxine.
# Neurogenic bladder: Pt has no urinary complaints. Foley
catheter in place. Continued bethanechol.
# Neuropathy: Pt has chronic neuropathy and lacks sensation
below the ankles bilaterally. Continue gabapentin.
She has had 2 days with low fingersticks in ___ overnight and
37 ___. We recommended that she stay in the hospital an
additional day to monitor labs and blood gluocse, especially
because blood sugar was 37 this afternoon. We have discussed
this extensively with her and notified her that she is leaving
against medical advice this evening, but you chose to be
discharged anyway.
Dr. ___ an extensive discussion with her to try to convince
her to stay, but she was adamant about leaving, and was able to
communicate back the risks/benefits and harms of leaving early,
including but not limited to death, renal failure / dialysis,
heart failure, arrhythmia, or hypoglycemic episodes with brain
death or seizure. Despite these risks, she requested discharge,
and left AMA.
We have given her follow-up for INR, electrolytes, and HF care.
She will also need ___ follow-up for her blood sugars.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Bethanechol 50 mg PO TID
4. Cetirizine 10 mg PO DAILY
5. Cyanocobalamin 500 mcg PO DAILY
6. Ezetimibe 10 mg PO DAILY
7. Gabapentin 300 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO HS
9. Nephrocaps 1 CAP PO DAILY
10. Omeprazole 40 mg PO DAILY
11. lactobacillus acidophilus (lactobacillus acidoph & bulgar) 1
billion cell oral BID
12. Torsemide 20 mg PO BID
13. NPH 30 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
14. Acetaminophen 325-650 mg PO Q6H:PRN pain
15. LOPERamide 2 mg PO QID:PRN diarrhea
16. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Bethanechol 50 mg PO TID
5. Cetirizine 10 mg PO DAILY
6. Cyanocobalamin 500 mcg PO DAILY
7. Ezetimibe 10 mg PO DAILY
8. Gabapentin 300 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO HS
10. Nephrocaps 1 CAP PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Torsemide 60 mg PO BID
RX *torsemide 20 mg 3 tablet(s) by mouth twice a day Disp #*180
Tablet Refills:*0
13. Warfarin 4 mg PO DAILY16
14. HydrALAzine 20 mg PO Q8H
RX *hydralazine 10 mg 2 tablet(s) by mouth three times a day
Disp #*180 Tablet Refills:*0
15. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
16. Levothyroxine Sodium 25 mcg PO DAILY
RX *levothyroxine 25 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
17. lactobacillus acidophilus (lactobacillus acidoph & bulgar) 1
billion cell oral BID
18. LOPERamide 2 mg PO QID:PRN diarrhea
19. NPH 27 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnosis:
acute on chronic diastolic heart failure
atrial fibrillation
hypertension
secondary diagnosis:
chronic kidney disease
diabetes mellitus
anemia
hyperlipidemia
coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms ___,
It was a pleasure to take care of you. You were admitted to
___ because you were having a heart failure exacerbation and
you were very fluid overloaded. We gave you diuretics ('water
pills') by IV and then orally while monitoring your kidneys,
electrolytes, and fluids very closely. We also monitored and
treated your diabetes whiel you were here. You were seen by the
kidney specialists, podiatry team, and wound care specialists
while you were here. We have set up follow up appointments for
you with heart failure clinic, ___ (diabetes), and
rescheduled your hyperbaric evaluation at ___ Eye and Ear.
It is very important that you continue take the
torsemide(diuretics) when you go home, otherwise the fluid will
reaccumulate and you will have to return to the hospital. It is
also extremely important that you keep your heart failre
appointment, where they may need to adjust your diuretic
medications.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We recommend that you stay in the hospital an additional day to
monitor your labs and blood gluocse, especially because your
blood sugar was 37 this afternoon. We have discussed this
extensively with you and notified you that you are leaving
against medical advice this evening, but you have chosen to be
discharged anyway.
We wish you all the best.
-Your ___ team
Followup Instructions:
___
|
19855099-DS-23 | 19,855,099 | 20,927,436 | DS | 23 | 2170-02-13 00:00:00 | 2170-02-19 20:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Augmentin / heparin
Attending: ___.
Chief Complaint:
Elevated Cr, ___, abnormal Labs
Major Surgical or Invasive Procedure:
Tunneled line placement and initiation on dialysis
Skin biopsy
History of Present Illness:
Ms. ___ is a ___ h/o dCHF, DMI w/microvascular complications,
CABG, MVR s/p bioprosthetic repair, CKD stage IV, and PVD who
was recently discharged from ___ on ___ for dCHF
exacerbation who now represents from rehab. While at rehab, she
was noted to have an elevated BUN/Cr and weight gain of 7
pounds. She denies any symptoms of chest
pain/pressure/discomfort, SOB, dizziness, lightheadedness. As
for the weight gain she states the scale at the rehab might have
been incorrect.
In the ED, the patient's initial VS 97.6, 68, 102/53, 18, 97% on
RA. Patient was AOx3, speaking in full sentences with unlabored
respirations and mild bibasilar crackles on lung exam without
any lower extremity edema. Labs were notable for Cr 4.7 (from
2.8 at discharge), WBC 6, Hgb/Hct 8.7/28.5 stable from prior,
___ 37572 (down from ___ in ___. Lactate 1.3. UA
equivocal for UTI. CXR showed mild to moderate pulmonary edema,
improved from prior. The patient received a 250 cc NS bolus in
the ED.
Of note, during her last hospitalization, the patient was found
to have hyperosmolar nonketotic diabetic state possibly
triggered by a UTI, treated with insulin drip in MICU and 7-days
of ceftriaxone, and subsequently transferred to the heart
failure service for management of acute on chronic CHF, where
she was treated with a lasix drip and discharged on torsemide 80
mg BID (EDW 72 kg). Her course was complicated by C.diff
colitis and recurrent complicated UTI with enterococcus and
resistant Pseudomonas for which she received a course of
Fosfomycin (last day ___. Patient continues to have loose
bowel movements as per the C.diff. Does not know if she has seen
any blood.
On arrival to the floor, VS 97.1 160/61 57 18 97%RA
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, constipation
or abdominal pain. No dysuria. Denies arthralgias or myalgias.
Ten point review of systems is otherwise negative.
Past Medical History:
- diastolic CHF
- CAD s/p CABG/bio MVR ___
- Afib (following CABG) on coumadin
- DM1 (complicated by retinopathy, nephropathy, neuropathy,
gastroparesis, endometriosis)
- HTN
- PVD with non-healing L heel ulcer s/p angio (___)
- HLD
- Mitral regurgitation
- orthostatic hypotension secondary to autonomic neuropathy
- CAD
- CKD
- Endometriosis
- Diabetic foot ulcers
- Charcot foot
- Blind in R eye
PAST SURGICAL HISTORY
- CABG w/MVR (___)
- Laproscopic procedures for endometriosis
- Tonsillectomy
- Multiple eye surgeries
- Multiple B/L foot debridements (with podiatry)
Social History:
___
Family History:
Mother: HTN, ___
Father: ___, CVA, CAD, MI
No history of malignancy
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS 97.1 160/61 57 18 97%RA
General: NAD, uncomfortable laying in bed, pleasant
HEENT: NCAT, Blind in right eye, discoloration of right pupil
Neck: obese, unable to appreciated JVD
CV: irregular rhythm, no m/r/g, S1 and S2 appreciated
Lungs: CTA in frontal fields, no w/r/r
Abdomen: soft, mild suprapubic and lower abdominal
tenderness/ND, BS+
Ext: WWP, 2+ distal pulses bilaterally, bilateral foot ulcers
wrapped with dressing, severely tender pitting edema 2+ to knee
Neuro: moving all extremities gross
PHYSICAL EXAMINATION:
VS: 98.3 59-69 111-156/53-70 18 99%RA
I/O: 1235/0
General: ill appearing, A&O x 3 in no apparent distress seen at
dialysis.
HEENT: clouding of the right cornea, sclerae anicteric, EOMI,
Neck: JVD 8 cm
CV: soft heart sounds, normal sinus rhythem, normal S1 and S2
with grade I/IV diastolic murmur without radiation
Lungs: Crackles at bases, no wheezes
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds
Ext: Warm, well perfused, with 1+ pitting edema to above the
knees bilaterally; feet bilaterally wrapped in dressing- left
ankle has ulceration over heel with well healing granulation
tissue. Right foot as scabbed healing lesions located on arch of
foot.
Neuro: CN II-XII intact, motor ___ throughout
Skin: Improved skin exam. Bilateral heel ulcers (see above)
PULSES: dorsalis pedis pulses unable to assess - feet wrapped,
___ pulses 1+ bilaterally, radial pulses 2+ bilaterally
Pertinent Results:
LABS ON ADMISSION:
___ 03:01PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 03:01PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
___ 03:01PM URINE RBC-0 WBC-8* BACTERIA-FEW YEAST-NONE
EPI-1
___ 09:54AM LACTATE-1.3
___ 09:50AM GLUCOSE-225* UREA N-119* CREAT-4.7*#
SODIUM-133 POTASSIUM-3.8 CHLORIDE-91* TOTAL CO2-23 ANION GAP-23*
___ 09:50AM ___
___ 09:50AM WBC-6.0 RBC-3.47* HGB-8.7* HCT-28.5* MCV-82
MCH-25.2* MCHC-30.6* RDW-19.4*
___ 09:50AM NEUTS-75.0* LYMPHS-14.8* MONOS-7.1 EOS-2.8
BASOS-0.4
IMAGING:
___ Imaging CT HEAD W/O CONTRAST
1. No acute intracranial abnormality.
2. Unchanged chronic infarcts in the right and left internal
capsule.
Correlate clinically to decide on the need for further workup or
followup.
___ Imaging LIVER OR GALLBLADDER US
IMPRESSION:
Minimal ascites and small bilateral pleural effusions.
Pulsatile portal
venous flow suggests right heart strain or of tricuspid
insufficiency
(consider possible cardiac cirrhosis).
Cholelithiasis.
___ Imaging RENAL U.S.
IMPRESSION:
1. Normal renal ultrasound.
2. Urinary bladder wall thickening, consistent with
hypertrophy.
3. Trace perihepatic fluid.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
Mild to moderate pulmonary edema, improved from ___.
DISCHARGE LABS
___ 07:50AM BLOOD WBC-12.3* RBC-3.07* Hgb-7.8* Hct-25.2*
MCV-82 MCH-25.4* MCHC-31.0 RDW-20.6* Plt ___
___ 07:35AM BLOOD Neuts-80.5* Lymphs-9.3* Monos-4.7
Eos-5.4* Baso-0.1
___ 12:55PM BLOOD ___ PTT-37.2* ___
___ 07:50AM BLOOD Glucose-221* UreaN-32* Creat-2.8* Na-129*
K-4.0 Cl-91* HCO3-28 AnGap-14
___ 07:35AM BLOOD ALT-34 AST-35 AlkPhos-1049* TotBili-0.5
___ 07:50AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.2
Brief Hospital Course:
Ms. ___ is a ___ h/o ___, DMI w/microvascular complications,
CABG, MVR s/p bioprosthetic repair, CKD stage IV, and PVD who
was recently discharged from ___ on ___ for ___
exacerbation who now represents from rehab with acute kidney
injury Cr now 4.7 up from baseline of 2.2. Patient was found to
be fluid overloaded and diuretic refractory and failed multiple
treatments with IV diuresis and drips requiring hemodialysis,
her hospital stay included a brief CCU stay for altered mental
status likely due to hypoglycemia, elevated LFTs likely due to
congestive hepatopathy and a diffuse drug reaction now
improving. Patient improved after initiation of dialysis and
tolerated it well.
# AoCKD- Baseline of 2.2, Cr on most recent discharge was 2.8
now presenting with Cr of 4.7. Chronic kidney disease secondary
to diabtes. Patient discharged on torsemide 80mg BID. Diuresis
was stopped in the setting of suspected ___. Cr started to down
trend and stabilized at 4.1. However patient appeared fluid
overloaded and was 2kg heavier from previous dry weight of 77
kg. Patient was started on IV lasix bolus + drip and Cr bumped
to 4.5. Renal ultrasound was negative for obstruction. Urine
microscopy showed pyuria, no evidence of muddy brown casts.
FeUrea 27. Urine cultures were negative. Renal team was
consulted and recommended patient be initiated on dialysis. She
underwent tunneled line placement with interventional radiology.
Patient underwent dialysis and her symptoms started to improve.
Patient also was started on sevelamer for elevated phosphate
levels. Patient was seen by vascular surgery for plans for AVF
formation as outpatient. PPD was noted to be negative.
# Chronic diastolic CHF : Patient treated during last hospital
stay with lasix drip, metolazone and transitioned to torsemide
80mg BID. On discharge her weight was 77kg and is likely her dry
weight. Patient now admitted at 79kg and lower extremity
swelling however denied dyspnea. Cr was 4.7 on admission.
Concerns that this may have been cardiorenal. Diuresis was held
initially and Cr improved to 4.1. Patient appeared fluid
overloaded and was started on IV lasix with bolus and urine
output was minimal. Patient was transferred to the CCU for
further work up and was initially diuresed with lasix drip and
metolazone, which had ___ output Patient continued to be
volume overloaded/ She refused a right heart cath as well as a
central line for closer hemodynamic monitoring. On ___ she
is net negative, with clear lungs, moderate lower extremity
edema. Patient was transferred back to floor. On the floor the
patient still appeared fluid overloaded and it was determined
that the patient likely fluid overloaded secodary to her renal
failure in conjunction with her diastolic CHF. Patient was
initiated on dialysis and her fluid status impoved. Patient was
aggresively diuresed with ultrafiltrate during dialysis and was
brought down to 79kg. She was fully well without dyspnea, chest
pain, or any other symptoms on discharge.
#Nausea/Vomiting/Elevated WBC count- During hospital stay
patient started to have worsening nausea and vomiting. She also
became lethargic, and poorly responsive. Her white count on the
floor elevated to 16. She was afebrile and normotensive. Her
LFTs showed elevation notably her alk phos. Could be secondary
to her CHF. Given her history and concern she was transferred
to the CCU for further management. Patient continued to be
afebrile during hospital stay. She completed her treatment for
c.diff (see below). Nausea and vomiting may have been secondary
to her gastroparesis. Patient did have more nausea and vomiting
after initiation of hemodialysis but it resolved in subsequent
days. Patient's white count remained elevated for unclear
reasons - she had no localizing signs of infection. Advised
rehab to continue to monitor her infection status, temperature,
fever curve.
#Change in mental status, resolved- Patient was poorly
responsive and appeared lethargic. VBG was 7.35/46/44 and
lactate 1.3. She had elevated ALT 121, AST 127, Alk Phos 1148.
Her extremities were warm and SBP in the 110s-120s. It was
unclear from the team the cause of her altered mental status,
but team felt it to be either CHF exacerbation versus uremia.
She was therefore transferred to the CCU for closer monitoring
and central line placement for serial CVO2s. CT head was
performed. She also underwent RUQ ultrasound for further
evaluation of transaminitis. Per RN report, at this time, her
FSG was 49 - and that the day prior, she also had a FSG of 39,
in the setting of 12 units NPH insulin and poor PO intake. Low
FSG may likely be the cause of the patient's altered mental
status, which appears to have clinically resolved at this time.
AMS may also be related to uremia (latest BUN 113). CT head
showed unchanged chronic infarcts. RUQ ultrasound showed
cholelithiasis. ___ team saw the patient and
provided recommendations on titration of insulin regimen.
Patient's blood sugars improved by time of discharge.
# Complicated UTI- Patient treated at last hospital stay with
fosfomycin. Completed on ___. Admission UCX negative.
Sterile pyuria. Patient was asymptomatic during hospital stay.
#C diff colitis: Diagnosed during last hospital stay treated
with flagyl and switched to PO vancomycin with goal to treat
till ___ however patient continued to have diarrhea.
Vancomycin was continued to with goal to treat 1 week after
completion of abx till ___ which she completed. Patients
diarrhea resolved.
# Drug reaction: Now significantly improved. Patient has had
recent onset of rash in the setting of having been on fosfomycin
(1% drug rash as adverse reaction), also has been on high dose
lasix and metolazone recently. Patient has notable eosinophila
of 6.7 (Eosiniphilia >7 generally concerning in DRESS).
Associated with low grade fevers up to 100.3 on ___. Patient
was evaluated by dermatology who thought this may be a drug
reaction vs leukoclastic vasculitis. Her symptoms improved with
medical therapy - clobetasol and desonide creams.
# Elevated LFTs and Alk Phos - Likely congestive hepatopathy-
improving. RUQ US w/o cholestasis. Most likely ___ passive
hepatic congestion from acute decompenstated CHF per hepatology;
no abd pain on exam; no evidence budd chiari, no jaundice, no
elvation bilirubin; possible infiltrative, though this would be
new for pt. Hepatology recommended outpatient follow-up with
Dr. ___. Of note, workup for other etiologies of
congestive hepatopathy were negative - Iron studies (normal),
AMA (negative), ___ (negative), ___ (negative), Hep B
serologies perviously show immunity, repeat hep C (neg) and VL
(pending), Immunoglobulins (normal). CEA elevated at 5.3, ___
normal. Liver team will follow her.
# ATRIAL FIBRILLATION: CHADS2 3 also MVR, currently in NSR.
Patient could not be bridged because of allergy to heparin but
she was restarted on her coumadin dosing and her INR was
therapeutic at time of discharge.
# BILATERAL HEEL ULCERS: the patient is following with podiatry
as an outpatient and plans to undergo hyperbaric oxygen therapy.
Podiatry is following the patient while in house, and underwent
debridement. By time of discharge, patient was able to bear
weight and pivot. She was provided tylenol for pain control. Her
heels appeared healing well without any erythema or drainage on
discharge, or any signs of infection, and she had no pain there.
#HTN: controlled on imdur and hydralazine. She was transitioned
from metoprolol to carvedilol.
#Hyperlipidemia: continued statin
#GERD: continued omeprazole
#Neuropathic pain: ___ DM; continued gabapentin
#Hypothyroidism: continued levothyroxine
#DM TYPE 2: Patient was seen by ___ consult who made
appropriate recommendations with improvement in blood glucose
sugars.
TRANSITIONAL ISSUES
- Monitor patient's INR for her atrial fibrillation, goal ___
- Monitor patient's rash which has improved with topical
steroids
- Monitor leukocytosis, no localizing signs/symptoms of
infection at this time
- Consider restarting statin if patient's LFT's improve
- On discharge, her weight was 77kg and is likely her dry
weight.
- Patient will be called by vascular surgery to have appointment
set up with ___ and have vein mapping done at that
time
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Bethanechol 50 mg PO TID
4. Cetirizine 10 mg PO DAILY
5. Cyanocobalamin 500 mcg PO DAILY
6. Gabapentin 100 mg PO TID
7. HydrALAzine 25 mg PO Q8H
8. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Warfarin 4 mg PO T, W, TH, SAT, SUN
13. Warfarin 2 mg PO M, F
14. Acidophilus (L.acidoph &
___ acidophilus) 175 mg oral
bid
15. Nephrocaps 1 CAP PO DAILY
16. Torsemide 80 mg PO BID
17. Fosfomycin Tromethamine 3 g PO EVERY OTHER DAY
18. Multivitamins W/minerals 1 TAB PO DAILY
19. Vancomycin Oral Liquid ___ mg PO Q6H
20. Collagenase Ointment 1 Appl TP DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Collagenase Ointment 1 Appl TP DAILY
3. Cyanocobalamin 500 mcg PO DAILY
4. Gabapentin 100 mg PO TID
5. HydrALAzine 50 mg PO Q8H
6. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Nephrocaps 1 CAP PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Warfarin 4 mg PO 5X/WEEK (___)
12. Warfarin 3 mg PO 2X/WEEK (MO,FR)
13. Acetaminophen 650 mg PO Q6H:PRN pain
14. Carvedilol 6.25 mg PO BID
15. Cepastat (Phenol) Lozenge 1 LOZ PO Q4H:PRN throat irritation
16. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID rash on
legs/arms Duration: 14 Days
Last dose ___. Clotrimazole Cream 1 Appl TP BID to perianal rash
18. Desonide 0.05% Cream 1 Appl TP BID Duration: 14 Days
Last dose ___. Docusate Sodium 100 mg PO BID:PRN constipation
20. NPH 24 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
21. Lidocaine 5% Patch 1 PTCH TD QPM pain
22. Senna 8.6 mg PO BID:PRN constipation
23. Sarna Lotion 1 Appl TP BID:PRN itchiness
24. sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Acute decompensated diastolic heart failure EF>55%
Secondary diagnosis:
Leukocytoclastic vasculitis vs Drug reaction
Acute on chronic kidney disease, initiated on HD
Congestive hepatopathy
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you here at ___. You were
admitted for worsening kidney function and weight gain of 7 lbs.
During your hospitalization, you were started on dialysis which
you tolerated well. You were also found to have increased liver
enzymes thought to be due to your heart failure. You will have a
follow-up appointment with the liver doctor in 1 month. You
also had a skin rash thought to be due to a drug reaction - you
were seen by the dermatologist and your symptoms improved with
administration of creams.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. On discharge your weight was 77kg and is likely your
dry weight.
Followup Instructions:
___
|
19855099-DS-27 | 19,855,099 | 29,977,744 | DS | 27 | 2170-05-28 00:00:00 | 2170-05-28 21:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Augmentin / heparin
/ ciprofloxacin / gabapentin
Attending: ___.
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with type 1 diabetes mellitus complicated
by retinopathy, nephropathy, neuropathy, and gastroparesis, CAD
s/p CABG with bioprosthetic MVR, HFpEF, and recurrent diabetic
foot ulcers who presents with hyperglycemia. The patient reports
difficulty controlling her blood sugars given her lower
extremity infection. She was found by her caretaker to have
persistent blood sugars greater than 500. The patient has been
on vancomycin and ceftazidime for her lower extremity
infections. She denies chest pain, shortness of breath,
abdominal pain, nausea, vomiting. Of note, the patient is
scheduled for BKA of her left lower extremity on ___.
In the ED, initial vital signs were 97.4 57 146/52 16 92%/RA.
Initial labs were notable for WBC 7.1k, HCT 31.6%, Na 132, FSBG
>500, pH 7.40. UA had bacteria, WBC, yeast, and glucose, but was
without ketones. Repeat sodium was 136. The patient was given
fluconazole, vancomycin, and her home medications. Given her
extended stay in the ED, the patient underwent HD on ___.
Prior to transfer, her vitals signs were 71 159/70 16 100%/RA
with a FSBG 168.
On the floor, the patient is in bed without complaint.
Review of Systems:
(+) per HPI
(-) 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:
- HFpEF
___ TTE: Well seated bioprosthetic mitral prosthesis high
normal gradient. Mild symmetric LVH. LVEF >55%
- Mild PAH
- ESRD: tunneled HD line ___
- CAD s/p CABG/bio MVR ___
- Afib (following CABG) on coumadin
- DM1 (complicated by retinopathy, nephropathy, neuropathy,
gastroparesis)
- Diabetic foot ulcers, PVD: non-healing L heel ulcer s/p angio
___ followed by ___
- CAD s/p CABG and MVR ___
- Charcot foot
- HLD
- HTN
- Mitral regurgitation s/p bioprosthetic MVR ___
- Endometriosis
- Blind in R eye
- Orthostatic hypotension secondary to autonomic neuropathy
Recent admissions:
___ (C diff, ___
___ (___)
___ (foot ulcer, UTI, ___)
___ (___ - CMED)
___ (foot ulcer - VSurg)
___ (___)
___ (CHF)
___ (___)
___ (___)
___ (pyelonephritis)
PAST SURGICAL HISTORY
- CABG w/MVR (___)
- Laproscopic procedures for endometriosis
- Tonsillectomy
- Multiple eye surgeries
- Multiple B/L foot debridements (with podiatry)
Social History:
___
Family History:
Mother: HTN, ___
Father: ___, CVA, CAD, MI
No history of malignancy
Physical Exam:
>> Admission Physical Exam:
VS: 98.7 126/45 95 18 97RA
GENERAL: NAD, lying flat in bed
HEENT: NCAT, cataract of right eye
NECK: Supple
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Generally CTA b/l on anterior exam
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: Tender edema of RLE, open heal ulcer of LLE without
significant purulence
NEURO: CN II-XII grossly intact
ACCESS: R-sided HD line without surrounding erythema
.
>> Discharge Physical Exam:
99.3, 105-131/50-60, HR 53-70s, RR 18, ___ RA
General: NAD, AOx3
HEENT: enuculeated R eye, conjunctiva pink, sclera anicteric,
MMM
NECK: supple, FROM, no LAD
CV: RRR, no m/r/g
LUNG: CTAP b/l
ABD: soft, non tender non distended
EXT: pulses difficult to appreciated. Erythematous on the shin
bilaterally. Left heel ulcer, dressed. no exudate, or
surrounding erythema.
NEURO: grossly intact
Pertinent Results:
>> Admission Labs:
___ 01:30AM BLOOD WBC-7.1 RBC-3.26* Hgb-10.1* Hct-31.6*
MCV-97 MCH-30.8 MCHC-31.8 RDW-18.1* Plt ___
___ 01:30AM BLOOD Glucose-561* UreaN-17 Creat-1.5* Na-132*
K-4.9 Cl-92* HCO3-28 AnGap-17
___ 01:45AM BLOOD ___ pO2-32* pCO2-48* pH-7.40
calTCO2-31* Base XS-3
.
>> Discharge Labs:
___ 06:35AM BLOOD WBC-6.1 RBC-3.71* Hgb-11.1* Hct-36.1#
MCV-97 MCH-29.8 MCHC-30.6* RDW-17.6* Plt ___
___ 06:35AM BLOOD Glucose-119* UreaN-15 Creat-1.5* Na-136
K-4.5 Cl-97 HCO3-31 AnGap-13
.
>> Pertinent Reports:
___ (PA & LAT): Mild to moderate pulmonary
vascular congestion and interstitial edema. Stable cardiomegaly.
.
>> Microbiology:
___ CULTURE-FINAL: MIXED BACTERIAL
FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
Brief Hospital Course:
Ms. ___ is a ___ w/ h/o DM1 c/b retinopathy, nephropathy,
neuropathy, gastroparesis, CAD s/p CABG with bioprosthetic MVR,
HFpEF, recurrent diabetic foot ulcers admitted with
hyperglycemia unresponsive to her usual insulin requirements
(FSBG > 500) likely 2'/2 worsening infection of L calcaneal
ulcer, but otherwise not septic appearing.
.
>> ACTIVE ISSUES:
# Hyperglycemia: Patient was found to have a FSBG > 500, and
given history of DM Type I, initial concerns for DKA. Initial
labs obtained in the ED not consistent with DKA, as no acidosis
on ABG. Possible precipitants for her hyperglycemia included
worsening infection of a chronic calcaneal osteomyelitis (see
below), which may be contributing to her erratic blood sugars.
Her blood sugar responded well to initial doses of insulin, and
therefore was continued on home insulin regimen with additional
sliding scale humalog as needed. Patient's blood sugars remained
well controlled upon arrival to the medical floor, and was
discharged on insulin regimen as an outpatient.
.
# Calcaneal Osteomyelitis: Patient has an extensive history of
osteomyelitis, most likely complicated by uncontrolled DM.
Patient is scheduled to have a BKA to obtain source control next
week by vascular surgery. Patient was previously on vancomycin,
ceftazadime, and metronidazole as an outpatient, with outpatient
ID follow-up. Given concerns for possible worsening of
infection, this was changed from ceftazadime to zosyn for better
coverage. Patient continued to appear non-toxic, and therefore
further antibiotic regimen was difficult to narrow given prior
resistant organisms in urine (not from ulcer). Discussed with
patient risks and benefits, and patient ultimately was changed
to short course of cefepime, and then back to original home
antibiotic regimen. It was discussed that given elevated blood
sugars, may represent uncontrolled treatment of an infection
resistant to current antibiotics, however patient requested to
leave hospital. Discussed risks and benefits with resuming prior
antibiotic therapy, however patient insisted on leaving on same
antibiotics, as patient did not wish to stay in hospital to
continue to receive daily antibiotics, and long-term access
discussed may not be helpful and patient deferred. Case was
discussed with vascular surgery upon admission, and plan for BKA
as scheduled. Vascular surgery requested risk stratification
from cardiovascular standpoint. Patient was deemed high risk
candidate given past medical history for possible medium risk
surgery. This was conveyed to vascular surgery prior to
discharge, and information regarding cardiology services as an
outpatient relayed to patient. Wound care per nursing, and
dosing of antibiotics scheduled with HD sessions while
inpatient.
.
# Urinary Tract Infection: Patient was intially found to have a
grossly posisitve UA, with pyuria. She was given fluconazole
initially given yeast in urine, however urine culture was
consistent with mixed flora. Patient has a large history of
resistant organisms, including Klebsiella and Enterococcus
resistant to both vancomycin and ceftazadmine. Patient also has
an extensive history of straight catherization, therefore at
very high risk for UTIs.
.
# Hyponatremia: Patient with baseline hyponatremia most likely
___ to hypervolemic hyponatremia. Patient had resolution of
this, with 1L fluid restriction per Nephrology.
.
# Diabetes Mellitus Type I: Patient with long standing history
complicated by retinopathy, neuropathy, nephropathy and
gastroparesis. Patient with history of very brittle diabetes,
and episodes of hypoglycemia in the past. Patient was continued
on home insulin regimen with good effect. Gabapentin
discontinued per patient request.
.
>> CHRONIC ISSUES:
# ESRD on HD: Patient was continued on HD per normal home
schedule, with additional session of ultrafiltration.
Antibiotics correctly dosed with HD schedule.
# CAD: Patient was continued on home regimen of aspirin,
carvedilol and lisinopril.
# dCHF: Patient initially presented with volume overload,
however resolved with HD. Her initial dyspnea also resolved with
HD, and was continued on home ___ regimen.
# Hypothyroidism: Patient was continued on home levothyroxine.
# Atrial Fibrillation: Patient was no longer on anticoagulation,
and was continued on home regimen as outpatient.
.
>> TRANSLATIONAL ISSUES:
# Antibiotics: Although no culture data from calcaneal
osteomyelitis, patient with UTI with very resistant organism to
ceftaz, cipro. Risks/benefits of long-term IV access for
antibiotic change.
# BKA: Patient to require cardiac clearance as outpatient.
Medicine to risk stratify. ___ also require recs regarding
glucose control as Type I DM.
# Hyponatremia: Patient to continue chronic 1L fluid restriction
# ESRD: Patient to continue dialysis ___, with antibiotics
with HD
# Surgery Risks: Given patients history, she would be considered
a high risk candidate for a medium risk surgery. Patient was
given information regarding cardiology services for further risk
stratifcation prior to planned BKA.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Cetirizine 10 mg PO DAILY
4. Cyanocobalamin 500 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Gabapentin 100 mg PO TID
7. HydrALAzine 10 mg PO Q8H
8. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Lidocaine 5% Patch 1 PTCH TD QPM pain
11. Lisinopril 10 mg PO DAILY
12. MetRONIDAZOLE (FLagyl) 500 mg PO TID
13. Nephrocaps 1 CAP PO DAILY
14. Omeprazole 40 mg PO DAILY
15. Senna 8.6 mg PO BID:PRN constipation
16. sevelamer CARBONATE 800 mg PO TID W/MEALS
17. Vancomycin 1000 mg IV HD PROTOCOL
18. Carvedilol 6.25 mg PO BID
19. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN severe pain
20. CefTAZidime 1 g IV POST HD (___)
21. NPH 25 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Carvedilol 6.25 mg PO BID
4. Cetirizine 10 mg PO DAILY
5. Cyanocobalamin 500 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. HydrALAzine 10 mg PO Q8H
8. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN severe pain
9. CefTAZidime 1 g IV POST HD (___)
IF ON HD, administer dose on the ward after patient returns from
each hemodialysis session.
10. Vancomycin 1000 mg IV HD PROTOCOL
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. Senna 8.6 mg PO BID:PRN constipation
13. Omeprazole 40 mg PO DAILY
14. Nephrocaps 1 CAP PO DAILY
15. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
16. Levothyroxine Sodium 25 mcg PO DAILY
17. Lidocaine 5% Patch 1 PTCH TD QPM pain
18. Lisinopril 10 mg PO DAILY
19. MetRONIDAZOLE (FLagyl) 500 mg PO TID
20. NPH 25 Units Breakfast
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Hyperglycemia
Secondary Diagnoses:
1. Type I DM
2. Calcaneal osteomyelitis
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 hospital stay
at ___. You were admitted here
to the hospital for high blood sugars. While here, you were
continued on antibiotics for the infection in your foot. We also
spoke with the vascular surgeons, who are still planning on the
operation next week. Your blood sugars remained controlled here,
and you also underwent dialysis while here per your usual
schedule.
Although you were still just in the hospital and are returning
shortly for your surgery, we still would recommend you return
for your ___ clinic appointments as these are important.
The following changes were made to your home medication regimen:
1. STOP Gabapentin - You did not tolerate this medicine in the
hospital
Please continue to weigh yourself every morning, call MD if
weight goes up more than 3 lbs. Please follow up with your
primary care doctor upon discharge from the hospital, and good
luck next week with your upcomming surgery.
Take Care,
Your ___ Team
Followup Instructions:
___
|
19855167-DS-19 | 19,855,167 | 29,745,665 | DS | 19 | 2140-06-20 00:00:00 | 2140-06-28 09:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pancreatic Leak
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a pleasant ___ year old ___ gentleman w/
h/o Stage III colon cancer s/p resection and recently PNET s/p
central pancreatectomy with PG anastomosis (___) who now
presents with one day of fevers to 103.1 and shaking chills. He
was recently discharge on ___ and doing well. He left with a
JP
drain which had about 50 cc/day of output. He was seen in the ED
the following day for dramatically decreased drain output to
only
10 cc/day. Given the low quantity, the drain was most recently
removed in clinic on ___. At the time he was afebrile, but did
report some nausea with salt tabs and constipation. His shaking
chills began on ___ and then a fever of 103. His family
called Dr. ___ recommended they come in for evaluation.
His
family took him to ___ where CT abd/pelvis showed two
fluid collections in the lesser sac and around the anastomosis.
He was given acetaminophen and dose of Zosyn and transferred to
___ for further evaluation given his recent surgical history.
He otherwise has no complaints of chest pain, shortness of
breath, nausea, vomiting, abdominal pain, blood per rectum. He
and his family report having poor, fatigue, weakness over all
since return from the hospital
Past Medical History:
PAST MEDICAL HISTORY:
Stage III colon CA s/p resection, adjuvant chemo
2. BPH.
PAST SURGICAL HISTORY
Back lipoma excision
sigmoid colectomy ___ - ___
Social History:
___
Family History:
Mother died of coronary artery disease.
Father dead from "throat infection"
Physical Exam:
Gen: Lying in bed, resting, not in acute distress. Alert and
cooperative
CV: RRR, S1S2
Pulm: Mildly rhonchorus chest, no wheezes or respiratory
distress
Abd: Soft, non-tender, non-distended. Well healing surgical
incisions without surrounding erythema, induration or drainage.
No hepatosplenomegaly.
Ext: Pulses and sensation all 4 extremities
Brief Hospital Course:
The patient was admitted to the ___ Surgery service for
pancreatic leak. His CT scan showed an undrained retrogastric
fluid collection, thus the patient was made NPO, started on IV
antibiotics, and initiated on TPN. He was also noted to be
hyponatremic so his free water intake was restricted to 1L. JP
drain fell out during his hospitalization. The patient did well
with this treatment and was eventually advanced to clears. After
he tolerated clears and had no fevers, chills, and white count
normalized, he was then transitioned to a regular diet and TPN
was discontinued. He completed a 7 day course of antibiotics.
After 24 hours the patient remained afebrile on a regular diet
and off of antibiotics, he was deemed safe for discharge home.
He was discharged home with plan to follow up with Dr. ___ in
clinic in 2 weeks with repeat CT scan to assess for improvement
or resolution of fluid collections.
Medications on Admission:
ASA 81', Colace, senna
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
ASA 81', Colace, senna
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic Leak
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for pancreatic leak and intra-abdominal fluid
collection that was not amenable to drainage. You have completed
a course of IV antibiotics and are tolerating a regular diet,
and you are ready to be discharged home. You should continue to
eat a regular diet and drink fluids.
Please call the office immediately if you experience fevers,
chills, drainage from your wound, worsening redness around your
wound, dizziness, nausea or vomiting.
Followup Instructions:
___
|
19855286-DS-18 | 19,855,286 | 20,551,005 | DS | 18 | 2201-05-23 00:00:00 | 2201-05-23 15:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Erythromycin Base / Lidocaine /
Lisinopril / Zoloft / Novocain / Keflex / atenolol / Mavik /
Avapro / Prilosec / Lipitor / Statins-Hmg-Coa Reductase
Inhibitors
Attending: ___.
Chief Complaint:
Palpatations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a ___ yo woman w/ a history of a "irregular heart
beat", hypertension, hypothyroidism and glacoma who presents
after having an episode of palpatations over night. Per the
patient's report she was at a friend's apartment the night prior
and had several pieces of fried chicken. She was hesitant to
eat this, because she felt it would upset her hiatal hernia, but
did so as not to offend her friend. Early the next morning
around 2 am she awoke from sleep with gas, belching and reflux
pain. She took some peptobismal and noticed around this same
time the abrupt onset of palpatations in her chest. She had
never had such a sensation before, but had been warned about it
by her cardiologist Dr. ___ at ___
given her history of a "irregular heart beat". She denies any
associated chest pain, jaw or arm pain, back pain, nausea,
vomitting, diaphoresis, light headedness or dizziness. She
called an ambulance, because it did not immediately resolve. By
report EMS found her to have a pulse between 140 and 200, but
were unable to capture it on an EKG before spontanesously
resolving.
In the Emergency Department 98.6 72 110/56 14 97%. She was
stable, a CXR was performed and negative for pneumonia, UA and
Troponin were negative and her CBC/CHEM 7 were within her normal
range. EKG showed normal sinus rhythm at a rate of 69 with no
ST segment changes.
On presentation to the floor she was 98.2, 113/55, 60, 20, 98.
She was asymptomatic at that time and without localizing
complaints.
ROS per HPI.
Past Medical History:
--CAD: Positive stress echo in ___, defect in PDA territory
--CHOLELITHIASIS W/O CHOLECCYS ___ ERCP
--CHOLEDOCHOLITHIASIS s/p ercp and papillotomy
--DIVERTICULOSIS
--GASTROESOPHAGEAL REFLUX
--BREAST CANCER
--HYPERTENSION
--HYPOTHYROIDISM
--MITRAL VALVE PROLAPSE
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM:
98.2, 113/55, 60, 20, 98
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, ___ murmur of
mitral regurgitation, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 05:40AM BLOOD WBC-8.5 RBC-3.84* Hgb-11.0* Hct-35.1*
MCV-91 MCH-28.6 MCHC-31.3 RDW-14.9 Plt ___
___ 05:40AM BLOOD Neuts-83.5* Lymphs-8.8* Monos-5.7 Eos-1.5
Baso-0.5
___ 05:40AM BLOOD Glucose-101* UreaN-19 Creat-0.7 Na-139
K-3.5 Cl-101 HCO3-27 AnGap-15
___ 05:55AM BLOOD cTropnT-<0.01
___ 05:40AM BLOOD Calcium-9.4 Phos-2.9 Mg-1.8
___ 05:40AM BLOOD TSH-11*
IMAGING
CXR:
The lungs are hyperexpanded, with biapical hyperlucency,
flattening of the hemidiaphragms, widening of the retrosternal
clear space. Again seen is pleural scarring at the lung apices,
left greater than right, with superior retraction of the left
hilum. There has been interval enlargement of the branch
pulmonary arteries. Heart size is normal. The aorta is tortuous
and unfolded. No pleural effusions, pneumothorax, or
pneumomediastinum. Left breast lumpectomy changes are noted.
IMPRESSION:
1. COPD, with worsening pulmonary hypertension.
2. Post-radiation left upper lobe volume loss.
Brief Hospital Course:
___ yo woman with a history of "irregular heart beat", mitral
valve regurgitaiton and hypertension presenting with
palpatations, found to be in sinus rhythm and discharged for PCP
and cardiology follow up.
.
PALPATATIONS: by the EMS report the patient had a heart rate of
140 to 200 and irregular at the time of initial presentaiton, by
the time she had arrived at ___ she was in normal sinus rhythm
and remained so on telemetry. The patient reported a history of
irregular heart beat and was being treated with diltizem 120 mg
AM and 90 mg QPM as well as past trials of lobateolol raising
the likelihood the patient had a history of paroxysmal afib. As
this was not felt to be new afib and despite the patient's CHADS
score of 2 the risks of anticoagulation were felt to outweigh
the benefits of starting a new medication in the acute setting.
She was discharged on her home regimen of diltizem 120 mg AM and
90 mg QPM and aspirin 81 mg daily with PCP and cardiology follow
up.
.
HYPOTHYROIDISM: as part of a work up of her palpatations
started in the emergency department a TSH was sent and was
mildly elevated at 11. She was continued her home synthroid 50
mcg daily as she did not exhibit clinical signs or symptoms of
hypothyroidism. Further dose changes were left to the PCP's
discression.
.
GLAUCOMA: Stable, continued home medications.
.
GERD: Stable, continued home ranitidine 150 mg BID>
.
OSTEOPEROSIS: Stable, continued home medications.
.
TRANSITIONAL ISSUES:
-blood and urine cultures were pending at the time of discharge
Medications on Admission:
diltiazem 120 mg AM and 90 mg QPM
dorzolamide-timolol 0.5%-2% 1 drop both eyes BID
Lantanoprost 0.005% 1 drop both eyes QHS
Levothyroxine 50 mcg daily
ranitidine 150 mg BID
aspirin 81 mg daily
calicum carbonate
vitamin D3
Colace
PreserVision multivitamin
Discharge Medications:
1. diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
2. diltiazem HCl 30 mg Tablet Sig: Three (3) Tablet PO QPM (once
a day (in the evening)).
3. dorzolamide-timolol ___ % Drops Sig: One (1) Drop
Ophthalmic BID (2 times a day).
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO Q6H (every 6 hours).
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
-paroxysmal afib
-hypothyroidism
SECONDARY
-mitral regurgitation
-osteoperosis
-gluacoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you while you were at ___
___ ___. You were admitted for
evaluation of your palpatations which were felt to be an acute
exacerbation of your known irregular heart beat. You were
discharged on your home medications and for follow up with your
primary care doctor and cardiologist.
You should take the following medications for your heart rate
-diltiazem 120 mg every morning
-diltiazem 90 mg every evening
-STOP lobateolol 200 mg twice daily
-CONTINUE aspirin 81 mg daily
-CONTINUE all other medications
Followup Instructions:
___
|
19855286-DS-21 | 19,855,286 | 20,473,821 | DS | 21 | 2207-12-18 00:00:00 | 2207-12-18 15:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Erythromycin Base / Lisinopril / Zoloft / Keflex /
Mavik / Avapro / Prilosec / Lipitor / Statins-Hmg-Coa Reductase
Inhibitors / Losartan
Attending: ___.
Chief Complaint:
Hemibody paresthesias
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with a past medical
history of afib on Eliquis, hypertension, PPM for tachy-brady
syndrome who presents with one week of intermittent left neck
pain, and one episode of hemibody paresthesias x5 minutes on the
day of presentation.
Patient reports that she has been in her usual state of health
as of late, although she hasn't been exercising at the gym as
frequently as she usually does for the past month because she's
been "lazy". She says that for the past week she has had daily
episodes of left neck pain that progresses to bilateral upper
back pain. She describes this pain as "pulling" and "tight". She
has had at most 2 episodes per day, but usually just 1 episode
per day. The pain lasts for about 10 to 15 minutes. For relief,
she has been wearing a soft cervical collar, as well as applying
heat locally and taking hot showers. All of these measures
improve the pain, but she continued to have episodes of pain.
On ___, she was experiencing a typical episode of pain, when
she suddenly felt "pins and needles" of her left arm and leg.
This lasted for about 5 minutes and then subsided and has not
recurred. It did not involve her face. She was concerned about
these symptoms, so she called a cab and was brought to ___
___ Urgent Care. There, they performed some basic lab studies
which were within normal limits including CBC and chemistry.
They had her brought in by ambulance to ___ for further
evaluation given concern for stroke.
Past Medical History:
ANEMIA
CHOLELITHIASIS W/O CHOLECCYS ___ ERCP
BREAST CANCER
ESOPHAGEAL SPASM
GOUTY ARTHROPATHY ????
HYPERTENSION
HYPOTHYROIDISM
MACULAR DEGENERATION
OPEN ANGLE GLAUCOMA
OSTEOPOROSIS
SCIATICA
SMALL BOWEL DIVERTICULOSIS
H/O MICROSCOPIC HEMATURIA
H/O TREMOR,ESSENTIAL
ATRIAL FIBRILLATION
TACHYCARDIA/BRADYCARDIA S/P ___
Social History:
___
Family History:
Father died of strokes.
Physical Exam:
ADMISSION EXAM:
===============
Vitals: T: 97.8 P: 58 R: 18 BP: 178/77 SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal
rigidity.
There is reproduction of her neck pain with head turn to either
side. There is decreased range of motion bilaterally.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: irregularly irregular. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
NIHSS: 0 (___)
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk, postsurgical. EOMI
without nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5- 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 1
R 2+ 2 2 1 1
Plantar response was flexor bilaterally. Pec jerk present on
the
right but not the left. No crossed adductors or suprapatellars.
No clonus. Negative ___ bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
DISCHARGE EXAM:
===============
VS: Temp: 98.1 (Tm 98.1), BP: 128/61 (128-149/61-68), HR: 60
(60-61), RR: 18, O2 sat: 96% (96-98), O2 delivery: RA
Exam
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
There is reproduction of her neck pain with head turn to either
side. There is decreased range of motion bilaterally.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: irregularly irregular. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk, postsurgical. EOMI
without nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone, strength throughout. No pronator
drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs: ___ this AM
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
Pertinent Results:
LABS:
=====
___ 09:32PM URINE HOURS-RANDOM
___ 09:32PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 09:32PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:32PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:32PM URINE RBC-5* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 09:32PM URINE MUCOUS-RARE*
___ 07:50PM cTropnT-<0.01
___ 07:50PM CALCIUM-9.3 PHOSPHATE-3.3 MAGNESIUM-1.9
___ 07:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 01:58PM GLUCOSE-86 UREA N-13 CREAT-0.7 SODIUM-142
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-26 ANION GAP-11
___ 01:58PM estGFR-Using this
___ 01:58PM cTropnT-<0.01
___ 01:58PM WBC-6.8 RBC-3.74* HGB-11.3 HCT-36.1 MCV-97
MCH-30.2 MCHC-31.3* RDW-14.6 RDWSD-51.3*
___ 01:58PM NEUTS-71.1* LYMPHS-13.8* MONOS-10.8 EOS-2.7
BASOS-0.7 IM ___ AbsNeut-4.80 AbsLymp-0.93* AbsMono-0.73
AbsEos-0.18 AbsBaso-0.05
___ 01:58PM PLT COUNT-193
___ 01:58PM ___ PTT-36.5 ___
IMAGING:
========
CTA HEAD/NECK ___:
1. There is no acute intracranial abnormality on noncontrast CT
head.
Specifically no acute large territory infarct or intracranial
hemorrhage.
2. Mild periventricular and subcortical white matter
hypodensities,
nonspecific, but compatible with chronic microangiopathy in a
patient this
age.
3. Allowing for atherosclerotic disease, essentially
unremarkable CTA of the head and neck.
4. 1.1 cm left parotid tail lesion which may represent an
abnormal lymph node versus primary parotid neoplasm. Further
evaluation with ultrasound is recommended.
5. Oval soft tissue asymmetry associated with the right
submandibular gland, which may represent asymmetric size of the
gland itself rather than
superimposed abnormal lymph node. This could be further
evaluated with
ultrasound at the same time as the left parotid lesion.
6. Additional findings described above.
NOTIFICATION: Further evaluation of 1.1 cm left parotid tail
lesion with
ultrasound.
Brief Hospital Course:
PATIENT SUMMARY:
================
___ is a ___ year old woman with a past medical
history of atrial fibrillation on Eliquis, hypertension, and
tachy-brady syndrome s/p PPM who presents with one week of
intermittent left neck pain, and one episode of hemibody
paresthesias for 5 minutes on the day of presentation.
Physical exam is non-focal, with no myelopathic signs. She does
not have brisk reflexes to suggest cervical spine disease but
she does have atrophy of the intrinsic hand muscles.
Suspect
that her symptoms are related to a degenerative cervical spine
disease. Pt. has a pacemaker and cannot undergo MRI. However,
doubt that MRI c-spine or brain will be of added value. We
advised Pt. to use a cervical collar more regularly. We will
discuss our plan with her primary Neurologist, Dr. ___. Her
tiredness may be related to her known hypothyroidism. TSH is 5.
Her dose of levothyroxine may need to be adjusted. Anticipate
D/C
home today, and follow up in Neurology clinic.
Etiology of episode of hemibody paresethesias was unclear. We
doubted a TIA as she experienced positive symptoms
(pins/needles) rather than numbness & her sensory symptoms
spared the face. Given ongoing neck pain, we suspected that her
symptoms were related to a degenerative cervical spine
disease. She has a pacemaker and cannot undergo MRI easily.
Additionally, patient is already on anticoagulation for atrial
fibrillation, and is allergic to statins. Therefore, we deferred
MRI and advised Pt. to use a cervical collar more regularly.
Her tiredness may be related to her known hypothyroidism. TSH is
5.
Her dose of levothyroxine may need to be adjusted.
TRANSITIONAL ISSUES:
====================
# Continue to wear cervical collar when sleeping
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amiodarone 200 mg PO DAILY
2. Apixaban 2.5 mg PO BID
3. Atenolol 25 mg PO BID
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Apixaban 2.5 mg PO BID
4. Atenolol 25 mg PO BID
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Muscle strain
Degenerative cervical spine disease
Abnormal skin sensations
Atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at ___
___.
You came to the hospital because of a pins and needles type of
sensation on the left hand side of your body. You were concerned
that you may have had a stroke.
Based on our physical examination, we do not believe that you
had a stroke. We decided to not do an MRI as you are already on
Eliquis for atrial fibrillation.
We think that the most likely explanation for your symptoms is
muscle strain.
After leaving the hospital, you should continue to take your
medications as prescribed. You should also continue to wear the
soft cervical collar to help with the arthritis in your neck.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
19855550-DS-10 | 19,855,550 | 24,986,476 | DS | 10 | 2144-05-22 00:00:00 | 2144-06-03 15:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Effexor XR / Zoloft
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy
History of Present Illness:
___ with known history of gallstones who presents to the ED
with complaint of epigastric abdominal pain which began last
night after eating a large meal. She reports that the pain
worsened around 1PM today, and has since been constant,
non-radiating, and achy in nature. Also reports + nausea, and
has
had one episode of emesis in the ED, non-bilious non-bloody. No
fevers/chills. No CP/SOB. Had a BM yesterday with an enema
(patient with chronic constipation at baseline), passing flatus.
No BRBPR/melena/hematochezia.
Past Medical History:
Gallstones, chronic back pain, history of
UTI, depression, epidermoid cyst
Social History:
___
Family History:
Non-contributory
Physical Exam:
T 98.2 HR 85 HP 130/82 Sat 95% RA
GEN: NAD, pleasant, somewhat anxious
CV: RRR, peripheral pulses intact
PULM: Mostly clear, bi-basilar rhonchi (improving), no Wheezing
or respiratory distress.
ABD: Soft, appropriately tender to palpation. Active bowel
sounds, no guarding. Laparoscopic sites are C/D/I
EXT: no edema, ambulating without difficulty.
NEURO: A+Ox3
Pertinent Results:
Admission labs
___
WBC-10.1# RBC-4.29 Hgb-13.1 Hct-38.7 MCV-90 MCH-30.4 MCHC-33.7
RDW-12.7 Plt ___
___
Glucose-106* UreaN-15 Creat-0.8 Na-138 K-5.0 Cl-103 HCO3-26
AnGap-14
___
ALT-30 AST-61* AlkPhos-79 TotBili-0.8
Discharge labs
___
WBC-6.8 RBC-3.40* Hgb-10.4* Hct-31.0* MCV-91 MCH-30.7 MCHC-33.7
RDW-12.5 Plt ___
___
Glucose-96 UreaN-10 Creat-0.7 Na-138 K-3.6 Cl-102 HCO3-28
AnGap-12
___
ALT-34 AST-30 AlkPhos-72 TotBili-1.1
Brief Hospital Course:
The patient presented Emergency Department on ___ with
symptomatic cholecystitis. Ultrasound evaluation showed numerous
mobile gallstones. She underwent laparoscopic cholecystectomy on
___. After an unevently recovery in the PACU, she was
transported back to the floor for post op recovery. On the
evening of ___, she experienced an acute desaturation event.
Based on exam findings and drastically increased oxygen demand,
she underwent CTA of the chest to rule out PE. There was no
evidence of pulmonary embolism, however, the CT did show
bilateral pleural effusion, Left lower lobe pneumonia and right
lower lobe atelectasis. Respiratory therapy was called to
bedside and performed recruitment manuevers and required
rebreathing face mask. We ensured monitored incentive spirometer
and out of bed activities. Her respiratory status graudally
improved, able to ambulate around the unit and weaned off oxygen
on POD#2.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: Negative work up for PE (see above), graudally weaned
off of oxygen without difficulty.
GI/GU/FEN: The patient was initially kept NPO for the procedure
and advanced to regular diet post op, she tolerated diet well.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Senna PRN, lactulose PRN, Vit D3, Vit B12
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drive while taking.
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
2. Senna 8.6 mg PO BID:PRN constipation
hold for diarrhea
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*20
Capsule Refills:*0
3. Docusate Sodium 100 mg PO DAILY:PRN constipation
hold for diarrhea
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth once a
day Disp #*20 Capsule Refills:*0
4. Acetaminophen 650 mg PO Q6H:PRN pain
Do not take more than 3000mg in a 24 hour period
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cholelithiasis
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
19855614-DS-14 | 19,855,614 | 22,273,842 | DS | 14 | 2145-10-30 00:00:00 | 2145-10-30 16:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___ posterior fossa crani for tumor resection
___ Left Parietal craniotomy evacuaton epidural hematoma
___ trach/peg
History of Present Illness:
Mr. ___ is a ___ year old male with history of headaches for
one year who presents with an abnormal OSH MRI. Patient first
noted head aches one year ago, mainly when first waking in the
morning with extension into his neck. His headache would
progressively resolve over the day and was mainly in the
occiptal
region. He has also had bouts of nausea and vomiting, also
mainly
in the morning. He denies fevers, chills, and malaise. Over the
last few weeks, he has had difficulty walking due to feeling
like
he was tilting to one side (not sure which side he favors). He
had been seen in the ED a few times over the year but with only
an xray of his neck. His PCP today recommended MRI which showed
a
suspicious mass, prompting presentation to the ED.
Past Medical History:
Gastritis from H. pylori
Social History:
___
Family History:
Brother with an unknown neck tumor
Physical Exam:
On admission:
98.2 80 ___ 97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: Reactive EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: able to complete finger-nose-finger but slow,
difficulty with rapid alternating movements, heel to shin
On Discharge:
AVSS
Gen: WD/WN, comfortable, NAD. Trach mask.
HEENT:normocephalic Pupils: 3-2mm bilat, slight right eye
deviation. EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
3-2mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: unable to assess
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Left upper and lower extremities ___. Right lower extremity
IP/QUAD/HAM ___ ___ ___. Right upper extremity follows
commands, ___
Incision: clean, dry, intact
Pertinent Results:
MRI & MRA BRAIN, W/O CONTRAST ___
Large cystic cerebellar mass with an enhancing nodule. Severe
hydrocephalus.
MRI of the C/T/L spine ___
Cerebellar mass again identified. No evidence of metastases or
paraspinal
abnormality.
NCHCT ___
IMPRESSION:
Given differences in modality, no evidence of acute change in
the severe
ventriculomegaly caused by the obstructing posterior fossa mass.
___ NON CONTRAST HEAD CT:
IMPRESSION:
1. New large extra-axial hemorrhage in the posterior fossa and
left
parieto-occipital regions, most likely epidural with mass effect
as described above. Focal hypodensities are concerning for
hyperacute hemorrhage.
2. Improved hydrocephalus compared to preoperative images.
4. Post-surgical changes from suboccipital craniectomy.
___ NON CONTRAST HEAD CT:
IMPRESSION:
1. Interval left parieto-occipital evacuation of extra-axial
hematoma with improvement of mass effect.
2. Ventriculomegaly remains improved compared to preoperative
CT. Stable
effacement of the sulci.
3. Postoperative changes from suboccipital craniectomy.
___ CTV:
IMPRESSION:
1. Large tentorial falx venous collateral extending below the
torcula with an abrupt termination at the level of surgical
clips in the posterior fossa may represent the source of the
patient's postoperative epidural hemorrhage. This vessel was
not visualized on the preoperative MR, possibly related to
compression secondary to the cerebellar mass.
2. New dural venous collaterals elsewhere maybe due to
compression of the
transverse sinuses by the epidural hematoma.
3. No evidence of acute dural venous sinus thrombosis with poor
opacification of the diminutive bilateral sigmoid sinuses
unchanged from the preoperative MR of ___.
4. Status post left parietal craniotomy and evacuation of
posterior epidural hematoma with unchanged extent of residual
blood products from the most recent prior CT and minimal
persistent rightward shift of midline structures.
5. Status post suboccipital craniotomy with stable postsurgical
appearance and mass effect in the posterior fossa. Hypodensity
of the right cerebellum may be related to chronic compression by
the large right cerebellar cystic mass with or without
superimposed postsurgical change
___ MRI w/wo
IMPRESSION:
1. 18 x 11 mm residual cystic structure in the right superior
vermis of the
cerebellum.
2. Probable small infarction or contusion inferior and
posterior to the
residual cystic structure. A small focus of linear enhancement
within this
area, not contiguous with the cystic structure, may be related
to blood/brain
barrier breakdown due to the infarct or postsurgical change;
attention on
follow-up is recommended to exclude residual enhancing tumor.
3. Stable small residual posterior fossa epidural collection of
air and small
amount of residual blood products.
4. Persistent right cerebellar tonsillar herniation and
effacement of CSF in the foramen magnum. Persistent effacement
of the basal cisterns.
Stable left subdural hematoma.
___: CXR
IMPRESSION: New bibasilar opacities which may reflect
aspiration or pneumonia in the appropriate clinical setting.
___ CTA:
IMPRESSION:
1. No pulmonary embolism.
2. Tiny left apical pneumothorax, hyperinflation, and
pneumomediastinum.
This raises concern for barotrauma.
3. Bibasilar consolidations consistent with aspiration
pneumonia.
___: NCHCT
IMPRESSION:
1. No significant change from prior with persistent
postoperative epidural air and blood.
2. Hypodensity within the cerebellum is concerning for
infarction but better seen on the prior MRI.
___: CXR
In comparison with study of ___, there is continued bibasilar
opacifications, more prominent on the right, consistent with
pneumonia.
Monitoring and support devices remain in place.
___: CXR
Again seen is a nodular appearing infiltrates in the right lower
lobe is has a slightly worsened appearance compared to 7 6 but
is improved compared to 7 3 in the left lower lobe infiltrate
has almost completely cleared. The ET tube and NG tube are
unchanged.
___: MRI with and without
New focal area of infarct in the midbrain. Stable cerebellar
and medial left temporal lobe infarcts. High-signal intensity
within dural sinuses as described above suggestive of thrombus.
Recommend CTV or MRV for further evaluation.
___ MRV
IMPRESSION:
Decreased signal in the region of the right sigmoid sinus likely
due to its small size. Findings are stable when compared to
prior CTA of the head.
There is no flow signal within the right jugular bulb. Findings
could
represent either slow flow or thrombosis.
___ CT
1. No significant interval change in the amount of postoperative
blood
present. However, there has been interval decrease in the
amount of air noted in this area.
2. Improvement in posterior fossa mass effect is noted as
compared to CT head from ___.
3. Ventricular size is stable as compared to CT head from ___.
___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
___ TEE with bubble
IMPRESSION: Small LV cavity size with hyperdynamic LV systolic
function. No significant valvular abnormality. Early appearance
of agitated saline bubbles in the left atrium/ventricle with the
patient performing the Valsalva maneuver. This finding is most
consistent with a patent foramen ovale
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
ENTEROBACTER AEROGENES. MODERATE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
___ upper extremity US
1. No evidence of a DVT in the right upper extremity veins.
2. There is a concern for a thrombus in the superficial vein
below the elbow which contains the peripheral IV.
___ CXR: The tip of the endotracheal tube is at the lower
clavicular level, approximately 5 cm above the carina. The
right IJ catheter appears somewhat more caudal than previously
and could well be in the upper portion of the right atrium.
Otherwise, little change.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
11:45 AM
IMPRESSION:
1. Subtle right greater than left basal opacities similar to
prior which could represent aspiration.
2. Tracheostomy tube in standard position.
___ Lower extremity doppler ultrasound:
No evidence of DVT in the bilateral lower extremities.
Brief Hospital Course:
___ y/o M with one year of headaches presents with R cerebellar
mass with significant ventriculomegaly. Patient was admitted to
neurosurgery for further management. On ___, patient was intact
on exam except for slow RAM. Surgery was discussed with patient
and family and MRI spine was ordered to rule out drop mets. An
MRI of the C/T/L spine was negative for any metastatic disease.
On ___, the patient had an episode of nausea and vomiting as
well as a reversion to his native tongue. Per the patient, he
felt more sleepy as well. He was sent for a stat NCHCT which
showed stable, but severe hydrocephalus. The decision was made
to take the patient emergently to the OR to resect the
cerebellum due to the recent neurological changes. Please refer
to operative note for details. The patient experienced
significant blood loss during the case requiring blood
transfusion. Post operatively the patient was taken to SICU.
Post op head CT showed new left epidural hematoma. He was taken
emergently back to the OR for evacuation. The patient was taken
back to ___ post operatively. Non contrast head CT showed
resolution of epidural hematoma, with improved ventriculomegaly.
Perioperatively he received antibiotics. He was started in
Decadron 10 mg every 6 hours.
On ___ in the morning, the patient was weaned off sedation. He
initally had equal and reactive pupils, he was moving all
extremities. He became more lethargic throughout the morning. He
became tachycardic and hypertensive. He was taken for STAT non
contrast head CT scan that was stable. CTV was also obtained
that showed large tentorial falx venous collateral which could
have been the source of epidural hemorrhage. The patient's
systolic blood pressure was kept strictly below 140. He was
started on Keppra. Throughout the day his exam improved. The
began to move all extremities to command.
On ___ the patient underwent an MRI that showed 18x 11 mm
residual cystic mass in the posterior fossa. HCT was 23.8, he
received 1 unit of PRBCs. His exam continued to improve.
Extubation was attempted, however the patient had to be
emergently reintubated. Decadron taper was started.
On ___ Pt self-extubated, CXR was completed to r/o PNA.
Re-intubated w/ poor O2 sat. Started on short-acting paralytic
and propophol but was dc'ed same day. Yesterday patient had a
L&R ___ gaze palsy and today he was noted to have a R
eye deviation (no blink reflex), moves BLE antigrav to command
and LUE, but nothing on RUE. Got stat HCT, load with 1G Keppra,
ordered EEG. CT showed increased swelling, no inc bleed. Got 50
mg Mannitol.
___: Continuous EEG reading showed seizures. He was loaded with
1500mg Keppra and increased his maitenance dose to 1500mg TID.
The right eye deviation continued on exam. Right sided neglect
mild on RLE but moves right side with coaching. Left side moves
and follows commands.
___: No seizures on EEG.
___: Due to previously transient, but now stable right upper
extremity plegia, Mr. ___ had an MRI
___: A chest x-ray showed a right lower lobe pneumonia. He was
started on vancomycin, cefepime as well as tobramycin. His
sputum was positive for gram negative rods. A 150g bolus of
Mannitol was given to improve cerebral edema in addition to his
50g every six hour dosing after an MRI showed increased edema
and a new infarct on his midbrain. For remainder of day and into
___, the pateint received 150g of Mannitol every six hours. His
serum sodiums and osms were consistently within limit.
Bilateral lower extremity ultrasounds were performed which were
negative for deep vein thrombosis.
___: The patient was started on 3% sodium started at 50cc/hr and
given 30cc of 23%NS following a central line placement. A MRV
showed no flow in R jugular but echo showed patency. He was
restarted on Dex 4q6.
___: In the early morning, the patient had a fever upto 102.
Cultures for blood/urine/sputum were sent. A final cultures for
urine was finalized from the ___ which showed the patient was
growing E. Aerogenes. Sputum was growing E. Aerogenes as well.
He was given another 30 ml of 23%NS and his 3%NS was increased
to 70cc an hour.
___: The patient's WBC was elevated to 23. He had loose stools
and a stool sample was sent to rule out CDiff. He was started on
Flagyl empirically for CDiff. His sodium levels remained in the
low 140s and he was slowly weaned off of 3% and 23%. His
Dilantin levels remained subtherapeutic and these labs were
discontinued yet he remained on his current dilantin regimen. He
continued on Vancomycin 1500 TID. The ECHO showed a PFO. It was
determined there was nothing to do. A right upper extremity
non-invasive vascular study was obtained on his right upper
extremity which was negative for DVT but showed a small thrombus
in a superficial vein below the elbow which contains a
peripheral IV. No intervention was warranted.
___: The stool culture was positive. He remained on Flagyl and
his WBC decreased to 17. He failed extubation. ACS was consulted
for placement of a trach.
On ___ his neuro checks were liberalized to q4h and he had a
trach and PEG placed without incident by the ACS service.
On ___ he was OOB to chair and was able to follow simple
commands in the Right hand.
On ___ he continued to spike fevers. ID was consulted. ___
were consulted. Speech was consulted for passey muir valve.
On ___, The patient was seen by OT & ___. Speech saw the
patient to evaluate for use of passy muir and it was noted that
there were a lot of oral secretions when testing for passey
muir. The cefipime was discontinued per infectious disease.
The dilantin was not thought to be a source of fevers and was
continued. Case management was contacted and rehabilitation was
initiated. The foley catheter was discontinued and a condom
catheter was placed.
On ___ he was seen by speech and swallow and again there were
too many secretiions to adequately assess his usage of a passey
muir valve. He was again febrile overnight to 101.8.
On ___ he was stable and was again febrile.
On ___ he worked with speech and swallow, he was afebrile, and
deemed fit for transfer to the floor with telelmetry given his
tracheostomy.
He remained stable on the neuroscience floor ___.
On ___, the Vancomycin and Flagyl were discontinued. He was
discharged to rehab in stable condition.
Medications on Admission:
Omeprazole 20 mg daily
Discharge Medications:
1. Dexamethasone 2 mg iv bid Duration: 2 Days
2. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
3. Docusate Sodium (Liquid) 100 mg PO BID
4. Ferrous Sulfate 325 mg PO DAILY
5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
6. Glucose Gel 15 g PO PRN hypoglycemia protocol
7. Heparin 5000 UNIT SC TID
8. Insulin SC
Sliding Scale
Fingerstick q6H
Insulin SC Sliding Scale using REG Insulin
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
10. LeVETiracetam Oral Solution 1000 mg PO BID
11. Methocarbamol 500 mg PO QID
12. Metoprolol Tartrate 50 mg PO Q6H
13. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
14. Ondansetron 4 mg IV Q8H:PRN nausea
15. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
16. Phenytoin (Suspension) 100 mg PO Q8H
17. Senna 1 TAB PO BID constipation
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R cerebellar lesion
Epidural hemotoma
Pneumonia
Urinary Tract infection
Respiratory failure
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance.
Discharge Instructions:
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101.5° F.
Followup Instructions:
___
|
19855614-DS-16 | 19,855,614 | 23,972,691 | DS | 16 | 2145-11-28 00:00:00 | 2145-11-28 14:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pseudomeningocele
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ years old male known to the neurosurgical service s/p
posterior craniotomy and resection of pilocytic astrocytoma on
___, left parietal craniotomy and evacuation of hematoma on
___,
trach and peg on ___, and drainage of pseudomeningocele on ___.
Now presents with reoccurrence of pseudomeningocele. He was
discharged to ___ on ___. While at
rehab, he and his family noticed an increased swelling in the
posterior aspect of his neck and intermittent headaches. A
ultrasound of his neck was obtained at the rehab facility and
showed re-accumulation of fluid in his neck measuring 7.2 X 5 X
4.5 cm. Patient was transferred to here to the ED for further
evaluation.
Past Medical History:
PMHx:
pilocytic astrocytoma
___ posterior fossa crani for tumor resection
___ Left Parietal craniotomy evacuation epidural hematoma
___ trach/peg
Gastritis from H. pylori
Social History:
___
Family History:
Brother with an unknown neck tumor
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
O: T:99 BP: 95/56 HR:98 R:18 O2Sats: 100% ra
Gen: Thin , well developed, NAD.
Neuro:
Mental status: Awake and alert, cooperative, normal
affect.
Orientation: Oriented to person, place, and date.
Moves all extremities.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors.
PHYSICAL EXAM ON DISCHARGE:
VSS
Gen: Thin , well developed, NAD.
Neuro:
Mental status: Awake and alert, cooperative, normal
affect.
Orientation: Oriented to person, place, and date.
Moves all extremities.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. R delt 4, Bi 4, Tri 4+, Grip 4, Left upper + bilateral
lowers full
Pertinent Results:
___ CT neck:
IMPRESSION:
1. Recurrent fluid collection in the posterior midline soft
tissues of the upper neck extending through the suboccipital
craniectomy defect measuring 9.9 x 5.4 x 5.3 cm is compatible
with pseudomeningocele. No enhancing nodular component is seen.
2. Stable post-surgical appearance of the posterior fossa,
status post
cerebellar mass resection with unchanged extent of hyperdense
material
posterior to the cerebellum. Resolution of pneumocephalus from
___.
3. Stable hypodensity of the cerebellum compatible with
evolving infarction.
___ 01:04PM LACTATE-1.4
___ 12:40PM GLUCOSE-86 UREA N-13 CREAT-0.4* SODIUM-141
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-29 ANION GAP-14
___ 12:40PM estGFR-Using this
___ 12:40PM WBC-5.2 RBC-3.69* HGB-10.7* HCT-32.4* MCV-88
MCH-28.9 MCHC-32.9 RDW-15.6*
___ 12:40PM NEUTS-71.3* ___ MONOS-6.2 EOS-3.8
BASOS-0.7
___ 12:40PM PLT COUNT-343
___ 12:33PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 12:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 12:33PM URINE RBC-2 WBC-9* BACTERIA-FEW YEAST-NONE
EPI-0
___ 12:33PM URINE CA OXAL-OCC
___ 12:33PM URINE MUCOUS-OCC
Brief Hospital Course:
Mr. ___, who is well known to our service was admited for
imaging and operative planning. CT of neck showed reaccumulation
of posterior fluid collection consistent with pseudomeningocele.
The patient was otherwise neurologically intact. He showed no
signs of infection.
On ___ the patient was screened to return to rehab. He has a
follow up appointment with Dr. ___ on ___ treatment planning.
He also worked with speech and swallow who recommended deferring
swallowing evaluation to therehab SLP who "knows Mr. ___
better." On ___ physical therapy recommend discharging to rehab
as patient is functioning well below baseline and has excellent
potential to make gains in rehab secondary to age, PLOF, ability
to perform antigravity movements and isolation of movement in
all extremities, and success in ___ thus far. A rehab bed was
available on ___ and it was determined that the patient had met
criteria to be discharged to rehab until a follow up appointment
on ___ ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN fever; pain
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. CloniDINE 0.1 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Famotidine 20 mg PO BID
6. Fentanyl Patch 12 mcg/h TD Q72H
7. Ferrous Sulfate 325 mg PO DAILY
8. Heparin 5000 UNIT SC TID
9. LeVETiracetam 1000 mg PO BID
10. Methocarbamol 750 mg PO TID:PRN muscle spasm
11. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
14. Senna 1 TAB PO BID
15. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
16. Sodium Chloride 3% Inhalation Soln 15 mL NEB PRN mucus
buildup
Discharge Medications:
1. Sodium Chloride 3% Inhalation Soln 15 mL NEB PRN mucus
buildup
2. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
3. Senna 1 TAB PO BID
4. Acetaminophen (Liquid) 650 mg PO Q6H:PRN fever; pain
5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
6. CloniDINE 0.1 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Famotidine 20 mg PO BID
9. Fentanyl Patch 12 mcg/h TD Q72H
10. Ferrous Sulfate 325 mg PO DAILY
11. Heparin 5000 UNIT SC TID
12. LeVETiracetam 1000 mg PO BID
13. Methocarbamol 750 mg PO TID:PRN muscle spasm
14. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pseudomeningocele
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
You
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Followup Instructions:
___
|
19855614-DS-19 | 19,855,614 | 23,939,520 | DS | 19 | 2149-08-09 00:00:00 | 2149-08-09 15:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right lower extremity weakness
Major Surgical or Invasive Procedure:
___ - T2-7 laminectomy and fenestration of arachnoid cyst
History of Present Illness:
___ yo M with complicated neurosurgical hx including
resection pilocytic astrocytoma and nonprogrammable VP shunt who
has had progressing right ___ weakness for several months. He
was
found to have a T2 arachnoid cyst causing compression of the
spinal cord and cord signal change at T2. He initially declined
intervention in ___. Since that time his weakness has
been progressing and he presents today with acute worsening of
weakness in the right leg and foot over the past ___ days. He
denies any sensory changes. Denies bowel or bladder
incontinence.
He states he is ready now for surgery given his inability to
walk
without a walker.
Past Medical History:
PMHx:
pilocytic astrocytoma
___ posterior fossa crani for tumor resection
___ Left Parietal craniotomy evacuation epidural hematoma
___ trach/peg
Gastritis from H. pylori
Social History:
___
Family History:
Brother with an unknown neck tumor
Physical Exam:
Upon Admission:
Gen: WD/WN, comfortable, NAD.
HEENT: incisions well healed at the VP shunt site and posterior
crani site
Neck: Supple. no meningismus
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Bilateral nystagmus in lateral gazes, rotational
nystagmus in upward gaze bilaterally
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors.
Upper Extremities ___ bilat
LLE: ___
RLE: IP, Q and H ___
AT and Gastroc ___
___ ___
No pronator drift
Sensation: Intact to light touch bilaterally. No sensory level.
Reflexes: B T Br Pa Ac
Right 2+2+2+ 3+ 0
Left 2+2+2+ 3+ 2+
Toes upgoing bilaterally
___ Beats Clonus at the Left Ankle only
No Hoffmans
Upon Discharge:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
D B T Grip IP Q H AT ___ G
R 4- 5 5 5 4- 4- 4- 4- 4+ 4-
L 4- 5 5 5 4 4+ 4+ 5------------>
Sensation: Intact to light touch bilaterally. No sensory level.
Pertinent Results:
Please see OMR for relevant imaging findings
Brief Hospital Course:
___ is a ___ year old male known to the neurosurgery service
who has had progressing right lower extremity weakness in the
setting of thoracic arachnoid cyst.
#Arachnoid cyst
Further workup with MRI of the spine shows no evidence of
changes from prior MRI earlier this month as well as from
___. MRI brain was completed and was stable. On ___,
he underwent T2-7 laminectomy and fenestration of cyst. The
procedure was uncomplicated. For further procedure details,
please see separately dictated operative report by Dr. ___. The
patient was extubated in the operating room and transported to
the PACU for post-procedure monitoring. Once stable, he was
transferred to the floor. On POD1, his diet was advanced, foley
was removed, and he began to mobilize. On ___ he was
deemed safe and ready for discharge to acute rehab with
appropriate follow-up with Dr. ___.
#Tachycardia: Patient was tachycardic post-operatively in the
low 100's. A EKG was reviewed with a medicine attending who
confirmed the findings were his baseline when compared to prior
EKGs and there is nothing acute. The patient denied
palpitations, chest pain, shortness of breath and sats are high
90's on room air. His fluid balance was positive 3 days after
surgery so his IV fluids were stopped.
#Pneumonia: A CTA chest was ordered in the setting of
tachycardia to rule out PE. The study was negative for PE
however did show left upper and lower lobe infiltrates
consistent with pneumonia. Patient was started on a 7 day course
of Levaquin.
#Disposition: Physical therapy and occupational therapy
evaluated the patient and recommended rehab.
Medications on Admission:
Vitamin D
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN for fever or pain
2. Bisacodyl 10 mg PO/PR DAILY
3. Dexamethasone 8 mg IV Q6H Duration: 4 Doses
This is dose # 2 of 6 tapered doses
4. Dexamethasone 6 mg IV Q6H Duration: 4 Doses
This is dose # 3 of 6 tapered doses
5. Dexamethasone 4 mg IV Q6H Duration: 4 Doses
This is dose # 4 of 6 tapered doses
6. Dexamethasone 2 mg IV Q6H Duration: 4 Doses
This is dose # 5 of 6 tapered doses
7. Dexamethasone 2 mg IV Q12H Duration: 2 Doses
This is dose # 6 of 6 tapered doses
8. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
9. Diazepam 2 mg PO Q8H:PRN muscle spasm
RX *diazepam 2 mg 1 tab by mouth every 8 hours as needed Disp
#*25 Tablet Refills:*0
10. Docusate Sodium 100 mg PO BID
11. Famotidine 20 mg PO BID
12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
13. Glucose Gel 15 g PO PRN hypoglycemia protocol
14. Heparin 5000 UNIT SC BID
15. HydrALAZINE 10 mg IV Q6H:PRN for SBP > 160
16. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
17. Levofloxacin 750 mg PO DAILY Duration: 7 Days
End ___
18. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours as
needed Disp #*50 Tablet Refills:*0
19. Senna 17.2 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Arachnoid cyst
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Discharge Instructions:
Discharge Instructions
Surgery
Your dressing may come off on the second day after surgery.
Your incision is closed with staples. You will need staple
removal. Please keep your incision dry until staple removal.
Do not apply any lotions or creams to the site.
Please avoid swimming for two weeks after suture/staple
removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
19855625-DS-9 | 19,855,625 | 21,673,287 | DS | 9 | 2167-05-27 00:00:00 | 2167-05-27 12:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
cc: fall
Major ___ or Invasive Procedure:
ERCP ___
History of Present Illness:
___ with history of mild dementia, CAD s/p CABG, s/p CCY, APPY
presented to OSH after unwitnessed fall. The patient pressed her
lifeline when she was unable to getup. She was on the floor and
the TV had fallen. It looked like the patient had tripped on the
rug and hit her hed on the TV stand. The pateint does not recall
how she fell. She denies having chest pain, feeling dizzy, no
loss of consciousness. She does report decreased appetite for
the last ___ months. Son reports she has not lost weight. She
went to ___ where she was found to have a C2
fracture and elevated LFTs and was transferred to ___ for
neurosurgical evaluation. The patient's son is at bedside and
provides much of the history, although he does not know much
about his mother's medical history. He reports she fell in
___ and broke her left shoulder she was sent to rehab at
that time but now lives alone.
She was seen by neurosurgery in the ED who recommended hard
collar at all times. She was transferred to the ___ for
evaluation of elevated LFTs.
On arrival to the floor, the patient denies neck pain. She has
no abdominal pain, no nausea or vomiting. No fevers or chills.
No weight loss. Has not noticed that her skin is yellow.
ROS: Remainder 10 point ROS negative
Past Medical History:
CAD s/p CABG
Hypertension
Hyperlipidemia
Mild Dementia
Left arm (?humerus) fracture ___
S/P CCY for gallstones
Social History:
___
Family History:
No history of CAD, diabetes or cancer
Physical Exam:
Vitals:
T97.9 BP:124/86 P:88 R:18 O2:97RA
Laying in bed in NAD with hard collar in place
HEENT: Pinpoint pupils, +scleral icterus, EOMI, dry mouth
Lungs: clear on anterior auscultation
___: RRR S1 S2 present
Abdomen: Soft, tender on palpation of epigastrium, RUQ, no
rebound or guarding. +RUQ scar
Ext: No edema. +tenderness to light touch
Neuro: CN II-XII grossly intact. Grip streghth good b/l.
Oriented to person, not year, can not name president. Says she
is in senior apartment (son says this is baseline).
Pertinent Results:
___ 07:57AM LACTATE-1.1
___ 07:55AM URINE HOURS-RANDOM
___ 07:55AM URINE HOURS-RANDOM
___ 07:55AM URINE UHOLD-HOLD
___ 07:55AM URINE GR HOLD-HOLD
___ 07:55AM URINE COLOR-Amber APPEAR-Clear SP ___
___ 07:55AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-0.2 PH-6.5
LEUK-SM
___ 07:55AM URINE RBC-5* WBC-10* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 07:40AM GLUCOSE-78 UREA N-27* CREAT-1.2* SODIUM-132*
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-20* ANION GAP-17
___ 07:40AM ALT(SGPT)-36 AST(SGOT)-48* ALK PHOS-210* TOT
BILI-9.0*
___ 07:40AM LIPASE-25
___ 07:40AM ALBUMIN-2.4*
___ 07:40AM WBC-11.7* RBC-3.78* HGB-11.6 HCT-33.4* MCV-88
MCH-30.7 MCHC-34.7 RDW-14.6 RDWSD-46.5*
___ 07:40AM WBC-11.7* RBC-3.78* HGB-11.6 HCT-33.4* MCV-88
MCH-30.7 MCHC-34.7 RDW-14.6 RDWSD-46.5*
___ 07:40AM NEUTS-81.5* LYMPHS-7.1* MONOS-10.8 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-9.55* AbsLymp-0.83* AbsMono-1.26*
AbsEos-0.01* AbsBaso-0.02
___ 07:40AM PLT COUNT-235
___ 12:05AM GLUCOSE-65* UREA N-28* CREAT-1.2* SODIUM-129*
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-20* ANION GAP-16
___ 12:05AM estGFR-Using this
___ 12:05AM ALT(SGPT)-38 AST(SGOT)-51* ALK PHOS-222* TOT
BILI-9.6* DIR BILI-8.0* INDIR BIL-1.6
___ 12:05AM LIPASE-42
___ 12:05AM ALBUMIN-2.7*
___ 12:05AM WBC-12.6* RBC-3.75* HGB-11.4 HCT-32.9* MCV-88
MCH-30.4 MCHC-34.7 RDW-14.5 RDWSD-46.4*
___ 12:05AM NEUTS-79.1* LYMPHS-10.4* MONOS-9.9 EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-9.93* AbsLymp-1.31 AbsMono-1.24*
AbsEos-0.01* AbsBaso-0.01
___ 12:05AM PLT COUNT-229
___ 12:05AM ___ PTT-30.8 ___
Imaging:
MR cervical spine: Wet Read
1. Increased STIR signal at the base of the odontoid process and
bilateral
pedicles, consistent with acute hangman fracture of C2.
2. No evidence of cord signal abnormality.
3. No frank ligamentous disruption.
4. Moderate degenerative changes of the cervical spine with
moderate spinal canal stenosis at C4-5, C5-6 due to disc bulge
and uncovertebral hypertrophy.
Ct Torso:
IMPRESSION:
1. No acute fracture. No solid organ injury.
2. Mild peripancreatic standing and retroperitoneal fascial
thickening. ___
represent pancreatitis. Please correlate with laboratory
results. No large
fluid collection.
3. Mild dilatation of the intrahepatic ducts and biliary ductal
dilatation,
may relate to prior cholecystectomy.
4. Bilateral adnexal hypodensities measuring up to 4.1 cm with
right gonadal
vein enlargement and right lymphadenopathy. Nonemergent pelvic
ultrasound is
recommended for further evaluation if clinically indicated.
5. Subcentimeter hypodensity in the right adrenal gland. If
clinically
indicated, nonemergent dedicated imaging of the adrenal glands
recommended for
further evaluation.
CTA:
IMPRESSION:
1. Carotid and vertebral arteries are patent with no evidence of
dissection or
stenosis.
2. Known fracture of C2 extending into lateral masses and
involving the right
transverse foramen.
MRI- C spine
IMPRESSION:
1. Study is moderately degraded by motion.
2. Grossly stable acute type 3 odontoid process fracture at
odontoid process
base.
3. Partially visualize chronic wedge T6 vertebral body
compression fracture.
4. Within limits of study, no definite cervical spinal cord
lesion
identified.
5. Moderate to severe cervical spondylosis as described, most
prominent at
C4-C5 through C6-C7, where there is moderate vertebral canal
narrowing.
6. Severe C5-6 right, moderate C4-5 and C6-7 bilateral, and
moderate C5-6 left
neural foraminal stenosis.
7. Occipital condyle/skullbase nonspecific edematous changes as
described.
8. C1-2 interspinous ligament edema, which may represent
ligamentous injury.
ECHO: ___
The left atrial volume index is normal. Normal left ventricular
wall thickness, cavity size, and regional/global systolic
function (biplane LVEF = 77 %). Diastolic function could not be
assessed. Right ventricular chamber size and free wall motion
are normal. The number of aortic valve leaflets cannot be
determined. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Normal biventricular regional/global systolic
function.
Brief Hospital Course:
___ with history of CAD s/p CABG, fibromyalgia, s/p CCY for
gallstones who presented with mechanical fall found to have C2
fracture and elevated LFTs concerning for biliary obstruction.
#C2 Fracture
In setting of mechanical fall. The patient was evaluated by
neurosurgery. She had an MRI which did not reveal cord
involvement and a CTA which ruled out vascular involvement. Seen
by neurosurgery who have recommended no surgical intervention.
The patient should wear a hard collar at all times. She will
need outpatient follow up in ___t that time.
#Obstructive Jaundice
Patient with elevated LFTs, bilirubin. CT abdomen with dilated
bile ducts and stranding surrounding pancreas concerning for
pancreatitis. The patient underwent ERCP without findings of
stone. The patient most likely passed a stone as her LFTs
trended down without intervention. She was continued on Cipro
500mg BID x 5 days total.
#Dementia
#Encephalopathy
Patient with mild-moderate dementia at baseline. Remains
intermittently confused- more than her baseline per her
daughter. She was started on Trazodoone to help maintain
sleep/wake cycle. Nameda was continued.
#Atrial fibrillation
Patient had transient atrial fibrillation on admission. She was
given one dose of IV metoprolol and converted to sinus rhythm.
She was rule out for ACS and had a ECHO without WMA or valvular
disease. She was not started on anticoagulation d/t transient
nature of the arrhythmia.
#Dysphagia
In setting of C2 fracture and c-collar. She was seen by speech
and swallow and started on a modified diet.
#Hyponatremia
Likely hypovolemic in setting of reported poor PO intake.
- resolved with IVF
#Acute renal failure
Creatinine improved with IVF
#CAD S/p CABG
#?CHF
On Lasix as outpatient, does not appear volume overloaded on
exam. No longer on simvastatin per pharmacy. ECHO without WMA.
EF preserved. Lasix was held while she was inpatient. She was
continued on her home BB.
Transitional issues:
- Bilateral adnexal hypodensities measuring up to 4.1 cm with
right gonadal vein enlargement and right lymphadenopathy.
Nonemergent pelvic ultrasound is recommended for further
evaluation if clinically indicated.
- Subcentimeter hypodensity in the right adrenal gland and left
adrenal gland nodularity. If clinically indicated, nonemergent
dedicated imaging of the adrenal glands recommended for further
evaluation.
- Short duration A-fib in the hospital. Not anticoagulated due
to recent trauma. Consideration as an outpatient for initiation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Potassium Chloride 10 mEq PO BID
3. pilocarpine HCl 5 mg oral TID
4. Omeprazole 20 mg PO DAILY
5. Memantine 10 mg PO BID
6. Metoprolol Tartrate 25 mg PO BID
7. Furosemide 40 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN ches pain
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp
#*30 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Senna 8.6 mg PO QHS
5. TraZODone 25 mg PO QHS insomnia
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. Memantine 10 mg PO BID
9. Metoprolol Tartrate 25 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN ches pain
12. Omeprazole 20 mg PO DAILY
13. pilocarpine HCl 5 mg oral TID
14. Potassium Chloride 10 mEq PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fall with C2 fracture
Obstructive LFTs likely due to passed stone
Hyponatremia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms ___,
You were admitted to the hospital following a fall and were
found to have a broken bone in your neck. You must remain in the
neck brace until you have a repeat CT scan to ensure that it is
healing. You were also noted to have what may have been an
obstruction in your biliary ducts and had a procedure (ERCP) but
there was nothing blocking. It is thought that you had a stone
that passed on its own. Your liver tests continued to improve.
Followup Instructions:
___
|
19855999-DS-11 | 19,855,999 | 26,076,118 | DS | 11 | 2131-07-05 00:00:00 | 2131-07-05 15:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with a history of pBPH
complicated brecurrent UTIs who was originally brought to the
ED on ___ after fall from the 2
story window of his memory care unit. He was transferred to
___ on ___ for further care.
The history was obtained by the patient's daughter, ___, and
through OMR notes.
The patient was in his normal state of health, living
independently on a 200 acre farm until this past ___. At
that time he and his wife, moved to an independent living
facility. Both the patient and his wife seemed to decompensate
slightly from their baseline after this move. The patient
seemed
more forgetful. He would also drive around all day, and drive
back to the farm that he just moved away from, because he missed
it.
On ___, when he was walking outside, he suffered a
massive PE. He was transported to ___. At that
time, a CTA showed bilateral pulmonary emboli, so he was
transferred to ___. At ___, he got TPA. After receiving TPA, the patient became
very aggressive, rude, agitated, and started having
hallucinations. The medical team was using Haldol to chemically
restrain him, which his daughter reported made him more
confused.
After several days of this, they checked a UA which was notable
for a urinary tract infection. He started treatment for his
urinary tract infection, and his mental status improved. From
there, he was discharged to rehab. He was accepted back into
the
___ facility from rehab on the condition that he
would have a home health aide. He was refusing to let the home
health aide in, and he was becoming aggressive and rude again at
his home.
On ___, he was agitated,
aggressive, and tried to hit his daughter, for which he was sent
to ___ and found to have a UTI. His
daughter reported that he was evicted out of his independent
living facility for his
aggressive episode and so he went to live on the dementia floor
of the ___ living facility in ___. On
___, he had another episode of agitation, hallucinations and
was again found to have a UTI at ___.
On ___, patient's son and ___ grandson visited him at
___. He really enjoyed spending time with his family. His
daughter reported that he told his son that he was trying to get
out of ___ as he did not like it there. He was much more
functional than everyone else in the facility and said that
"this
is a place where people come to die." He told his son he had
found a way to escape.
Two days later, he fell out of a second story window. His
daughter thinks that when patient went out the ___ floor window,
he was thinking his son would be there
with a car ready to pick him up and help him "escape" from
___. She does not think that Mr. ___ had attempted to
commit suicide.
His daughter reported that at his PCP's office about 2 weeks
ago,
patient scored ___ on MMSE.
Mr. ___ was brought into the ED by EMS after a fall from
2-stories with systolics in the 140s and was noted to have
altered mental status, back pain, and a deformity of the left
ankle. He was taken to the CT scanner where his SBP dropped to
the ___. Preliminary reports of imaging showed a left pelvic
fracture with active extravasation and a space of Retzius
hematoma. Subsequently, patient's SBP dropped as low as ___
systolic and transfusion of blood products was started. ___ was
emergently consulted for embolization.
In addition to known left ankle fracture and left pelvic
fracture, patient was noted to have multiple spinal fractures as
well as concern for a left renal clear cell carcinoma with
possible metastases. All of these findings were conveyed to
___
and again to her brother ___ when he arrived (also a HCP).
___ also told the team that her father had extensive
behavioral
issues of late, related to his worsening dementia, and had been
threatening suicide for weeks-to-months. She verbalized that she
believed this incident to be a suicide attempt and that he would
not any extreme measures to be undertaken to save him. She also
voiced concern that her father was already losing his memory and
that his mobility was all that he had left of his health. She
was
concerned that the aforementioned skeletal injuries would
greatly
impede his mobility and thus take away any remaining quality of
life that he previously enjoyed. The patient's son, ___, agreed
with all of these statements and together, they agreed that they
would like to call off the Interventional Radiology Procedure
and
proceed with CMO care.
The patient was returned to the TSICU intubated with plans for
extubation after clearance of previously dosed paralytic.
After further discussion with the patient's family (specifically
his daughter and his HCP ___, the decision was made to
continue with DNR/DNI code status but not to pursue CMO status
at
this time. The family agreed with continuing medical management
with the goal of discharge to a rehab facility when appropriate.
As such, the patient was extubated. Psychiatry was consulted for
assistance with management of his depression and dementia. Spine
surgery and orthopedic surgery were consulted for
recommendations
regarding non-operative management of his injuries, the family
had agreed not to pursue any surgical interventions. The patient
was transferred to the floor when deemed clinically stable.
He got two doses of zosyn for possible UTI.
Neurosurgery was consulted on ___ for the spinal
fractures. They recommended obtaining an MRI of the spine to
further evaluate this ___ years. This was done on ___.
Neurosurgery evaluated patient again on ___. At that
time, they recommended that the patient wear a TLSO brace when
out of bed. The plan was for follow-up with neurosurgery
outpatient in 1 month and x-ray imaging.
He continued to recover on the floor. His mental status
improved,
and the family elected to pursue further medical care with the
patient's DNR and DNI status continuing. Given the absence of
operative intervention in the management of his injuries, the
difficult management of his cognitive status, and his ongoing
chronic medical conditions, the decision was made to transfer
the
patient to the Medicine service for further management.
Past Medical History:
Past Medical History:
- BPH
- colonic polyps (gets colonscopies every ___ years given family
history - sister died of colon CA at age ___
- diverticulosis
- history of lyme disease treated with doxycycline
- pulmonary nodule followed with serial CT at ___
Social History:
___
Family History:
-strong family history of colon CA (sister died at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
GEN: NAD
HEENT: PERRLA, no scleral icterus, blood in oropharynx, no
active lacerations/bleeding
CV: RRR
PULM: non-labored breathing, nasal cannula
ABD: soft, NT/ND, incarcerated left inguinal hernia
GU: uncircumcised penis, no blood at meatus
EXT: WWP, obvious deformity of left ankle with medial rotation
NEURO: opens eyes spontaneously, GCS 11
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: Alert, sitting up in bed, pleasant
CV: RRR,
PULM: CTAB, no increased work of breathing
EXT: Cast on left foot. RLE warm and well perfused, no edema
NEURO: AAOx1, face symmetric, grossly moving all extremities.
Pertinent Results:
Notable Labs/Reports:
=====================
MICROBIOLOGY:
=============
ime Taken Not Noted Log-In Date/Time: ___ 3:57 pm
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.
ESCHERICHIA COLI. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S =>32 R
CEFAZOLIN------------- <=4 S =>64 R
CEFEPIME-------------- <=1 S R
CEFTAZIDIME----------- <=1 S 4 S
CEFTRIAXONE----------- <=1 S =>64 R
CIPROFLOXACIN---------<=0.25 S =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 128 R <=16 S
PIPERACILLIN/TAZO----- <=4 S 8 S
TOBRAMYCIN------------ <=1 S =>16 R
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
IMAGING
=======
___ CT Head
No evidence of fracture, hemorrhage or infarction.
___ CT Chest/Abdomen/Pelvis
1. Space of Retzius hematoma with contrast extravasation along
the course of the distal left internal pudendal the artery,
adjacent to the left pubic bone/inferior pubic ramus. Small
additional hematoma anterior and inferior to the pubic
symphysis. Pubic symphysis diastasis noted.
2. Comminuted left acetabulum fracture extending into the left
iliac wing with hematomas adjacent to/involving the left
iliacus, obturator internus, and piriformis musculature.
3. Subtle nondisplaced inferior right acetabulum fracture.
4. T12 burst fracture without osseous retropulsion. Subtle L1
burst fracture near the superior endplate. Additional fractures
include the T11 and T12 spinous processes, left T11 inferior
articular process, and T12 and L1 transverse processes.
5. A 2.8 cm left renal mass is very concerning for a clear cell
renal cell
carcinoma.
6. Right hepatic lobe lesions measuring up to 2 cm are
indeterminate. Consider MRI for further evaluation.
7. Indeterminate 1.9 cm hypoattenuating lesion along the dorsal
aspect of the proximal pancreatic tail. Consider MRI for further
evaluation.
8. A 1.8 cm hyperenhancing lesion in the spleen could reflect a
hemangioma,
but in the presence of a probable left clear cell renal cell
carcinoma,
metastasis cannot be excluded. Recommend attention on additional
imaging as recommended above.
9. Incidental 5 mm right lower lobe pulmonary nodule with
moderate
centrilobular emphysema. For incidentally detected single solid
pulmonary
nodule smaller than 6 mm, no CT follow-up is recommended in a
low-risk
patient, and an optional CT in 12 months is recommended in a
high-risk
patient.
10. Multinodular thyroid gland with individual nodules measuring
up to 1.3 cm. Per ACR guidelines, no specific follow-up imaging
is recommended.
11. Diffuse fusiform aneurysmal dilation of the very tortuous
bilateral common iliac arteries.
12. Mild nonspecific enlargement of bilateral pelvic sidewall
lymph nodes.
13. Severe prostatomegaly.
RECOMMENDATION(S):
1. A 2.8 cm left renal mass is very concerning for a clear cell
renal cell
carcinoma. Urology consult.
2. Right hepatic lobe lesions measuring up to 2 cm are
indeterminate. Consider MRI for further evaluation.
3. 1.9 cm hypoattenuating lesion along the dorsal aspect of the
proximal
pancreatic tail. This could also be evaluated on the MRI
performed for the hepatic lesions.
4. A 1.8 cm hyperenhancing lesion in the spleen could reflect a
hemangioma, but in the presence of a probable left clear cell
renal cell carcinoma, metastasis cannot be excluded. Recommend
attention on MRI.
5. Incidental 5 mm right lower lobe pulmonary nodule with
moderate
centrilobular emphysema. For incidentally detected single solid
pulmonary
nodule smaller than 6 mm, no CT follow-up is recommended in a
low-risk
patient, and an optional CT in 12 months is recommended in a
high-risk
patient.
___ CT C-spine
1. No evidence of fracture.
2. Mild degenerative subluxations at multiple levels.
3. Multinodular thyroid gland with nodules measuring up to 1.3
cm. Per ACR recommendations, no follow-up imaging is
recommended.
___ L Ankle Xray
Possible trimalleolar fracture with an obliquely oriented
fracture along the medial aspect of the distal tibia, a
transversely oriented fracture through the distal fibula, and a
possible vertically oriented fracture along the posterior aspect
of the distal tibia. The mortise is disrupted.
___ MRI Thoracic and Lumbar Spine
1. Acute compression fractures of the T12 and L1 vertebral
bodies associated with a posterior epidural hematoma measuring
43 x 11 x 4 mm which, in association with a disc bulge at this
level, result in severe spinal canal narrowing. No cord signal
abnormality.
2. Right facet joint edema at T11-T12, could be associated with
a fracture.
3. Incomplete and limited imaging of the thoracic spine
demonstrate posterior soft tissue edema and probable
interspinous edema involving T2-T3 through T4-T5. Ligamentous
injury at these levels cannot be excluded.
4. Multilevel degenerative changes as described in detail above,
including
mild retrolisthesis of L2 over L3 and L3 over L4, and spinal
canal and neural foraminal narrowing most significant at T11-T12
through T12-L1, and L3-L4.
5. 2.1 x 1.8 cm left cortical renal mass for which nonemergent
follow-up
ultrasound is recommended.
6. Thickening of the partially imaged urinary bladder wall,
nonspecific.
Could also be evaluated with nonemergent ultrasound.
___ CTA
1. No evidence of pulmonary embolism to the segmental level,
with limited
assessment at the lung bases due to respiratory motion.
2. Bibasilar consolidations are likely predominantly
atelectasis, although
superimposed aspiration or pneumonia could also be considered if
clinically appropriate.
3. Small left and trace right nonhemorrhagic pleural effusions.
4. Minimally displaced left ninth through eleventh rib
fractures.
5. Bilateral L1 transverse process fractures.
6. T12 spinous process fracture.
7. Re-demonstrated burst fracture of T12 extending to the
posterior elements and compression fracture of L1. The known
epidural hematoma is not well assessed on CT.
___ Video Swallow Evaluation
There is penetration with thin liquids. No penetration or
aspiration with
nectar thick liquids.
___
Medial and lateral malleolar fractures as described above.
Slight medial displacement of the medial malleolar fracture with
suggestion of widening of the medial clear space.
___ MRI Brain
1. Likely a punctate subacute infarct in the right posterior
frontal convexity region. Otherwise, no other acute
abnormalities.2. Moderate to severe changes secondary to chronic
microvascular angiopathy.3. Brain and medial temporal atrophy.4.
No enhancing brain lesions.
___ Pelvis 2-view
IMPRESSION:
There is a subtle linear lucency projected over the medial wall
of the
acetabulum, may represent a nondisplaced fracture.
There are background mild to moderate degenerative changes of
the hips, and SIjoints, with degenerative discopathy and facet
OA at the lower lumbar spine.
___ PELVIS AP ___ VIEWS
IMPRESSION:
There remain mildly displaced bimalleolar fractures, with
progressive talar
tilt, and subluxation of the tibiotalar joint, potentially
unstable.
Constellation of Findings favored to represent supination
adduction injury,
___ stage II.
___:
CT Lumbar/Thoracic Spine
1.There are mildly displaced fractures of the posterior left
seventh and
eighth ribs. These fractures were not included in the field of
view on MRI ___.
2. T12 burst fracture with extension into the right facet and
left lamina isgrossly unchanged as compared to ___.
No retropulsion.
3. Transversely oriented fracture of the L1 vertebral body is
grossly
unchanged in morphology as compared to ___.
4. Non-displaced fracture of the spinous process and bilateral
lamina of T11and non-displaced fractures of both transverse
processes of the L1 vertebralbody were not definitely visualized
on ___.
5. Previously characterized posterior epidural hematoma is
poorly evaluated on the CT scan. MRI can be considered for
further characterization for
evaluation of an epidural collection.
6. Re-demonstration of a subtle cortically based mass in the
left kidney,
better characterized on ___, for which nonurgent MRI
is
recommended for further characterization.
Brief Hospital Course:
This is a ___ male with a past medical history of BPH
status post multiple urinary tract infections, mild cognitive
impairment , who presented to the hospital after traumatic fall
from a second story with multiple fractures. Orthopedic surgery
evaluated the fractures, and determined that he was
non-operative. His left ankle was casted. Neurosurgery
determined that his spinal fractures did not require operation.
His hospital course was complicated by sepsis from urinary
source with Klebsiella and E. coli. He also had a E. coli
bacteremia. He was treated with 2 weeks of antibiotics. His
mental status gradually improved. He was discharged to rehab on
suppressive antibiotic therapy with Bactrim which should be
continued indefinitely to prevent recurrent UTI
#MRD E-coli Bacteremia
#Sepsis due to urinary source, Klebsiella and E. coli
On admission, the patient's UA was without evidence of
infection. His urine culture was negative. He became
intermittently agitated and delirious during hospitalization.
He pulled out his Foley at one point. He was reinserted.
Several days after that, he had fever, chills, ___. I
repeat UA at that time grew Klebsiella and E. coli. Blood
cultures at that time grew E. coli. Infectious disease was
consulted. He was started on ceftaz edema continue to 14-day
course of ceftazidime from ___ - ___. After this,
he was continued on suppressive Bactrim per infectious disease
recommendations. Bactrim should be continued indefinitely to
prevent recurrent UTI. If patient becomes confused at rehab, UTI
should be considered as top priority. The patient is known to
become increasingly delirious and confused with UTI. At his
baseline he is very pleasant.
# Severe BPH:
# Urinary obstruction
The patient retained urine on 3 different trials of voids. He
was started on tamsulosin twice daily and finasteride. The
urology team evaluated him as an inpatient, and recommended that
he keep the Foley in place. The patient should have foley
catheter changed every 4 weeks to prevent infection. ___ was
replaced on ___ prior to transfer. Foley should be
changed on ___ and every four weeks there after. He should
follow with urology as an outpatient for re-attempt at voiding
trial and consideration for urodynamic testing.
In addition, the rehab team should follow the following
protocol:
- Flush foley with normal saline once per shift.
- If patient is starting to get agitated or more confused,
please bladder scan him. His foley tends to clog and can cause
him discomfort. Please flush the foley if it is clogged. If it
doesn't flush, please replace the foley. Pain can also cause
agitation in the patient. Please ensure that his pain is well
treated.
-Please Check periodic cbc and chemistry-7 while on Bactrim.
#L Renal Mass
#R hepatic lobe lesion
#Pancreatic lesion
#Hyperenhancement of spleen
Given imaging findings concerning for renal cell carcinoma,
urology was consulted. They did not recommend any further
workup while inpatient. Given that renal cell carcinoma is slow
growing, the risks of biopsy and further workup would outweigh
the benefits of treatment. He should continue to follow-up with
urology as an outpatient for continued discussion for workup of
L Renal Mass.
# Incidental Masses:
L renal mass, R hepatic lobe lesion, pancreatic lesion,
hyperenhancement of spleen. Left renal mass is concerning for
with RCC. Pancreatic mass is likey a cyst. Liver mass is
unclear. Brain MRI without metastatic disease. The patient and
HCP may elect to have MRI as outpatient to reevaluate renal and
liver mass
# Previous massive PE:
Given that the patient had a previous massive PE, and imaging
findings were concerning for malignancy, the patient was started
on therapeutic Lovenox twice daily. He should be continued on
lovenox indefinitely for DVT prevention.
#T12 and L1 compression fracture
#T11 and T12 spinous process fractures
#Left T11 inferior articular process fracture
#T12 and L1 transverse processes
#Epidural hematoma
He was found to have T12 and L1 compression fractures, T11 and
T12 spinous process fractures, T12 and L1 transverse process
fractures, and an epidural hematoma. Neurosurgery evaluated the
patient and recommended nonsurgical management. The patient
underwent repeat CT T/S spine on ___ which showed
stability of T12/L1 burst fracture. Patient wear a TLSO brace
when out of bed for 2 additional months (untill ___ and
follow-up with neurosurgery in two months for re-evaluation for
the need of TLSO brace. He will follow with Dr ___ in
outpatient clinic.
# Left trimalleolar fracture
# Left distal tibia fracture
# Left distal fibula fracture
# Left disrupted mortise
The orthopedic team casted the patient's foot on ___. He
had repeat imaging on ___ which showed the fracture was
stable and healing. He had a repeat cast placed on ___.
The patient should continue to be nonweightbearing to the left
lower extremity until followup with in 3 weeks with ___
___ in ___ clinic.
#Comminuted L acetabular fracture
#Non-displaced R acetabular fracture
#Pelvic fracture
He was also found to have a left and right acetabular fracture
as well as a pelvic fracture. Orthopedic surgery evaluated the
patient, determined to be nonoperative. The patient was
actively extravasating into his pelvis. This stopped without
intervention. He remained hemodynamically stable while on
lovenox for DVT. The acetabular fracture was reassed with X-rays
of pelvis on ___. No intervention was indicated. He will
followup with orthopedics in clinic with ___ in
___ clinic in 3 weeks.
#Toxic metabolic encephalopathy
#Dementia
#Hospital delirium
MRI brain performed with no lesions identified to be causing
delirium/dementia. Haldol, Seroquel, Zyprexa made the patient's
dementia worse. He was maintained on citalopram for his mood,
standing ramelteon nightly, and standing trazodone nightly.
Please continue to try to avoid any antipsychotics as in
patients has paradoxical effect.
In addition, the rehab team should follow the following
protocol:
- Flush foley with normal saline once per shift.
- If patient is starting to get agitated or more confused,
please bladder scan him. His foley tends to clog and can cause
him discomfort. Please flush the foley if it is clogged. If it
doesn't flush, please replace the foley. Pain can also cause
agitation in the patient. Please ensure that his pain is well
treated.
# Dysphagia
Patient was found to have concern for aspiration. He underwent
a video swallow, which showed concerning signs of aspiration. A
goals of care discussion was held with the family, and they
determined that he would have a ground diet with thin liquids.
The patient mental status continued to improve. He was advanced
to a regular diet with think liquids. He was discharged with the
following diet:
1. Diet: regular solids/ thin liquids
2. Medications: whole in puree as tolerated
3. Aspiration precautions:
- alternating liquids and solids
- ensure patient is upright at 90 degrees for all PO intake
-small bites/sips, and minimize distractions with PO.
4. Oral care: TID
#Pain control
And the multiple fractures detailed below, the patient was
maintained on standing Tylenol, lidocaine patches, and initially
standing oxycodone. The oxycodone was transitioned to as needed
as the patient healed. The patient's agitation was attributed
to his pain, as when his pain was controlled, he was very much
less agitated. At the time of discharge he did not require any
opiates for pain control.
# Hypovitaminosis D
The patient was found to have a low vitamin D level. He was
started on vitamin D supplementation.
TRANSITIONAL ISSUES
===================
- Follow-up with Neurosurgery in 2 months form discharge for
evaluation of TLSO
- Follow-up with Orthopedic trauma clinic with ___
___ 3 weeks from discharge
- Foley should stay in pace until followup with urology.
Outpatient follow-up with urology for urinary retention and
evaluation of renal mass
-Patient should continue lovenox indefinitely for DVT
prophylaxis in setting of L renal mass of unknown etiology
-Patient should continue bactrim for UTI prophylaxis
-PCP to order outpatient liver MRI to characterize mass and 6
month surveillance CT for ___
-Please Check periodic cbc and chemistry-7 while on Bactrim.
In addition, the rehab team should follow the following
protocol:
- Flush foley with normal saline once per shift.
- If patient is starting to get agitated or more confused,
please bladder scan him. His foley tends to clog and can cause
him discomfort. Please flush the foley if it is clogged. If it
doesn't flush, please replace the foley. Pain can also cause
agitation in the patient. Please ensure that his pain is well
treated.
Medications on Admission:
1. OLANZapine 5 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. cefUROXime axetil 250 mg oral BID
4. TraZODone 50 mg PO QHS:PRN insomina
5. Doxazosin 2 mg PO HS
6. Ipratropium Bromide MDI 2 PUFF IH QID
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Citalopram 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 60 mg SC Q12H
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Ramelteon 8 mg PO QHS
7. Senna 8.6 mg PO BID
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Tamsulosin 0.4 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. TraZODone 25 mg PO QHS insomina
12. Finasteride 5 mg PO DAILY
13. Ipratropium Bromide MDI 2 PUFF IH QID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-left ankle fracture
-left pelvic fracture with active extravasation
-T12 burst fracture
-T11, T12 spinous process fracture
-T12, L1 transverse process fracture
-L1 burst fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital after falling out of a building
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital, the orthopedic team, neurosurgery team, and
urology team evaluated you. They determined that there was no
need to do any operations on any of your fractures.
- You developed a urinary tract infection and a bloodstream
infection. The infectious disease team evaluated you, and
recommended that you complete a 2-week course of antibiotics,
which you finished while you were in the hospital.
- The urology team recommended that you follow-up with a
urologist as an outpatient.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19855999-DS-12 | 19,855,999 | 28,516,422 | DS | 12 | 2131-08-07 00:00:00 | 2131-08-07 13:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
COMPLETE
History of Present Illness:
Mr. ___ is a ___ man with history of dementia,
urinary tract infections and urinary retention with indwelling
Foley, recent admission for multiple traumatic injuries after a
fall, now presenting with altered mental status and urinary
retention.
Per review of OMR, the patient was admitted from ___
after a two-story fall from the window in his memory care unit.
He had multiple traumatic injuries (T12 and L1 compression
fractures; T11 and T12 spinous process fractures; Left T11
inferior articular process fracture; T12 and L1 transverse
processes; Epidural hematoma; Left trimalleolar fracture; Left
distal tibia fracture; Left distal fibula fracture; Left
disrupted mortise; Comminuted L acetabular fracture;
Non-displaced R acetabular fracture; Pelvic fracture.) His left
leg was casted, and his other injuries were managed
non-operatively.
His course was complicated by sepsis due to MDR E. coli
bacteremia and Klebsiella and E. coli urinary tract infection
for which he was treated with ceftazidime and then started on
Bactrim suppressive therapy. He also had severe BPH and urinary
obstruction; a Foley was placed.
His course was also complicated by the discovery of multiple
incidental masses including one suspicious for renal cell
carcinoma. In light of this and his prior history of massive PE,
he was started on Lovenox for DVT prevention.
Per ED provider notes, the patient's daughter provided history.
She states she went with him from rehab to his orthopedic
appointment today. Upon arrival there, patient was agitated and
confused. He kept stating that he needed to urinate. He
complains of discomfort in the lower abdomen. His daughter
states that in the past when this has happened, he has had a
urinary tract infection, and has developed a fever about 2 days
later. No recent falls. No recent fevers. Has not been
complaining of any chest pain, shortness of breath, cough,
vomiting, diarrhea, blood in the stool. She reports the small
amount of urine in his Foley catheter bag has been there since
___ AM.
In the ED, initial vitals: 97 95 143/98 18 92% 2L NC Exam
notable for: Patient very hard of hearing. Seems to be confused,
identifies his daughter is his wife. Pupils equal round
reactive. Facial movement symmetric. Moving all extremities.
Abdomen is soft, with tenderness to palpation in the lower
abdomen. Foley catheter in place, small amount of urine in the
bag.
Labs notable for: WBC 9, Hb 13, BUN/Cr ___ lactate 1.2; UA
with many bacteria, WBC >182, RBC >182, lg leks, neg nitrites,
>600 protein Patient given: ___ 16:48 IV CefTAZidime 2 g
In the ED, bedside ultrasound showed >700 cc of urine in the
bladder. Foley catheter was exchanged, with output of a few
clots and purulent urine.
On arrival to the floor, the patient denies any complaints,
however, unable to obtain accurate review of systems due to
patient's altered mental status.
ROS: Unable to obtain due to patient's altered mental status.
Past Medical History:
Past Medical History:
- BPH
- colonic polyps (gets colonscopies every ___ years given family
history - sister died of colon CA at age ___
- diverticulosis
- history of lyme disease treated with doxycycline
- pulmonary nodule followed with serial CT at ___
Social History:
___
Family History:
-strong family history of colon CA (sister died at age ___
Physical Exam:
ADMISSION:
VITALS: 97.8 136 / 72 62 18 92 2LNC
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: + suprapubic fullness and tenderness to palpation; Foley in
place draining light yellow urine
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs; left lower limb in cast
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented to self, place, and date, face symmetric,
gaze conjugate with EOMI, speech fluent, moves all limbs,
sensation to light touch grossly intact throughout
PSYCH: Pleasant, appropriate affect
DISCHARGE:
98.1 PO 133 / 74 68 18 91 RA
GENERAL: Alert and in no apparent distress.
EYES: Anicteric, pupils equally round
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: Foley in place draining clear urine
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs; left lower limb in cast
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented to self, place, and date, face symmetric,
gaze conjugate with EOMI, speech fluent, moves all limbs
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
==========================
___ 02:55PM BLOOD WBC-9.2 RBC-4.08* Hgb-13.2* Hct-40.1
MCV-98 MCH-32.4* MCHC-32.9 RDW-14.9 RDWSD-54.4* Plt ___
___ 02:55PM BLOOD Neuts-76.4* Lymphs-12.3* Monos-9.4
Eos-1.1 Baso-0.5 Im ___ AbsNeut-7.00* AbsLymp-1.13*
AbsMono-0.86* AbsEos-0.10 AbsBaso-0.05
___ 02:55PM BLOOD Glucose-110* UreaN-28* Creat-0.7 Na-140
K-4.5 Cl-101 HCO3-26 AnGap-13
___ 03:04PM BLOOD Lactate-1.2
LABS AT DISCHARGE:
=================
___ 08:04AM BLOOD WBC-7.6 RBC-3.94* Hgb-12.6* Hct-38.8*
MCV-99* MCH-32.0 MCHC-32.5 RDW-14.9 RDWSD-53.7* Plt ___
___ 08:04AM BLOOD Glucose-108* UreaN-17 Creat-0.5 Na-143
K-4.4 Cl-103 HCO3-30 AnGap-10
___ 08:04AM BLOOD Calcium-9.5 Phos-3.4 Mg-1.9
MICRO:
=====
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
___ Blood Cx: NGTD
___ Urine Cx:
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
FOSFOMYCIN Susceptibility testing requested per ___
___
(___), ___.
THIS IS A CORRECTED REPORT Reported to and read back by
___
___ (___), ___ @ 11:57AM. PREVIOUSLY
REPORTED AS :.
CEFTAZIDIME MIC = 4 MCG/ML = RESISTANT.
MEROPENEM MIC >= 16 MCG/ML = RESISTANT.
Piperacillin/Tazobactam MIC = 8 MCG/ML = RESISTANT.
FOSFOMYCIN SUSCEPTIBLE.
FOSFOMYCIN test result performed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=1 S
___ Blood culture: No growth to date
IMAGING/OTHER STUDIES:
======================
___ Ankle X-Ray
Cast material obscures fine osseous detail. The patient is post
open reduction internal fixation with placement of a medial
sideplate and multiple screws in addition to a retrograde nail
extending through the calcaneus, talus and tibia. There is no
interval change in alignment of the medial and lateral malleolar
fractures. No acute hardware related complications.
___ CT abd/pelv with contrast
1. Large mass posterior to the bladder is indistinguishable from
the prostate with mass effect on the bladder pushing it
anteriorly, overall measuring 7.0 x 5.6 x 8.3 cm. 2. 2.8 cm
heterogeneously enhancing left upper pole mass concerning for
renal cell carcinoma. 3. Large amount of fecal loading. 4. No
evidence for acute intra-abdominal infection. 5. Prominent lymph
nodes are noted anterior to the bladder, within a left inguinal
hernia containing fat, as well as a right pelvic sidewall lymph
node. 6. Subcutaneous air in the right lower anterior abdomen is
noted, correlate with history of subcutaneous injections. 7.
Evaluation of previously noted epidural hematoma is
significantly limited on CT, and should be further evaluated by
MR if there is ongoing clinical concern.
___ Ankle film
No significant short-term changed in displaced bimalleolar ankle
fractures with substantial inversion.
___ CXR
Bibasilar atelectasis with probable small bilateral pleural
effusions.
Brief Hospital Course:
Mr. ___ is a ___ man with history of dementia,
frequent urinary tract infections and urinary retention with
indwelling Foley catheter, and recent admission for multiple
traumatic injuries after a fall, now presenting with altered
mental status and recurrent urinary tract infection.
# BPH
# Urinary retention:
# Catheter-associated urinary tract infection:
Patient with urinary retention during previous admission
requiring Foley catheter, failed 3 voiding trials. Seen by
Urology at that time, who recommended keeping Foley in with
outpatient voiding trial. Plan to exchange Foley every 4 weeks;
exchanged last on ___, and on day of admission ___ with next
change planned for ___. On admission, UA grossly positive;
ultimately growing Enterococcus sensitive to ampicillin. He
developed a second urinary tract infection on ___ with E. Coli
sensitive to Ceftazidime, Zosyn, Meropenem and Fosfomycin. Of
note patient has had seven urinary tract infections since
___.
There was an extensive conversation with Urology regarding his
case (___). In brief, given his multiple failed voiding
trials, advanced age, and the massive size of his prostate with
compression against the bladder, repeat voiding trial would
result in near certain failure. Intermittent straight
catheterization is not a viable solution in his case due to the
severity of his prostamegaly and risk of injury. Additionally,
per urology, he is likely a poor candidate for interventions
including TURP (and certainly a poor candidate for a radical
prostatectomy). Overall will likely need chronic indwelling
foley with emphasis placed on excellent foley hygiene to prevent
clogging or recurrent infections. Can ultimately follow up with
Urology as outpatient but likely not much to offer. Interval CT
a/p obtained ___ with no nidus of infection, but demonstrates
severe prostamegaly.
ID was consulted for recurrent urinary tract infections and to
discuss prophylactic medication. For his Enterococcus on ___
he received 7d Ampicillin 875mg BID (___). For his E.
Coli urinary tract infection on ___ he received Ceftazidime
(___) and per ID recommendation was then transitioned to
Fosfomycin 3g Q3 days for 21 days (___). As it was
difficult to exclude prostatitis, plan to treat from prolonged
21 day course to appropriately cover for prostatitis. After
completing treatment course he should then be transitioned to
Fosfomycin 3g Q weekly for UTI prophylaxis with next dose
(___). Per ID, can trial Methenamine Hippurate and vitamin C
(for urine acidification) to help with UTI prophylaxis. Patient
can follow up with ID as an outpatient in early ___.
***In order to prevent urinary tract infections, he will need to
have excellent foley care with foley changed every 4 weeks (next
change ___ and flushed with normal saline once per shift (or
3x a day) after discharge to prevent recurrent obstruction. If
patient is starting to get agitated or more confused, please
bladder scan him. If greater than 600cc, please replace foley.
His foley tends to clog and can cause him discomfort. Please
flush the foley if it is clogged. If it doesn't flush, please
replace the foley. If foley is not draining spontaneously and
only drains when flushed, this would also indicate an issue and
we would recommend bladder scan and consideration of foley
replacement.
# Toxic-metabolic encephalopathy:
# Dementia:
Patient presented from outpatient clinic with confusion, found
to have urinary retention as below. Likely multifactorial
secondary to pain, severe hard of hearing, urinary retention,
urinary tract infection, severe constipation, and delirium in
unfamiliar environment in setting of concern for progressive
dementia. This was an ongoing issue during prior hospitalization
and past discharges. In setting of relieving his urinary
retention, starting antibiotics, and providing him with his
hearing aides, he became much calmer and appeared to be back to
his recent baseline per family.
****Of note patient does not tolerate haldol/olanzapine or other
anti-psychotics and these medications paradoxically agitate him
(concern for underlying ___ body dementia). Albuterol also
worsens his agitation. He has response to Ativan IV 0.5mg in
setting of severe agitation.
# Pain control:
Patient with pain related to traumatic fractures and urinary
retention. Some inconsistency whether he's supposed to be taking
tramadol or oxycodone based on daughter and rehab records, but
both were held in setting of severe constipation. Pain well
controlled on standing Tylenol, discharged off opioid
medications.
# Severe constipation:
Unclear when last BM was prior to admission (despite attempts to
verify). CT with massive fecal loading ~9cm in diameter.
Attempted manual disimpaction evening of ___ with moderate
amount of thick, ___ stool removed, overall challenging in
setting of severe BPH. Again disimpacted on ___ with a small
amount of soft brown stool removed but had to stop due to severe
patient discomfort. Please ensure patient receives aggressive
bowel regimen and avoid opioid medications if possible.
# Left trimalleolar fracture
# Left distal tibia fracture
# Left distal fibula fracture
# Left disrupted mortise:
S/p casting of left lower extremity. Orthopedic surgery followed
closely with observation of left lateral malleolus skin lesion
concerning for underlying worsening displacement of fracture.
Patient seen by Dr. ___ underwent underwent left
ORIF ___. Continue with strict non weight bearing status with
plan for reassessement in 3 weeks from procedure (approximately
___ with ___. He has been maintained on Lovenox.
# T12 and L1 compression fracture
# T11 and T12 spinous process fractures
# Left T11 inferior articular process fracture
# T12 and L1 transverse processes:
Non-operatively managed during last admission. Patient moving
lower extremities without pain or difficulty, sensation appears
to be intact. Last seen by Neurosurgery on ___ with plan for
continued TLSO brace for two additional months. ___ put on at
edge of bed. Please follow up with Dr ___ in
outpatient clinic in two months (approx ___. He will
need a CT thoracic and lumbar spine at that time.
# History of pulmonary embolism
Continued twice daily Lovenox except for heparin gtt
___. He will require outpatient follow up for
evaluation of suspected underlying malignancy (ie Renal cell
carcinoma) but given overall frailty, he is likely not a
candidate for aggressive surgical or medical therapies.
#Concern for Renal Cell Carcinoma
Patient with less than 3.5cm lesion on kidney and found to have
small lesion on liver. In discussion with Dr. ___, MD
in urology along with the patient and daughter, no biopsy is
indicated at this time, discussion documented ___. Per
urology, active surveillance with renal US Q6months (next
___ is the preferred intervention in this case as it will
help determine how quickly (or not) this lesion may grow and
will help prognosticate and determine next steps.
CHRONIC/STABLE PROBLEMS:
# Hypovitaminosis D
Continue vitamin D supplementation
# Dysphagia with concern for aspiration:
Ground diet with thin liquids per prior nutrition notes; per
discussion with daughter/healthcare proxy advance to regular
diet despite known risk of aspiration.
#Full Code confirmed ___ with HCP
#Contacts/HCP/Surrogate and Communication: ___ (daughter) -
___
TRANSITIONAL ISSUES:
=================
[] In order to prevent urinary tract infections, he will need to
have excellent foley care with foley changed every 4 weeks (next
change ___ and flushed with normal saline once per shift (or
3x a day) after discharge to prevent recurrent obstruction. If
patient is starting to get agitated or more confused, please
bladder scan him. If greater than 600cc, please replace foley.
His foley tends to clog and can cause him discomfort. Please
flush the foley if it is clogged. If it doesn't flush, please
replace the foley. If foley is not draining spontaneously and
only drains when flushed, this would also indicate an issue and
we would recommend bladder scan and consideration of foley
replacement.
[] Patient does not tolerate haldol/olanzapine or other
anti-psychotics and these medications paradoxically agitate him
(concern for underlying ___ body dementia). He has response to
Ativan 0.5mg in setting of severe agitation.
[] Please avoid Albuterol as this can contribute to his
agitation.
[] Please ensure patient receives aggressive bowel regimen and
avoid opioid medications if possible.
[] Please continue Fosfomycin 3g Q3 days for 21 days
(___). Then transition to prophylaxis dosing of
Fosfomycin 3g Qweekly (starting ___. Patient will need to
follow up with infectious disease.
[] Can trial Methenamine Hippurate and vitamin C (for urine
acidification) to help with UTI prophylaxis.
[] Continue with strict non weight bearing status of L lower
extremity with plan for re assessement in 3 weeks from procedure
with ___
[] He will require TLSO brace when out of bed given spinal
compression fractures. Will need re-evaluation by neurosurgery
in ___.
[] Given renal mass, recommend active surveillance with renal US
Q6months (next ___ is the preferred intervention in this
case as it will help determine how quickly (or not) this lesion
may grow and will help prognosticate and determine next steps.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ipratropium Bromide MDI 2 PUFF IH QID
2. Finasteride 5 mg PO DAILY
3. TraZODone 25 mg PO QHS insomina
4. Vitamin D 1000 UNIT PO DAILY
5. Tamsulosin 0.4 mg PO BID
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Enoxaparin Sodium 60 mg SC Q12H
8. Citalopram 20 mg PO DAILY
9. Acetaminophen 1000 mg PO TID
10. Ramelteon 8 mg PO QHS
11. Docusate Sodium 100 mg PO BID
12. Senna 8.6 mg PO BID
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
14. OxyCODONE (Immediate Release) 2.5 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO BID
2. Bisacodyl 10 mg PO/PR BID
3. Fosfomycin Tromethamine 3 g PO Q72H Prostatitis treatment
Duration: 7 Doses
4. methenamine hippurate 1 gram oral BID
5. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
6. Polyethylene Glycol 17 g PO BID
7. Acetaminophen 1000 mg PO TID
8. Citalopram 20 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Enoxaparin Sodium 60 mg SC Q12H
11. Finasteride 5 mg PO DAILY
12. Ipratropium Bromide MDI 2 PUFF IH QID
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Ramelteon 8 mg PO QHS
15. Senna 8.6 mg PO BID
16. Tamsulosin 0.4 mg PO BID
17. TraZODone 25 mg PO QHS insomina
18. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Urinary retention:
# Catheter associated UTI:
# Toxic-metabolic encephalopathy:
# Severe constipation:
# Left malleolar fracture:
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a priviliege to care for you at the ___
___. You were admitted with worsening confusion and
distress in the setting of urinary retention from a clogged
urinary catheter tube. Your foley was exchanged and you were
treated with antibiotics for an infection.
You were seen by the Orthopedic Surgeons who noted that your
ankle fracture wasn't healing properly so you underwent surgical
repair.
Please continue to take all medications as prescribed and follow
up with all appointments as detailed below.
We wish you the best!
Sincerely,
Your ___ team
Followup Instructions:
___
|
19856485-DS-11 | 19,856,485 | 20,923,421 | DS | 11 | 2172-02-13 00:00:00 | 2172-02-13 20:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
CHIEF COMPLAINT: Generalized weakness
REASON FOR MICU TRANSFER: hypotension, anemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with breast cancer metastatic to bone, lymph nodes and
liver, s/p one cycle of gemcitabine/xeloda (last dose ___,
afib on pradaxa, presents with generalized weakness, chills,
darker stools and morning epistaxis for 4 days. Also reports
traumatic fall on the stairs three days ago. When she fell, she
hit her head, L shoulder, and lower back on a railing. No H/A,
dizziness or mental status changes.
She reports that since chemo ___, she has felt extremely
fatigued and just "crashed" over the following days, unable to
get off the couch due to severe fatigue. She has also been
experiencing fevers and chills, with max temperature of 100.9 on
___, temperatures since have been around 99. Her oncologist
told her that influenza-like symptoms were common with
gemcitabine/capecitabine. Denies cough, abdominal pain, dysuria
or increased urinary frequency.
She endorses dizziness upon standing, as well as worsening
dyspnea with minimal exertion - activities such as rising to the
bathroom. Reports dark formed stool yesterday, prior to that
was constipated so she took senna.
Initial vitals in ED: 98.4 61 94/41 (baseline 110/70's) 15 98%
ON EXAM: Rectal exam showed brown, guaiac positive stool. She
developed mild epistaxis after flu swab. Found to have
ecchymoses over lumbar spine. Abdomen benign.
LABS NOTABLE FOR:
- H/H 7.2 (down from 9.7 on ___, WBC 10.2 with 84%N, 2 metas 2
myelos 2nrbc, PLT 143, INR 1.8
- Creatinine 1.9 (up from 1.2 on ___
- AST 265, AST 68, AP 381, LDH 545. CEA 193 from 96 on ___.
- Flu negative
- CXR showed Osseous metastatic disease. No acute intrathoracic
process.
- CT spine and head non-acute, with known ___.
- CT abdomen/pelvis also non-acute, no RP bleed.
She was transfused 1u pRBC's, crossmatched, and started on mIVF.
Vitals prior to transfer: 98.0 60 ___ 16 100% RA
Patient was transferred to ___ out of concern for sepsis vs.
internal bleed.
Past Medical History:
-Lobular breast cancer dx ___, s/p right mastectomy and left
partial mastectomy, cytoxan adriamycin, tamoxifen, and
radiation, complicated by bone ___, PET scan ___ with marked
improvement, ___ PET showing progressive disease (increased
avidity, increased bulky LAD, and new bony lesions in spine)
-? Diastolic heart failure: cath c/w diagnosis, but normal TTE
in ___
-Paroxysmal afib s/p two pulmonary vein isolations in ___ and
___
-OSA: unable to tolerate CPAP
-GERD
-HLD
-HTN
-OA
-Hypothyroidism
-h/o Hep A
-R TKA ___
Social History:
___
Family History:
FAMILY HISTORY:
Father died of MI at ___ yrs. Mother had CVA and renal failure.
No DM. Sister with asthma.
Physical Exam:
Admission exam:
VITAL SIGNS: T 98 BP 112/43 P 62 R 13 100%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, slightly dry MM, oropharynx clear
LUNGS: Good air excursion, +bibasilar rales, no wheezes
CHEST: L port c/d/i
CV: Regular rate and rhythm, no murmurs/rubs/gallops
ABDOMEN: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: No foley
EXTR: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: strength & sensation intact, no asterixis
SKIN: warm, dry, ecchymosis over left scapula, ecchymoses over
both shins
DISCHARGE EXAM;
Physical Exam:
BPTm 99.0 Tc 98.0 128/43 RR 20 100% RA
Gen: well-appearing, calm, in bed
HEENT; No blood or erythema in oropharynx, no oral mucosal
bleeding
PULM: crackles at bases bilaterally no wheezes
CV: rrr no m/r/g
Skin: L POC c/d/i, stable bruising behind left axilla
Abd: nontender, no masses palpable
Extr: no edema in lower extr
Neuro ___ strength throughout no asterixis, sensation intact
throughout
Pertinent Results:
Admission labs:
___ 10:15AM BLOOD WBC-10.2 RBC-2.48*# Hgb-7.2*# Hct-21.5*#
MCV-87 MCH-29.1 MCHC-33.6 RDW-21.6* Plt ___
___ 10:15AM BLOOD Plt Smr-LOW Plt ___
___ 10:15AM BLOOD UreaN-50* Creat-1.9* Na-137 K-3.9 Cl-109*
HCO3-21* AnGap-11
___ 10:15AM BLOOD ALT-265* AST-68* LD(LDH)-545*
AlkPhos-381* TotBili-0.5
___ 10:15AM BLOOD TotProt-5.8* Albumin-2.7* Globuln-3.1
Calcium-8.6 Phos-3.0 Mg-2.5
___ 10:15AM BLOOD CEA-193* ___ 10:15AM BLOOD Hapto-335*
___ CT ABDOMEN (Prelim):
1. No evidence of acute intra-abdominal or intrapelvic process.
No evidence of retroperitoneal hematoma.
2. Multifocal hypodense liver lesions, compatible with known
hepatic
metastases.
3. Stable diffuse mixed osteolytic and osteosclerotic bone
lesions, as above.
4. Small bilateral layering simple pleural effusions.
CT HEAD: No acute intracranial process. Calvarial metastasis.
CT C-SPINE:
1. No acute fracture or traumatic malalignment
2. Diffuse sclerotic metastases - no pathological fracture.
CHEST X-RAY: Osseous metastatic disease. No acute intrathoracic
process.
___ COLONOSCOPY:
Impression: Grade 2 internal hemorrhoids. Normal colonoscopy to
cecum
___ 05:46AM BLOOD WBC-11.0 RBC-3.17* Hgb-9.1* Hct-26.7*
MCV-84 MCH-28.9 MCHC-34.2 RDW-20.2* Plt Ct-76*
___ 07:26AM BLOOD ___ PTT-39.4* ___
___ 05:46AM BLOOD Glucose-83 UreaN-13 Creat-0.8 Na-140
K-3.4 Cl-107 HCO3-25 AnGap-11
___ 05:46AM BLOOD ALT-119* AST-154* AlkPhos-393*
TotBili-1.2
___ 05:46AM BLOOD Calcium-7.6* Phos-2.8 Mg-1.6
___ 10:15AM BLOOD Hapto-335*
___ 05:46AM BLOOD TSH-8.9*
___ 10:15AM BLOOD CEA-193* ___
Brief Hospital Course:
___ with breast cancer metastatic to bone, lymph nodes and
liver, s/p one cycle of gemcitabine/xeloda (last dose ___,
afib on pradaxa, presents with generalized weakness, chills,
darker stools and morning epistaxis for 4 days found to be
acutely anemic, relatively hypotensive.
# Acute anemia: Symptomatic (orthostasis, shortness of breath)
and hypotensive. Multifactorial, likely related to mucosal
bleeding - epistaxis and trace guaiac positive stools in the
setting of dabigatran. Also completed cycle 1 of gemcitabine /
capecitabine (last dosed ___, which is likely contributing to
marrow suppression. Received 1U PRBCs in ED ___ and 1U in FICU
___. Hemoglobin stablized, hypotension resolved. Low
reticulocyte count consistent with marrow suppression. DIC labs
unremarkable. 1u transfused for Hct 23 on ___ with good bump to
26 prior to discharge. Her pradaxa was held on discharge given
question of possible bleed though felt to be less likely and
also due to her persistent thrombocytopenia.
# Hypotension: Likely hypovolemic given acute anemia, appears
mildly dehydrated on exam. Infectious workup unremarkable.
Hypotension resolved with IVF resuscitation and PRBC
transfusion. Held home antihypertensives but continued her
lasix. We tried to re-introduce her metoprolol but her blood
pressure went to the low 100s with this so it was held. There
was nothing to suggest infection at any point other than a
slight runny nose prior to admission which could have been
consistent wiht a viral illness but cultures, UA, and CXR here
unremarkable. RUQ also didn't suggest infectious etiology though
LFTs were elevated as below. Echo showed new mild-mod mitral
valve regurgitation but she was never in decompensated heart
failure clinically, and her lasix was restarted with good
effect.
# Acute kidney injury: Pre-renal vs ATN in the setting of
hypovolemia and hypotension. Volume resuscitation as above.
Encouraged PO intake. Trended creatinine.
# Abnormal liver function tests: Most likely related to hepatic
___ though could be effect of gemcitabine administration. NO
RUQ pain. Enzymes trending down at dischare. RUQ showed only
hepatic ___, no biliary duct dilation. Smear not suggestive of
hemolysis. She may have had transient ischemia to the liver in
the setting of hypotension also.
# Fever: Reported temperature at home. Possibly a side effect of
chemotherapy vs viral infection (had rhinorrhea but nothing
else). No localizing signs or symptoms of infection at this
time and imaging is unrevealing for a source of infection. CXR
and CT abdomen without signs of infection. Cultures all
negative. No further fevers in house.
# Guaiac positive stools: No frank melena or BRBPR. Stools
remained brown not black. Guaiac positivity was likely due to
the patient being on pradaxa, she presented with some minor
coagulpathy which also corrected with discontinuation of
pradaxa. During the admission there was nothing else to suggest
GI bleeding.
# Metastatic Breast Cancer: Metastatic to bone, liver, lymph
nodes. S/p cycle 1 gemcitabine / capecitabine, last dose ___.
Chemotherapy on hold. Further management per heme/onc. She will
follow up with her oncologist.
# Paroxysmal atrial fibrillation: Currently in sinus. Continued
amiodarone. Metoprolol on hold given hypotension / acute anemia.
Held pradaxa given acute anemia and more importantly persistent
thrombocytopenia.
# Diastolic heart failure: No acute exacerbation. Furosemide
on hold given hypotension and acute anemia.
# Hypertension: Anti-hypertensives on hold given hypotension
and acute anemia
# Hypothyroidism / Latent Graves Disease: ___ TSH 3.9,
stopped methimazole for now given marrow suppressive effects as
she is trending toward hyperthyroidism at present. Repeat TSH 9.
Her outpatient endocrinologist was notified who will follow up
with her soon after discharge. Repeat TFTs prior to discharge
were stable.
TRANSITIONAL ISSUES:
holding pradaxa, holding BP meds, f/u CBC attn to Hct and
thrombocytopenia, f/u TFTs
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Dabigatran Etexilate 150 mg PO BID
4. Furosemide 40 mg PO DAILY
5. Methimazole 5 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Spironolactone 25 mg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Docusate Sodium 100 mg PO DAILY
5. Senna 8.6 mg PO DAILY
6. Outpatient Physical Therapy
Rx: Outpatient physical therapy
Evaluation and treatment
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic Breast Cancer
Anemia
Thrombocytopenia
Hypotension
Atrial Fibrillation
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with low blood pressure and a blood count drop
which we think was from your chemotherapy and your blood
pressure medications. We stopped some of these medications as a
result and your blood pressure normalized. Your blood count
stayed stable with transfusions.
You will need to follow up with Dr. ___ Dr. ___
endocrinologist this is very important. We are holding your
methimazole for the time being.
Holding pradaxa (bc of bleeding possibility and low platelets)
Holding metoprolol (because of low blood pressure), losartan (bc
of low blood prssure), spironolactone (low blood pressure,
atorvastatin (liver function tests)
Followup Instructions:
___
|
19856613-DS-4 | 19,856,613 | 27,264,494 | DS | 4 | 2193-10-24 00:00:00 | 2193-10-24 19:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / powdered condiments
Attending: ___.
Chief Complaint:
Leg pain/Syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with sciatica, chronic back pain, fibromyalgia, followed by
pain clinic, hypothyroidism presented to ED with back pain
exacerbation. Patient was at ___ for lateral epicondylitis,
went to bathroom and collapsed from back pain that shot down
from left side to left hip. Pain improved in the ED but then
when attempting to ambulate, she became pale/diaphoretic with bp
drop to ___ so admitted to medicine for further work-up and pain
control. Denies fevers, saddle anesthesia, incontinence, focal
weakness or numbness. No trauma to the area.
In the ED, initial vitals were: 97.9 59 118/58 18 98% RA
- Labs were significant for none drawn.
- Imaging revealed no pelvic fracture.
- The patient was given tylenol 1 g PO x 1, ibuprofen 800 mg PO
x 1, tramadol 25 mg PO x 1, valium 5 mg PO x 2.
Vitals prior to transfer were: 97.8 60 96/61 16 98% RA
Upon arrival to the floor, patient initially sleeping. When
roused from sleep, she states she is in persistent pain,
requesting something stronger than tylenol. She describes her
pain as band-like across her pelvis from front to back, with
radiation down legs with extension.
REVIEW OF SYSTEMS:
(+) Per HPI
Past Medical History:
- chronic low back pain due to degenerative disc disease
- sciatica
- fibromyalgia
- lateral epicondylitis
- asthma
- allergies
- hypothyroidism
Social History:
___
Family History:
Denies familial back pain
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
====================
PHYSICAL EXAM:
Vitals: 97.8 109/64 63 18 100 RA
General: Alert, oriented, intermittent distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema, right hand with
plastic cast overlyigng. pain elicited with bilateral straight
leg raise. patient declines moving for spinous process exam
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation b/l lower extremities.
PHYSICAL EXAM ON DISCHARGE:
=====================
Vitals: T 97.8, BP 109/64, P 63, R 18, 100% RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley. no incontinence
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Patient with positive leg raise on both legs at around 30
degrees. Pain felt in shooting nature down the left leg with
left leg raise and felt in a band distribution around her lower
abdomen and back with bilateral leg raise. No tenderness to
palpation on the paraspinal muscles or on the vertebral
processes diffusely.
Neuro: CNs2-12 intact, motor function grossly normal. Motor
strength ___ in bilateral lower extremities limited only by
pain. Normal sensation to light tough. No saddle anesthesia.
Pertinent Results:
LABS ON ADMISSION/DISCHARGE:
======================
___ 01:42AM BLOOD WBC-4.7 RBC-4.28 Hgb-13.0 Hct-39.4 MCV-92
MCH-30.4 MCHC-33.0 RDW-12.4 RDWSD-41.3 Plt ___
___ 01:42AM BLOOD Plt ___
___ 01:42AM BLOOD Glucose-85 UreaN-9 Creat-0.7 Na-144 K-3.8
Cl-106 HCO3-28 AnGap-14
___ 01:42AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.0
Pelvis x-ray ___:
================
FINDINGS:
There is no fracture or focal osseous abnormality. Pubic
symphysis and SI
joints are preserved. Soft tissues are unremarkable.
IMPRESSION:
No fracture.
Brief Hospital Course:
___ year old female with a history notable for chronic back pain
and sciatica, fibromyalgia, followed by the pain clinic, and
hypothyroidism, who presented to ___ ED with a back pain
exacerbation and was found to have a syncopal episode in the ED.
#Syncopal episode:
Patient had syncopal episode while undergoing evaluation for
back pain in the ED and was admitted to the inpatient medicine
service. Workup for syncope was consistent with vasovagal
episode likely due to pain from acute on chronic back pain
exacerbation given patient's prodromal symptoms of pain, feeling
warm, and flushed. Telemetry and EKG overnight were unrevealing.
Patinet's history furthermore was not consistent with seizure.
The patient had no evidence of hypovolemia on orthostatics,
laboratory values, or history.
#Low back pain
For the patient's back pain, pelvix XRAY in the ED showed no
fracture. Exam was consistent with exacerbated sciatica given
straight leg raise. The patient was continued home pain regimen
and added toradol IV for breakthrough pain while in hospital.
Started patient on short course flexeril for back muscle spasm
pain. Patient worked with physical therapy and was discharged
home with continued outpatient ___. Also recommended crutches fro
short period of time given patient's inability to use walker due
to chronic epicodylitis.
#Brain aneurysm:
-Continued home TCA
# Hypothyroidism:
TSH was normal. Levothyroxine was continued.
# Thrombocytopenia: Chronic and stable. Platelets of 132
compared to baseline of 139.
====================
TRANSITIONAL ISSUES:
=====================
- flexeril 5mg TID started this hospitalization
- follow up with outpatient provider
# CONTACT: daughter ___ ___
# CODE STATUS: full(confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
2. Acetaminophen ___ mg PO Q8H:PRN pain
3. Albuterol Inhaler ___ PUFF IH Q4-6H:PRN sob, wheeze
4. Amitriptyline 10 mg PO QHS
5. Gabapentin 100 mg PO TID:PRN pain
6. HydrOXYzine 10 mg PO TID:PRN itching
7. Ibuprofen 400 mg PO BID:PRN pain
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Loratadine 10 mg PO DAILY:PRN allergies
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q4-6H:PRN sob, wheeze
3. Gabapentin 100 mg PO TID:PRN pain
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Loratadine 10 mg PO DAILY:PRN allergies
6. Amitriptyline 10 mg PO QHS
7. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. HydrOXYzine 10 mg PO TID:PRN itching
10. Cyclobenzaprine 5 mg PO TID:PRN back pain
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
11. Ibuprofen 400 mg PO Q8H:PRN pain
12. Axillary Crutches
Axillary Crutches
Diagnosis: Unsteady gait R 26.2
Prognosis Good and length of need 13 months
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Vasovagal syncopal episode
Acute on chronic low back pain w/ sciatica
Secondary:
Hypothyroidism
Thrombocytopenia
Discharge Condition:
Mental Status: Alert, oriented to person and date.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you here at the ___
___. You came to us because you had acute
worsening of your chronic low back pain. While in the ___ ED,
you were found to have a fainting episode. You were admitted to
the medical floor for observation, workup of why you fainted,
and management of your worsening back pain.
For your fainting episode, we monitored your heart with
overnight monitoring and with EKG and found no abnormalities. We
checked your blood levels and they were all normal. Overall, we
felt that your fainting episode was due to a vasovagal response
to pain from your sciatica. This can be experienced during
episodes of severe pain or emotion.
For your back pain, we continued your home pain medications. We
also added valium in the ED and then toradol while on the
medical floor. We recommend continued NSAID treatment of your
back pain. NSAIDS include ibuprophen, motrin, toradol. We also
had your work with physical therapy. We will have you continue
to work with physical therapy upon discharge.
Please follow up with you primary care physician for continued
management of your chronic back pain as well as for your recent
fainting episode.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
19857454-DS-21 | 19,857,454 | 29,355,998 | DS | 21 | 2191-08-23 00:00:00 | 2191-08-24 08:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ceftin / Bactrim / Tetracycline / Rifampin / Levaquin in D5W /
Penicillins
Attending: ___.
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
Bronchoscopy with transbronchial biopsy
History of Present Illness:
Ms. ___ is a ___ year old woman with a PMHx s/f DMII, HTN, ESRD
on dialysis and awaiting transplant. She has been having fevers
chills for approximately 1 month. Cultures from ___
demonstrated stretococcus mitis for which she was started on IV
vancomycin. As a result of the positive cultures and persistent
fevers, she was admitted to ___ from ___
to ___ unt. CT and TTE were performed with no evidence of
infectious source. She was discharged with 2 weeks of total
vancomycin therapy which ended on ___. Ms. ___ has noted
recurrent fevers (approximately 3 times weekly to ___,
malaise, and daily chills. She also notes ___ myalgias which are
baseline for her, and states that her vertigo is at baseline
with daily dizziness which is positional in nature and responds
to epley maneuver.
.
In the ED, initial VS were 99 100 138/54 20 94% 4l, CXR was
obtained which demonstrated mild/moderate pulmonary edema and
left pleural effusion. Vancomycin was given for temperature of
101. Labs were notable for anemia to 29.0. No leukocytosis.
Blood Cultures were drawn.
.
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:
DM (insulin dependent on insulin pump)
morbid obesity
ESRD on Dialysis
OSA on bipap ___
asthma
Diverticulosis s/p partial colectomy
COPD on home oxygen
Cholecystectomy
Paroxysmal afib in the setting of hyperkalemia
Social History:
___
Family History:
Mother and sister with DM and HTN. Father died at ___ years old
with stroke and lung cancer. Mother died at ___ with CHF.
Physical Exam:
VS - Temp 99.8 F, 130/55 BP , 84 HR , 18 R , 94 O2-sat % 3L
GENERAL - obese woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - b/l crackles, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use, NC in place
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2, no JVD
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 1+ edema, 2+ peripheral pulses (radials, DPs)
SKIN - LUE graft side without tenderness or erythema
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact
Upon discharge, afebrile, otherwise physical exam is unchanged.
Pertinent Results:
Admission labs:
___ 02:20PM BLOOD WBC-5.8 RBC-2.96* Hgb-9.4* Hct-29.0*
MCV-98 MCH-31.6 MCHC-32.4 RDW-14.7 Plt ___
___ 02:20PM BLOOD Plt ___
___ 07:15AM BLOOD ESR-45*
___ 02:20PM BLOOD Glucose-86 UreaN-22* Creat-4.2*# Na-142
K-4.3 Cl-102 HCO3-31 AnGap-13
___ 07:18AM BLOOD ALT-25 AST-24 LD(LDH)-265* AlkPhos-107*
TotBili-0.4
___ 08:00AM BLOOD Calcium-8.6 Phos-3.0# Mg-1.8
___ 07:18AM BLOOD calTIBC-226* Ferritn-534* TRF-174*
___ 08:00AM BLOOD CRP-66.8*
Discharge Labs:
___ 06:20AM BLOOD WBC-9.9 RBC-2.85* Hgb-9.5* Hct-26.6*
MCV-94 MCH-33.2* MCHC-35.5* RDW-16.0* Plt ___
___ 06:20AM BLOOD Glucose-115* UreaN-101* Creat-8.2*#
Na-136 K-4.7 Cl-94* HCO3-24 AnGap-23*
___ 06:55AM BLOOD ALT-25 AST-21 LD(LDH)-267* AlkPhos-111*
TotBili-0.2
___ 06:20AM BLOOD Calcium-9.2 Phos-5.8* Mg-1.9
Pertinent studies:
___ 03:30PM BLOOD HCV Ab-NEGATIVE
___ 08:00AM BLOOD C3-112 C4-24
___ 08:00AM BLOOD CRP-66.8*
___ 07:50AM BLOOD dsDNA-NEGATIVE
___ 04:40PM BLOOD ___ * Titer-1:80
___ 09:43AM BLOOD ANCA-NEGATIVE B
___ 03:30PM BLOOD HBsAb-NEGATIVE HAV Ab-POSITIVE IgM
HAV-NEGATIVE
___ 07:00AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE
___ 07:18AM BLOOD calTIBC-226* Ferritn-534* TRF-174*
___ 08:00AM BLOOD %HbA1c-6.3* eAG-134*
B Glucan--negative
Galactomannan--negative
Right Upper Extremity US: IMPRESSION: Patent graft with no
appreciable fluid collection
TEE: IMPRESSION: No valvular vegetation seen. Right ventriclar
enlargement with preserved systolic function. At least moderate
tricuspid regurgitation is present with severe pulmonary
arterial sysolic hypertension.
Lower Extremity Non-Invasive Doppler US: IMPRESSION: No evidence
of DVT (although the right calf veins were not
visualized); bilateral ___ cysts.
MRI Lumbar Spine:
IMPRESSION:
1. Status post L3/L4 diskectomy and posterior instrumented
fusion with no
evidence of hardware failure, allowing for the limitations of
this imaging
modality.
2. No evidence of paraspinal or epidural phlegmon/abscess or
spondylodiscitis
(on this non-enhanced study).
3. Multilevel degenerative changes of the lumbar spine as
detailed above, with
most notable but only mild spinal canal stenosis at the L4/L5
level.
CT Chest: IMPRESSION:
1. Findings concerning for multifocal infection, less likely
hemorrhage.
2. Lymphadenopathy in the mediastinum and left hilum most likely
reactive.
3. Surveillance with chest radiograph is recommended.
After pulmonary findings resolve, reevaluation with chest CT is
recommended z8-10 weeks after the current examination.
Tagged WBC Scan: IMPRESSION: Slightly asymmetric tracer uptake
in the proximal right upper extremity could be due to an
infectious or inflammatory process.
CXR (2 days s/p CT chest): Moderate cardiomegaly and enlarged
main pulmonary artery are again noted and unchanged. Asymmetric
multifocal opacities, larger on the left side, have minimally
improved on the left upper lobe. There is no pneumothorax or
large pleural effusion.
Lung, left upper lobe, transbronchial biopsy:
Alveolar tissue with hemosiderosis and reactive pneumocyte
hyperplasia.
The biopsy specimen consists of six tissue fragments, four of
which contain alveolar tissue. Several fragments show
mild-to-moderate hemosiderosis with background reactive changes.
This finding is non-specific and can be seen in multiple
clinical settings. Clinical, radiologic, and laboratory
correlation is necessary.
AFB and GMS stains are negative for micro-organisms.
BAL Cx:
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
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Studies pending at discharge:
None
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a past medical history
significant for end stage renal disease on hemodialysis, type 2
diabetes mellitus and chronic obstructive pulmonary disease
admitted for fevers x1 month, which were ultimately felt to be
drug fever from either Vancomycin or minoxidil. Hospital course
was notable for a mild COPD exacerbation and steroid induced
hyperglycemia
#Fever of unknown origin/Drug Fever: Given history of bacteremia
with strep mitis and preceding 1 month of persistent fevers with
normal TTE and CT abdomen, initially our efforts focused on
finding a source persistent infection. Initial culprits were
thought to be the dialysis graft or endocarditis. Negative TTE
at OSH, and negative TEE in house made endocarditis unlikely.
Unremarkable US of right upper extremity graft made this
unlikely. Furthermore, there was only a mild increase in tracer
uptake in the right upper extremity compared to the left upper
extremity on tagged white blood cell scan. Bilateral lower
extremity vascular ultrasounds were negative for DVT. Blood
smear was negative for parasites. Hepatitis serologies were also
negative and LFTs were normal. An MRI was also obtained given
spinal hardware and was negative for signs of
infection/inflammation. Due to worsening shortness of breath
discovered in house, a CT of the chest was performed which was
significant for ground glass opacities involving the posterior
aspect of left upper lobe, lingula and left lower lobe. BAL and
bronchial biopsy were significant only for ___ cfu of gram
negative rods and respiratory flora. A transbronchial biopsy was
non-specific without evidence of malignancy or granulomas. Six
sets of blood cultures were obtained while Ms. ___ was off of
antibiotics. Beta Glucan and Galactomannal were within normal
limits.Rheumatologic labwork was relatively unimpressive with a
normal ANCA/RF and intermediate ___ (1:80). Given absence of
positive infectious workup, Vancomycin was discontinued, as was
minoxidil as patient gave history fevers starting around the
time of minoxidil initiation. After stopping these medications,
the patient defervesced and was afebrile for >5 days suggesting
drug fever.
#Mild exacerbation of chronic obstructive pulmonary disease:
Overall Ms. ___ respiratory symptoms and radiographic
findings were seen as most consistent with a COPD exacerbation.
Patient was treated with azithromycin and prednisone 40mg po
with improvement in symptoms and patient was discharged to
complete a one week total course. Of note, it took ~4 days for
patient to start responding to the steroids, which was similar
to when patient has required steroids for COPD exacerbation in
the past. Although patient grew ___ cfu E. coli in the BAL it
was not felt that these were pathogenic as patient responded to
treatment with azithro and prednisone.
#End stage renal disease on dialysis: MWF dialysis was continued
in house. Due to hypophosphatemia, revela and phoslo were
temporarily discontinued.
#Type II diabetes mellitus: Ms. ___ was maintained on her
insulin pump which was closely monitored by the ___.
Her blood sugars increased while on steroids (up to 400s), and
basal parameters of her pump were increased while she was on
steroids with input from ___. She was discharged with close
followup in ___ clinic two days post discharge and was
made aware that her insulin requirements will fall once her
steroids are completed. She is aware of signs of hypoglycemia
and was discharged with glucagon injectable as needed.
# BPPV: Meclizine was continued.
#Disposition:
Patient was discharged home with one more day of prednisone to
take. She ___ with her Endocrinologist who will give her
instructions on how to change her insulin as she comes off
prednisone. She will also follow up with her PCP, outpatient
renal and pulmonary doctors.
Medications on Admission:
Symbicort 120 inhalations, 160-4.5 mcg 2 puffs BID
Levetiracetam 500 BID
Renelva 800mg tablet 2 tabs TID, ___
Meclizine 25mg 1 tab by mouth three times daily
Furosemide 160mg BID ___, Furosemide 160mg
daily other days
Vitamin B-1 100mg daily
Calcium acetate 667mg three tabs four times daily
Amlodipine 10mg daily
Benicar 60mg daily
Calcium w/ Vitamin D ___ tab by mouth dialy
Ferrous Sulfate 325mg tablet 1 tab daily
Minoxidil 2.5 mg daily
Omeprazole 20mg daily
Vitamin D3 5000 units daily
Doxazosin 4mg qhs
Simvastatin 20mg daily
Acetaminophen 650mg QID PRN
dulcolax PRN
Enema PRn
Vicodin 5mg/500mg q4h PRN
Milk of Magnesia PRN
Ventolin HFA PRN SOB
Insulin Pump
albuterol nebs q4h PRN
ipratropium nebs q4h PRN
1 nephrocap daily
Discharge Medications:
1. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) Inhalation 2 puffs BID ().
2. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO qam on
___.
3. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): at noon and bedtime (in addition to AM dose on
non-dialysis days).
4. Renvela 800 mg Tablet Sig: Two (2) Tablet PO TID on
___.
5. meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
6. furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID ON
SAT/SUN/TUES/THURS ().
7. furosemide 80 mg Tablet Sig: Two (2) Tablet PO ONCE DAILY
___ ().
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. calcium acetate 667 mg Tablet Sig: Three (3) Tablet PO four
times a day.
10. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
12. Benicar 20 mg Tablet Sig: Three (3) Tablet PO daily ().
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
15. doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
16. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
17. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain/fever.
18. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
19. hydrocodone-acetaminophen ___ mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for pain.
20. Milk of Magnesia 400 mg/5 mL Suspension Sig: 400 mg PO
every four (4) hours as needed for nausea.
21. insulin pump cartridge Cartridge Sig: use as directed by
Diabetes Clinic Subcutaneous continuous.
22. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*90 Capsule(s)* Refills:*0*
23. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*90 Tablet(s)* Refills:*0*
24. dextromethorphan-guaifenesin ___ mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
Disp:*200 ML(s)* Refills:*0*
25. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
26. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulization Inhalation every four (4)
hours as needed for dyspnea, wheezing.
Disp:*90 nebulizations* Refills:*0*
27. ipratropium bromide 0.02 % Solution Sig: One (1)
nebulization Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
Disp:*90 nebulizations* Refills:*0*
28. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO BID (2 times a day).
Disp:*90 packets* Refills:*2*
29. Glucagon Emergency 1 mg Kit Sig: One (1) Injection three
times a day as needed for hypoglycemia.
Disp:*30 kits* Refills:*0*
30. prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 doses.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diabetes Mellitus II
End Stage Renal Disease
Obstructive Sleep Apnea
Obesity
Asthma
Chronic Obstructive Pulmonary 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 admitted with fever of unknown origin. Your fever is
likely due to the drug minoxidil or from the antibiotic
vancomycin. You underwent workup with tagged white blood cell
scan with was positive only for slightly increased uptake in the
right upper extremity, however ultrasound of your graft does not
indicate that it is infected. While here you also developed a
COPD exacerbation, and were found to have some infiltrates on CT
of your chest. A bronchoscopy was performed without signficant
growth. A small amount of bacteria grew on culture which your
outpatient doctors ___ follow up ___ final results
regarding these bacteria are still pending. In light of your
overall clinical status, a pneumonia appears unlikely.
The following changes were made to your medications:
Please START prednisone 40mg daily for 1 more day.
START colace scheduled daily, senna as needed, and miralax daily
for your constipation.
START guaifenasin for your cough
STOP minoxidil as this may have caused your fevers
STOP vancomycin as this may have caused your fevers
- Your Insulin doses on the insulin pump have been changed and
will need to be changed further at your Endocrinology
appointment tomorrow. ** Please be sure to make it to your
Endocrinology appointment this week. **
- You will also be prescribed glucagon injectable to be used as
needed for low blood sugars.
Followup Instructions:
___
|
19857454-DS-22 | 19,857,454 | 29,320,527 | DS | 22 | 2193-02-18 00:00:00 | 2193-02-18 14:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ceftin / Bactrim / Tetracycline / Rifampin / Levaquin in D5W /
Penicillins / Heparin Analogues / minoxidil / vancomycin
Attending: ___.
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Ms. ___ is a ___ woman with a history of DMII, COPD on
home O2, OSA on bipap, HTN, ESRD on HD (___) via RUE
brachiobrachial AVG (___) who presents with clotted AVG s/p
failed thrombectomy. Found to be hyperkalemic.
Patient has a RUE AVG placed ___. She had recurrent
problems with outflow stenosis and difficulty with cannulation
due to the course of the graft. On ___ she underwent
revision with a jump graft and then another revision with patch
angioplasty of the venous anastomosis on ___. Over the
past two weeks, patient has had difficulty at graft site
including pain and swelling during HD treatments, but graft has
been functioning. Today, HD could not be completed and she was
sent to the ___ due to concern for clot, where an
ultrasound showed a thrombus extending from the graft proximally
to the sublcavian vein (imaging not yet available in our
system). This was felt to be indicative of a central stenosis
that would not be amenable to an open thrombectomy. An ___
thrombectomy was attempted and 4 mg TPA was instilled without
success. Because of use of TPA, ___ was not comfortable placing
another HD line. Of note, she does have a left forearm fistula
with a thrill placed in ___ at an OSH, which was never used
because it was too deep. She was sent to the ER for further
eval.
In the ED, initial vitals were 98.3 64 138/53 18 97% RA. Initial
labs were notable for hyperkalemia to 6.4 and thrombocytopenia
(54). Patient received kayexalate, calcium gluconate, and
insulin. Renal was consulted and will see patient in the morning
but preliminarily recommended kayexalate and NPO at ___. She was
seen by ___, who recommended 6 months of anticoagulation for her
RUE DVT. Of note, she has a heparin allergy which limits
anticoagulation options. She was admitted to the MICU for
further care.
On arrival to the MICU, patient confirms the above history. She
has not noted SOB above her baseline or palpitations. She
endorses pain and swelling over the graft site.
In terms of her thrombocytopenia, patient reports it was
diagnosed ___ years ago. Platelets nadired in the low 30's. She
was seen at ___, where she was told she should not take
heparin again in case thrombocytopenia is related to heparin.
She was not formally diagnosed with HIT. She received N-plate
but has not taken it recently. Baseline plt is 100, most
recently ~106. She has had no recent mucosal bleeding, blood in
stool, or hematuria.
Past Medical History:
DM (insulin dependent on insulin pump)
morbid obesity
ESRD on Dialysis
OSA on bipap ___
asthma
Diverticulosis s/p partial colectomy
COPD on home oxygen
Cholecystectomy
Paroxysmal afib in the setting of hyperkalemia
Social History:
___
Family History:
Mother and sister with DM and HTN. Father died at ___ years old
with stroke and lung cancer. Mother died at ___ with CHF.
Physical Exam:
Admission Physical Exam:
Vitals: 156/67 79 98 4L
General- Alert, oriented, no acute distress, morbidly obese
HEENT- Sclera anicteric, MMM, oropharynx clear, no mucosal
bleeding
Neck- supple, difficult to assess due to habitus
Lungs- LCTAB with exceptions of very faint bibasilar rales, no
wheezes, rales, ronchi
CV- RRR, S1 + S2, III/VI systolic murmur heard throughout
precordium, no r/g
Abdomen- obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused. RUE with AVG with bruit and overlying
ecchymoses, tenderness. No erythema or drainage. Left forearm
with AVF with thrill/bruit. ___ pulses 1+ and symmetrical.
Neuro- A+O x 3, CN2-12 intact, motor function grossly normal,
decreased sensation of feet and ankles
DISCHARGE:
Vitals: 98.4 90/40 57 20 98 3L
General: lying bed, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: mild crackles at bases bilaterally, no rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: no cce, ecchymoses present over R inner arm, 6cmx7cm
Pertinent Results:
ADMISSION LABS
___ 07:40PM BLOOD WBC-9.3 RBC-3.41* Hgb-10.8* Hct-32.6*
MCV-96 MCH-31.7 MCHC-33.2 RDW-15.2 Plt Ct-57*#
___ 07:40PM BLOOD Neuts-91.8* Lymphs-6.1* Monos-1.5*
Eos-0.4 Baso-0.2
___ 07:40PM BLOOD ___ PTT-34.5 ___
___ 07:40PM BLOOD Glucose-253* UreaN-93* Creat-9.2* Na-136
K-6.4* Cl-100 HCO3-19* AnGap-23*
___ 07:40PM BLOOD Calcium-8.6 Phos-6.9* Mg-2.2
CXR ___:
FINDINGS: Comparison is made to prior study of ___.
There is cardiomegaly. There is improvement of vascular
congestion since the prior study. There remains some prominence
of pulmonary interstitial
markings. There is no focal consolidation or pneumothoraces.
REPORTS:
RUE US:
IMPRESSION: No right upper extremity deep vein thrombosis.
LUE vein mapping: pending
DISCHARGE:
___ 08:35AM BLOOD WBC-9.4 RBC-3.00* Hgb-9.6* Hct-28.3*
MCV-94 MCH-31.9 MCHC-33.9 RDW-15.1 Plt Ct-69*
___ 08:35AM BLOOD Glucose-142* UreaN-73* Creat-7.7*# Na-136
K-3.9 Cl-95* HCO3-22 AnGap-23*
___ 08:35AM BLOOD Calcium-8.1* Phos-6.8*# Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of DM II (on
insulin), COPD (on ___ home O2), OSA, and ESRD on HD (___)
who presented from HD with a clotted RUE AVG and hyperkalemia
and thrombocytopenia.
# Hyperkalemia: Likely ___ to ESRD and missing HD session on
___. Per patient, K occasionally runs in low 6's prior to HD
sessions. She was unable to be dialyzed ___ due to graft
dysfunction from clot. Reportedly had peaked Ts on EKG in ED,
received kayexalate and calcium gluconate. EKG on arrival to the
MICU did not show hyperkalemic changes. No arrhythmias on
telemetry. Kayexelate was continued and her potassium
downtrended to 5.2 by HD 1. Pt's HD line appeared to be
functioning well (see below), and pt was dialyzed. Post-HD
potassium was within normal limits.
# RUE DVT: Extends to right subclavian. ___ recommended 6 months
of anticoagulation. but patient has a heparin allergy, limiting
anticoagulation options. Because of tenuous IV access (#20 PIV R
hand) and thrombocytopenia, the risk of starting a
non-reversible anticoagulant such as argatroban was judged to
outweigh the benefit, esp given that pt was scheduled for
temporary HD line placement by ___ the next day. Patient did not
require a procedure as her RUE DVT was no longer present after
repeat RUE ultrasound did not show a clot. Pt started warfarin
however it was discontinued prior to her discharge given that
transplant surgery was planning a procedure on ___ (see
below).
# Thrombocytopenia: Etiology unclear. Recent baseline 100.
History is not convincing for HIT, though OSH hematology records
were not available to confirm. ITP also possible. Trended
platelets w/ plan to transfuse if fell <10 or if actively
bleeding which did not occur.
# ESRD: On HD ___. After clot prevented completion of HD on
___, flow in HD line reportedly could not be restored after an
attempted ___ thrombectomy and TPA instillation. Could not
receive heparin ___ reported allergy. In the MICU, pt was
continued on her home furosemide, sevelamer and nephrocaps.
Initially RUE AVG was non-functional, and ___ HD line
placement was planned. However, trial of accessing HD line was
successful, possibly delayed effect of TPA infusion, and pt was
dialyzed on ___. Post-HD potassium was wnl, and pt was
transferred to the floor in stable condition. Pt underwent US of
her L forearm fistula to evaluate for possibility of
superficializing, which showed patent AVF. Patient had a patent
RUE and LUE fistula. She is scheduled to have a
superficialization procedure by transplant surgery on ___,
at which time she will likely restart warfarin.
# DM II. Continued insulin pump.
# COPD. Continued O2 by NC @ 3L during day, 4L at night
(baseline), continue Symbicort, albuterol.
# OSA: per patient, had sleep study which showed resolution of
OSA, not on CPAP
# Hypercholesterolemia. Continued simvastatin.
# HTN. Continued amlodipine, doxazosin.
# pHTN. Stable.
# GERD. Continued omeprazole.
# Tremor: Patient confirmed she has no seizure history; Keppra
is for tremor only. Continued Keppra.
TRANSITIONAL ISSUES:
-Patient is to receive surgery on ___ from transplant for
LUE fistula
-Patient should restart warfarin after procedure to prevent
clots
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation 2 puffs BID
2. LeVETiracetam 500 mg PO TID ON SAT, SUN, TUES, THURS
3. LeVETiracetam 500 mg PO BID MON, WEDS, FRI
Dose after HD
4. sevelamer CARBONATE 1600 mg PO TID W/MEALS
5. Furosemide 160 mg PO BID: SAT, SUN, TUES, THURS
6. Furosemide 160 mg PO DAILY: MON, WEDS, FRI
7. Thiamine 100 mg PO DAILY
8. Amlodipine 10 mg PO DAILY
Hold for SBP < 110 or HR < 65
9. Calcium 600 *NF* (calcium carbonate) 600 mg (1,500 mg) Oral
daily
10. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
11. Ferrous Sulfate 325 mg PO DAILY
12. Omeprazole 20 mg PO BID
13. Doxazosin 2 mg PO HS
Hold for SBP < 110
14. Simvastatin 20 mg PO HS
15. Bisacodyl 10 mg PO DAILY:PRN constipation
16. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
17. Insulin Pump SC (Self Administering Medication)
Target glucose: 80-180
18. Docusate Sodium 100 mg PO BID
19. Senna 1 TAB PO BID:PRN constipation
20. Nephrocaps 1 CAP PO DAILY
21. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheezing
22. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheezing
2. Amlodipine 10 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Doxazosin 2 mg PO HS
6. Ferrous Sulfate 325 mg PO DAILY
7. Furosemide 160 mg PO BID: SAT, SUN, TUES, THURS
8. Furosemide 160 mg PO DAILY: MON, WEDS, FRI
9. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
10. Insulin Pump SC (Self Administering Medication)
Target glucose: 80-180
11. LeVETiracetam 500 mg PO TID ON SAT, SUN, TUES, THURS
12. LeVETiracetam 500 mg PO BID MON, WEDS, FRI
13. Nephrocaps 1 CAP PO DAILY
14. Omeprazole 20 mg PO BID
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Senna 1 TAB PO BID:PRN constipation
17. sevelamer CARBONATE 1600 mg PO TID W/MEALS
18. Simvastatin 20 mg PO HS
19. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation 2 puffs BID
20. Thiamine 100 mg PO DAILY
21. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
22. Calcium 600 *NF* (calcium carbonate) 600 mg (1,500 mg) Oral
daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ESRD on Dialysis
R AV fistula clot
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ after your dialysis fistula clotted.
While you were here, your fistula was re-evaluated and you had
tPA and a thrombectomy of that fistula. An ultrasound later
showed the fistula to be working well. You also had an
ultrasound of your left fistula (which you haven't been using)
and can follow up with the transplant surgeon regarding that
fistula. We started you on warfarin (coumadin) to help prevent
clots in that fistula. We stopped this so you could potentially
have surgery ___ for your Left fistula.
Please follow up with your primary care doctor, your
nephrologist, and transplant surgery. The transplant surgeons
would like to see you later this week, likely on ___, to
potentially superficialize your left upper extremity fisutla or
place a new fistula if necessary. It was a pleasure taking care
of you.
Followup Instructions:
___
|
19857684-DS-8 | 19,857,684 | 27,434,798 | DS | 8 | 2157-08-13 00:00:00 | 2157-08-13 08:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Zoloft / Neurontin / NSAIDS (Non-Steroidal Anti-Inflammatory
Drug) / Depakote
Attending: ___.
Chief Complaint:
Right knee pain
Major Surgical or Invasive Procedure:
I&D of right knee
History of Present Illness:
Mrs. ___ is a ___ who presents as a transfer from OSH with
4
day history of R knee pain. She reports that there was a skin
lesion (wart) that she picked off. She noticed progressive
stiffness and swelling of the right knee. She presented to
___ where the knee was aspirated which
demonstrated 89k TNC with pending gram stain. Yellow-green fluid
was aspirated. She denies any fevers. No IVDU
Past Medical History:
Bipolar disorder and chronic pain
Social History:
___
Family History:
NC
Physical Exam:
NAD
Breathing comfortably
Right lower extremity:
- Skin intact
- pain with attempted ROM of R knee.
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a native septic knee arthritis and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for I&D of her right knee, 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 infectious disease services was consulted for antibiotic
choice and treatment length. They recommended cefazolin 2 gram
via IV every 8 hours for 42 days
The patient worked with ___ who determined that discharge to Home
was appropriate. You are weight bearing as tolerated. 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, and will be discharged on aspirin
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:
Ativan, Topamax, zolpidem, zolpidem
Discharge Medications:
1. Acetaminophen 1000 mg PO Q12H
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
4. LORazepam 1 mg PO Q8H:PRN anxiety
5. Methadone 30 mg PO TID
6. Phenytoin Sodium Extended 100 mg PO BID
7. Topiramate (Topamax) 150 mg PO BID
8. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Septic arthritis of knee
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
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin or 4 weeks to prevent blood clots
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 change dressing only as needed for drainage
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
Followup Instructions:
___
|
19857684-DS-9 | 19,857,684 | 22,596,540 | DS | 9 | 2157-08-28 00:00:00 | 2157-08-29 11:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zoloft / Neurontin / NSAIDS (Non-Steroidal Anti-Inflammatory
Drug) / Depakote
Attending: ___.
Chief Complaint:
R knee pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with a history of bipolar
disorder, fibromyalgia, RA, recent R knee septic arthritis s/p
washout on ___, discharged on ___ on IV cefazolin via ___,
presenting from ___ for evalulation of
severe right knee pain. Patient reports significant pain in her
right knee since her operation and states she has been bedbound
at home due to the pain.
On her OPAT visit on ___, it was noted that she had elevated
inflammatory markers (ESR: 119 CRP: 56.43). The patient
subsequently called the ___ clinic on ___, the following is the
note from ___ regarding this call:
"Patient called us yesterday wanting her ___ line pulled out
and
regarding pain medications and being very upset about pain. She
is followed at ___ for pain management, and had hung up
the phone before we could discuss further options for managing
her pain. We had highly advised against discontinuing her IV
antibiotics but she stated that she "would rather die" than
follow-up at our clinic. This morning we had called her again
and she stated her pain was out of control and would be coming
to
the ED. Her recent OPAT follow-up labs had also been elevated
with inflammatory markers, which we weren't able to inform her
of
yesterday prior to her hanging up. We have informed the
orthopedic team of these events as well, and will evaluate her
when she is admitted. Ed referral placed."
She presented to ___, and was transferred to ___
for further management.
In the ED, initial VS were T 97.4 HR 80 BP 112/64 RR 16 O2sat
99%
Exam notable for linear surgical incision with staples on
anterior aspect of R knee, C/D/I with no erythema. R knee not
erythematous or warm to touch, intact active and passive ROM. ___
warm and well perfused, 2+ DP pulses.
Labs notable for WBC 12.9, Hg 7.9, Hct 25.4, Platelets 806,
Bicarb 20, CRP 11.2, UA with few bacteria, WBC, RBCs.
Imaging showed CXR with no acute cardiopulmonary process, Knee
radiograph with moderate soft tissue swelling and suprapatellar
joint effusion.
Received
___ 06:38 PO/NG Methadone 30 mg
___ 06:42 PO Phenytoin Sodium Extended 100 mg
___ 08:13 PO/NG Docusate Sodium 100 mg
___ 08:13 PO/NG LORazepam 1 mg
___ 08:13 PO/NG Topiramate (Topamax) 50 mg ___
08:13 PO OxyCODONE (Immediate Release) 10 mg
___ 09:23 SC Enoxaparin Sodium 40 mg
___ 09:23 IV CefazoLIN (2 g ordered)
Ortho were consulted, reported that this does not seem to be a
recurrence of her infection and does not require further
orthopedic intervention. Recommended pain control. Decision was
made to admit to medicine for further management.
On arrival to the floor, patient reports ongoing right knee
pain, and was very upset that she hadn't received her afternoon
home meds yet. She is frustrated that she has failed to progress
at home, and says that she has been laying on her couch, unable
to even get up to go to the bathroom because of the pain. She
expressed that she does not like dilaudid for pain, and that
oxycodone works best for her. She is worried that she is on the
wrong antibiotic since her pain has not improved.
Past Medical History:
- Bipolar disorder, with inpatient psych hospitalization in
___ due to suicidal ideation
- Fibromyalgia
- Chronic pain
- Rheumatoid arthritis- not on immunosuppressant
- Degenerative disease in spine
- L ankle surgery, metal plate placed in ___
- Extensive R knee surgery after car accident involving
dashboard
___, she was thrown out the car
- Patient endorses that she is accident prone and has had
multiple
broken bones (ribs, wrist, ankle, jaw surgery ___ abusive
boyfriend)
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.1 BP 145/78 HR 81 RR 20 O2sat 99% on RA
___: agitated woman, appears older than stated age, pt very
angry and accusatory but ultimately redirectable
HEENT: anicteric sclera, pink conjunctiva, MMM, poor dentition
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: R knee with midline vertical scar with staples in
place, no erythema or purulent drainage, swollen compared to
left knee with TTP along medial aspect
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, pt has several scattered scabs on
extremities and trunks, she say sshe is a "picker" and often
picks at skin lesions
DISCHARGE PHYSICAL EXAM:
VS: 98.0 PO 106 / 67 L Lying 68 18 100 RA
___: Pt lying in bed in NAD, mood much improved this am
compared to last night
HEENT: No icterus or injection. Voice hoarse.
CV: RRR, no murmurs.
RESP: CTAB.
ABD: Soft, NDNT.
EXTR: R knee with midline vertical surgical incision with
staples in place, no erythema, drainage, or asymmetric warmth,
swollen compared to left knee with mild TTP along medial aspect.
Multiple scabbed lesions on bilateral arms and R knee where
patient reports skin picking.
NEURO: A&Ox3. CN intact.
PSYCH: Pt appropriate this morning, mood becomes more labile
when discussing her pain
Pertinent Results:
==============
ADMISSION LABS
==============
___ 05:00AM BLOOD WBC-12.9*# RBC-2.97* Hgb-7.9* Hct-25.4*
MCV-86 MCH-26.6 MCHC-31.1* RDW-15.3 RDWSD-47.5* Plt ___
___ 05:00AM BLOOD Neuts-61.3 ___ Monos-5.8 Eos-2.9
Baso-0.5 Im ___ AbsNeut-7.88* AbsLymp-3.73* AbsMono-0.74
AbsEos-0.37 AbsBaso-0.07
___ 05:00AM BLOOD Glucose-83 UreaN-14 Creat-0.5 Na-136
K-4.2 Cl-106 HCO3-20* AnGap-14
___ 05:00AM BLOOD CRP-11.2*
___ 05:21AM BLOOD Lactate-1.5
==============
MICROBIOLOGY
==============
Blood Culture: No Growth
___ 6:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
==============
IMAGING
==============
+ ___ KNEE (AP, LAT & OBLIQUE)
Moderate soft tissue swelling and a moderate suprapatellar joint
effusion which are nonspecific and can be secondary to recent
surgery
+ ___ (PA & LAT)
Right-sided PICC terminates in the low SVC.The lungs are clear
without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac size is slightly enlarged and
the mediastinal silhouettes are unremarkable.
==============
DISCHARGE LABS
==============
None checked, as labs were stable after admission
Brief Hospital Course:
___ with bipolar disorder, fibromyalgia, RA, recent R knee
septic arthritis s/p washout on ___ discharged on IV cefazolin
via ___, presenting from ___ for severe
right knee pain.
#R Knee Septic Joint:
#Pain Control:
Patient showed no evidence of recurrent knee infection, so
ongoing course of IV cefazolin was continued. Per the
orthopedics team, she required no further drainage of her knee,
and had her staples removed while in-house. The chronic pain
team was consulted, and patient's methadone was increased from
30 to 35mg TID, and her oxycodone was weaned down and eventually
stopped. The infectious disease team was also consulted, and the
patient was discharged with the plan to receive an infusion of
dalbavancin on the day of discharge, after which her PICC will
be pulled. Pt has infectious disease appointment next week to
determine whether any further oral medication needed. Her
lovenox for DVT prophylaxis was stopped on discharge, as she has
completed more than two weeks of therapy and now has improved
mobilization.
#Outpatient followup: Case management and social work were
involved in helping set the patient up with new primary care at
___, as patient was discharged from her last PCP
due to ___ positive UDS (for cocaine and clonazepam), and has no
one prescribing her methadone (and other meds) currently. Pt was
given information for local ___ clinic and emergency
mental health services, and was also set up with a back-up PCP
appointment at ___, should it not work out with
___. Last two social work note details were
as follows:
Social work note ___:
Warm handoff today with primary care at ___. They have assigned this pt to a senior clinician.
PT1s submitted for both PCPs and for ___ clinic followup.
Met with pt. Reviewed her discharge instructions (from SW
perspective) and gave her written instructions, below. Pt was
pleasant and cooperative, continues to be labile. Very worried
about new providers changing her meds. Agrees to
phone-follow-up.
Social work note ___:
Sw continues to follow Ms ___. Case discussed today with
psych, ___, and medicine teams. Discussed pt's
discharge plans.
- Ongoing outreach to pt's prospective primary care at ___ to assess whether feel comfortable
seeing this pt.
- Made a second PCP apt with ___ for next ___ in case
the doctor at her ___ apt will not accept her.
- If pt is declined at her ___ apt, she can attend a walk-in
intake at a local ___ clinic on ___ morning, 8am.
- Discussed restarting pt's ___
- discussed discharging pt with Narcan rx
Appt information:
Primary care - ___ ___
___ at 2:15pm
Dr. ___ can have a referral to behavioral health from the PCP and
can
be seen by a counselor as early as ___, who would then refer
the
pt to psychiatry for med management.
Pt reports she normally drives, but cannot now that her knee is
injured. ___ submitted.
Pt agreed to short term post-discharge phone follow-up.
Alternative plans in case the pt does not access ___
___:
___ walk-in hours in the early morning
___ ___
Primary care - ___
fax - ___ (PCP, but will be seen by ___, ___ at
___)
___ at 1:30pm
___ psychiatry dept is not accepting new patients for med
management (psychotherapy only).
Pt describes having support from her mother and sister who both
live on the ___. Pt's ___ year old dtr currently staying
with sister.
#Bipolar disorder: Continued home topiramate, phenytoin, and
lorazepam. Pt was seen by our psychiatry team in-house to help
smooth the transition to this new PCP. No changes were made to
her psychiatric regimen per inpatient psychiatric
recommendations. Patient recommended to have outpatient
behavioral health, which was discussed with new ___ clinic and
she has a preliminary appointment. Assessment and plan portion
of Psychiatry consult note as follows:
Ms. ___ is a ___ year old woman with history of
bipolar disorder, fibromyalgia, rheumatoid arthritis, recent
right knee septic arthritis who represented with right knee
pain.
Psychiatry was consulted for management of intermittent
agitation
and difficulty cooperating with the team. On interview she
reports that she is frustrated by her prolonged hospital stay.
She reports past symptoms consistent with a spectrum of bipolar
disorder including episodes of decreased need for sleep for
weeks, paranoia, impulsive spending, and depressive episodes, as
well as a family history of bipolar disorder. Her interpersonal
difficulty, multiple hospitalizations, past suicide attempts,
may
be also consistent with a longstanding personality disorder
marked by emotional lability and decreased stress tolerance. On
examination today she is tangential though does not appear
psychotic, does not appear manic, and does not endorse any
thoughts of harm towards herself or others. She is amenable to
following up with psychiatry for medication management.
PLAN:
- no acute psychiatric contraindication to discharge once
medically stable
- Ms. ___ has a complicated past psychiatric history and
would
benefit from seeing a outpatient psychiatrist
- continue lorazepam, zolpidem, and topiramate for now, as she
reports stabilization on these medications. ___ explore
alternatives in outpatient psychopharmacology, for example, she
reports never having trialed lamotrigine.
#Chronic anemia
Pt with Hg 7.9 on admission, slightly lower than baseline of
8.5. Suspect ACI ___ RA, with possible additional contribution
from acute inflammatory process. No history or exam findings to
suggest bleeding or hemolysis. Pt did not require blood
transfusion.
#Thrombocytosis
Pt with platelets elevated to 806, baseline within normal
limits. Likely reactive thrombocytosis in the setting of recent
septic joint and surgery. No evidence of recurrent infection per
above. Improved over course of admission.
#Rheumatoid Arthritis
___ be contributing to elevated CRP, right knee pain. Not
currently on immunosuppressants.
TRANSITIONAL ISSUES
===================
*Antibiotic plan: Dalbavancin infusion ___ at ___,
followed by infectious disease appointment next week to
determine whether any further oral medication needed
[] Please repeat CBC at upcoming PCP appointment to follow up on
chronic anemia
[] Pt should be set up with outpatient psychiatry at her
upcoming PCP ___
[] If pt is declined at her ___ apt, she can attend a walk-in
intake at a local ___ clinic on ___ morning, 8am
(information below)
[] Pt discharged with prescription for naloxone given her high
dose of methadone, please ensure that this prescription is
refilled if necessary
[] Pt discharged with 5 day supply of methadone for pain
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q12H
2. Docusate Sodium 100 mg PO BID
3. LORazepam 1 mg PO Q8H:PRN anxiety
4. Methadone 30 mg PO TID
5. Phenytoin Sodium Extended 100 mg PO BID
6. Topiramate (Topamax) 150 mg PO BID
7. Zolpidem Tartrate 5 mg PO QHS
8. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
9. Enoxaparin Sodium 40 mg SC DAILY
10. CeFAZolin 2 g IV Q8H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
4. Narcan (naloxone) 4 mg/actuation nasal ONCE
RX *naloxone [Narcan] 4 mg/actuation 1 spray nasal once Disp #*1
Spray Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*24 Packet Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
7. LORazepam 1 mg PO Q8H:PRN anxiety
RX *lorazepam 1 mg 1 tablet by mouth every eight (8) hours Disp
#*15 Tablet Refills:*0
8. Methadone 35 mg PO TID
for pain
RX *methadone 5 mg 7 tablets by mouth three times a day Disp
#*105 Tablet Refills:*0
9. Phenytoin Sodium Extended 100 mg PO BID
10. Topiramate (Topamax) 150 mg PO BID
11. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary Diagnoses: Septic knee joint, pain control
Secondary Diagnoses: chronic pain/fibromyalgia, bipolar
disorder, anemia, rheumatoid arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches)
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
WHY DID YOU COME TO THE HOSPITAL?
You were having knee pain after your surgery.
WHAT HAPPENED WHILE YOU WERE HERE?
We continued treating you with antibiotics for your joint
infection, and we adjusted your pain medications. We worked very
hard on getting you set up with a new primary doctor and mental
health doctor at ___. Please keep the
appointments as below.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
Please continue to take all of your medications as directed, and
follow up with your new doctor ___ below). As we
discussed, we tried to get a new psychiatry appointment and you
should discuss that with your new PCP on your ___ visit. If for
whatever reason it does not work out with your new PCP on the
___, we have also set you up with an appointment at ___ on
the ___ (listed below). We have provided you with information
for a local ___ clinic should you need to go there to
obtain your medication.
We are discharging you straight to an appointment to receive an
infusion of antibiotics, after which we will be able to remove
your PICC line (IV line in your arm). You have been set up with
an infectious disease appointment next week to determine whether
you need any further antibiotics. You do not need to do lovenox
shots anymore as long as your are walking and out of bed most of
the day.
Again, it was a pleasure taking care of you!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19857858-DS-24 | 19,857,858 | 22,550,659 | DS | 24 | 2191-03-02 00:00:00 | 2191-03-02 15:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lethargy, failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with hypertrophic obstructive cardiomyopathy
with ethanol ablation in the past, dual-chamber pacemaker
without ICD for complete heart block, hypertension, diastolic
heart failure, and atrial fibrillation who presented from
___ with subacute decline in mental status since
___ and family was requesting further workup. Per family, they
have also noted increased leg swelling, and poor appetite. Since
being started on wellbutrin and sertraline, they have noted
increased sleepiness. According to her daughters, patient was
communicative in ___ but since that time has become more
progressively more debilitated and less interactive. She is now
wheelchair bound and unable to feed herself due to increased
contractions of her bilateral hands. She remains oriented and
recognizes her children but sometimes does not respond to
questions. She herself has never endorsed any complaints of
chest pain, shortness of breath, abdominal discomfort.
In the ED, initial VS were: 97 60 138/64 16 97% ra. She was
given 40 mg IV lasix as CXR showed mild pulmonary edema. BNP
notable for 12,000 and troponin .09 (baseline .03). ECG was
V-paced.
Currently, patient is able to state she is ___ and is feeling
"fine."
Past Medical History:
- Hypertrophic obstructive cardiomyopathy, status post alcohol
ablation in ___
- Endocarditis in ___
- Status post benign inguinal node biopsy
- Hypercholesterolemia
- Hypertension
- Diastolic CHF
- Complete Heart Block s/p DDD pacemaker
- atrial fibrillation
- Urinary incontinence s/p bladder stimulator
- Depression
- diastolic CHF with class III symptoms, recently seen by Dr.
___
- CKD III, ___ Cr 1.4
- blind in L eye
- s/p right clavicular fracture after fall in ___
Social History:
___
Family History:
Coronary artery disease versus hypertrophic obstructive
cardiomyopathy in father and brother.
Physical Exam:
Admission exam
VS - 98.6 103/33 55 16 95% RA
GENERAL - elderly female, NAD, alert, minimally verbal
(baseline)
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVP ___, no carotid bruits
LUNGS - +crackles at the bases, R>L
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - 1+ pitting edema to thighs bilaterally, dependent
edema
Discharge exam
VS - 97.5 115/60 55 16 97%ra
GENERAL - elderly female, NAD, alert, minimally verbal
(baseline)
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVP ___, no carotid bruits
LUNGS - +crackles at the bases, R>L
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - 1+ pitting edema to thighs bilaterally, dependent
edema is significant in the feet, area of painless erythema on
left foot
Pertinent Results:
Admission labs
___ 08:06PM ___ PO2-41* PCO2-54* PH-7.36 TOTAL
CO2-32* BASE XS-2
.
___ 08:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
.
___ 07:45PM GLUCOSE-109* UREA N-22* CREAT-1.2* SODIUM-142
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-28 ANION GAP-14
___ 07:45PM CALCIUM-9.7 PHOSPHATE-2.8 MAGNESIUM-2.2
___ 07:45PM cTropnT-0.09*
___ 07:45PM ___
.
___ 07:45PM WBC-7.1 RBC-4.05* HGB-12.4 HCT-38.4 MCV-95
MCH-30.6 MCHC-32.3 RDW-14.5 PLT COUNT-290
___ 07:45PM NEUTS-69.4 ___ MONOS-6.6 EOS-4.0
BASOS-0.3
___ 07:45PM ___ PTT-27.4 ___
.
Discharge labs
___ 08:00AM BLOOD WBC-7.1 RBC-3.89* Hgb-12.2 Hct-36.4
MCV-94 MCH-31.3 MCHC-33.5 RDW-14.5 Plt ___
___ 08:00AM BLOOD Glucose-105* UreaN-18 Creat-1.2* Na-141
K-4.5 Cl-104 HCO3-29 AnGap-13
___ 08:00AM BLOOD Calcium-9.6 Phos-2.6* Mg-2.1
___ 08:00AM BLOOD CK-MB-5 cTropnT-0.11*
.
CXR 1. Mild pulmonary vascular congestion with small bilateral
pleural effusions.
2. Retrocardiac opacification could reflect atelectasis but
pneumonia is not excluded
Brief Hospital Course:
___ year old female with hypertrophic obstructive cardiomyopathy
with ethanol ablation in the past, dual-chamber pacemaker
without ICD, complete heart block, hypertension, diastolic heart
failure, and atrial fibrillation presenting with increased
lethargy and leg swelling and generalized subacute failure to
thrive.
.
ACUTE ISSUES:
# Acute on chronic diastolic heart failure: Patient had elevated
BNP in ED, though breathing was comfortable on room air. She had
some signs of mild volume overload on exam, and CXR showed
evidence of mild pulmonary vascular congestion with small
bilateral pleural effusions. She was given one additional dose
of PO lasix 60mg, and was discharged on her home PO lasix 60mg
daily. She remained asymptomatic throughout the
hospitalization.
.
# Elevated troponin: Likely demand ischemia in setting of heart
failure exacerbation. She was given aspirin 325 in ED, but
suspicion for true ACS was low. She was continued on her daily
aspirin and metoprolol.
.
# Failure to Thrive: Overall presentation suggestive of subacute
decline, potentially related to neurologic causes such as
cerebrovascular disease, worsening dementia, or depression. New
antidepressants may potentially be contributing to sleepiness
described by family so we have decided to discontinue her
wellbutrin, and decrease sertraline from 100mg to 50mg daily. We
also discussed with her family the possibility of an outpatient
neurology workup of her mental status decline.
.
CHRONIC ISSUES:
# Hyperlipidemia: Stable, continue statin
# Hypothyroid: Stable, continue levothyroxine
# Code status: Confirmed DNR/DNI
.
TRANSITIONAL ISSUES
-Continue outpatient workup of generalized decline
-Patient scheduled for generator change of pacemaker next year
-Continue titration of antidepressants
-Patient is high risk for DVT given immobility so continue DVT
prophylaxis
-Patient is high risk for aspiration given decreased level of
alertness
PATIENT WAS DISCHARGED TO HER NURSING HOME AND WAS READMITTED TO
___ SHORTLY AFTER WITH CONTINUED MENTAL STATUS CHANGES
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Nursing home chart.
1. Docusate Sodium 100 mg PO BID
2. Simvastatin 40 mg PO DAILY
3. BuPROPion 75 mg PO DAILY
4. Furosemide 60 mg PO DAILY
5. traZODONE 25 mg PO HS:PRN sleep
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Omeprazole 20 mg PO DAILY
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Lisinopril 2.5 mg PO DAILY
11. Sertraline 100 mg PO DAILY
12. Cyanocobalamin Dose is Unknown PO DAILY
13. Vitamin D Dose is Unknown PO DAILY
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Calcium Carbonate 500 mg PO BID
16. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Metoprolol Succinate XL 25 mg PO DAILY
5. traZODONE 25 mg PO HS:PRN sleep
6. Simvastatin 40 mg PO DAILY
7. Sertraline 50 mg PO DAILY
8. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Omeprazole 20 mg PO DAILY
11. Lisinopril 2.5 mg PO DAILY
12. Levothyroxine Sodium 75 mcg PO DAILY
13. Furosemide 60 mg PO DAILY
14. Heparin 5000 UNIT SC TID
15. Cyanocobalamin 250 mcg PO DAILY
16. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
Acute on chronic diastolic heart failure
Failure to thrive
SECONDARY
Depression
Atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure participating in your care at the ___
___. You were admitted to the hospital
with increasing sleepiness and leg swelling and were found to
have an exacerbation of your heart failure. You have also been
less interactive with your family over the past several months
which should be further investigated by neurology outside of the
hospital.
Followup Instructions:
___
|
19857858-DS-25 | 19,857,858 | 26,126,576 | DS | 25 | 2191-03-05 00:00:00 | 2191-03-05 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:
change in mental status (unresponsive and sleepy)
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Primary Care Physician:
___: change in MS
History of Present Illness:
___ dCHF,CKD, dementia, recently discharged for failure to
thrive and heart failure presented with AMS and fever from
nursing home. Daughter was told she was well when she arrived to
the ___ last night and was found unresponsive this am per nursing
home. At baseline pt does not talk, does not feed herself, wears
a diaper, but usually she will interact more with others, this
morning she was sleeping and unresponsive.
Vitals in ED: 99.4 60 110/60 22 95%
pt was given ceftriaxone and vanc
blood cultures and urine cultures sent
Past Medical History:
- Hypertrophic obstructive cardiomyopathy, status post alcohol
ablation in ___
- Endocarditis in ___
- Status post benign inguinal node biopsy
- Hypercholesterolemia
- Hypertension
- Diastolic CHF
- Complete Heart Block s/p DDD pacemaker
- atrial fibrillation
- Urinary incontinence s/p bladder stimulator
- Depression
- diastolic CHF with class III symptoms, recently seen by Dr.
___
- CKD III, ___ Cr 1.4
- blind in L eye
- s/p right clavicular fracture after fall in ___
Social History:
___
Family History:
Coronary artery disease versus hypertrophic obstructive
cardiomyopathy in father and brother.
Physical Exam:
on admission
Physical Exam:
Vitals-97.6 106/50 58 20 94%RA
General-sleeping, difficult to arrouse
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- contracted b/l hands, left leg larger than right
Pertinent Results:
___ 08:00AM BLOOD WBC-7.1 RBC-3.89* Hgb-12.2 Hct-36.4
MCV-94 MCH-31.3 MCHC-33.5 RDW-14.5 Plt ___
___ 10:40AM BLOOD WBC-6.7 RBC-3.79* Hgb-11.9* Hct-35.8*
MCV-95 MCH-31.4 MCHC-33.2 RDW-14.6 Plt ___
___ 07:35AM BLOOD WBC-7.5 RBC-3.69* Hgb-11.5* Hct-35.6*
MCV-96 MCH-31.1 MCHC-32.3 RDW-14.7 Plt ___
___ 07:35AM BLOOD ___ PTT-150* ___
___ 08:00AM BLOOD Glucose-105* UreaN-18 Creat-1.2* Na-141
K-4.5 Cl-104 HCO3-29 AnGap-13
___ 10:40AM BLOOD Glucose-116* UreaN-20 Creat-1.4* Na-143
K-4.2 Cl-107 HCO3-27 AnGap-13
___ 07:35AM BLOOD Glucose-91 UreaN-21* Creat-1.3* Na-144
K-4.3 Cl-106 HCO3-27 AnGap-15
lower ext u/s
FINDINGS: Echogenic material is seen with non-compressible left
common
femoral and proximal superficial femoral veins. A small amount
of flow is
demonstrated around the clot in the left common femoral vein.
Normal
compressibility and flow are seen in the mid and distal left
superficial
femoral and popliteal veins. The left calf veins are not well
seen.
The right common femoral, superficial femoral, and popliteal
veins demonstrate normal compressibility, flow and augmentation.
Flow is demonstrated in the right posterior tibial veins. The
right peroneal veins are not seen.
IMPRESSION: Deep venous thrombosis in the left common femoral
and proximal superficial femoral veins. Proximal extent of this
clot cannot be evaluated on this study
Brief Hospital Course:
___ year old female with advanced dementia, hypertrophic
obstructive cardiomyopathy with ethanol ablation in the past,
dual-chamber pacemaker without ICD, complete heart block,
hypertension, diastolic heart failure, and atrial fibrillation
with recent discharge for failure to thrive and acute CHF
presented from nursing home for change in mental status, found
to have a UTI and DVT.
.
#Worsening Change in Mental status: Believed to be from UTI with
urine showing positive nitrates and 22 WBCs and pt was started
on ceftriaxone. Though urine cultures grew back no organisms we
felt that patient would benefit from a total of 7 days of
antibiotics for presumed UTI (transitioned to cefpodoxime at
time of discharge, 100 mg POQ12h until ___. Per daughter pt
has had steady decline over the past year where now she is no
longer able to feed herself, interact much but prior to
admission she was very sleepy and unable to arouse. We also
checked an RPR while she was here which was negative. TSH was
4.4. Over hospital course patient became more interactive she
knew she was at ___ though did not know the year, which is
closer to her baseline. Per daughter pt was the best she had
seen her in the past month.
#DVT: Patient was asymptomatic but her left leg appeared larger
than right. Lower extremity duplex showed deep venous thrombosis
in the left common femoral and proximal superficial femoral
veins. She was started heparin drip on ___ at night was
swtiched to ___ 70 mg daily on ___ and coumadin was
started on ___. Her INR was followed and she was discharged on
lovenox to coumadin bridge for nursing home to follow. These
finding were discussed with the patient's daughter who was in
agreement with initiating anticoagulation.
# UTI: As above, however in brief here, CTX x 3 days, discharged
on cefpodoxime 100 mg POQ12h to finish 1 week course to end on
___. UCx was negative here, however still treated given AMS.
#CKD: baseline 1.2, while here 1.3--> 1.0 on date of discharge.
#chronic diastolic heart failure: pt did not appear volume
overloaded on exam and per daughter her ankles had very little
edema. CXR showed small to moderate bilateral pleural effusions
and retrocardiac similar to ___. We continued her
home medications of lasix and metoprolol while she was in house.
weight 155 during this admission
# Failure to Thrive: Overall presentation suggestive of subacute
decline, potentially related to neurologic causes such as
cerebrovascular disease, worsening dementia, or depression. Pt
did not talk much and was unable to feed herself at baseline.
Family did not want an inpatient workup of this issue.
# Hyperlipidemia: continued statin
# Hypothyroid: continued levothyroxine
# Code status: Confirmed DNR/DNI
TRANSITIONAL ISSUES:
#DVT: with lovenox to coumadin bridge - daily INRs by nursing
home
#UTI: continue cefpodoxime, last day ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Metoprolol Succinate XL 25 mg PO DAILY
5. traZODONE 25 mg PO HS:PRN sleep
6. Simvastatin 40 mg PO DAILY
7. Sertraline 50 mg PO DAILY
8. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K > 5
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Omeprazole 20 mg PO DAILY
11. Lisinopril 2.5 mg PO DAILY
12. Levothyroxine Sodium 75 mcg PO DAILY
13. Furosemide 60 mg PO DAILY
14. Heparin 5000 UNIT SC TID
15. Cyanocobalamin 250 mcg PO DAILY
16. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Warfarin 3 mg PO DAILY16
2. Enoxaparin Sodium 70 mg SC Q24H
please discontinue when INR is therpaeutic
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K > 5
5. Aspirin 81 mg PO DAILY
6. Calcium Carbonate 500 mg PO BID
7. Cyanocobalamin 250 mcg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Furosemide 60 mg PO DAILY
10. Levothyroxine Sodium 75 mcg PO DAILY
11. Lisinopril 2.5 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Sertraline 50 mg PO DAILY
15. Simvastatin 40 mg PO DAILY
16. traZODONE 25 mg PO HS:PRN sleep
17. Vitamin D 800 UNIT PO DAILY
18. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 4 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Urinary tract infection
deep vein thrombosis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic sometimes arousable other
times not at all.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You came to the hospital because you had a change in mental
status (very sleepy wouldn't respond to us) while at your
nursing home and were found unresponsive. We treated you for a
UTI and treated you with intravenous antibiotics but though the
urine cultures grew back no bacteria we feel you should continue
taking oral antibiotics for a total of 7 day course. While you
were here and you started to get better and were closer to your
baseline. While you were here you were found to have a DVT (a
clot) in the vessel in your leg. You were treated with
anticoagulation (heparin for about 12 hours then lovenox and
then we added coumadin). You will need to have your INR levels
checked daily till your coumadin dose is therapeutic and until
you can discontinue the lovenox.
We made the following changes to your medications:
please START lovenox 70mg daily SC (discontinue when therapeutic
INR)
please START coumadin 3mg daily (this dose will likely need to
be titrated up or down depending on your INR levels especially
when you are taking antibiotics)
cefpodoxime 100 mg q12H (last day ___, to start tonight
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19857858-DS-26 | 19,857,858 | 25,270,105 | DS | 26 | 2191-03-12 00:00:00 | 2191-03-12 21:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Supratherapeutic INR and confusion
Major Surgical or Invasive Procedure:
Blood transfusion
History of Present Illness:
___ yo F w/ dementia, recently diagnosed DVT on warfarin, who
presents from ___ with altered mental status and
hypotension. Pt was recently admitted here from ___ with
altered mental status and was found to have UTI (cefpodoxime
until ___ and DVT in the left common femoral and proximal
superficial femoral veins(started on warfarin on ___, bridged
with lovenox).
She was also admitted from ___ with lethargy and failure
to thrive, where she was thought to have acute on chronic
diastolic heart failure (discharged on her home 60mg po daily
lasix). Failure to thrive was thought to be subacute in nature
and per her most recent dc summary, pt has had steady decline
over the past year where now she is no longer able to feed
herself.
Per records, she was on coumadin and had her last dose of
lovenox 70mg subq at 8AM on ___. Pt had T 100.2 at the nursing
home. In the ED, initial VS were: 96.4 60 100/30 28 99% 2L. Her
INR was 12.8 and she was subsequently given 10mg IV vitamin K.
Pt was also given Ciprofloxacin 400mg IV, Vancomycin 1gm IV, and
Metronidazole 500mg IV as she was hypotensive and was unclear if
there was infection. Of note, her WBC is 11.5, up from 6.4 on
___ her HCT was 25.3, down from 34.3 on ___. She was
given 2 units FFP and 1 unit pRBC. Gave 1.5L NS and per report
had loose, guaiac negative stool. FAST exam showed no
intraperitoneal bleed and prelim CT torso showed no hematoma. VS
upon transfer 99.2 55 ___ 98%, and BP upon manual recheck
118/30.
On arrival to the MICU, pt is in no acute distress, resting
comfortably in bed. She is accompanied by her daughter. Sounds
like over the past two days she has been back at ___,
she hasn't been having fevers, cough, pain or any new symptoms,
though the daughter does note that she was receiving tylenol
yesterday at the nursing home, though was unsure why. The
daughter also mentioned the pt's propensity to aspirate often
and reported she was on a special diet at ___, which is
documented as 2gm sodium, pureed nectar, prethickened liquids,
fluid restriction 2L.
.
ROS is otherwise negative except per above
.
Past Medical History:
- Hypertrophic obstructive cardiomyopathy, status post alcohol
ablation in ___
- Endocarditis in ___
- Status post benign inguinal node biopsy
- Hypercholesterolemia
- Hypertension
- Diastolic CHF
- Complete Heart Block s/p DDD pacemaker
- atrial fibrillation
- Urinary incontinence s/p bladder stimulator
- Depression
- diastolic CHF with class III symptoms, recently seen by Dr.
___
- CKD III, ___ Cr 1.4
- blind in L eye
- s/p right clavicular fracture after fall in ___
Social History:
___
Family History:
Coronary artery disease versus hypertrophic obstructive
cardiomyopathy in father and brother.
Physical Exam:
ADMISSION PHYSICAL EXAM
General: A&Ox1, no acute distress
HEENT: Sclera anicteric, MM dry, EOMI
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally when auscultated
anteriorly, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley draining minimal urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Bilateral hands contracted.
Neuro: Did not perform
.
Discharge PE
VS not checked-patient is CMO
General: patient is comfortable, speaks in a soft voice but is
able to answer questions and follow simple command
Pertinent Results:
ADMISSION LABS
___ 01:45PM BLOOD WBC-11.5*# RBC-2.69*# Hgb-8.4* Hct-25.3*#
MCV-94 MCH-31.4 MCHC-33.3 RDW-15.4 Plt ___
___ 01:45PM BLOOD ___ PTT-52.9* ___
___ 01:45PM BLOOD Glucose-145* UreaN-26* Creat-1.6* Na-140
K-4.4 Cl-103 HCO3-27 AnGap-14
___ 01:45PM BLOOD ALT-37 AST-64* LD(LDH)-310* AlkPhos-75
TotBili-0.3
___ 01:45PM BLOOD Albumin-2.8*
___ 02:06PM BLOOD Lactate-2.3*
___ 01:45PM BLOOD Hapto-214*
.
___ CT AP
IMPRESSION:
1. No CT evidence for large hematoma or site of acute bleeding.
2. Small bilateral pleural effusions measuring simple fluid
density.
.
___ H-CT
IMPRESSION: No CT evidence for acute intracranial process.
Progressed
cortical atrophy compared to ___.
.
Brief Hospital Course:
___ yo F w/ dementia, HTN, afib, ___ presenting with
supratherapeutic INR and AMS with HCT drop of 9 points in two
days and hypotension. On arrival the hospital, family wished to
not pursue aggressive measures. Patient received 3 units of
packed RBCs. Family discussion was held with patient and given
recent hospitalizations and overal health decline, it was the
patient's wish to reorient care around comfort. ___
___ will follow patient and patients wishes to not be
rehospitalized.
***For patient's comfort, please be sure to have thickened water
at bedside. Family and patient under stand risks of aspiration
and asphyxiation.***
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Bisacodyl ___AILY:PRN constipation
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. Cyanocobalamin 250 mcg PO DAILY
6. Furosemide 60 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Sertraline 25 mg PO DAILY
12. Simvastatin 40 mg PO DAILY
13. traZODONE 25 mg PO HS:PRN insomnia
14. Vitamin D 800 UNIT PO DAILY
15. Cefpodoxime Proxetil 100 mg PO Q12H
until ___. Metoprolol Succinate XL 25 mg PO DAILY
hold for sbp < 100 and hr < 60
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q2H:PRN
pain
3. Lorazepam 0.5-2 mg PO Q4H:PRN anxiety/agitation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted because you were found to be more lethargic.
On admission, you were found to have anemia because your
coumadin level was high. You were in the ICU for some time where
you received blood and then you were transferred to floor. While
on the floor, we had a discussion with you and your family about
your goals of care and you decided to focus your care around
comfort. You are being discharged to the ___ with
hospice care.
Followup Instructions:
___
|
19858208-DS-8 | 19,858,208 | 24,287,437 | DS | 8 | 2121-11-29 00:00:00 | 2121-11-29 15:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
meperidine
Attending: ___.
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
Right short TFN ___
History of Present Illness:
___ h/o lupus and lupus nephritis was trying to step over a
baby gate when she fell directly onto her right hip. No
preceding syncopal symtpoms. Did not hit head, no LOC. Endorses
right hip pain and no other areas of discomfort. No numbness or
tingling in the right leg. Transferred from ___ for
orthopaedic evaluation and care.
Past Medical History:
Lupus, Lupus nephritis, HTN, tubal ligation, neck lymph node
removal prior to lupus diagnosis
Social History:
___
Family History:
NC
Physical Exam:
In general, the patient is a very ___ female in NAD,
appears younger than stated age
Right lower extremity:
Skin intact
Shortened and externally rotated
TTP at hip, no TTP at knee, calf or ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Pertinent Results:
___ 06:45PM GLUCOSE-110* UREA N-39* CREAT-1.0 SODIUM-140
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15
___ 06:45PM estGFR-Using this
___ 06:45PM MAGNESIUM-1.8
___ 06:45PM URINE HOURS-RANDOM
___ 06:45PM URINE UCG-NEGATIVE
___ 06:45PM WBC-9.9 RBC-3.63* HGB-10.6* HCT-33.4* MCV-92
MCH-29.1 MCHC-31.6 RDW-13.7
___ 06:45PM PLT COUNT-245
___ 06:45PM ___ PTT-25.7 ___
___ 06:45PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 06:45PM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right subtrochanteric hip fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for R femur TFN, which the patient
tolerated well (for full details please see the separately
dictated operative report). The patient was taken from the OR to
the PACU in stable condition and after recovery from anesthesia
was transferred to the floor.
Musculoskeletal: prior to operation, patient was NWB RLE.
After procedure, patient's weight-bearing status was
transitioned to WBAT RLE. Throughout the hospitalization,
patient worked with physical therapy.
Neuro: post-operatively, patient's pain was controlled by IV
pain medication and was subsequently transitioned to oxycodone
with good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: Hematocrit was monitored. Lowest Hct 24.0,
asymptomatic. The patient was not transfused blood during this
hospitalization.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #2, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 4 mg PO DAILY
2. Atenolol 200 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Atorvastatin 10 mg PO EVERY OTHER DAY
5. Hydroxychloroquine Sulfate 200-400 mg PO BID
6. Mycophenolate Mofetil 1000 mg PO DAILY
7. Epoetin Alfa 10,000 units SC EVERY 2 WEEKS
8. Ranitidine 150 mg PO HS
9. Aspirin 81 mg PO DAILY
10. Reclast (zoledronic acid-mannitol-water) 5 mg/100 mL
injection annually
Discharge Medications:
1. Atorvastatin 10 mg PO EVERY OTHER DAY
2. Hydroxychloroquine Sulfate 200-400 mg PO BID
3. Lisinopril 40 mg PO DAILY
4. Mycophenolate Mofetil 1000 mg PO DAILY
5. PredniSONE 4 mg PO DAILY
6. Ranitidine 150 mg PO HS
7. Acetaminophen 650 mg PO Q6H
8. Docusate Sodium 100 mg PO BID
9. Enoxaparin Sodium 40 mg SC QPM Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
11. Aspirin 81 mg PO DAILY
12. Atenolol 200 mg PO DAILY
13. Reclast (zoledronic acid-mannitol-water) 5 mg/100 mL
injection annually
14. Epoetin Alfa 10,000 units SC EVERY 2 WEEKS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right hip 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.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- WBAT RLE
Physical Therapy:
- WBAT RLE
Treatments Frequency:
- 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.
Followup Instructions:
___
|
19858471-DS-15 | 19,858,471 | 21,665,822 | DS | 15 | 2152-12-27 00:00:00 | 2152-12-28 16:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
aspirin / codeine / doxycycline / ibuprofen / magnesium /
methadone / morphine / Nitro-Dur / prednisone / terbutaline /
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / topiramate /
tramadol / acetaminophen / fentanyl / vicodan / Neurontin
Attending: ___.
Chief Complaint:
Acute on chronic back ___ and lower extremity ___ and weakness
Major Surgical or Invasive Procedure:
L5-S1 LAMI DISCECTOMY
History of Present Illness:
___ female with history of chronic back ___ L5-S1
discectomy ___, right knee sarcoma ___ CRT, DVT ___ IVC
filter (removed ___, G6PD deficiency who presents as a
transfer from ___ for back ___.
The patient presented to BID-P ED on ___ for multiple
complaints. She had apparently complained of chest ___ for
several weeks, worsening low back ___, chronic left lower
extremity weakness/numbness, and new urinary incontinence.
She was transferred to ___ ED for further evaluation. She
underwent MRI C/T/L scan that showed no cord signal abnormality
or cord compression.
Here she was given IV vancomycin for presumed cellulitis of legs
She did get IV CTX for presumed UTI at BID-P ED as well. SHe got
dilaudid, ativan and was admitted to the floor for ___ control.
Per Medicine team mgmt, on the floor, the patient denied any
chest ___, dyspnea, fever/chills, abdominal ___, nausea,
vomiting, or diarrhea.
She did report chronic but worsening low back ___ radiating
into back of entire left leg and worsening numbness/tingling in
the entire left leg. She says she had falls (uses a cane to
walk) related to worsening symptoms over the past few weeks, but
no head strike or loss of consciousness, she always fell into
seated position SHe reports new urge urinary incontinence in
last several days.
BID-P ED: At ___, PVR was <20 cc and troponin was
normal.
UA was c/f UTI and she was given ceftriaxone.
___ ED: dilaudid, Ativan, IV vancomycin for presumed leg
cellulitis"
She persisted to have ___ leg ___ and ___ and Medicine
team consulted Ortho spine for consideration of lumbar
decompression for lumbar stenosis.
Past Medical History:
DDD with L5S1 disc herniation and radiculopathy/foot drop ___
hemilami/discectomy ___ Dr. ___ DVT in setting of pregnancy ___ IVC filter (removed ___
morbid obesity, BMI 40+
HTN
Neuropathy
ovarian cyst
___ cholecystectomy
___ tubal ligation
___ microdiscecttomy
___ knee scopes x 7
extensive allergies listed
Social History:
___
Family History:
Mother with MI at ___ died of a heart attack at ___
Diabetes
Physical Exam:
Admission Exam:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
PSYCH: pleasant, appropriate affect
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time.
___ strength left hip and knee extension/flexion. Has left foot
drop (chronic). Painful to light touch in entire left lower
extremity.
Discharge Exam:
Last 24h:NAE's overnight. She reports some legs spasm this
morning and is agreeable to trying the flexeril. ___ strength
and
___ remains improved except for ___ weakness. ___
controlled improved on Q3H dosing. She is tolerating the
decreased IV dilaudid prn dosing well. Continues to have very
low
grade fevers. UA/Cx and CXR negative for any infectious source.
HVAC removed this am. Prevena removed this morning.
PE:
VS 99.6 PO 116 / 78 R Lying 91 18 93 Ra
NAD, A&Ox4
nl resp effort
RRR
Incision c/d/I. well approximated with sutures intact. No
erythema noted. Scant sanguinous drainage noted. Prevena and
HVAC
removed and dry gauze dressing applied.
Sensory:
UE
C5 C6 C7 C8 T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
R SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
Motor:
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 4 4 0
R 5 ___ ___ 5 5 5 5 5 5 5
Babinski: Downgoing
Clonus: No beats
Labs:
___: WBC: 16.8*
___: HGB: 11.4
___: HCT: 35.5
___: Plt Count: 263
___: Neuts%: 64.3
___: Na: 136 (New reference range as of ___: K: 4.0 (New reference range as of ___: Cl: 96
___: CO2: 24
___: Glucose: 146* (If fasting, 70-100 normal, >125
provisional diabetes)
___: BUN: 6
___: Creat: 0.8
___: ___: 12.9*
___: INR: 1.2*
___: PTT: 26.0
Imaging:
CXR
IMPRESSION:
No acute cardiopulmonary process. No focal consolidation.
A/P:
A/P:
___ is a ___ y/o female long standing with low back nd
left low extremity ___ that has left her essentially bed
ridden.
This ___ began ~ 3 months ago and has gotten progressively
worse. Of note, patient underwent previous L5-S1 microdiscetomy
by Dr. ___ in ___. She has had a left foot drop since that
time. She is now ___ L5-S1 LAMI DISCECTOMY on ___ with Dr.
___. Post op course is complicated by uncontrolled surgical
site ___ which is significantly improved this morning. CPS
continues to follow for ___ control.She has responded well to
Q3H dosing and requiring less IV prn Dilaudid. We will start prn
flexeril this morning for her muscle spasms and stop the IV
dilaudid this morning in efforts to get her discharged to REHAB.
___ cleared her for REHAB and Prevena and HVAC were removed
today.
Activity: as tolerated, no lifting, twisting or bending, ___
consult
Bracing: none
Anticoag: ___ pneumoboots, encourage OOB, SC Heparin TID
Abx: ancef x24 h post op done
Analgesia: oxycodone po, prn flexeril
Medications: home medications
Imaging: none
Labs: AM CBC/BMP
FEN: Regular Diet, MIVF
Drains: removed ___
Foley: removed, voiding
Dressing change: dry dressing placed today ___
Dispo: ___ control on PO meds, ___ clearance
Follow-up: in Spine Clinic in 2 weeks
Follow-up: Follow up with CPS as outpatient.
___:
98.9
PO 96 / 65
L Lying 88 18 95 Ra
NAD, A&Ox4
nl resp effort
RRR
incision well approximated, no marginal e/e/e
Sensory:
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
Motor:
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 4 3 5 4+
Pertinent Results:
ADMISSION LABS:
___ 08:00PM BLOOD WBC-10.8* RBC-4.65 Hgb-12.0 Hct-38.5
MCV-83 MCH-25.8* MCHC-31.2* RDW-14.4 RDWSD-43.0 Plt ___
___ 08:00PM BLOOD Glucose-99 UreaN-8 Creat-0.9 Na-141 K-4.4
Cl-103 HCO3-23 AnGap-15
___ 05:52AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.0
MICRO:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
CTA Chest (___):
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Marked enlargement of the multinodular thyroid gland causing
mass effect on
the trachea. Thyroid ultrasound is recommended, if not already
performed
elsewhere.
MRI spine:
-Degenerative changes of the lumbar spine most marked at the
L5-S1 level where
there is a large central and left paracentral disc protrusion
which displaces
the left S1 nerve root posteriorly as well as causing moderate
to severe
narrowing of the left neural foramina.
-No vertebral body metastatic lesions. No acute fractures.
-No epidural or paraspinal collections.
-Degenerative changes of the cervical spine but no findings to
suggest
compromise of the cervical spinal cord. No high-grade neural
foraminal
stenosis.
-No compromise of the thoracic cord in the thoracic spinal
canal.
-Small nonenhancing cystic lesion and anterior to the T5
vertebral body is
unchanged compared to prior exam done ___ and most likely
represents a
foregut duplication cyst
-Enlarged multinodular thyroid gland displaces the trachea to
the right-side
and evaluation on a non urgent basis with thyroid ultrasound may
be performed
if clinically indicated.
-Trace left-sided pleural effusion.
___:
IMPRESSION:
Slightly limited exam as above due to patient body habitus.
Within this
limitation, no evidence of deep venous thrombosis in the left
lower extremity
veins.
Thyroid US:
IMPRESSION:
There is an enlarged thyroid goiter. A large partially cystic,
partially
solid nodule is seen within both thyroid lobes. These nodules
would be
amenable to fine needle aspiration biopsy on a non-emergent
basis.
DISCHARGE LABS:
***
___ 06:00AM BLOOD WBC-16.8* RBC-4.30 Hgb-11.4 Hct-35.5
MCV-83 MCH-26.5 MCHC-32.1 RDW-14.7 RDWSD-43.8 Plt ___
___ 01:00PM BLOOD WBC-9.4 RBC-4.48 Hgb-11.7 Hct-37.2 MCV-83
MCH-26.1 MCHC-31.5* RDW-14.5 RDWSD-43.8 Plt ___
___ 07:33AM BLOOD WBC-8.8 RBC-4.83 Hgb-12.7 Hct-40.6 MCV-84
MCH-26.3 MCHC-31.3* RDW-14.3 RDWSD-43.8 Plt ___
___ 08:00PM BLOOD Neuts-64.3 ___ Monos-5.3 Eos-1.1
Baso-0.5 Im ___ AbsNeut-6.94* AbsLymp-3.03 AbsMono-0.57
AbsEos-0.12 AbsBaso-0.05
___ 06:00AM BLOOD Plt ___
___ 01:00PM BLOOD Plt ___
___ 06:40AM BLOOD ___ PTT-26.0 ___
___ 07:33AM BLOOD Plt ___
___ 05:52AM BLOOD Plt ___
___ 08:25AM BLOOD Plt ___
___ 08:00PM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-146* UreaN-6 Creat-0.8 Na-136
K-4.0 Cl-96 HCO3-24 AnGap-16
___ 06:40AM BLOOD Glucose-121* UreaN-9 Creat-0.9 Na-137
K-4.6 Cl-101 HCO3-24 AnGap-12
___ 05:52AM BLOOD Glucose-122* UreaN-9 Creat-0.9 Na-139
K-4.5 Cl-101 HCO3-24 AnGap-14
___ 06:00AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.6
___ 06:40AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.8
___ 05:52AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.0
___ 08:25AM BLOOD TSH-5.3*
___ 08:25AM BLOOD Free T4-1.1
___ 08:25AM BLOOD CRP-8.8*
Brief Hospital Course:
SUMMARY/ASSESSMENT:
___ female with history of chronic back ___ L5-S1
discectomy ___, right knee sarcoma ___ CRT, DVT ___ IVC
filter
(removed ___, G6PD deficiency who presents as a transfer
from
___ for back ___. She initially presented to the
Medicine team for ___ control. Ortho spine was consulted for
her persistent ___ leg ___ and weakness. She is now ___ L5-S1
LAMI DISCECTOMY on ___ with Dr. ___.
ACUTE/ACTIVE PROBLEMS:
#Acute on chronic back ___ with sciatica left leg
-She had MRI C/T/L scan. No cord signal abnormality or
compression. A 1.6 x 0.6 x 1.3 cm T2 hyperintense/T1 hypointense
nonenhancing cystic lesion anterior to the T5 vertebral body, to
the right of midline is not significantly changed compared to
the
prior exam in ___. A similar appearing pathology proven
bronchogenic cyst anterior to the T3 vertebral body on the prior
exam has since been excised. There is a large left paracentral
disc bulge at L5-S1 causes severe left neural foraminal
narrowing
at this level. She was seen by neurology who recommended spine
surgery evaluation of the disc bulge as the foraminal narrowing
is probably causing her nerve root ___. THe patient initially
wanted to follow up with Dr. ___ spine surgeon who did
her discectomy last year) at ___ after discharge, but given
per persistent ___ she would like to see someone here.
- Chronic ___ consult
- Patient reports she has adverse reactions to the following and
that we should not use:
lidocaine patch (wheeze)
fentanyl patch (wheezes)
methadone (rash)
lyrica (rash)
gabapentin (swelling)
tramadol (weight gain)
toradol (rash)
Tylenol (welts)
amitriptyline (rash)
-She says she tolerates IV or PO dilaudid (but does not want PO
dilaudid on discharge, she says she's afraid of respiratory
effects), oxycodone, diazepam, flexeril. We will use these
agents
-Spine surgery consult - plan on laminectomy
# Vulvovaginitis
Symptoms are most consistent with ___ although she does not
have any discharge.
- Start miconazole cream applied to the labia; continue
miconazole vaginal suppositories
- ___ fluconazole 150 mg PO x1
# Concern for UTI: On presentation concern for UTI. She has a
Urine cx with mixed flora. ___ grew Lactobacillus and UA
at ___ grew mixed bacteria. Treated with CTX but unlikely to
be
UTI. Received 2 days of CTX total prior to this being
discontinued.
# History of DVT/concern for cellulitis
-Had negative ___ DVT US
-Had negative CTA chest for PE
-Also, there is no evidence of cellulitis on exam. The IV
vancomycin started in the ED was not continued.
#Incidental large multinodular goiter on CTA chest. Ultrasound
with multinodular thyroid amenable to biopsy if necessary.
-Check TSH (5.3)
-Needs outpatient US done and endocrinology follow up
-Pushes on trachea but clinically no evidence of respiratory
effects or dysphagia
___ is a ___ y/o female long standing with low back and
left low extremity ___ that has left her essentially bed
ridden.
This ___ began ~ 3 months ago and has gotten progressively
worse. Of note, patient underwent previous L5-S1 microdiscetomy
by Dr. ___ in ___. She has had a left foot drop since that
time. She is now ___ L5-S1 LAMI DISCECTOMY on ___ with Dr.
___. Post op course is complicated by uncontrolled surgical
site ___ which is significantly improved this morning. CPS
continues to follow for ___ control.She has responded well to
Q3H dosing and requiring and started prn flexeril for spasm. We
were able to transition her off iv dilaudid by ___. ___ cleared
her for REHAB and Prevena and HVAC were removed on ___. She did
not want to go to rehab, however, and was re-evaluated by ___ on
___. Ultimately they recommended she return home with services.
She was discharged on ___ without incident.
Activity: as tolerated, no lifting, twisting or bending, ___
consult
Bracing: none
Anticoag: ___ pneumoboots, encourage ambulation
Abx: ancef x24 h post op done
Analgesia: oxycodone po, prn flexeril
Medications: home medications
Imaging: none
Labs: AM CBC/BMP
FEN: Regular Diet, MIVF
Drains: removed ___
Foley: removed, voiding
Dressing change: dry dressing placed today ___
Dispo: ___ control on PO meds, ___ clearance
Follow-up: in Spine Clinic in 2 weeks
Follow-up: Follow up with CPS as outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 5 mg PO BID:PRN ___ - Moderate
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY
2. Cyclobenzaprine ___ mg PO BID:PRN spasm
may cause drowsiness
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC TID
5. OxyCODONE (Immediate Release) 20 mg PO Q3H ___
Please wean as patient tolerates.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
lumbar stenosis
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:
Lumbar Decompression Without Fusion
You have undergone the following operation: Lumbar Decompression
Without Fusion
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit or stand more than~45 minutes without moving around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Diet:Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:You may have been given a brace.If you
have been given a brace, this brace is to be worn when you are
walking.You may take it off when sitting in a chair or lying in
bed.
Wound Care: Keep the incision covered with a
dry dressing until your follow up appointment. Do not soak the
incision in a bath or pool.If the incision starts draining at
anytime after surgery,do not get the incision wet.Cover it with
a sterile dressing and call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your ___ allow 72 hours for refill of
narcotic prescriptions,so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___.We are not allowed to call in or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In
addition,we are only allowed to write for ___ medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your incision,
take baseline X-rays and answer any questions.We may at that
time start physical therapy.
We will then see you at 6 weeks from the day of
the operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
1)Weight bearing as tolerated.2)Gait,balance training.3)No
lifting >10 lbs.4)No significant bending/twisting.
Treatments Frequency:
Keep the incision covered with a dry dressing until your follow
up appointment. Do not soak the incision in a bath or pool.If
the incision starts draining at anytime after surgery,do not get
the incision wet.Cover it with a sterile dressing and call the
office.
Followup Instructions:
___
|
19858494-DS-20 | 19,858,494 | 27,361,663 | DS | 20 | 2186-05-21 00:00:00 | 2186-05-21 19:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
___
Attending: ___.
Chief Complaint:
Increasing abdominal girth and pain
Major Surgical or Invasive Procedure:
Placement of L sided ___ placed drain
History of Present Illness:
___ w/ PMH significant for necrotizing hemorrhagic
pancreatitis complicated by abdominal compartment syndrome and
cardiac arrest, who presents from rehab with increased right
flank swelling after his right anterior drain fell out 2 days
ago. Patient went to ___, where a ABD/PELVIS CT was performed
and per report, shows an increased intraabdominal fluid
collection. Therefore the patient was transferred to ___ for
direct admission for ___ drainage placement.
Per rehab records and patient's son, the patient has been doing
well at rehab. His right upper flank drain continues to dry
light
tan purulent appearing fluid. He started taking in food by mouth
approx 2 weeks ago which he has been tolerating well. He
continues with tube feeds. He has had diarrhea for several days,
which is being attributed to his tube feeds per report. He has
been afebrile and tolerating trach collaring. Decannulation was
planned, but delayed given concern for new procedures. Patient
currently reports no abdominal pain.
Past Medical History:
PSH: Cataract removal with lens prosthesis, ___- Bedside
exploratory laparotomy for abdominal compartment syndrome,
___- Re-exploration with placement ___ gastrostomy
and
debridement of subcutaneous tissue, muscle, and fascia in the
suprapubic region; ___ - Uncomplicated placement of a 16
___ pigtail catheter into the right complex air and fluid
collection, ___: ex lap, drainage of infected hemorrhagic
collections with placement of sump drains x3, ___ & ___:
wash
out and partial closure of abdominal wound, ___: closure of
abdominal wound, ___: Open tracheostomy, ___:
Tracheostomy exchange
.
PAST MEDICAL HISTORY:
1. Gastroesophageal reflux disease
2. Vitamin deficiency
3. Hypertension
4. B12 deficiency anemia
5. Gastritis
6. Benign prostatic hypertrophy
7. Hyperlipidemia
8. Calculus of the kidney
9. Macular degeneration of the retina
10. Cataracts, status post cataract removal with lens
prosthesis
Social History:
___
Family History:
No family history of pancreatitis or pancreatic malignancy
Physical Exam:
96.9 79 142\80 18 95RA ___ 143-167
Gen: Aox3, NAD, pleasant
CV: RRR s1s2nl no MRG
Resp: decreased breath sounds throughout, but satting well
Abd: soft, non-tender, non-distended, feeding GJ, L and R sided
flank drains clean dry and intact putting out greyish fluid with
occasional red tinge
Extr: warm, well perfused
Skin: large sacral pressure ulcer with covering in place
Pertinent Results:
___ 07:18AM BLOOD WBC-9.2 RBC-3.23* Hgb-9.6* Hct-28.4*
MCV-88 MCH-29.6 MCHC-33.6 RDW-16.1* Plt ___
___ 05:25AM BLOOD ___ PTT-25.5 ___
___ 07:18AM BLOOD Glucose-131* UreaN-16 Creat-0.4* Na-144
K-3.3 Cl-111* HCO3-28 AnGap-8
___ 07:18AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.1
___ 05:25AM BLOOD calTIBC-163* Ferritn-7762* TRF-125*
Brief Hospital Course:
Neuro: Throughout the course of the hospital stay, the
patient's pain was well controlled. He very rarely complained
of pain and only occasionally required medication.
CV: The patient's heart rate was monitored. He became
occasionally tachycardic which resolved upon restarting his rate
control medications. His blood pressure remained stable
throughout his stay.
Resp: The patient's sats were monitored. He had excellent
oxygen saturation throughout his stay. He had stable pleural
effusions and his breath sounds were somewhat diminished
consistently. His trach was downsized to #6 prior to discharge.
FEN: He was restarted on his tube feeds at goal on HD 1. He
tolerated his tube feeds throughout his stay. His diet was
advanced as he appeared able and on discharge he was eating a
regular diet.
GI: He had a PPI given throughout his stay.
ID: His R flank drain, present on admission was flushed by ___
and began to function immidiately, putting out purulent fluid.
Cultures from that drain grew out cefepime sensitive
pseudomonas. On HD 3, a left sided drain was placed in ___. It
also returned purulent fluid which eventually grew out
pseudomonas. Infections disease was consulted for
recommendations for long term antibiotic treatment. Their
recommendations were followed. Fever curve was monitored.
Heme: The patients blood counts and WBC were periodically
monitored. They remained stable throughout his stay.
He was discharged on tube feeds at goal, tolerating a regular
diet, afebrile and with no abdominal pain, with both drains and
his feeding GJ tube functioning well.
Medications on Admission:
MAR:
FLUCONAZOLE - 100 mg Tablet - 1 Tablet(s) by mouth per feeding
tube once a day
HEALTHY SHOT - 74 ml per feeding tube bolus twice a day
HEPARIN, PORCINE (PF) - 5,000 unit/0.5 mL Solution - one
injection every eight (8) hours
LIPASE-PROTEASE-AMYLASE [PANCRELIPASE 5000] - 5,000 unit-17,000
unit-27,000 unit Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth three times a day via feeding tube
MEROPENEM - 1 gram Recon Soln - every six (6) hours IV
METOPROLOL TARTRATE - 100 mg Tablet - 1 Tablet(s) by mouth twice
a day per feeding tube
PANTOPRAZOLE [PROTONIX] - 40 mg Recon Soln - twice a day IVPB
TIMOLOL [BETIMOL] - 0.5 % Drops - 1 (One) drop both eyes twice a
day
ACETAMINOPHEN - 325 mg Tablet - 2 (Two) Tablet(s) feeding tube
every four (4) hours as needed for fever or pain
INSULIN REGULAR HUMAN [HUMULIN R] - 100 unit/mL Solution - per
sliding scale
LACTOBACILLUS ACIDOPHILUS - Capsule - 1 packet by mouth every
eight (8) hours via feeding tube
NUT.TX. METABOLIC DISORDER,SOY [PERATIVE] - 0.067 gram-1.30
kcal/mL Liquid - full strength feeding tube continuous at 55 ml
per hour
THIAMINE HCL - 100 mg Tablet - 1 (One) Tablet(s) feeding tube
once a day
Discharge Medications:
1. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
2. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
3. CefePIME 2 g IV Q24H
4. Thiamine 100 mg IV DAILY
5. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) syringe
Injection TID (3 times a day): while non-ambulatory.
8. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic BID
(2 times a day).
9. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO QID (4 times a day) as needed for abd cramping.
10. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS): may increase number of caps as needed for
diarrhea.
11. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
12. insulin regular human 100 unit/mL Solution Sig: see below
Injection every six hours: Glucose Insulin
___ 0
151-200 2
201-250 4
___ 8
351-400 10.
13. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) mL Injection
every eight (8) hours: Please flush both R and L flank drain
q8h.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Intraabdominal infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Please ___ your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. ___ or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please ___ your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
___ the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation
___ Drain Care Rx:
Drain Catheter: To gravity drainage. Cleanse insertion site with
___ strength hydrogen peroxide and rinse with saline moistened
q-tip or with mild soap and water. Apply a drain sponge if
needed. Change dressing daily and as needed. Monitor for s/s
infection or dislocation. Check the patency of tube and that the
tube and drainage bag are secured to the patient. Monitor and
record quality and quantity of output.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions.
You can have the tracheostomy decannulated when the rehab
facility feels it is appropriate.
Please flush each of the flank drains with 5cc of normal saline
every 8 hours.
Followup Instructions:
___
|
19858494-DS-21 | 19,858,494 | 21,694,788 | DS | 21 | 2186-06-23 00:00:00 | 2186-06-23 14:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
XIBROM
Attending: ___.
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
___: Technically successful CT-guided drain upsizing with a
___ biliary drain inserted into the right-sided peritoneal
collection.
___: IVC filter placement
___: Successful upsizing x 2 two and placement of a third
percutaneous drainage.
History of Present Illness:
___ hx necrotizing hemorrhagic pancreatitis c/b abd compartment
syndrome requiring decompressive laparotomy, MOSF, cardiac
arrest, intraabdominal abscesses and hemorrhage requiring
re-exploration, multiple washouts, and ultimately drain
placement, prolonged intubation and tracheostomy at ___ and
subsequent ___ drainage at ___ presents from ___ with
sudden onset sustained tachycardia and pleuritic chest pain
x24hrs.
Per rehab records and patient's son, the patient has been doing
well at rehab with the exception of persistent watery stool
until today when, per report, pt noted to have new onset
tachycardia to 120-130 with intermittent chest discomfort
without radiation. No antecedent or precipitating factors
reported. Per conversation with ___ Staff ___
___ RN) and their review of facility MAR, it seems pt was
refusing SCD/ambulation, but confirms receiving HSQ 5000unit
TID. Denies associated dyspnea, SOB, orthopnea, hemoptysis,
cough, fevers, or chills.
Pt is tolerating PO intake which is supplemented by cycled
Vivonex tube feeds via GJT. His bilateral flank drains continue
to drain light tan purulent appearing fluid. Persistent
diarrhea with ___ loose watery stools overnight while on tube
feeds and ___ watery stools during the day. Per rehab records,
pt was empirically started on PO Vancomycin ___ for empiric
coverage for C.Diff. No culture data available at time of
consultation.
Last seen in clinic ___ where note is made of persistent
diarrhea and initiation of empiric antibiotics for concern of
C.Diff with ID follow-up. At that time, HR recorded as 105 with
SaO2 100% rm air.
At time of consultation, pt is afebrile with sustained sinus
tachycardia 120-130, otherwise hemodynamically appropriate with
SaO2 97% rm air. Lung fields clear to auscultation with clear
and equal breath sounds at bilateral bases. Abdomen is soft
without rebound or guarding, GJT in place, bilateral flank
drains secured. Pt comfortable and conversant, and otherwise
nontoxic appearing.
Past Medical History:
PMH:
1. Gastroesophageal reflux disease
2. Vitamin deficiency
3. Hypertension
4. B12 deficiency anemia
5. Gastritis
6. Benign prostatic hypertrophy
7. Hyperlipidemia
8. Calculus of the kidney
9. Macular degeneration of the retina
10. Cataracts, status post cataract removal with lens prosthesis
.
PSH:
remote: Cataract removal with lens prosthesis
___: Bedside decompressive laparotomy for abdominal
compartment syndrome
___: Re-exploration, ___ gastrostomy, debridement of
suprapubic subcutaneous tissue, muscle, and fascia.
___ (___): exploratory laparotomy, drainage of infected
hemorrhagic collections with placement of sump drains ___ & ___ (___): wash out and partial closure of abdominal
wound
___ (___): closure of abdominal wound
___ (___): Open tracheostomy
___ (___): Tracheostomy exchange
___: Uncomplicated placement of a 16 ___ pigtail
catheter into right collection
Social History:
___
Family History:
No family history of pancreatitis or pancreatic malignancy
Physical Exam:
Physical Exam on Admission:
VS: T 98.7, HR 123, BP 124/77, RR 17, SaO2 99% rm air
GEN: NAD, A/Ox3
HEENT: MMM, EOMI, no scleral icterus
CV: sinus tachycardia, no M/R/G
PULM: CTAB, clear bases bilaterally, equal excursion
BACK: bilateral flank drains secured to skin, nonerythematous. R
drain with dark brown effluent, no blood/clots. L drain with tan
yellow effluent, no blood/clots.
ABD: soft, well healed midline laparotomy incision, GJ in place,
no surrounding erythema/fluctuance/drainage.
PELVIS: deferred
EXT: WWP, no edema, distal pulses intact
.
Physical Exam on Discharge:
VS: 98.4, 110, 100/64, 16, 97% RA
GEN: NAD, Comfortably lying in bed
CV: Sinus tachycardia
CTAB: Diminished on bases b/l
ABD: Right flank/Left flank/Right Presacral Drains to bulb
suctions and secured to the patient with sutures and butterfly
dressing. Left drain with minimal yellowish output, right drains
with ___ purulent output.
GJ tube in place and patent.
PELVIS: Flexiseal in place with
EXTR: No edema, + distal pulses
Pertinent Results:
___ 01:15PM BLOOD WBC-6.8 RBC-3.30* Hgb-9.8* Hct-28.4*
MCV-86 MCH-29.8 MCHC-34.5 RDW-16.3* Plt ___
___ 08:40AM BLOOD WBC-8.0 RBC-3.52* Hgb-10.4* Hct-30.7*
MCV-87 MCH-29.5 MCHC-33.8 RDW-16.5* Plt ___
___ 01:15PM BLOOD Neuts-76.9* Lymphs-17.2* Monos-4.1
Eos-1.4 Baso-0.4
___ 01:15PM BLOOD ___ PTT-26.7 ___
___ 06:15AM BLOOD ___
___ 06:15AM BLOOD Plt ___
___ 08:40AM BLOOD Glucose-106* UreaN-21* Creat-0.6 Na-141
K-3.4 Cl-115* HCO3-16* AnGap-13
___ 01:15PM BLOOD ALT-43* AST-35 AlkPhos-216* TotBili-0.4
___ 01:15PM BLOOD cTropnT-0.09*
___ 09:20PM BLOOD CK-MB-4 cTropnT-0.17*
___ 03:23AM BLOOD CK-MB-4 cTropnT-0.14*
___ 06:50AM BLOOD Albumin-2.5* Calcium-8.7 Phos-2.7 Mg-2.0
___ 08:40AM BLOOD Calcium-7.8* Phos-2.3* Mg-2.0
.
___ CTA torso:
IMPRESSION:
1. Large bilateral pulmonary emboli without CT evidence of right
heart strain. Right base opacity grossly stable compared to
prior, most likely atelectasis, however early underlying infarct
is difficult to exclude. Apparent filling defects in the
bilateral common femoral veins which could reflect thrombus.
Ultrasound could be considered for further characterization if
clinically indicated. 2. Unchanged moderate nonhemorrhagic
pleural effusion and bibasilar atelectasis. 3. Slight decrease
in the size of the left posterior intra-abdominal fluid
collection. All other collections appear grossly unchanged
compared to prior and continue to be concerning for abscesses.
Percutaneous pigtail drains appear in standard position. 4.
Stable enhancement of the pancreatic parenchyma without new
areas of necrosis. Patent splenic artery and vein centrally. 5.
Moderate mesenteric and subcutaneous edema. 6. Unchanged mild
right hydroureteronephrosis with gradual tapering at the
level of the mid ureter secondary to extrinsic compression from
adjacent fluid collections.
.
___: BLE US - Significant nonocclusive deep vein thrombosis
seen bilaterally in the femoral veins. Clot at the left common
femoral vein is large and is soft, appearing to be partially
mobile.
.
___ ECHO:
Conclusions
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). The
estimated cardiac index is high (>4.0L/min/m2). Right
ventricular chamber size is normal with normal free wall
contractility. There is abnormal septal motion/position possibly
consistent with increased right ventricular pressure. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
___ EGD normal. Colonoscopy: Diverticulosis of the colon.
Areas of likely necrotic tissue with some overlying clot was
seen in the transverse colon. With washing, white fluid was
repeatedly flowing out of the area raising the possibility of a
Otherwise normal colonoscopy to cecum
___ CXR:
Moderate left lower lobe atelectasis and small left pleural
effusion are unchanged. New azygos distention suggests elevated
central venous pressure or volume, but not reflected in
pulmonary vascular congestion or any edema. No pneumothorax.
Brief Hospital Course:
___ history necrotizing hemorrhagic pancreatitis c/b abdominal
compartment syndrome/hemorrhage/cardiac arrest/MOSF requiring
multiple exploratory laparotomies and intraabdominal fluid
collection drainage presented with tachycardia. He was found to
have bilateral pulmonary emboli and significant nonocclusive
deep vein thromboses in bilateral femoral veins. He was begun on
empiric anticoagulation with a heparin drip, transitioned to
Coumadin. A leak was noted around his right flank drain, and he
underwent technically successful CT-guided drain upsizing on
___ with a ___ biliary drain inserted into the
right-sided peritoneal collection. 130 mL of purulent fluid was
drained along with a significant amount of fluid which drained
along the drain tract prior to insertion of the ___ drain.
On HD3 his hematocrit was noted to drop from a baseline of 30 to
25, and he was transfused 2u. He passed 1L of BRBPR with clots
on HD3, his heparin drip was held, and the GI service was
consulted (PTT at the time was 40). EGD was normal and
colonoscopy showed likely pancreatico-colic fistula (likely the
source of his bleeding). In the setting of a lower GI bleed and
bilateral PE's the decision was made to stop Coumadin, and the
patient was taken to the OR for IVC filter placement on HD4 by
the vascular surgery service. On ___, given persistent
intra-abdominal collections, his bilateral ___ drains were
upsized to ___ and a presacral drain was placed. The infectious
disease service followed the patient throughout his
hospitalization, and antibiotic coverage was adjusted
appropriately. Abscess cultures returned GPC/GNR/pseudomonas
sensitive to meropenem, and he was found to have Cdiff + stool.
He was discharged with a PICC (placed ___, on an
antibiotics. Outpatient ID follow up was arranged.
He was continued on tube feeds while in patient, which he
tolerated well.
Neuro: Patient alert and oriented x 3. Minimal requirement for
pain medication during hospitalization.
CV: Patient remained sinus tachy 100-120s during his
hospitalization, his PO dose of Metoprolol was increased to 100
mg TID from 100 mg BID. Cardiac Echo revealed LVEF > 55% and
moderate pulmonary artery hypertension. The patient's HR was
monitored with telemetry device.
PULM: The patient with bilateral pulmonary emboli remained
stable with O2 sats within normal limits on room air during
hospitalization.
GU: Patient known to have right kidney hydronephrosis caused by
pre sacral fluid collection. Renal function test remained stable
and patient denied flank pain. Urology was consulted and
treatment was not indicated at this time.
Medications on Admission:
PO Vanco 500'' (___-), Occuflex R eye'''', Timoptic 0.5% L
eye'', Heparin 5000''', Lispro SSI, Creon 24 2cap''',
Lactobacillus 1''', Megace 400'', Prilosec 40'', NaCl 325'',
Tobramycin oint R eyeqHS, Lopressor 100'', MVT, Lisinopril 2.5,
APAP 650:prn
Discharge Medications:
1. tobramycin-dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl
Ophthalmic QHS (once a day (at bedtime)).
2. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day: Please hold if SBP < 100 or HR < 60.
3. ciprofloxacin 0.3 % Drops Sig: ___ Drops Ophthalmic QID (4
times a day).
4. Creon 3,000-9,500- 15,000 unit Capsule, Delayed Release(E.C.)
Sig: Four (4) Cap PO twice a day.
5. potassium chloride 20 mEq Packet Sig: One (1) Packet PO DAILY
(Daily).
6. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 weeks: was satred on ___.
7. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
8. Tylenol ___ mg Tablet Sig: ___ Tablets PO every six (6) hours
as needed for fever or pain.
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
11. Meropenem 500 mg IV Q6H
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Necrotizing hemorrhagic pancreatitis
2. Pancreatico-colic fistula
3. Infected intra abdominal fluid collections
4. Bilateral pulmonary emboli
5. Bilateral lower extremities DVT
6. Right-sided hydronephrosis
7. Sepsis
8. Stool positive for Clostridium Difficile
9. Persistent tachycardia
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:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised. Please follow up with the infectious disease
physicians as recommended.
.
Right flank/Left flank/Right Presacral Drains: To bulb suction.
Flush drains with ___ cc of NS TID. Change dressing QD and prn.
Please note color, consistency, and amount of fluid in the
drain. Make sure to keep the drain attached securely to your
body to prevent pulling or dislocation. Clean the skin around
drains with commercial wound cleanser spray and patted dry. Then
apply Critic Aid Clear ointment to the ___ skin to
protect from the drainage and promote healing. Apply Allevyn
Trach foam around the drain to help absorb the
drainage.
.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
___
|
19858494-DS-22 | 19,858,494 | 28,714,383 | DS | 22 | 2186-07-10 00:00:00 | 2186-07-10 17:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
___
Attending: ___.
Chief Complaint:
Abdominal pain, fevers
Major Surgical or Invasive Procedure:
___: US guided placement of ___ percutaneous catheter into
a walled necrotic collection ___ the right flank
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a history of
necrotizing hemorrhagic pancreatitis c/b abdominal compartment
syndrome and cardiac arrest, multiple abdominal fluid
collections s/p ___ drain placement, pancreatico-colic fistula
now maintained on TPN with recent admission for bilateral
pulmonary emboli s/p anticoagulation c/b GIB s/p IVC filter. Mr.
___ was discharged back to ___ approximately two
weeks ago with three drains ___ place and there he was maintained
on TPN and was started on a clear liquid diet today. He has
continued on his antibiotic regimen of PO vancomycin for c. diff
infection and meropenem for pseudomonas. Approximately three
days ago his superior right flank drain fell out and over the
past ___ hours he has experienced increasing diffuse
abdominal discomfort and distension with fevers to 102.
.
ROS:
(+) per HPI
(-) Denies pain, fevers chills, night sweats, unexplained weight
loss, fatigue/malaise/lethargy, changes ___ 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:
PMH:
1. Gastroesophageal reflux disease
2. Vitamin deficiency
3. Hypertension
4. B12 deficiency anemia
5. Gastritis
6. Benign prostatic hypertrophy
7. Hyperlipidemia
8. Calculus of the kidney
9. Macular degeneration of the retina
10. Cataracts, status post cataract removal with lens prosthesis
11. necrotizing hemorrhagic pancreatitis c/b multiple abdominal
fluid collections
12. pancreatico-colic fistula
13. GIB
.
PSH:
remote: Cataract removal with lens prosthesis
___: Bedside decompressive laparotomy for abdominal
compartment syndrome
___: Re-exploration, ___ gastrostomy, debridement of
suprapubic subcutaneous tissue, muscle, and fascia.
___ (___): exploratory laparotomy, drainage of infected
hemorrhagic collections with placement of sump drains ___ & ___ (___): wash out and partial closure of abdominal
wound
___ (___): closure of abdominal wound
___ (___): Open tracheostomy
___ (___): Tracheostomy exchange
Social History:
___
Family History:
No family history of pancreatitis or pancreatic malignancy
Physical Exam:
Physical Exam on admission:
Vitals: ___ 18 98 RA
GEN: A&O, comfortable
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, moderately distended, mild diffuse tenderness to
palpation, RIH with erythema, mildly tender to palpation
Ext: No ___ edema, ___ warm and well perfused
.
Physical Exam on discharge:
Vitals: 99.8, 99.2, 107, 140/71, 20, 98RA
Gen: ___ NAD, ___ speaking
CV: RRR, no m/r/g
Resp: Crackles at bases
Abd: Soft, mildly distending
Back: Sacrum is protruding with 2 cm x 1 with 1 unstageable
ulcer on the (R) measuring 1 cm with white fibrin ___ the base
and granular buds noted.
Ext: 2+ ___ edema, bilateral thighs are tense.
Tubes/Lines/Drains: left brachail PICC, rectal flexiseal,
J-tube, foley catheter, R presacral pigtail, left abdominal
pigtail, newly placed R flank pigtail.
Pertinent Results:
___ 06:01PM BLOOD WBC-9.1 RBC-3.35* Hgb-9.9* Hct-30.8*
MCV-92 MCH-29.7 MCHC-32.3 RDW-15.4 Plt ___
___ 06:02AM BLOOD WBC-7.0 RBC-2.89* Hgb-8.7* Hct-27.1*
MCV-94 MCH-30.2 MCHC-32.2 RDW-15.3 Plt ___
___ 05:23AM BLOOD WBC-5.6 RBC-3.03* Hgb-8.9* Hct-28.2*
MCV-93 MCH-29.3 MCHC-31.4 RDW-15.7* Plt ___
___ 06:01PM BLOOD Neuts-83.4* Lymphs-13.8* Monos-1.8*
Eos-0.6 Baso-0.4
___ 10:20PM BLOOD ___ PTT-31.7 ___
___ 05:23AM BLOOD ___ PTT-29.9 ___
___ 05:23AM BLOOD Glucose-127* UreaN-19 Creat-0.4* Na-142
K-3.5 Cl-108 HCO3-26 AnGap-12
___ 06:02AM BLOOD ALT-70* AST-60* AlkPhos-329* TotBili-0.8
___ 05:23AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.0
___ 06:20PM BLOOD Lactate-1.5
___ 06:01PM BLOOD Lipase-18
.
___ CT a/p:
INDICATION: Fever to 102 degrees, recent complicated surgical
history, collection on back draining pus and apparent right
inguinal hernia that is
erythematous and tender. Please evaluate for incarcerated hernia
or abscess.
.
COMPARISON: Comparison is made to CT abdomen and pelvis
performed ___.
.
TECHNIQUE: Contrast-enhanced axial images obtained from the lung
bases to the pelvic outlet. Coronal and sagittal reformations
are provided.
FINDINGS: Though this exam is not tailored for
supradiaphragmatic evaluation, the moderate left pleural
effusion with adjacent compressive atelectasis is stable. There
is a new small right pleural effusion with increased right
basilar atelectasis. Heart size demonstrates stable mild
enlargement and is without pericardial effusion.
.
The liver is homogenous ___ attenuation without discrete masses
or lesions. Minimal periportal edema is decreased compared to
prior. The gallbladder is nondistended. The spleen and bilateral
adrenal glands are unremarkable.
There is mild proximal right-sided hydroureteronephrosis,
unchanged compared to ___ and may be related to
extrinsic compression of the mid ureter due to the multiple
abdominal fluid collections or possibly inflammatory stricture.
.
Patient has history of necrotizing pancreatitis with stable
minimally heterogeneous enhancement and no new areas of necrosis
identified. On a background of mesenteric edema, multiple retro-
and intra- and extraperitoneal rim enhancing air fluid
collections are generally unchanged ___ distribution compared to
the ___ study. As before, a complex retroperitoneal
air fluid collection extends anteriorly into the anterior
pararenal space surrounding the pancreas and duodenum then
crosses into the intraperitoneal cavity into the lesser sac. The
complex collection also spans the retromesenteric plane
bilaterally and dissects down the bilateral retrorenal spaces to
the pelvic extraperitoneal spaces and along the bilateral
iliopsoas muscles into the soft tissues of the thigh as well as
the right inguinal canal. Note, no herniated bowel is evident
within the right inguinal canal, only fluid collection.
.
There has been interval removal of the pigtail catheter draining
the largest air-fluid collection on the right with subsequent
increase ___ size of this collection measuring 15 x 10 cm
compared to 12 x 7 cm at a comparable level on the prior study
as well as extension of fluid collection along the prior
drainage tract into the subcutaneous tissues of the right lower
back (2:45). The left-sided collection with a pigtail catheter
___ situ is minimally increased ___ size when measured at the same
level measuring 10 x 5.3 cm on today's study compared to 9 x 5.8
on the prior study. There has been interval placement of a
right-sided transgluteal pigtail catheter draining the presacral
air fluid collection which is relatively unchanged ___ size if
not minimally decreased at the level of drain insertion.
.
The main portal vein is patent. The splenic vein demonstrates a
similar degree of attenuation though no evidence of thrombus or
pseudoaneurysm. The splenic artery appears patent. The inferior
vena cava filter is ___ standard infrarenal position. Stable
thrombus identified ___ bilateral common femoral veins. The aorta
is of normal caliber throughout.
.
Gastrojejunostomy catheter is ___ standard position. The bowel is
collapsed with no evidence of obstruction. Stable mesenteric
edema noted throughout. The bladder is relatively collapsed
around a Foley catheter. Stable thrombosis of the bilateral
common femoral veins. No suspicious lytic or blastic lesions
identified. Stable subcutaneous edema present.
.
IMPRESSION:
1. Generally stable distribution of the known intra-abdominal
air fluid collections, including gas and rim enhancement,
although a right posterior retroperitoneal collection ___
particular has increased somewhat. Interval removal of drain ___
the right-sided pararenal collection with interval subsequent ___
size of collection now measuring 15 cm. Interval placement of a
right trans-gluteal catheter draining the presacral collection,
which is stable if not minimally decreased ___ size.
2. Fluid collections continue to extend inferiorly ___ soft
tissues of bilateral thighs as well as right inguinal canal. No
herniated bowel within right inguinal canal.
3. Stable moderate left pleural effusion. New right small
pleural effusion with increased right basilar atelectasis.
4. Stable bilateral common femoral venous thrombosis.
5. Stable heterogeneous enhancement of the pancreatic parenchyma
without no new areas of necrosis. Attenuated but patent splenic
vein. No splenic artery pseudoaneurysm.
6. Stable moderate mesenteric and subcutaneous edema.
7. Stable mild right hydroureteronephrosis with gradual tapering
to the level of mid ureter possibly due to extrinsic compression
by fluid collection or due to inflammatory stricture.
.
___ US guided insertion of R flank ___ drain: IMPRESSION:
uncomplicated placement of percutaneous catheter into a walled
off necrosis collection ___ the right flank. Specimen was sent
for microbiology analysis.
.
___ 3:25 pm ABSCESS
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ CHAINS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): YEAST(S).
WOUND CULTURE (Preliminary): pnd
ANAEROBIC CULTURE (Preliminary): pnd
.
___ 8:20 pm BLOOD CULTURE Blood Culture, Routine (Pending)
.
___ 1:50 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with a history of
necrotizing hemorrhagic pancreatitis c/b abdominal compartment
syndrome and cardiac arrest, multiple abdominal fluid
collections s/p ___ drain placement, pancreatico-colic fistula
now maintained on TPN with recent admission for bilateral
pulmonary emboli s/p anticoagulation c/b GIB s/p IVC filter. His
___ right flank drain fell out at rehab recently and he returned
to ___ on ___ with abdominal pain, distension and fevers
to 102 likely secondary to enlarging pararenal fluid collection,
which was confirmed on CT a/p. He was kept NPO, continued on
TPN, and underwent US guided re-placement and upsizing of his
previous ___ Fr right flank drain with a 14 ___ right flank
drain by interventional radiology on ___. Gram stain from
his R flank collection showed 1+PMNs/2+GPC/2+GNR/1+yeast
(unchanged from prior gram stains) with final cultures pending
at the time of discharge. He was continued on his
vancomycin/meropenem/fluconazole while inpatient (the course of
which is being managed by his ID physicians at ___. He
otherwise remained afebrile throughout his hospitalization:
blood cultures were pending on discharge, urine culture was
negative, and WBC was 5.6 on discharge. Regarding his
tubes/lines/drains, he has: foley catheter which was placed ___
the ED ___ on admission (he should undergo a voiding trial
at rehab), his left brachial PICC was left ___ place, flexiseal
rectal tube left ___ place, J-tube (tube feeds were held), left
abdominal pigtail, one right pre-sacral pigtail, and one new
right flank pigtail (newly placed this admission). The wound
care service helped with recommendations regarding his right
sacral unstagable decubitus ulcer. His coumadin was held while
inpatient and may be restarted at rehab (his INR on ___ was
1.3). He was scheduled to follow up with infectious disease and
with Dr. ___ on ___bdomen/pelvis. Of note, on
discharge both of his thighs were noted to be tense: given his
history of DVT (with IVCf placement, on coumadin), surveillance
lower extremity ultrasounds may be necessary ___ the future. If
he spikes another fever ___ the near future he may need drain
upsizing of most recent drain.
Medications on Admission:
Meds from ___ (___): cadexomer iodine gel', cipro 0.3%
opth soln 1gtt'''' OD, ferrous sulfate elixir 325'' (Jtube),
fluconazole 400' (Jtube), meropenem 0.5g IV q6h, metoprolol
100'''' (Jtube), miconazole 2% pwd', omeprazole 40' (Jtube),
tobramycin/dexamethasone 1gtt OD qhs, vancomycin 125''''
(Jtube), coumadin 4', APAP 650 q6 (Jtube)
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
3. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
4. Meropenem 500 mg IV Q6H
5. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
6. insulin regular human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
7. Pantoprazole 40 mg IV Q24H
8. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q3H:PRN pain
please hold for over-sedation
9. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
10. ciprofloxacin 0.3 % Drops Sig: ___ Drops Ophthalmic QID (4
times a day).
11. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO QID
(4 times a day).
12. tobramycin-dexamethasone 0.3-0.1 % Drops, Suspension Sig:
One (1) Drop Ophthalmic QHS (once a day (at bedtime)).
13. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right flank abdominal necrotic collection.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with fevers and found to have an increased
size of a right abdominal collection after your drain fell out
at rehab. The drain was replaced and you were continued on
antibiotics. You should continue to take your antibiotics as
prescribed at rehab. Your coumadin should be restarted at rehab.
A foley catheter was placed while you were ___ the emergency room
and will be removed when you are at rehab. You should follow up
with infectious disease and Dr. ___ as scheduled.
Followup Instructions:
___
|
19858686-DS-23 | 19,858,686 | 26,389,476 | DS | 23 | 2164-10-12 00:00:00 | 2164-10-12 12:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Compazine
Attending: ___
___ Complaint:
right knee infection
Major Surgical or Invasive Procedure:
___: arthroscopy right knee irrigation and debridement
History of Present Illness:
___ s/p R knee arthroscopy, medial meniscectomy, synovectomy
(___) presented to ED with increased pain, swelling, joint
aspiration concerning for infection, now s/p arthroscopy R knee
I&D (Dr. ___, ___.
Past Medical History:
PMHx:
ANXIETY
ADVANCED MATERNAL AGE
ANEMIA
BORDERLINE HYPERTENSION
COCCYDYNIA
CONTRACEPTION
DEPRESSION
EDEMA
GESTATIONAL HYPERTENSION
HEMORRHOIDS
HERPES SIMPLEX
LEFT KNEE PAIN
MARIJUANA USE
OBESITY
PAIN
PRIOR C/S
SLEEP APNEA
BACK PAIN
ARTHRITIS
HEARTBURN
MRSA ABSCESS
NARCOTICS AGREEMENT
H/O GESTATIONAL DIABETES
PSH:
right knee medial meniscal tear s/p arthroscopic subtotal
medial meniscectomy, removal of loose bodies, lateral
femoral chondroplasty and major arthroscopic synovectomy of
3 or more compartments ___
left total knee replacement ___
repair of left knee meniscal tear in ___
right Achilles tendon repair x 2 in ___
s/p c-section x 3 in ___ and ___
tubal ligation
Social History:
___
Family History:
Her family history is noted for mother living in her ___ with
diabetes, obesity and arthritis; sister living age ___ with
obesity; son age ___ and ___ with obesity and arthritis and
another son age ___ with asthma. She is on disability for
depression and she is single with 3 children.
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:
* Incision healing well, no signs of erythema or ecchymosis.
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 05:55AM BLOOD WBC-6.1 RBC-2.61* Hgb-8.8* Hct-26.7*
MCV-102* MCH-33.7* MCHC-33.0 RDW-12.4 RDWSD-47.1* Plt ___
___ 06:10AM BLOOD WBC-6.8 RBC-2.42* Hgb-8.2* Hct-25.2*
MCV-104* MCH-33.9* MCHC-32.5 RDW-12.4 RDWSD-47.3* Plt ___
___ 05:32AM BLOOD WBC-7.4 RBC-2.52* Hgb-8.5* Hct-25.8*
MCV-102* MCH-33.7* MCHC-32.9 RDW-12.5 RDWSD-47.3* Plt ___
___ 05:55AM BLOOD WBC-8.3 RBC-2.59* Hgb-8.8* Hct-26.8*
MCV-104* MCH-34.0* MCHC-32.8 RDW-12.8 RDWSD-48.3* Plt ___
___ 05:30AM BLOOD WBC-11.5* RBC-3.27* Hgb-11.4 Hct-33.9*
MCV-104* MCH-34.9* MCHC-33.6 RDW-13.0 RDWSD-49.9* Plt ___
___ 05:30AM BLOOD Neuts-65.4 ___ Monos-6.9 Eos-2.4
Baso-0.3 Im ___ AbsNeut-7.48* AbsLymp-2.82 AbsMono-0.79
AbsEos-0.28 AbsBaso-0.03
___ 05:55AM BLOOD Plt ___
___ 06:10AM BLOOD Plt ___
___ 05:32AM BLOOD Plt ___
___ 05:55AM BLOOD Plt ___
___ 11:51AM BLOOD ___ PTT-28.3 ___
___ 05:30AM BLOOD Plt ___
___ 05:55AM BLOOD Glucose-102* UreaN-7 Creat-0.7 Na-139
K-3.8 Cl-103 HCO3-22 AnGap-14
___ 05:30AM BLOOD Glucose-112* UreaN-14 Creat-0.8 Na-139
K-3.8 Cl-101 HCO3-23 AnGap-15
___ 05:55AM BLOOD Calcium-7.8* Phos-3.6 Mg-1.9
___ 05:30AM BLOOD CRP-13.1*
___ 03:30PM BLOOD Vanco-34.8*
___ 05:41AM BLOOD Lactate-2.0
Brief Hospital Course:
The patient was admitted to the orthopedic surgery service and
was taken to the operating room 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:
POD #1, Infectious disease was consulted for further management
and recommendations of antibiotics. Joint fluid cultures showed
growth of s. aureus. ID recommended IV Vancomycin and Cefepime
2g every 12 hours.
POD #2, patient had a temp of 102.0 at 4am. Fever work-up was
obtained. UA showed epi 10, otherwise unremarkable. Chest x-ray
did not show evidence of PNA. Blood cultures were obtained.
Joint fluid cultures showed likely growth of MSSA. ID
recommended discontinuation of Vanco and Cefepime and IV Ancef
2g every 8 hours was started. Patient was taken off bedrest
precautions started physical therapy per post-meniscectomy
protocol. Drain remained in place.
POD #3, ID recommended continuing IV Ancef 2g every 8 hours x 2
to 4 weeks at discharge. Duration of treatment to be determined
at outpatient follow up. A midline was placed per ID for long
term IV antibiotics. Repeat urinalysis was obtained due to
complaint of urinary frequency, which was negative. Urine and
blood cultures were pending at time of discharge. The patient
will be contacted if urine and blood cultures come back positive
and need to be treated.
POD #4, hemovac drain was pulled prior to discharge.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient received Aspirin 325 mg daily for
DVT prophylaxis starting on the morning of POD#1. 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 weight bearing as
tolerated on the operative extremity.
Ms. ___ is discharged to home with services in stable
condition.
Medications on Admission:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Amitriptyline 50 mg PO QHS
3. amLODIPine 10 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN congestion
5. Hydrochlorothiazide 25 mg PO DAILY
6. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
8. ValACYclovir 500 mg PO Q12H:PRN genital rash
9. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
10. Aspirin EC 325 mg PO DAILY
11. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit
oral BID
12. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
13. Cyanocobalamin 500 mcg PO DAILY
14. Docusate Sodium 100 mg PO BID
15. Senna 8.6 mg PO BID:PRN Constipation - First Line
16. Multivitamins 2 TAB PO DAILY
Discharge Medications:
1. CeFAZolin 2 g IV Q8H
2. Gabapentin 300 mg PO TID
3. Pantoprazole 40 mg PO Q24H
Take daily while on Aspirin x 28 days
4. Acetaminophen 1000 mg PO Q8H
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
6. Amitriptyline 50 mg PO QHS
7. amLODIPine 10 mg PO DAILY
8. Aspirin EC 325 mg PO DAILY
9. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit
oral BID
10. Cyanocobalamin 500 mcg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN congestion
13. Hydrochlorothiazide 25 mg PO DAILY
14. Multivitamins 2 TAB PO DAILY
15. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
16. Senna 8.6 mg PO BID:PRN Constipation - First Line
17. ValACYclovir 500 mg PO Q12H:PRN genital rash
18. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
19. HELD- Ibuprofen 400 mg PO Q8H:PRN Pain - Mild This
medication was held. Do not restart Ibuprofen until you've been
cleared by your surgeon
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right knee infection
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 in three (3) weeks.
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. You may wrap the knee with an ace bandage
for added compression. 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 Aspirin 325 mg daily
with food for four (4) weeks to help prevent deep vein
thrombosis (blood clots). Continue Pantoprazole daily while on
Aspirin to prevent GI upset (x 4 weeks). If you were taking
Aspirin prior to your surgery, take it at 325 mg daily until the
end of the 4 weeks, then you can go back to your normal dosing.
9. WOUND CARE: 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 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 drainage.
10. ___ (once at home): Home Infusions for IV antibiotics
11. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Mobilize with assistive devices (___) if
needed. Knee immobilizer on at all times until follow up in
clinic. No strenuous exercise or heavy lifting until follow up
appointment.
12. PICC CARE: Per protocol
13. WEEKLY LABS: draw on ___ and send result to ID RNs
at: ___ R.N.s at ___.
- CBC/DIFF
- CHEM 7
- LFTS
- ESR/CRP
Physical Therapy:
WBAT
Wean assistive device as able
Mobilize frequently
Treatments Frequency:
daily dressing changes as needed for drainage
wound checks daily
ice
Followup Instructions:
___
|
19858961-DS-8 | 19,858,961 | 24,026,475 | DS | 8 | 2132-07-27 00:00:00 | 2132-07-27 23:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left ankle pain
Major Surgical or Invasive Procedure:
1. Open reduction and internal fixation of left
trimalleolar ankle fracture.
2. Manual stress examination of left distal tibia-fibula
joint.
History of Present Illness:
___ yo healthy male p/w L ankle pain/deformity after falling in a
mosh at a local club. He was unable to weightbear after this
injury. He endorses mild numbness on his medial foot. He denies
any other symptoms. He presentes to the ___ ED on ___.
Past Medical History:
none
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION UPON ADMISSION:
In general, the patient is a well-appearing young male
Vitals: 99.8 80 131/62 16 97% RA
Left lower extremity:
Skin intact
Visible gross deformity at ankle
Soft, non-tender thigh and leg
Full, painless AROM/PROM of hip and knee
+motor to toes
+SILT SPN/DPN/TN/saphenous/sural distributions, but with mild
decreased sensation at medial foot
___ pulses, foot warm and well-perfused
PHYSICAL EXAMINATION UPON DISCHARGE:
AFVSS
Well-appearing male, A&Ox3
Respirations non-labored
LLE: below-knee splint in place; wiggles toes; sensation intact
over DP/SP/T distributions as testable with splint; toes warm
and well-perfused; no pain with passive stretch of big toe
Pertinent Results:
___ 08:20PM GLUCOSE-77 UREA N-9 CREAT-1.1 SODIUM-142
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-25 ANION GAP-17
___ 08:20PM estGFR-Using this
___ 08:20PM WBC-9.9 RBC-4.74 HGB-15.7 HCT-44.0 MCV-93
MCH-33.0* MCHC-35.6* RDW-13.2
___ 08:20PM NEUTS-69.4 ___ MONOS-4.4 EOS-2.6
BASOS-0.9
___ 08:20PM PLT COUNT-305
___ 08:20PM ___ PTT-27.1 ___
Final Report
LEFT ANKLE AND LEFT FOOT RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Status post fall with pain and deformity of
the left ankle and foot, question fracture/dislocation.
FINDINGS: Four images provided including AP, oblique, lateral
views of the left ankle as well as a lateral view of the left
foot were provided. There is posterior dislocation of the
tibiotalar joint, best seen on the lateral
projection. There is also disruption of the tibiofibular
syndesmosis. Fractures of the distal fibula and medial
malleolus are also noted.
IMPRESSION: Fractures involving the distal fibula and medial
malleolus with widening of the tibiofibular syndesmosis
indicative of ligamentous disruption as well as tibiotalar
dislocation.
Brief Hospital Course:
As noted in the HPI, the patient presented to the ___ ED was
was subsequently admitted to the Ortho Trauma service. In the
ED, his ankle was reduced and splinted. Lovenox subq was
started. He received IV morphine for pain control. He underwent
operative fixation on ___, performed by Dr. ___
___. Lower-leg splint applied postoperatively.
Post-operatively, the patient received aspirin for DVT
prophylaxis. Regular diet resumed and ___. IVF
discontinued when patient taking in appropriate POs. He was made
non-weight-bearing on the operative extremity. On POD1, ___, he
was discharged to home, afebrile and eating well. He will
remained non-weightbearing. He will follow-up with Dr. ___
in clinic in 2 weeks.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
this medication is available over the counter. do not exceed
4000mg (4g) per day.
2. Aspirin 325 mg PO DAILY
continue for 2 weeks. this medication is available over the
counter.
3. Docusate Sodium 100 mg PO BID
this medication is available over the counter.
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drink alcohol or drive while taking this.
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp
#*45 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left trimalleolar ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin 325mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
-Splint must be left on until follow up appointment unless
otherwise instructed
-Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
Non-weight-bearing in left lower extremity. Keep splint elevated
as much as possible.
Followup Instructions:
___
|
19859018-DS-2 | 19,859,018 | 24,910,307 | DS | 2 | 2167-03-18 00:00:00 | 2167-03-18 17:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with a surgical history of open
appendectomy, ex-lap small bowel resection, and open
cholecystectomy who presented to ED with abdominal pain,
distention, nausea, and absent BM and flatus. He reported
feeling a "pop" 3 days prior when working out. He also notes
that he was previously diagnosed with an umbilical hernia but
has not had it repaired. Since yesterday afternoon, he reports
distention and firmness in his abdomen. He reported feeling pain
that worsened overnight to the point that he could not sleep,
after which he presented to the ED with ___ pain. He
describeed the pain as burning, constant, and diffuse, but worst
in the periumbilical region. He reported that he has not had a
BM since the day before presentation. He had not passed flatus
and was burping consistently. He reported nausea without
vomiting. He denied dysuria. He had not eaten since the pain
started but had been drinking water.
In the ED, Mr. ___ received acetaminophen 1000 mg IV,
morphine sulfate 4 mg IV Q4H:PRN, Ondansetron 4 mg IV, morphine
sulfate 4 mg IV as well as 1000 mL LR Bolus.
Past Medical History:
Past Medical History:
-Hypertension
Past Surgical History:
- Open appendectomy (___) in ___ with complication of
infection that required drainage
- Small bowel resection (___) with complications of
inflammation, infection, and intestinal blockage that required
second surgery
- Open cholecystectomy (___)
Social History:
___
Family History:
Family History:
-Father - deceased (MI)
-3 brothers - deceased (MI/stroke)
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: Temp 97.4 HR 86 BP 157/101 RR 19 O2Sat 97% on RA
Gen: In pain but otherwise well-appearing
HEENT: Normocephalic. Sclerae anicteric. Hearing grossly intact.
MMM.
HEART: RRR, normal S1/S2, no murmurs, rubs, or gallops
LUNGS: CTAB. No crackles/wheezes/rhonchi. No respiratory
distress.
ABDOMEN: Scars from previous abdominal surgeries: along right
costal margin, vertical paramedian, vertical midline, small
circular scar in RLQ, small circular scar in LLQ. Firm,
distended, with hypoactive bowel sounds. Resonant to percussion
in all quadrants. Tender to palpation in all quadrants, worst in
periumbilical region.
PHYSICAL EXAM ON DISCHARGE:
Vitals: T 98.6 HR 89 BP 153/87 RR 18 SpO2 96% RA
Gen: NAD, A&Ox3, appears comfortable
HEENT: Normocephalic. Sclerae anicteric. Hearing grossly intact.
MMM.
HEART: RRR, normal S1/S2, no murmurs, rubs, or gallops
LUNGS: Breathing comfortably on room air. No respiratory
distress.
ABDOMEN: Scars from previous abdominal surgeries: along right
costal margin, vertical paramedian, vertical midline, small
circular scar in RLQ, small circular scar in LLQ. Soft,
nontended, minimal distension, no rebound or guarding
EXT: warm and well perfused, no edema
Pertinent Results:
CT ABD & PELVIS WITH CONTRAST Study Date of ___
1. Multiple dilated small bowel loops with gradual transition in
the right mid abdomen in the distal ileum is concerning for a
partial small bowel
obstruction, possibly due to adhesions.
2. 1.8 cm intermediate density left upper pole cystic lesion
which may contain internal septations. Recommend further
evaluation with nonemergent renal ultrasound.
3. Bilateral diaphragmatic hernias containing liver on the right
and stomach and colon on the left.
CHEST (PORTABLE AP) Study Date of ___
Enteric tube tip in the stomach. Low lung volumes with mild
bibasilar
atelectasis.
Brief Hospital Course:
Patient is a ___ year old male with pmh significant for
hypertension, and hx of appendectomy, bowel resection and open
cholecystectomy. Patient presented to the emergency department
with complaints of abdominal pain, nausea/vomiting and
constipation. Imaging was completed which demonstrated small
bowel obstruction, therefore he was treated non-operatively with
bowel rest, IV fluids and placement of a nasogastric tube for
decompression.
Upon admission to inpatient unit, the patient was also noted to
be hypertensive with blood pressures ranging 160-180s/100-120s
with heart rates between 80-100s. For this reason, he was given
IV labetalol with good effect and SBP improved to 150s. He was
placed on telemetry prior to administration and his heart rate
remained stable in ___. At this time he denied chest pain or
shortness of breath. Medicine was consulted for persistent
hypertension. Before discharge home he was restarted on his oral
antihypertensive medications.
Bowel function and output from the nasogastric tube was
monitored and when appropriate the nasogastric tube was removed
and he was trialed on a clear liquid diet which he tolerated
well. The following day he was advanced to a regular diet which
he tolerated without nausea, vomiting, or abdominal pain. He
continued to pass flatus and have bowel movements.
During this hospitalization, the patient voided without
difficulty and ambulated early and frequently. The patient was
adherent with respiratory toilet and incentive spirometry and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well. He was
afebrile and his vital signs were stable. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and his pain was well controlled. The patient was
discharged home without services. Discharge teaching was
completed and follow-up instructions were reviewed with reported
understanding and agreement.
Medications on Admission:
1. Lisinopril 10 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertension
Small Bowel Obstruction
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
evaluation of abdominal pain and were found to have a small
bowel obstruction. You were treated non-operatively with bowel
rest, IV fluids and a nasogastric tube. You are recovering well
and are now ready for discharge. Please follow the instructions
below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
|
19859188-DS-22 | 19,859,188 | 26,571,094 | DS | 22 | 2151-11-12 00:00:00 | 2151-11-12 22:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
Right lower quadrant/chest pain
Major Surgical or Invasive Procedure:
radiation
History of Present Illness:
___ ATTENDING ADMISSION NOTE
Date: ___
Time: 00:28
The patient is a ___ h/o metastatic pancreatic CA, UC; presents
with RUQ/right lower chest pain since this AM. She reports her
pain started suddenly after bending over to move a small stool.
She describes her pain as a new sharp, non-radiating right-sided
rib pain, which is exacerbated with deep inspiration. As a
result, she tries not to take deep breaths, but denies air
hunger. She endorses her usual nausea (for months since having
radiation therapy). She reports that her previous LUQ pain felt
similar and wonders if radiation may be helpful for her RUQ pain
since it mitigated her previous LUQ pain. She endorses poor po
intake since having radiation. She denies vomiting, bloody
stools, but stool has been dark since she started taking iron
tablets. She denies dysuria, fevers, cough, left-sided chest
pain.
Upon review of OMR, she was last admitted ___ to
the medicine service for severe back pain and was found to have
splenic infarct.
In ER:
VS: 97.5 93 117/101 16 97% RA, ___ RUQ pain
PX: R lower chest not TTP, RUQ TTP, otherwise benign exam
Studies: Na 128, WBC 9.3, ALT: 90, AP: 309, TB: 0.4, Alb: 4.0,
AST: 53, Lip: 11
CT abdomen w/o:
1. Increased size of right liver metastases without evidence for
acute
hemorrhage.
2. Multiple pulmonary nodules in the visualized portions of the
lower lungs
which appear to have increased in size and number compared to
study dated
___.
3. Pancreatic tail mass, incompletely evaluated in the absence
of intravenous
contrast.
Fluids given: none
Meds given: morphine 5 mg IV x2
Consults called:
VS prior to transfer to the floor: 98.2, 80, 14, 131/84, 100
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies visual changes, headache, dizziness, sinus
tenderness, neck stiffness, rhinorrhea, congestion, sore throat
or dysphagia. Denies chest pain, palpitations, orthopnea,
dyspnea on exertion. Denies shortness of breath, cough or
wheezes. Denies nausea, vomiting, heartburn, diarrhea,
constipation, BRBPR, melena, or abdominal pain. No dysuria,
urinary frequency. Denies rashes. No increasing lower extremity
swelling. No numbness/tingling or muscle weakness in
extremities. No feelings of depression or anxiety. All other
review of systems negative.
Past Medical History:
- Ulcerative colitis followed by Dr. ___
- PSC --> chronic, intermittent RUQ pain.
- Gastritis.
- Small bowel ulcers ___ NSAIDs w/ UGIB ___ requiring Tfx
- Hiatal hernia.
- Trochanteric bursitis (R) s/p cortisone injection
- Dermatofibroma ___ shave of left upper back
- Hypertension, benign
- Depression. Last hospitalization in ___. Stable on effexor.
- OA w/ severe T/L spine degenerative changes on CT ___.
- spine hemangiomas
- Right IJ clot ___ treated with anticoagulation.
- Sclerosing cholangitis
- Torn R lat meniscus s/p arthoscopic surgery ___
- Nevi, followed by Dr. ___
- ___ keratoses
- Basal cell carcinoma
ALLERGIES: Lisinopril
Social History:
___
Family History:
Her mother had apparent ___ disease and hx of vertebral
fracture.
Her father died from lung cancer at age ___.
Her maternal aunt died from pancreatic cancer at age ___.
Her 2 brothers died with COPD in their ___.
Father and brother died of diseases related to smoking -
emphysema, COPD. Mother with CHF, osteoporosis, TB. Also with
family history of EtOH abuse. No known history of cancer,
inflammatory bowel disease, or bleeding disorder.
Physical Exam:
admission exam
VS: 97.9 118/62 78 16 95%RA; ___ RUQ pain
GEN: No apparent distress
HEENT: no trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CV: regular rate and rhythm, no murmurs/gallops/rubs
PULM: Clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: soft, non-tender to deep palpation, non-distended; no
guarding/rebound
EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV
present
NEURO: Alert and oriented to person, place and situation; CN
II-XII intact, ___ motor function globally
DERM: no lesions appreciated
MUSCULOSKELETAL: no pain from palpation of ribs
.
discharge exam
VS 96.8 116/66-128/78 ___ 20 96% RA
GEN: No apparent distress
HEENT: NCAT, anicteric sclera, MMM
CV: regular rate and rhythm, no murmurs/gallops/rubs
PULM: Clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: +BS. soft, nondistended. mildly tender to palpation in RUQ.
EXT: no clubbing/cyanosis/edema; 2+ distal pulses
NEURO A&Ox3.
SKIN: warm, dry
Pertinent Results:
admission labs
___ 05:15PM BLOOD WBC-9.3# RBC-3.96* Hgb-12.5 Hct-36.5
MCV-92 MCH-31.6 MCHC-34.4 RDW-13.3 Plt ___
___ 05:15PM BLOOD Neuts-84.9* Lymphs-9.4* Monos-4.9 Eos-0.4
Baso-0.4
___ 05:15PM BLOOD Glucose-111* UreaN-9 Creat-0.5 Na-128*
K-3.8 Cl-92* HCO3-27 AnGap-13
___ 05:15PM BLOOD ALT-90* AST-53* AlkPhos-309* TotBili-0.4
___ 05:15PM BLOOD Lipase-11
___ 05:15PM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.8 Mg-2.1
.
discharge
___ 06:15AM BLOOD WBC-5.1 RBC-3.55* Hgb-11.0* Hct-34.0*
MCV-96 MCH-31.1 MCHC-32.4 RDW-13.4 Plt ___
___ 06:15AM BLOOD Neuts-69.6 Lymphs-15.4* Monos-9.6
Eos-4.7* Baso-0.7
___ 06:15AM BLOOD ___ PTT-32.5 ___
___ 06:15AM BLOOD Glucose-101* UreaN-7 Creat-0.5 Na-140
K-3.8 Cl-101 HCO3-33* AnGap-10
___ 06:15AM BLOOD ALT-61* AST-33 AlkPhos-241* TotBili-0.2
___ 06:15AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.0
.
studies:
CHEST RADIOGRAPH AND RIGHT RIB SERIES ___
Right lung nodules, better assessed on the prior CT. Port-A-Cath
appropriately positioned. No definite sign of rib fracture.
.
CT abdomen without contrast
1. Increased size of right liver metastases without evidence for
acute
intra-lesional hemorrhage.
2. Multiple pulmonary nodules in the visualized lower lungs
appear increased
in size and number compared to study dated ___.
3. Pancreatic tail mass, incompletely evaluated in the absence
of intravenous
contrast.
.
Brief Hospital Course:
___ yo F with hx of metastatic pancreatic cancer, ulcerative
colitis with primary sclerosing cholangitis who presents with
RUQ abdominal pain.
.
#. Abdominal pain, right upper quadrant: Patient presented with
RUQ pain. CXR negative for pneumonia or fracture. Abdominal CT
revealed increased size of right liver metastasis and increased
size and number of lung lesions. The CT scan did not reveal
inflammation around the gallbladder to suggest cholecystitis and
bili was not elevated to suggest obstruction. Pain was most
likely ___ to enlarged liver and lung lesions. Patient underwent
radiation planning on ___ and first of five radiation sessions
on ___. Her pain was controlled with the addition of long
acting morphine in addition to prn oxycodone. She was discharged
with plans to complete 4 more sessions of radiation.
.
#. Metastatic pancreatic cancer: Patient previously on folfox
therapy changed to folfirinox. Also tried gemcitabine but became
neutropenic so treatment held. Gemcitabine changed to folfiri
and continued to progress. She then underwent palliative XRT.
During admission, the patient had radiation planning on ___ and
had first of five sessions on ___. The palliative care team was
consulted. They recommended adding long acting morphine in
addition to her prn oxycodone to better control her pain. After
further discussion, it was also decided that the patient would
be transitioned into hospice care upon discharge.
.
#. Ulcerative Colitis: Not currently active per colonoscopy
___. She was continued on her home sulfasalazine
#. Primary Sclerosing Cholangitis: Stable. Continued ursodiol
#. GERD: Stable. Continued omeprazole
.
#. History of right IJ clot: Clot has subsequently resolved.
Continue lovenox
.
Transitional Issues
- no labs or studies pending at time of discharge
- patient will need to complete 4 additional radiation sessions
- patient was discharged with plans to transition into hospice
care
- patient DNR/DNI on admission
Medications on Admission:
(Home medication list reconciled on this admission)
ursodiol 300 mg 1 po BID
enoxaparin 60 mg/0.6 mL Sub-Q 60 mg SQ Q12 hours
calcium 500 + D 500 mg (1,250 mg)-200 Units 1 po daily
lipase-protease-amylase 5,000-17,000-27,000 U ___ caps po TID
with meals
lorazepam 0.5 mg ___ tabs po q6h and qhs prn anxiety/nausea
sulfasalazine 500 mg 1 o BID
omeprazole 20 mg 1 po daily
venlafaxine XR 150 mg 2 caps po qam
ibuprofen 200 mg ___ tabs po q6-8h prn back pain
docusate sodium 100 mg 1 po BID prn constipation
oxycodone 5 mg ___ tabs po q4h prn pain
pyridoxine 100 mg 1 po daily
multivitamin 1 po daily
folic acid 1 mg 1 po daily
miralax 17 gram/dose powder po prn constipation
ferrous sulfate 325 mg (65 mg iron) 1 po BID
Discharge Medications:
1. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
2. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous BID (2 times a day).
3. Calcium-Vitamin D Oral
4. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: ___ Caps PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety/nausea.
6. sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. venlafaxine 150 mg Tablet Extended Rel 24 hr Sig: Two (2)
Tablet Extended Rel 24 hr PO once a day.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
11. pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
14. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours): please do not drive
or perform other activities that require full attention while
taking this medication .
Disp:*60 Tablet Extended Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnosis: metastatic pancreatic cancer
secondary diagnoses: ulcerative colitis, primary sclerosing
cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you while you were admitted to
___. You were admitted because you were having worsening
abdominal pain. You had a CT scan which showed that the cancer
in your liver and lungs has enlarged and is likely contributing
to your pain. After discussion with your oncologist, you decided
that you would like to pursue palliative radiation and
subsequently underwent radiation planning and your first session
of radiation prior to discharge.
.
The following changes have been made to your medication regimen.
Please START taking
- MSContin 15 mg by mouth twice daily
.
There were no other changes made to your medication regimen.
Please take the rest of your medications as prescribed and
follow up with your doctors as ___.
.
Please do not drive as your pain medications may impair your
ability to react quickly.
Followup Instructions:
___
|
19859251-DS-22 | 19,859,251 | 26,709,658 | DS | 22 | 2173-07-25 00:00:00 | 2173-07-25 16:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Palpitations/Chest pain
Major Surgical or Invasive Procedure:
___ TEE/Cardioversion
History of Present Illness:
___ history of CHF with last EF 40%, HTN, HLD, current smoker,
paroxysmal atrial fibrillation, bad PAD with SFA and B/L iliac
stents, pulmonary embolism, reportedly non-compliant with
medications and reportedly taken off of couamdin by PCP, woke up
in middle of night with 12 hours of intermittent sensation of
palpaitations and chest pressure radiating to left arm lasting
about 30 minutes at a time. Pt reports that has a history of
atrial fibrillation 2 or ___ years ago and his PCP stopped the
warfarin which he was non-compliant with. Pt endorses drug
use--no alcohol or cocaine but snorts heroin with last use
several days ago. Noncompliant with HTN, HLD, atrial
fibrillation medications. Pt reports that his PCP actually took
him off coumadin and that he did not stop taking it on his own.
He states that he was very frustarated about needing to have his
___ drawn ___ times per week.
.
In the ED, VS 97.9 95 192/108 18 100% and troponins positive to
0.48 and BNP of 5000. pt's HRs jumped up to 210 and irregular.
EKG demonstrated atrial fibrillation with RVR as well as RBBB
with LAFB. Pt was given diltiazem 20mg iv at 0730 and at 0745.
pt's heart rate from the ___ on the monitor and started on
a diltiazem drip. Pt then converted into accelerated junctional
rhythm with a rate in the ___. the diltiazem drip was
discontinued at 1030. Pt was given aspirin 325 and nitro x1 sl
for ___ pain which noted did not relieve the pain. pt is
currently pain free. pt also started on heparin drip at 0920 -
1,050 units/hr and was given heparin bolus 4,000 units iv at
0920. pt currently receiving levofloxacin 750mg iv for apical
opacities on CT. ___ cultures x2 sent. Guiac negative. Pt
received CTA which showed no evidence of pulmonary embolism;
marked atheroscerotic disease, small pericardial effusion,
scattered ground glass opacities in apices bilaterally
suggestive of either inflammation or infection, right basilar
atelectasis, no pleural effusions. Vitals as pt left floor T
98.0, HR - 76, BP - 172/73, RR -20, O2 Sat - 98% 4LNC.
.
.
On the floor, pt found to be in NAD. However, reports now
constant ___ chest tightness with radiation to the left arm.
Also reports mild SOB worse with laying down. Also notes that
over past 3 days has been having increased coughing and
subjective fevers. Denies swelling, syncope, presyncope.
Reports being in atrial fibrillation day before ___ and
getting cardioverted at ___.
.
Pt left AMA on ___ due to anxiety and panic where he walked 12
miles to his sister in law's house; returned on morning of
___.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
.
3. OTHER PAST MEDICAL HISTORY:
PE ___ unknown cause
CHF
PVD s/p Aortoiliac bifurcation stents SFA ___ and CIA
___
Small Infarenal AAA
Scoliosis
+ Tobacco abuse ___ packs daily) Interested in quitting
smoking
Social History:
___
Family History:
Father: ___
Mother: emphysema, CHF
Mother died from CHF.
Physical Exam:
VS: BP 196/115 P81 RR20 97% on 2L
GENERAL: ___ M who appears stated age. Mildly tachpyneic, but
in NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP about 3cm above sternal anlge
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, S1 S2 clear and of good quality without murmurs, rubs
or gallops. No S3 or S4 appreciated.
LUNGS: Very poor air movement, with crackles at the bases.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. No
edema bilaterally. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
On Discharge:
VS: ___ pressures 130s/80s, P ___, RR20, 95% on RA. Increased
weight from admission by about 7 pounds.
JVP still elevated to about 18cm.
Heart RRR, ___ murmur heard best at RUSB and LUSB, thought to be
from aortic sclerosis
Improved air movement
Extremities show 1+ edema on left, trace on right
Otherwise unchanged physical exam
Pertinent Results:
Admission Labs:
___ 07:20AM WBC-8.9 RBC-4.53* HGB-12.8* HCT-38.5* MCV-85
MCH-28.2 MCHC-33.2 RDW-14.6 PLT COUNT-196
___ 07:20AM NEUTS-72.6* ___ MONOS-6.0 EOS-1.5
BASOS-0.5
___ 07:20AM GLUCOSE-134* UREA N-17 CREAT-1.0 SODIUM-137
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-26 ANION GAP-16
___ 07:20AM CALCIUM-9.0 PHOSPHATE-3.0# MAGNESIUM-2.0
___ 09:12AM ___ PTT-30.9 ___
___ 07:20AM D-DIMER-___*
Cholesterol/HgbA1c
___ 04:00PM TRIGLYCER-120 HDL CHOL-26 CHOL/HDL-6.4
LDL(CALC)-117 ___
___ 04:00PM CHOLEST-167
___ 07:20AM %HbA1c-6.0* eAG-126*
Drug screen:
___ 06:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 07:20AM ASA-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
Cardiac Enzymes:
___ 07:20AM CK-MB-9 CK(CPK)-886* proBNP-4935*
___ 07:20AM cTropnT-0.48*
___ 04:00PM CK-MB-7 CK(CPK)-573* cTropnT-0.51*
___ 12:53AM CK-MB-6 CK(CPK)-423* cTropnT-0.36*
___ 07:50AM CK-MB-4 CK(CPK)-153 cTropnT-0.18*
Other:
___ 07:50AM ___ TSH-7.1*
Significant imaging:
___ CTA chest:
1. No evidence of pulmonary embolism to the subsegmental levels
bilaterally.
2. Indeterminate biapical ground-glass scattered opacities could
be
infectious or inflammatory in etiology.
3. Left ventricular hypertrophy.
___ Echo:
The left atrium is moderately dilated. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is mild to moderate regional left
ventricular systolic dysfunction with severe hypokinesis of the
basal half of the inferior and inferolateral walls. The
remaining segments contract normally (LVEF = 40 %). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is a very small circumferential pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD. Mild mitral
regurgitation. Mild aortic regurgitation.
Compared with the prior study (images reviewed) of ___,
the left ventricular cavity is larger with similar regional
dysfunction. Mild mitral regurgitation and mild aortic
regurgitation are now seen. A very small circumferential
pericardial effusion is also now present.
Readmission:
___ 12:00PM ___ ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
___ 12:00PM ___ WBC-10.7 RBC-4.51* Hgb-13.0* Hct-38.8*
MCV-86 MCH-28.9 MCHC-33.7 RDW-14.4 Plt ___
___ 12:00PM ___ Neuts-62 Bands-0 ___ Monos-10 Eos-2
Baso-0 ___ Metas-1* Myelos-0
___ 12:00PM ___ TSH-6.8*
___ 12:00PM ___ Free T4-1.2
Notable Labs:
___ 06:30AM ___ ALT-24 AST-17 LD(LDH)-235 AlkPhos-92
TotBili-0.4
___ 03:23PM ___ ALT-20 AST-21
___ 05:46PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-
Metanephrines, Fract., Free
Normetanephrine, Free H 1.2 <
0.90 nmol/L
Metanephrine, Free <0.20 <
0.50 nmol/L
Urine metanephrines: Pending
Microbiology:
___ cultures x 2 negative
Urine culture x2 negative
Studies:
___ TEE:
IMPRESSION: No spontaneous echo contrast or thrombus seen in
___. Mild to moderate mitral regurgitation. Extensive
simple aortic atheroma.
___ CXRay
In the setting of severe chronic cardiomegaly and pulmonary
vascular
congestion, which worsened between ___ and ___,
it is
difficult to say whether heterogeneous opacification at the
right lung base is pneumonia or more likely a combination of
vascular congestion, mild dependent edema, atelectasis and
overlying costal calcification. No appreciable pleural effusion
is present. No pneumothorax. No mediastinal widening.
___ B/L lower extremity doppler US and US of groin:
No pathology: no DVT, groin hematoma, abscess
___ B/L hip x ray:
No bony pathology
Brief Hospital Course:
ASSESSMENT AND PLAN
.
___ history of CHF with last EF in ___: 40%, no CAD visible on
last cardiac cath in ___, HTN, HLD, current smoker, paroxysmal
atrial fibrillation x 2 cardioversion, bad PAD with SFA and B/L
iliac stents, ___ year history of daily opiate use presenting
with radiating chest pain, severe htn, atrial fibrillation with
LVH and strain pattern. In and out of afib with RVR. Now s/p
cardioversion in NSR on rate and rhythm control with coreg and
amiodarone, anticoagulated with pradaxa.
.
# Chest pain and troponin elevation: Pt described chest pain
with radiation to left arm and trop bump to 0.51. Likely NSTEMI
but not from CAD. Most likely due to high demand from patient's
htn and LVH with afib and rvr causing poor diastolic filling
time and wall tension. Pt w/ risk factors for CAD but ___ cath
was clean and EKG changes during hospitalization more suggestive
of strain pattern from LVH than ACS. BP was controlled with
coreg, lisinopril, and lasix. Pt's initial ___ pressures on
admission were in 200s/100, this decreased to 130s-180s/80s-90s.
Pain resolved with decrease in heart rates and improved BP
control and was not present for the past week. In terms of CAD,
pt's ___ risk score is >20% for CAD risk equivalent of
severe PAD. Pt necessitating aspirin anyway for PAD s/p stent
in ___. At this point, it is unknown what the efficacy is for
dabigatran for primary prevention of CAD. Pt should continue
with prevention including smoking cessation, lipid lowering and
stabalization of plaques with statin therapy, and treatment of
hypertension.
.
# Atrial fibrillation with RVR, SVR, and accelerated junctional
rhythm: Pt had atrial fibrillation that was extremely difficult
to rate control often sustaining in 140s-160s with pauses
lasting up to 5 seconds. When trying to rate control with
diltiazem, pt went into accelerated junctional rhythms with
retrograde p waves. The patient has been cardioverted twice in
past with return of atrial fibrillation. Thus, the patient was
started on amiodarone 400 mg BID for prevention of afib
recurrence and Pradaxa for anticoagulation. The pt had TEE and
underwent successful electrical cardioversion. Notably, the
patient reports a transaminitis with previous use of amiodarone;
thus, he will need to be closely monitored while on this
medication. Pt cannot use Droneardone given his Class II CHF
and his CHF exacerbation while in the hospital. Amio isn't an
excellent option given pt's baseline lung disease with apical
scarring, likely COPD from extensive smoking history,
subclinical hypothyroidism history of transaminitis while on the
medication, and young age. Pt will need PFTs as pt has not had
this before. Cxray and CT scan were performed during this
hospitalization; the results of which are as above. Pt remained
in NSR after cardioversion. Down the road, if rate/rhythm
control does not ___, it is also possible to perform AVJ
ablation with PPM implantation. CHADS score of 2 on dabigatran.
After much discussion, dabigatran was chosen as the
anticoagulant medication for this patient. He reported being
compliant with warfarin in the past, but was annoyed by the fact
that he needed such frequent ___ draws. We initially
preferred to keep the patient on aspirin with switch to
anticoagulant as outpatient when pt showed he was reliable.
However, after much discussion with patient and his wife, clear
understanding and assurances by patient to adhere to regimen,
and pt's request to avoid frequent lab draws, along with risk
post cardioversion it was decided that dabigatran would be an
acceptable choice for the patient.
Also, of note, pt had a very rapid wide complex tachycardia at
the time of admission. The most parsimonious explanation would
be Afib with aberrancy, but the morphology of the QRS complex
was rather atypical for simple aberrant conduction, and there
are periods noted on telemetry and ECG where there are wide
complex beats which should NOT be aberrantly conducted. It may
be that the patient has underlying atrial fibrillation, but has
a competing ventricular tachycardia that originates near the
left posterior fascicle. An EP study could help differentiate
these, but after cardioversion, pt only manifested 3 beat runs
of vtach, so no indication for further workup. EP study remains
option in future. Such dysrhythmias during the patient's
hospitalization made dofetilide a less appealing option.
.
# Acute on chronic systolic and diastolic CHF: BNP positive. On
echo, EF of 40% with severe hypokinesis of the basal half of the
inferior and inferolateral walls c/w prior echo. However, there
was worsening of left sided filling pressures. Through hospital
stay pt gained 10 pounds with elevation of JVD, increased
swelling. This responded well to IV lasix. Pt was placed on
lisinopril, Coreg, and lasix. Likely exacerbated by stunned
myocardium, htn, rapid ventricular response. Pt was told to
restrict fluid intake to diurese back to normal weight.
.
#SOB: Likely from CHF in combination with baseline lung
disease. Pt has extensive smoking history and CXRay revealed
flattening of diaphragms suggestive of COPD. Air movement poor
but responds well to inhalers. Started spiriva empirically with
albuterol prn. CT scan shows apical scarring, I wonder if this
could be from his inhaled heroin use. Will need PFTs both for
baseline for amiodarone monitoring as well as for
characterization of potential obstructive lung disease.
.
# ___: Creatinine increased from baseline of 0.9 to 1.7 on night
s/p cardioversion. Likely from decreased perfusion. FEurea
is<35%. Pt used to be very hypertensive; likely had stunned
myocardium post cardioversion, together with some transient
relative hypotension during anesthesia causing decreased
perfusion in the setting of a kidney that has lost ability to
autoregulate ___ to htn. Pt's creatinine trended down and was
at 1.1 at discharge.
.
# Groin pain: Severe but transient for one day. Had workup with
ultrasound, hip x ray which was unrevealing.
.
# Dyslipidemia/Diabetes screen: HgbA1c=6% indicates prediabetes
and lipids with LDL 117, HDL 26; Has CAD risk equivalent of PAD.
Outpatient physician can start nicotinic acid for HDL. Notably
has strong history of myopathies with statins. LDL should be at
100 given CAD risk equivalent of PAD disease. If statin to be
added would try pravastatin as pt has had difficulty with more
potent statins.
.
# HTN: On lisinopril, carvedilol. Still hypertensive to 180s
at times. Can uptitrate lisinopril as outpatient. Can also
increase coreg to 50mg, as patient tolerated this well while in
hospital. Secondary causes investigated in ___ included
angiography of the renal arteries which demonstrated no evidence
of any flow limiting lesions, negative plasma fractionated
metanephrines (very high NPV), elevated urine normetanephrines,
no evidence of coarctation, normal serum aldosterone and renin
while pt was on Ace-inhibitors. On this admission, htn assumed
to be most likely from essential htn. Ddx includes 1) renal
artery stenosis--No renal bruits and tolerated ACE inhibitors
including high dose captopril very well; 2)
pheochromocytoma--evaluated with plamsa and urine fractionated
metanephrines (plamsa normetanephrines mildly elevated but very
difficult to interpret in setting of opiate withdrawal, afib,
stress etc.), 3) adrenal hyperplasia, 4) hyperaldosteronism
(Conn's)-- no evidence of electrolyte abnormalities, and 5)
aortic coarctation-- not seen on CXRay and no pulse dissociation
between upper and lower extremities.
PCP can follow up with urine metanephrines at ___.
These are likely nondiagnostic given in hospital setting and
variety of adrenergic inducing issues ongoing. Would repeat
after one months time at PCP's discretion if secondary cause is
suspected. To my knowledge, pt's adrenals have never been
visualized either.
.
# Withdrawal: Started on methadone and given diazepam. Last
dose of methadone ___ was 10mg. Weaning down diazepam to prn.
Will be seen in ___ clinic today. For smoking, given
nicotine patches. Discharged with 6 tablets of diazepam for prn
use.
.
# Low Urine pH: Unclear cause: drug vs infection, vs RTA? Pt's
bicarbonate is good.
Negative for infection.
.
# Fluctuations in Hgb: Unclear cause; most likely ___ to fluid
shifts from hypertension, afib, heart failure, and swings in
volume status
.
# Subclinical hypothyroidism: Elevated TSH, normal free T4. Not
treated. Should continue to monitor.
.
# PVD: Pt with SFA and B/L iliac stents in ___. Stent
intervention has greatly improved his symptoms. Will keep pt on
aspirin. Will continue with secondary prevention including
smoking cessation, lipid lowering and stabalization of plaques
with statin therapy, and treatment of hypertension.
.
# Pneumonia: On initial admission, there was subjective fevers
over 3 days with increased cough in setting of radiographic
evidence of possible pneumonia. Pt treated with course of
levofloxacin
.
#CODE: Full
#CONTACT: Patient, wife ___ ___
.
Transitional: Needs to continuing taking dabigatran. Amiodarone
loading now for 10g then 200 mg daily. Need to monitor for amio
toxicity given previous hx of transaminitis while on drug,
baseline lung disease, subclinical hypothyroidism. Needs
baseline PFTs. HTN control can be more aggressive. HDL low,
can try nicotinic acid, can try pravastatin or less myopathic
statin for goal LDL<100. If pt goes back into afib and cannot
be controlled, then consider AVJ ablation with permanent pacer.
Medications on Admission:
None
Discharge Medications:
1. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
2. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
3. amiodarone 200 mg Tablet Sig: ___ Tablets PO As directed: Two
tabs twice daily through ___ Two tabs daily ___ through
___ Then 1 tab daily.
Disp:*45 Tablet(s)* Refills:*1*
4. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every ___ hours as needed for shortness
of breath or wheezing.
Disp:*1 unit* Refills:*0*
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
9. Valium 5 mg Tablet Sig: One (1) Tablet PO BID: PRN as needed
for anxiety: You should not drive or do anything that requires
alertness while taking this medication.
Disp:*6 Tablet(s)* Refills:*0*
10. Outpatient Lab ___
You will need to have ___ done on ___ when you
see your new PCP
___ on ___: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Atrial fibrillation w/ RVR s/p cardioversion to NSR,
Hypertension, Acute Kidney Injury, Dyslipidemia, Opiate
withdrawal
.
Secondary: Peripheral vascular 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 ___.
You were admitted for chest pain and were found to be in atrial
fibrillation with a very fast heart rate as well as having a
very high ___ pressure. Attempts at rate control were
ineffective and you had pauses of up to 5 seconds. After much
discussion, it was decided to electrically cardiovert you back
into sinus rhythm with prevention of future atrial fibrillation
with amiodarone. It is imperative that you take your dabigatran
(pradaxa) twice a day without fail. This will lower your risk
of having a stroke from your paroxysmal atrial fibrillation.
You previously suffered liver injury while on amiodarone. You
will need to be very closely monitored while on this medication.
The side effects of amiodarone include lung, thyroid, and liver
toxicity. One of the tests that your PCP should ___
set you up with is a pulmonary function test.
Your ___ pressure was very high when you came into the
hospital. We have started you on medications for this with good
response.
You had an exacerbation of your congestive heart failure. We
treated this with diuretics and have placed you on medications
to improve your heart function.
You also had acute kidney injury. This was most likely from
transient hypotension and temporary dysfunction of your heart
after cardioversion.
Please weigh yourself every morning and call MD if weight goes
up more than 3 lbs.
The following changes were made to your medications:
-STARTED Amiodarone 400 mg twice per day through ___.
-Amiodarone 400 mg daily from ___ through ___.
-Amiodarone 200 mg daily afterward for atrial fibrillation
-STARTED Spiriva inhaled for presumed COPD
-STARTED Albuterol inhaled as needed for shortness of breath
-STARTED Carvedilol for high ___ pressure and heart failure
-STARTED Dabigatran to prevent stroke
-STARTED Lasix for congestive heart failure
-STARTED Lisinopril for high ___ pressure and heart failure
-STARTED Nicotine patch for quitting smoking
Followup Instructions:
___
|
19859251-DS-23 | 19,859,251 | 23,465,876 | DS | 23 | 2173-08-06 00:00:00 | 2173-08-07 00:09:00 |
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:
Reveal monitor placement - ___
History of Present Illness:
___ year old male with history of systolic CHF (EF 40%), HTN,
HLD, pAfib, COPD, PE, severe PVD with SFA, opiate abuse and B/L
iliac stents who presents with chest pain.
He was recently admitted ___ for Afib with RVR and chest
pain. He ruled in for NSTEMI felt to be demand from
hypertensive urgency (SBP 200/100's) and RVR. He also underwent
DCCV and started on amiodarone (despite prior LFT elevations
with amiodarone). Consideration was given to AVJ ablation and
pacemaker placement as well but he remained in sinus rhythm
after DCCV and amiodarone initiation. Also treated with a
course of levofloxacin for pneumonia, and treated for a CHF
exacerbation. He was also started on dabigatran. There was
also some question if he was having intermittent short runs of
VT vs Afib with aberrancy.
Pt was in USOH on d/c until yesterday when pt felt increased
fatigue and generally unwell. Noted some increased chest
discomfort and nausea in the evening not relieved by ginger ale
and some SOB not relieved by his inhaler. At around 10p last
night, pt noted worsening of his chest squeezing now accompanied
by palpitations and continued SOB so he presented to the ED. Pt
says chest pain was intermittent, ___ at worst, and similar to
pain he felt on his admission a few weeks ago. Pain did not
radiate. Pt did have episode of diaphoresis possibly related to
a fever last night. Patient denies orthopnea, DOE, PND, leg
swelling, cough, diarrhea, dysuria, abdominal pain. Patient
states he has been taking all of his medications. No diet
changes recently. Pt states his BPs were well-controlled at his
PCP visit on ___. Has not used heroin since his d/c and has
not been treated at the ___ clinic.
In the ED, initial VS: 98.2, 85-108 HR (AFIB), 152/94, 20, 94%
on 4L O2. He initially had chest pain and was tachy to the
130's. EKG showed Afib with HR ___epressions and
TWI laterally (new from prior). He was given Diltiazem 15 mg IV
x1, 30 mg p.o. x1 w/improved HR to 90-100. He also received one
SL nitro and is now pain free. CXR revealed fluid overload so
he was given lasix 80mg IV x1. Labs were notable for a WBC
17.8, BNP 8488, Creat 1.2, and negative troponin x 1. UA
negative.
Currently, patient has no chest pain. Says it resolved on
arrival to the ED. Feels his breathing is comfortable as well.
No headache, vision changes, palpitations.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
Atrial fibrillation with RVR s/p multiple DCCV, most recently on
___ now on dabigatran and amio; has hx of poor rate control
partly due to noncompliance with meds
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
PE ___ unknown cause
CHF
PVD s/p Aortoiliac bifurcation stents SFA ___ and CIA
___
Small Infarenal AAA
Scoliosis
Tobacco abuse ___ packs daily)- Interested in quitting
smoking
Heroin abuse
Social History:
___
Family History:
Father: ___
Mother: emphysema, CHF
Mother died from CHF.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - T97.6 HR99 BP141/104 RR20 O2sat95%RA
GENERAL - pleasant, well-appearing in NAD, comfortable,
appropriate
HEENT - MMM
NECK - no JVD (JVP about 9cm)
LUNGS - unlabored repsirations, poor air entry bilaterally with
crackles at left base, decreased breath sounds at right base, no
wheezes
HEART - irregularly irregular, no MRG
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, +clubbing, no cyanosis, no edema, 2+DPs b/l
.
DISCHARGE PHYSICAL EXAM:
VS: 97.5 (Tm 97.6) 150/99 (136-151/85-109) 76 (66-95) 20 96% RA
Weight: 86.0 kg (___) I/O: 1400/2250, no BM recorded
but patient reports one yesterday
GENERAL: NAD, comfortable
NECK: no JVD
LUNGS: CTAB, no rales, wheezes or rhonchi
CV: irregularly irregular, no MRG
ABDOMEN: soft, non-tender, non-distended
EXTREMITIES: warm, well-perfused, no edema, 2+ DPs b/l.
Pertinent Results:
Admission Labs:
___ 05:00AM BLOOD WBC-17.8*# RBC-4.57*# Hgb-12.4* Hct-37.3*
MCV-82 MCH-27.2 MCHC-33.4 RDW-14.1 Plt ___
___ 05:00AM BLOOD Neuts-80.7* Lymphs-12.9* Monos-2.7
Eos-2.9 Baso-0.8
___ 05:00AM BLOOD ___ PTT-84.4* ___
___ 05:00AM BLOOD Glucose-124* UreaN-17 Creat-1.2 Na-138
K-4.4 Cl-96 HCO3-31 AnGap-15
___ 05:00AM BLOOD ALT-16 AST-25 AlkPhos-105 TotBili-0.4
___ 05:00AM BLOOD proBNP-8488*
___ 05:00AM BLOOD cTropnT-<0.01
___ 05:40AM URINE Color-Straw Appear-Clear Sp ___
___ 05:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 05:40AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Interim Labs:
___ 11:00AM BLOOD WBC-12.5* RBC-4.21* Hgb-11.5* Hct-34.9*
MCV-83 MCH-27.4 MCHC-33.1 RDW-14.3 Plt ___
___ 06:13AM BLOOD WBC-9.9 RBC-4.20* Hgb-11.6* Hct-35.1*
MCV-84 MCH-27.5 MCHC-33.0 RDW-14.4 Plt ___
___ 06:10AM BLOOD WBC-8.7 RBC-4.26* Hgb-11.8* Hct-35.4*
MCV-83 MCH-27.6 MCHC-33.2 RDW-14.5 Plt ___
___ 01:40AM BLOOD WBC-21.2*# RBC-3.95* Hgb-11.3* Hct-33.9*
MCV-86 MCH-28.6 MCHC-33.2 RDW-14.4 Plt ___
___ 10:01AM BLOOD WBC-11.8* RBC-4.42* Hgb-12.1* Hct-37.1*
MCV-84 MCH-27.3 MCHC-32.5 RDW-14.7 Plt ___
___ 10:01AM BLOOD Neuts-78.3* Lymphs-16.3* Monos-3.0
Eos-1.7 Baso-0.7
___ 07:10AM BLOOD WBC-8.9 RBC-4.41* Hgb-12.2* Hct-36.6*
MCV-83 MCH-27.7 MCHC-33.3 RDW-14.7 Plt ___
___ 06:05AM BLOOD WBC-9.0 RBC-4.45* Hgb-12.3* Hct-37.0*
MCV-83 MCH-27.7 MCHC-33.3 RDW-14.8 Plt ___
___ 06:10AM BLOOD ___ PTT-73.3* ___
___ 01:40AM BLOOD ___ PTT-103.8* ___
___ 10:01AM BLOOD ___ PTT-99.0* ___
___ 06:13AM BLOOD Glucose-103* UreaN-25* Creat-1.2 Na-141
K-3.9 Cl-100 HCO3-32 AnGap-13
___ 06:10AM BLOOD Glucose-106* UreaN-30* Creat-1.2 Na-142
K-3.9 Cl-102 HCO3-29 AnGap-15
___ 01:40AM BLOOD Glucose-152* UreaN-36* Creat-1.9* Na-143
K-3.9 Cl-101 HCO3-27 AnGap-19
___ 10:01AM BLOOD Glucose-100 UreaN-38* Creat-1.6* Na-141
K-3.9 Cl-102 HCO3-28 AnGap-15
___ 07:10AM BLOOD Glucose-104* UreaN-29* Creat-1.3* Na-144
K-3.7 Cl-106 HCO3-30 AnGap-12
___ 06:05AM BLOOD Glucose-107* UreaN-31* Creat-1.2 Na-142
K-3.7 Cl-105 HCO3-27 AnGap-14
___:13AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.3
___ 06:10AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.4
___ 01:40AM BLOOD Calcium-9.2 Phos-7.2*# Mg-2.4
___ 10:01AM BLOOD Albumin-4.1 Calcium-8.9 Phos-5.4*# Mg-2.4
Iron-38*
___ 07:10AM BLOOD Calcium-9.1 Phos-3.0# Mg-2.4
___ 06:05AM BLOOD Calcium-9.4 Phos-3.1 Mg-2.3
___ 11:00AM BLOOD cTropnT-<0.01
___ 06:13AM BLOOD TSH-2.3
___ 10:01AM BLOOD ALT-21 AST-20 LD(LDH)-167 AlkPhos-91
TotBili-0.4
___ 10:01AM BLOOD ESR-43*
___ 10:01AM BLOOD CRP-9.3*
___ 10:01AM BLOOD calTIBC-399 Ferritn-96 TRF-307
___ 12:01AM BLOOD Type-ART pO2-69* pCO2-77* pH-7.15*
calTCO2-28 Base XS--3
___ 12:01AM BLOOD Lactate-3.7*
Discharge Labs:
___ 06:00AM BLOOD WBC-8.6 RBC-4.18* Hgb-11.5* Hct-34.6*
MCV-83 MCH-27.5 MCHC-33.3 RDW-14.8 Plt ___
___ 06:00AM BLOOD Glucose-98 UreaN-26* Creat-1.1 Na-141
K-3.7 Cl-105 HCO3-27 AnGap-13
___ 06:00AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.1
Microbiology:
___ BLOOD CULTURE - No growth
___ BLOOD CULTURE - No growth
___ MRSA SCREEN - positive
___ BLOOD CULTURE - PENDING
___ BLOOD CULTURE - PENDING
Imaging:
CXR (___):
FINDINGS: There is pulmonary vascular congestion with mild
interstitial
pulmonary edema. Heterogeneous opacity at the right lung base
could be
atelectasis or pneumonia. Moderate cardiomegaly is slightly
decreased
compared to ___. The mediastinal contours are
normal. Aortic
calcifications are noted. There are no definite pleural
effusions. No
pneumothorax is seen. Carotid artery calcifications are noted.
IMPRESSION:
1. Mild interstitial pulmonary edema.
2. Decreased moderate cardiomegaly.
3. Heterogeneous right basilar opacity could be atelectasis or
pneumonia.
CXR (___):
FINDINGS/IMPRESSION: The heart size is at the upper limits of
normal. The
mediastinal and hilar contours are unremarkable. The lungs
demonstrate much improved pulmonary edema and no lobar
consolidation. Trace bilateral pleural effusions are seen. There
is no pneumothorax.
CXR (___):
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the quality of
the image is reduced due to respiratory motion artifacts.
However, the size of the cardiac silhouette has mildly increased
and there is increasing pulmonary edema with mild retrocardiac
atelectasis. No pleural effusions. No focal parenchymal opacity
suggesting pneumonia.
CXR (___):
COMPARISON: ___, 11:56 p.m.
FINDINGS: As compared to the previous radiograph, the
pre-existing pulmonary edema has slightly improved. Mild
cardiomegaly persists. Moderate retrocardiac atelectasis and
healed left rib fractures are constant. No newly appeared
parenchymal opacities. No pneumothorax.
Brief Hospital Course:
___ M w/ hx of poorly controlled Afib s/p DCCV last week here
with chest pain, SOB, and palpitations found to be in Afib w/RVR
and acute CHF exacerbation.
# Atrial fibrillation with RVR: The patient has a history of
Afib with RVR with multiple prior failed DCCV. He has been
difficult to rate control due to pauses and accelerated
junctional rhythms on diltiazem. During his last admission he
also had runs of sustained VT v. Afib with aberrancy. On the
last admission he was cardioverted and started on amiodarone.
The trigger for Afib on this occasion was not clear. As no
underlying infection could be identified, the patient was
up-titrated on diltiazem and switched from carvedilol to
metoprolol for improved rate control. He was monitored on
telemetry for possible pauses. He was continued on
anti-coagulation with dabigatran. On ___ an episode of Afib
with RVR resulted in flash pulmonary edema, for which the
patient was transferred to the CCU. Rate was better controlled
with amiodarone and carvedilol. Later on ___ he was
transferred back to the floor. He was started on digoxin from
___ with reduced NSVT and improvement in heart rate.
Diltiazem was started the evening of ___ for improved blood
pressure control. Due to concern for multiple nodal agents
leading to risk of bradycardia, the digoxin was then
discontinued. He was discharged with an amiodarone taper,
carvedilol, and diltiazem. Planned amiodarone schedule: 400mg
BID (___), then 300mg BID (___), then 200mg BID
(___), then 200mg daily maintenance starting ___.
The patient's afib is refractory to medical treatment. He
additionally has had poor medication compliance in the past. It
was decided that management should be taken out of the patient's
hands as much as possible. A Reveal loop recorder was placed to
better understand his long-term rhythm, with the intention of
doing PVI in ___ weeks as an outpatient.
# CHF exacerbation: The patient was admitted with an elevated
BNP, CXR suggestive of congestion, and crackles on exam. He was
diuresed successfully in the ED and repeat CXR showed reduced
pulmonary edema. This was most likely caused by impaired
filling in setting of Afib with RVR. Following diuresis he
remained clinically euvolemic with no hypoxia. On ___ the
patient again went into Afib with RVR and was transferred to the
CCU for flash pulmonary edema and increased O2 requirement. He
was given lasix, nitroprusside drip, and oxygen via NC. He was
also given a dose of hydralazine for BP control. His rate was
better controlled with amiodarone and carvedilol and his nasal
cannula oxygen requirement was weaned down to 4L NC. He was
transferred back to the floor for further management on the
afternoon of ___. He received further diuresis with good
effect.
# Leukocytosis: The patient presented with leukocytosis to 12.
UA was negative and CXR was not suggestive of focal opacity. The
patient remained afebrile. Blood cultures were unrevealing.
This was thought to be reactive to his heart disease, and
resolved as his rate improved. CRP and ESR were elevated as
expected. His leukocytosis resolved several days prior to
discharge.
# Lung disease: Although this has not been formally
characterized by PFTs, it is thought most consistent with COPD
given the patient's smoking history. The patient is observed to
have clubbing, poor air entry, and some coarse crackles
thoughout without wheezing. He has known apical scarring on
prior imaging. He was continued on treatment with tiotropium
and ipratropium PRN. Albuterol was avoided due to the risk of
tachycardia.
# Anemia: Hct ___ during admission. B12 and folate previously
normal. Iron studies borderline low iron level with normal TIBC
and transferrin.
Inactive Issues:
# Depression: continued Zoloft
# Anxiety: continued Valium
# Substance abuse: Utox showed positive only for benzos. The
patient denied heroin use since d/c. As he was a current smoker,
continued nicotine patch.
# CODE: FULL
Transitional Issues:
- Planned amiodarone schedule: 400mg BID (___), then 300mg
BID (___), then 200mg BID (___), then 200mg daily
maintenance starting ___.
- Plan for PVI as an outpatient in ___ weeks
- Blood cultures from ___ were pending final results at time
of discharge
Medications on Admission:
1. carvedilol 25 mg Tablet PO twice a day.
2. nicotine 21 mg/24 hr Patch 24 hr daily
3. amiodarone 200 mg Tablet Sig: ___ Tablets PO As directed: Two
tabs twice daily through ___ Two tabs daily ___ through
___ Then 1 tab daily.
4. dabigatran etexilate 150 mg PO BID
5. tiotropium bromide 18 mcg Capsule inh daily
6. Lasix 80 mg Tablet daily
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol inh every ___
hours as needed for shortness of breath or wheezing.
8. lisinopril 10 mg Tablet daily
9. Valium 5 mg Tablet PO BID: PRN as needed
10. Zoloft 100 mg PO daily
Discharge Medications:
1. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 2 days: ___.
Disp:*6 Capsule(s)* Refills:*0*
2. carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. diazepam 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
9. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
10. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
Disp:*30 Capsule, Extended Release(s)* Refills:*2*
11. amiodarone 100 mg Tablet Sig: Four (4) Tablet PO twice a
day: Take 400mg twice daily ___, 300mg twice daily ___,
200mg twice daily ___, then 200mg daily starting ___.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular response
Acute on chronic systolic congestive heart failure
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 came to the hospital with recurrent chest
pain. You have been evaluated for this pain previously, and it
is thought to be due to your irregular, rapid heart rate. You
also were found to have worsening heart failure. On ___ you
experienced an episode of difficulty breathing due to this
combination of rapid, irregular heart rate and heart failure
that led to increased fluid in the base of your lungs. You were
briefly transferred to our Cardiac Care Unit, then returned to
the floor that same day.
You were treated with medication to reduce your blood pressure
and keep your heart in a normal rhythm. You were also given
diuretics to reduce the extra fluid in your body. In order to
better understand your heart rhythm, a Reveal monitor was placed
on ___. The information from this monitor will be used to
determine how to intervene to improve your heart function.
We made the following changes to your mediations:
- START clindamycin for 2 more days. This is an antibiotic that
you should take to prevent infection of your Reveal heart
monitor
- INCREASE amiodarone to the following doses. This medication
is on a taper, with gradually decreasing dose until you reach
your maintenance level. The schedule is as follows:
___: 400mg twice a day
___: 300mg twice a day
___: 200mg twice a day
___ and ongoing: 200mg daily
- START diltiazem for blood pressure and heart rate control
- INCREASE lisinopril dose to 40mg daily for blood pressure
control
- INCREASE carvedilol dose to 37.5mg twice a day for heart rate
control
- STOP albuterol inhaler, as this can increase your heart rate
Please follow-up with your primary care physician and
cardiologist as listed below. You also have an appointment in
the device clinic in one week to follow-up on your new Reveal
monitor.
Weigh yourself every morning, and call your doctor if weight
goes up more than 3 lbs.
Followup Instructions:
___
|
19859251-DS-24 | 19,859,251 | 26,812,487 | DS | 24 | 2173-08-20 00:00:00 | 2173-08-20 17:03:00 |
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:
intubation
History of Present Illness:
___ yo male with history of CHF EF 40%, HTN, HLD, PAF, tobacco
abuse, COPD, PE, severe PVD with SFA and B/L iliac stents and
medication noncomplicance. He also underwent DCCV on ___
orning and started on amiodarone (despite prior LFT elevations
with amiodarone). He presented with chest pain ___ of sudden
onset while at the store doing some shopping; he also developed
shortness of breath at that time. The patient states that the
pain is pleuritic in nature. Otherwise the patient does not have
any leg swelling. Pain not worse with exertion. Otherwise no
abdominal pain, fevers, chills, cough, sputum. Pain not worse
with exertion. Otherwise no abdominal pain, fevers, chills,
cough, sputum.
.
He was recently admitted ___ for Afib with RVR and chest
pain. He ruled in for NSTEMI felt to be demand from hypertensive
urgency (SBP 200/100's) and RVR. Consideration was given to AVJ
ablation and pacemaker placement as well but he remained in
sinus rhythm after DCCV and amiodarone initiation. Also treated
with a course of levofloxacin for pneumonia, and treated for a
CHF exacerbation. He was also started on dabigatran. There was
also some question if he was having intermittent short runs of
VT vs Afib with aberrancy.Furthermore, this morning he had
undergone Successful electrical cardioversion of atrial
fibrillation to sinus rhythm.
.
ED Course (labs, imaging, interventions, consults):
- Initial Vitals/Trigger: Pain-7 98.5 73 182/103 20 93% RA
- EKG: sr 69, lad/no ST/TW changes.
[x] cxr - unremarkable.
[x] asa
[x] cmed attending: give lasix 120 mg iv, admit
Admission Vitals: Pulse: 63, RR: 21, BP: 166/87, O2Sat: 94 2L
PIV: 18 g x1.
CTA not done due to elevated creatinine.
.
On arrival to the floor, patient complained of mild chest pain,
which was unchanged from his initial presentation, and was
relieved with morphine. He had no other active complaints. His
blood pressures continued to go up to about 200/100, therefore
he was started on a nitro drip.
.
At about 7 am, he desatted to ___, was given atrovent nebs, and
became unresponsive. A code blue was called. BP 220s/110s. ABG
7.02/109/113. Lactate 5.5. IV lasix/NTG started, and pt
emergently intubated. During the code, he was also noted to
have some bleeding out of his left ear, and his pupils were
noted to be unequal He was intubated and transferred to the ICU.
In the CCU, initial vitals were 174/93, 113, 22, 99% on ___
70% FiO2. He became responsive, and was orientated x3. Pupils
were equal. Continues to complain of left-sided mild chest
pain, no worse than prior. He was started on fenatyl/
midazolam. His blood pressures started dropping, nitroglycerin
drip was stopped. However, BP plateaued at 85 systolic, and are
currently stable at around 110 systolic.
.
REVIEW OF SYSTEMS:
+
-fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
Atrial fibrillation with RVR s/p multiple DCCV, most recently on
___ now on dabigatran and amio; has hx of poor rate control
partly due to noncompliance with meds
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
PE ___ unknown cause
CHF
PVD s/p Aortoiliac bifurcation stents SFA ___ and CIA
___
Small Infarenal AAA
Scoliosis
Tobacco abuse ___ packs daily)- Interested in quitting
smoking
Heroin abuse
Social History:
___
Family History:
Father: ___
Mother: emphysema, CHF
Mother died from CHF.
Physical Exam:
On admission:
Gen: Intubated, calm, NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
Otoscopic examination: tympanic membranes both clear.
NECK: Supple, No LAD. Normal carotid upstroke without bruits
CV: Irreg/Irreg. Normal S1,S2. No murmurs.
LUNGS: CTAB. No wheezes, rales, or rhonchi. Reduced air entry
bilaterally.
ABD: NABS. Soft, NT, ND.
EXT: WWP, NO CCE. Full distal pulses bilaterally.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Grossly non-focal.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
.
At discharge:
Vitals:
97.9/97.9 HR:57-60 BP:160-168/88-101 RR:18 02 sat:97% RA
___ yo M in no acute distress, sitting in chair
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, ___ systolic
murmur at right upper sternal border.
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwp, no edema. DPs, PTs 2+.
NEURO: ___ strength in U/L extremities. gait WNL.
SKIN: no rash
PSYCH: a/o, pleasant, conversant
Pertinent Results:
___ 09:03PM BLOOD WBC-12.4* RBC-4.29* Hgb-12.1* Hct-36.5*
MCV-85 MCH-28.2 MCHC-33.2 RDW-15.3 Plt ___
___ 10:59AM BLOOD WBC-19.8*# RBC-4.09* Hgb-11.4* Hct-34.8*
MCV-85 MCH-27.9 MCHC-32.8 RDW-15.4 Plt ___
___ 05:03AM BLOOD WBC-8.5# RBC-4.02* Hgb-11.3* Hct-33.6*
MCV-84 MCH-28.1 MCHC-33.6 RDW-15.2 Plt ___
___ 06:34AM BLOOD WBC-8.4 RBC-4.10* Hgb-11.6* Hct-35.0*
MCV-86 MCH-28.4 MCHC-33.2 RDW-15.4 Plt ___
___ 06:20AM BLOOD WBC-8.0 RBC-4.19* Hgb-11.8* Hct-35.3*
MCV-84 MCH-28.1 MCHC-33.3 RDW-15.4 Plt ___
___ 09:03PM BLOOD Neuts-68.5 ___ Monos-3.3 Eos-3.8
Baso-1.0
___ 06:20AM BLOOD Neuts-62.5 ___ Monos-4.9 Eos-5.9*
Baso-1.3
___ 09:03PM BLOOD ___ PTT-87.1* ___
___ 09:03PM BLOOD Plt ___
___ 10:30PM BLOOD ___ PTT-90.5 ___
___ 10:59AM BLOOD ___ PTT-65.5* ___
___ 10:59AM BLOOD Plt ___
___ 05:03AM BLOOD Plt ___
___ 06:34AM BLOOD ___ PTT-77.3* ___
___ 06:34AM BLOOD Plt ___
___ 06:20AM BLOOD Plt ___
___ 09:03PM BLOOD Glucose-114* UreaN-26* Creat-1.3* Na-141
K-4.3 Cl-106 HCO3-24 AnGap-15
___ 10:59AM BLOOD Glucose-124* UreaN-26* Creat-1.9* Na-143
K-3.8 Cl-105 HCO3-26 AnGap-16
___ 07:51PM BLOOD UreaN-27* Creat-1.8* Na-145 K-3.2* Cl-103
___ 05:03AM BLOOD Glucose-98 UreaN-23* Creat-1.5* Na-145
K-3.1* Cl-104 HCO3-28 AnGap-16
___ 04:49PM BLOOD Glucose-101* UreaN-26* Creat-1.4* Na-144
K-3.7 Cl-104 HCO3-28 AnGap-16
___ 06:34AM BLOOD Glucose-116* UreaN-24* Creat-1.3* Na-145
K-3.5 Cl-106 HCO3-28 AnGap-15
___ 02:45PM BLOOD UreaN-26* Creat-1.5* Na-146* K-3.5 Cl-104
HCO3-28 AnGap-18
___ 06:20AM BLOOD Glucose-110* UreaN-25* Creat-1.2 Na-140
K-3.3 Cl-101 HCO3-27 AnGap-15
___ 03:40AM BLOOD CK(CPK)-51
___ 10:59AM BLOOD CK(CPK)-57
___ 09:03PM BLOOD proBNP-1870*
___ 09:03PM BLOOD cTropnT-<0.01
___ 03:40AM BLOOD CK-MB-2 cTropnT-<0.01
___ 10:59AM BLOOD CK-MB-3 cTropnT-0.02*
___ 10:59AM BLOOD Calcium-8.8 Phos-5.7*# Mg-2.2
___ 07:51PM BLOOD Mg-2.0
___ 05:03AM BLOOD Calcium-8.8 Phos-3.3# Mg-2.1
___ 06:34AM BLOOD Mg-2.2
___ 02:45PM BLOOD Mg-2.3
___ 06:20AM BLOOD Calcium-9.5 Phos-4.2 Mg-2.1
___ 07:35AM BLOOD Type-ART pO2-113* pCO2-109* pH-7.02*
calTCO2-30 Base XS--6 Intubat-NOT INTUBA
___ 11:51AM BLOOD Type-ART pO2-149* pCO2-44 pH-7.40
calTCO2-28 Base XS-2
___ 09:06PM BLOOD K-4.4
___ 07:35AM BLOOD Glucose-268* Lactate-5.5* Na-146* K-4.0
Cl-101
___ 11:51AM BLOOD Lactate-1.0
___ 07:35AM BLOOD Hgb-13.8* calcHCT-41 O2 Sat-94 COHgb-2
MetHgb-0
___ 07:35AM BLOOD freeCa-1.36*
.
Discharge labs:
___
06:20a
140 ___ AGap=14
3.6 26 1.1
Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes
Mg: 2.3
6.9>12.1/35.8<212
___ CXR
Slight vascular prominence with peribronchial cuffing, but
otherwise unremarkable.
.
___ Echocardiogram
The left atrium is moderately dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
There is mild to moderate regional left ventricular systolic
dysfunction with basal to mid inferior and inferolateral
hypokinesis. The other segments are very mildly hypokinetic.
Right ventricular chamber size is normal. with borderline normal
free wall function. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of ___,
the right ventricle is probably mildly hypokinetic on the
current study. Overall LV systolic dysfunction has worsened.
.
___ Echocardiogram
AP radiograph of the chest was reviewed in comparison to ___.
The ET tube tip is 5 cm above the carina. The NG tube tip is in
the stomach.
There is interval development of moderate interstitial pulmonary
edema. Note
is made that the left costophrenic angle was excluded from the
field of view
but small bilateral pleural effusions cannot be excluded.
Findings discussed with Dr. ___ the phone by Dr.
___ at 10:20
a.m. on ___.
Brief Hospital Course:
___ yo male with history of CHF EF 40%, HTN, HLD, PAF, tobacco
abuse, COPD, PE, severe PVD with SFA and B/L iliac stents and
medication noncomplicance, and cardioversion this morning, who
presented with chest pain ___ of sudden onset while at the
store doing some shopping, s/p code blue in hosptial for hypoxia
and unresponsiveness.
.
# Hypoxia/flash pulmonary edema: S/p pulmonary edema and
respiratory arrest ___ with hypoxemia and unresponsiveness,
intubated and then extubated 7 hours later. We diuresed him
with furosemide, then transitioned him to his home lasix dose.
He rapidly became euvolemic, had good oxygen saturation and
respiration, and was stable prior to dishcarge.
.
# HTN: Workup for secondary causes negative. Pt has strong
family history. Medication compliance an issue in the past, pt
states he has no cost issues now and takes his medicines
regularly. Has BP cuff at home. Goal BP 120-140. High this am
before meds. We continued carvedilol, lisinopril and amlodipine.
.
#Atrial fibrillation - He was in sinus rhythm during this
hospitalization. then started on amiodarone. At the time of
discharge he had cardioverted, in sinus with some bradycardia to
the high ___. Planned amiodarone schedule: 200mg BID (___),
then 200mg daily maintenance starting ___. He will also
continue carvedilol and pradaxa.
.
#Acute on Chronic Systolic CHF EF was mildly depressed from
previous TTE, however recently s/p cardioversion for afib. We
continued carvedilol, lisinopril and lasix. He was euvolemic at
the time of discharge.
.
___ baseline ___. Elevation to 1.9 likely in the setting
of flash pulmonary edema/respiratory arrest with poor forward
flow. We continued gentle diuresis until he was euvolemic. His
___ had resolved and his creatinine was trending down at the
time of discharge.
Medications on Admission:
1. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 2 days: ___.
Disp:*6 Capsule(s)* Refills:*0*
2. carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. diazepam 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
9. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
10. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
Disp:*30 Capsule, Extended Release(s)* Refills:*2*
11. amiodarone 100 mg Tablet Sig: Four (4) Tablet PO twice a
day: Take 400mg twice daily ___, 300mg twice daily ___,
200mg twice daily ___, then 200mg daily starting ___.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Medications:
1. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
4. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Imdur 30 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
11. diazepam 5 mg Tablet Sig: One (1) Tablet PO PRN as needed
for anxiety.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Acute on Chronic systolic congestive heart failure with
respiratory arrest
Atrial fibrillation s/p cardioversion
Hypertension, poorly controlled
Leukocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had high blood pressure after your cardioversion and
developed flash pulmonary edema or congestive heart failure. You
had to have a breathing tube inserted to help your breathe and
you were given diuretics to get rid of the extra fluid. You will
continue to take your lasix 80 mg daily at home. Your weight at
discharge is 191 lbs.
Weigh yourself every morning, call MD if weight goes up more
than 2 lbs in 1 day or 5 pounds in 3 days.
You will have a home tele monitoring system set up at home that
will check your weight, blood pressure, heart rate and oxygen
level at home once a day.
If you feel like your blood pressure is high at other times of
the day, you can check it and if the blood pressure is higher
than 150 (the top number) call the heartline or call your PCP
(Dr. ___.
When you are working nights, you should continue to take your
medicines every 12 hours if possible and make sure that you take
your twice a day medicines within a 24 hour period.
We made the following changes to your medicines:
-DECREASE the Amiodarone to 200mg daily
-DECREASE your Carvedilol to 25 mg every 12 hours (was 37.5 mg)
-ADD Imdur 30mg daily (long acting nitrate to help contol your
blood pressure)
Followup Instructions:
___
|
19859251-DS-25 | 19,859,251 | 25,165,505 | DS | 25 | 2173-09-27 00:00:00 | 2173-09-28 00:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, cough, shortness of breath
Major Surgical or Invasive Procedure:
___ line insertion ___
History of Present Illness:
___ year old male history of CHF EF 40%, hypertension,
hyperlipidemia, Paroxysmal AFib, tobacco abuse, COPD, PE, severe
PVD with SFA and B/L iliac stents on pradaxa presented with of
fever, cough, dyspnea and chest pain in the last 2 days prior to
admission. He was recently admitted in ___ for pulmonary
edema and unresponsiveness requiring intubation and diuresis
with dramatic improvement and successful extubation.
.
His current symptoms were characterized as a dull squeezing
sensation, substernal, radiates to left arm, currently minimal
increased with cough and deep breathing. Associated symptoms:
Subjective chills but no fever, nausea, cough with sputum
production of pinkish tinge that has changed to whitish
yellowish over the past 2 days, shortness of breath at rest and
effort with no home oxygen required, no lower extremity edema,
no calf pain, no dysuria, + abdominal pain (sharp, constant,
sudden, ___, on the left side). States that his chest pain
currently is similar to prior chest pain and thought it might be
cardiac in source. He recently had runny nose a few days prior
to this presentation. He also endorsed 3 loose stools in 1 day a
few days ago.
.
In the ED Initial vitals were: 98.8 81 138/67 22 97%. Exam was
notable for left lower quadrant tenderness. Initially he was
hypotensive (80/40) after receiving sublingual nitro and iv
morphine that improved with IVF. Labs were notable for
leukocytosis. CXR showed mild cardiomegaly and edema with slight
hazziness at the left cardiac border. d-dimer was elevated and
CTA did not reveal PE but revealed multifocal opacitities
suggestive of multilobar pneumonia with consolidation of left
lower lobe. Given abdominal tenderness, CT abdomen-pelvis with
contrast was done which didn't reveal acute intra-abdominal
pathology. He received 1.5L NS. Also received ASA 325 mg, IV
vancomycin and zosyn. EKG done showed sinus rhythm at 77bpm,
LAD, ___, LVH with repolarization changes, TW
flattening in III and aVF (on prior recent EKGs had been
inverted). Cardiology was consulted and impression was no STEMI
and to continue rule out with cardiac enzymes. Vitals on
transfer were: Temp: 97.9. HR: 54. BP: 109/48. O2: 94% 2L, RR:
20.
.
has had URI about a week prior to this presentation.
.
On the floor endorses chest pain and shortness of breath
minimal. Occasional cough. Also mentions about a left sided
abdominal pain that started ___ days ago. No change in bowel
habits.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, recent weight loss or gain. Denies headache,
sinus tenderness, rhinorrhea or congestion. Denied palpitations.
Denied vomiting, diarrhea, constipation. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
Atrial fibrillation with RVR s/p multiple DCCV, most recently on
___ now on dabigatran and amio; has hx of poor rate control
partly due to noncompliance with meds
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
PE ___ unknown cause
CHF
PVD s/p Aortoiliac bifurcation stents SFA ___ and CIA
___
Small Infarenal AAA
Scoliosis
Tobacco abuse ___ packs daily)- Interested in quitting
smoking
Heroin abuse
Social History:
___
Family History:
Father: ___
Mother: emphysema, CHF
Mother died from CHF.
Physical Exam:
Admission PE
Vitals: T: 97.7 BP: 114/58 P: 54 R: 18 O2: 96% 2LNC, weight 204
lb
General: Alert, orientedx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally except for left lower
zone insp crackles. Overall, exp phase slightly prolonged with
mild rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
best heard at mid left sternal border, faint diastolic murmur,
no rubs, gallops
Abdomen: soft, slightly tender left upper and lower quadrant,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
Ext: tenderness elicited over L shoulder/neck with palpation.
warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNs2-12 intact, motor function grossly normal
.
Discharge physical exam:
Vitals: T: 97.9 BP: (110-150/50-70) P: 50-60 R: 13 O2: 96% RA
General: Alert, orientedx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally except for very minimal
left lower zone insp crackles. No audible rhonchi or wheeze.
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
best heard at mid left sternal border, faint diastolic murmur,
no rubs, gallops
Abdomen: soft, slightly tender left upper and lower quadrant,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
Ext: tenderness elicited over L shoulder/neck with palpation.
warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
CBC and coagulation profile:
============================
___ BLOOD WBC-23.6*# RBC-4.43* Hgb-12.9* Hct-36.7* MCV-83
MCH-29.2 MCHC-35.2* RDW-15.6* Plt ___
___ BLOOD Neuts-89.1* Lymphs-7.2* Monos-2.5 Eos-0.9
Baso-0.3
___ BLOOD WBC-14.5* RBC-4.28* Hgb-12.3* Hct-36.6* MCV-86
MCH-28.8 MCHC-33.7 RDW-15.6* Plt ___
___ BLOOD ___ PTT-62.2* ___
___ BLOOD WBC-12.6* RBC-4.22* Hgb-12.4* Hct-35.5* MCV-84
MCH-29.4 MCHC-35.0 RDW-15.3 Plt ___
.
Blood chemistry:
================
___ BLOOD Glucose-192* UreaN-28* Creat-1.4* Na-134 K-4.1
Cl-100 HCO3-22 AnGap-16
___ BLOOD UreaN-20 Creat-1.1 Na-140 K-4.6 Cl-105
___ BLOOD ALT-23 AST-20 CK(CPK)-92 AlkPhos-76 TotBili-0.4
___ BLOOD Calcium-9.0 Phos-3.5 Mg-2.3
___ BLOOD Vanco-13.8
.
Cardiac enzymes:
================
___ BLOOD cTropnT-<0.01
___ BLOOD CK-MB-2 cTropnT-<0.01
___ BLOOD CK-MB-3 cTropnT-<0.01
.
Others:
========
___ BLOOD D-Dimer-518*
.
Urine:
======
___ URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0
___ URINE CastGr-2* CastHy-9*
___ URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG
amphetm-NEG mthdone-NEG (this was done after iv morphine in ED)
.
Microbiology:
=============
Urine culture: no growth
Blood culture: pending
Urine legionella Antigen negative
.
Imaging:
========
CXR AP:
mild cardiomegaly and edema with slight haziness at the left
cardiac border
.
CTA and CT-abdomen/pelvis:
IMPRESSION:
1. Multifocal bronchopulmonary pneumonia with consolidation of
the inferior
left lower lobe and lingula.
2. No pulmonary embolism, acute aortic syndrome, or congestive
heart failure.
3. No signs of acute abdominal or pelvic inflammatory process.
Diverticulosis without diverticulitis.
4. Extensive atherosclerotic disease without acute occlusion or
critical
stenosis.
Brief Hospital Course:
___ year old male with history of CHF EF 40%, hypertension,
hyperlipidemia, Paroxysmal AF, tobacco abuse, COPD, PE, severe
PVD with SFA and B/L iliac stents on pradaxa presented with of
Chest pain, dyspnea, productive cough, found to have
leukocytosis and multilobar infiltrates in addition to
consolidation of left lower lobe on CT, treated for pneumonia.
During his stay, dramatically improved, and oxygen saturation
was normal on ambulation prior to discharge.
.
# Pneumonia: 2 day history of productive cough, SOB, and chest
pain pleuritic in nature with leukocytosis. CT showed
multi-lobar infiltrates with consolidation in the left lower
lobe. He was hospitalized in ___ which raised the concern for
HCAP on this admission. CTA didn't reveal PE. IV vancomycin and
cefepime in addition to azithromycin were initiated in addition
to albuterol nebulizer and his home tiotropium. During his stay,
he was afebrile and leukocytosis trended down. He was weaned off
the oxygen and maintained normal saturation at rest and
ambulation prior to discharge. PICC line was placed to have
access for antibiotic regimen (vancomycin and cefepime) through
___ to complete a course of 7 days. Azithromycin will be
completed through ___ for a course of 5 days. Blood
cultures didn't show growth up to date but final report pending.
Based on the vancomycin trough level, vancomycin dose was
increased to 1500 mg twice daily. Vancomycin trough level will
be checked after 3 doses of Vancomycin 1500 mg and faxed to his
primary care physician.
.
# Chest pain: Pleuritic in nature, though radiating to left
shoulder however left shoulder was slightly tender to palpation.
Also, given there is consolidation in left lower quadrant, could
be irritating the diaphragm leading to LUQ pain referring to the
left shoulder. EKG not concerning for STEMI. Tpn x3 < 0.01. CTA
didn't reveal PE. His baby aspirin was continued.
.
# acute kidney injury: Cr 1.4 was up from baseline of 0.8-1.2.
Possibly pre-renal in addition to contrast exposure during CT.
He received IV fluids in the ED. Cr was back to his baseline on
discharge.
.
# chronic systolic heart failure: EF 35-40%. stable,
asymptomatic, not volume overloaded per exam. We continued home
medications carvedilol 25 mg twice daily, lisinopril 40 mg
daily, spironolactone 25 mg daily, imdur 30 mg daily and lasix
80 mg daily.
.
# Afib: CHADS-2 score of: 2 (Hypertension, CHF). Stable,
asymptomatic. Currently in sinus rhythm. regular rate and
rhythm. We continued amiodarone 200 mg daily, pradaxa 150 mg
twice daily and carvedilol as above.
.
# Hypertension: stable. We continued home regimen of amlodipine,
lisinopril, carvedilol, imdur, lasix.
.
# hyperlipidemia: continued home pravastatin 10 mg daily at bed
time.
.
.
# Transitional issues:
1. Consider repeat imaging in 6 weeks given age, gender, smoker
2. Final report of blood cultures pending
3. Vancomycin trough level after 3 doses of Vancomycin 1500 mg
4. Follow up with PCP ___ ___ weeks
Medications on Admission:
Medications: confirmed with patient
Aspirin 81mg daily
Amiodarone 200mg daily
Amlodipine 10mg daily
Carvedilol25 mg BID
Pradaxa 150mg BID
Lasix 80mg daily
Imdur 30mg daily
Lisinopril 40mg daily
Sertraline 100mg daily
Tiotropium 1 puff daily
spironolactone 25 mg daily
pravstatin 10 mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
5. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
8. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. pravastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln
Intravenous Q 12H (Every 12 Hours): through ___.
Disp:*25 Recon Soln(s)* Refills:*0*
14. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours): through ___.
Disp:*10 Recon Soln(s)* Refills:*0*
15. azithromycin 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 3 days: through ___.
Disp:*3 Tablet(s)* Refills:*0*
16. Outpatient Lab Work
Please check vanco level after pt receives 3 doses of 1500 mg of
vancomycin. Please fax to PCP ___ ___.
MD may call inpatient team if questions (Drs ___ and
___. at ___ ___ ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Health Care Associated Pneumonia
Acute Kidney Injury
chronic systolic heart failure
Secondary Diagnoses:
Hypertension
Hyperlipidemia
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 great pleasure taking care of you as your doctor. As
you know you were admitted to ___
___ cough, shortness of breath and chest tightness.
Through blood work up and imaging, it was found that you have
pneumonia. We treated you with antibiotics and nebulizers which
resulted in dramatic improvement in your symptoms. A PICC line
was placed to provide access for antibiotics while you are at
home.
.
We made the following changes in your medication list:
-Please START vancomycin 1500 mg twice daily through ___
-Please START cefepime 2 gram twice daily through ___
-Please START azithromycin 250 mg daily through ___
.
Please continue the rest of your home medications the way you
were taking them at home prior to admission.
.
Please follow with your appointments as illustrated below.
.
Please Weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Followup Instructions:
___
|
19859251-DS-27 | 19,859,251 | 24,380,225 | DS | 27 | 2177-05-15 00:00:00 | 2177-05-20 11:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ old man with CAD s/p NSTEMI with ___
and RCA in ___, pAF on dabigatran with Reveal monitor, COPD
presenting with two days of congestion and fatigue and shortness
of breath.
Patient reports he was in his usual state of health until two
days ago when he developed a cold with rhinorrhea, sneezing and
cough slightly productive of clear yellow sputum and shortness
of breath. He took Robitussin w/o improvement and sx worsened
while he was at work ___ shelves today at 1AM. He called
his wife who brought him into ED.
In the ED, initial vitals were: 96.9 138 115/70 17 90% RA, but
became hypotensive to 70/palpable w/RVR up to 150s, was
mentating well.
Exam: Wheezy, warm and dry
Labs: WBC 14.7, proBNP 1800 Cr 1.3 trop <0.01, VBG 7.38/45,
lactate 1.5
ECG: showed afib with RVR and no other acute changes
Imaging: CXR showed pulmonary edema
Consults: cardiology fellow called and performed bedside TTE
which showed normal squeeze and no pleural effusion
Patient was given: duonebs, methylpred 125 mg IV, ceftriaxone,
and azithromycin with 2L NS with BP to 101/61 with HR 120s on
96% NC.
Decision was made to admit to CCU for afib RVR with hypotension.
Vitals on transfer were: 97 129 101/61 20 96% Nasal Cannula in
the ED and he was sent to CTA to r/o PE before coming to CVICU.
On arrival to the CVICU, patient reports his breathing is
improved. He denies lightheadedness or palpitations which he
states is unusual as he generally feels palpitations when he is
in atrial fibrillation. He denies any fevers, chills, chest
pain, nausea, abdominal pain, diarrhea, constipation, dysuria.
He has had no recent travels or sick contacts.
Past Medical History:
-CAD status post ___ and RCA stenting in ___
-PAD status post bilateral iliac stents in ___
-paroxysmal atrial fibrillation with Reveal implant in ___
-HFpEF 60% ___
-hypertension
-hyperlipidemia
-small infrarenal AAA seen on angiogram in the past although
most recent CT abdomen without aneurysm
-right renal stenosis on CT abdomen
-neck arthritis
-COPD, not on any inhalers, reports he has had this diagnosis
for ___ years and tried Spiriva in the past and has had PFTs
before
Social History:
___
Family History:
His mother had heart disease in her ___. His
father had leukemia. No family history of sudden death.
Physical Exam:
Admission Exam
=================
VS: 98.9, HR 117 BP 112/63 RR 16 95% on 4L NC.
Weight: 82-kg (81.5-kg ___ clinic visit)
Tele: atrial fibrillation RVR 120s
Gen: Well-appearing in no acute distress, sleeping easily
arousable
HEENT: EOMI, PERRL, oropharynx is clear with dry MM
NECK: JVP at 2 cm above clavicle
CV: Irregularly irregular no appreciable m/r/g
LUNGS: No accessory muscle use, diffuse end-expiratory wheezes
in all lung fields, no crackles or rhonchi
ABD: ND, NTTP, normoactive BS, no appreciable HSM
EXT: WWP without edema, DP2+ bilaterally
SKIN: Dry, no rashes
NEURO: A&Ox3, moving all extremities symmetrically.
Discharge Exam
================
Vitals: 98 156/99 (110s-180s/50s-90s) ___ (60s-90s) 18 98% on
RA, wt 3.8 (78 on ___
Tele: alarm yesterday at 5:30pm for SVT, tachycardia to 184
I's and O's:
8 hr: 600 PO
24 hr: none recorded
Gen: Well-appearing in no acute distress
HEENT: EOMI, PERRL, MMM, oropharynx clear
NECK: no LAD, no JVP noted
CV: RRR, normal S1 + S2, II/VI systolic murmur, no rubs or
gallops
LUNGS: No accessory muscle use, diffuse expiratory wheezes in
all lung fields, no crackles or rhonchi
ABD: non-tender, non-distended, +bowel sounds, no organomegaly
EXT: WWP without edema, distal pulses 2+ bilaterally
NEURO: A&Ox3
Pertinent Results:
Admission Labs
===================
___ 03:20AM BLOOD WBC-14.7*# RBC-4.08* Hgb-11.1* Hct-35.4*
MCV-87 MCH-27.2 MCHC-31.4* RDW-16.3* RDWSD-52.0* Plt ___
___ 03:20AM BLOOD Neuts-85.8* Lymphs-5.4* Monos-5.6 Eos-2.1
Baso-0.5 Im ___ AbsNeut-12.60* AbsLymp-0.79* AbsMono-0.83*
AbsEos-0.31 AbsBaso-0.08
___ 03:20AM BLOOD ___ PTT-30.0 ___
___ 03:20AM BLOOD Plt ___
___ 03:20AM BLOOD Glucose-167* UreaN-26* Creat-1.3* Na-137
K-4.4 Cl-98 HCO3-25 AnGap-18
___ 03:30PM BLOOD Glucose-154* UreaN-21* Creat-0.9 Na-140
K-3.6 Cl-102 HCO3-26 AnGap-16
___ 03:20AM BLOOD proBNP-1800*
___ 03:20AM BLOOD cTropnT-<0.01
___ 06:55PM BLOOD CK-MB-4 cTropnT-<0.01
___ 04:34AM BLOOD CK-MB-3 cTropnT-<0.01
___ 03:20AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.0
___ 03:24AM BLOOD ___ FiO2-20 pO2-41* pCO2-45 pH-7.38
calTCO2-28 Base XS-0 Intubat-NOT INTUBA
___ 04:30AM BLOOD Lactate-1.5
___ 03:24AM BLOOD O2 Sat-71
Imaging
===========
CXR ___
FINDINGS:
Compared with the prior radiograph, increased bibasilar
opacities reflect
atelectasis. Heart size is top normal. Mediastinal and hilar
silhouettes are normal. Lungs are otherwise clear without focal
consolidation, pleural
effusion, or pneumothorax. Linear calcifications overlying the
right lung
apex are unchanged. Healed bilateral rib fractures are unchanged
in
appearance. A left-sided presumed pacer device is unchanged in
appearance and position.
IMPRESSION:
No evidence of pneumothorax.
CTA ___
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Airway wall thickening is likely due to inflammation.
3. Prominent mediastinal lymph nodes and thickening of the left
adrenal gland as on prior imaging.
CXR ___
IMPRESSION:
Comparison to ___. No relevant change is seen. Mild
overinflation. Mild cardiomegaly without pulmonary edema. No
pneumonia, no pleural effusions. Old healed left-sided rib
fractures.
TTE ___:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). 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.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is a very small pericardial effusion. There
are no echocardiographic signs of tamponade.
Microbiology
===============
___ Blood Cx: No growth
Discharge Labs
================
___ 06:00AM BLOOD WBC-11.7* RBC-4.77 Hgb-12.9* Hct-40.5
MCV-85 MCH-27.0 MCHC-31.9* RDW-16.2* RDWSD-50.2* Plt ___
___ 06:00AM BLOOD Glucose-93 UreaN-19 Creat-0.8 Na-140
K-3.3 Cl-103 HCO3-26 AnGap-14
___ 06:00AM BLOOD Calcium-9.5 Phos-3.0 Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ old man with CAD s/p NSTEMI with ___
and RCA in ___, pAF on dabigatran with Reveal monitor,
presenting with COPD exacerbation in setting of likely viral URI
c/b afib RVR with associated hypotension.
# COPD: The patient presented with COPD exacerbation likely in
the setting of viral URI with exam notable for diffuse wheezes
on admission. No PFTs in our system but reports had been done
in the past. Not on inhalers at home. The patient was placed on
standing duonebs and completed a 5 day course of prednisone 40mg
and doxycycline on ___ with improvement of symptoms. Remained
afebrile. Discharged home with nebulizer and duonebs with plans
follow-up with pulmonology clinic for further management.
# Afib with RVR: On admission, the patient was noted to be in
Afib with RVR with rates in 150s likely secondary to COPD
exacerbation and dehydration. Had a transient episode of
hypotension in ED with BP ___ which resolved with IVF
bolus; mentating well throughout and no sensation of
palpitations. Cardiology consulted and performed bedside TTE
that showed normal squeeze and no pleural effusion. The patient
was admitted to the CCU for further management. After admission,
he developed worsening chest pain with RVR in 140s which did not
respond to IVF bolus or diltiazem, and therefore he was loaded
with amiodarone gtt and 2 doses of digoxin. Troponins negative
and EKG negative for ST changes. He then converted to NSR. He
was later transitioned to amiodarone 200mg daily and continued
on dabigatran for CHADS2VASc score of 3 (HTN, CHF, PAD). He
remained in NSR and HD stable throughout the rest of his
hospitalization.
# Chest pain: The patient had chest pain in the setting of Afib
with RVR and COPD exacerbation. Troponins negative and EKG
remarkable for Afib but no e/o ST changes. CTA negative for PE.
Initially there was concern for pericarditis given positional
nature of the chest pain and recent URI symptoms (c/f viral
pericariditis) and the patient was started on colchicine in the
CCU. The medication was later discontinued once transferred to
the floor as concern for pericarditis was low-- no rub on exam,
no PR depression or diffuse ST elevations on ECG and his chest
pain resolved. It was likely that the patient's chest pain was
due to his underlying COPD and persistent coughing which
resolved as his symptoms improved.
# Hypertension: The patient has a history of refractory
hypertension currently on Amlodipine, lisinopril, carvedilol,
and labetolol. These medications were initially held in the
setting of hypotension. His blood pressure improved s/p
conversion to NSR and he again became hypertensive with SBPs as
high as 180. He was restarted on his home regimen with plans to
follow-up with Dr. ___ his primary care physician for
further management.
# HFpEF: BNP elevated to 1800 upon admission, but close to/less
than prior value. CXR showed mild pulmonary congestion but exam
was negative for crackles in the lungs or peripheral edema. TTE
___ with LVEF >55%, mild AR, very small pericardial effusion
consistent with prior echo from ___. No evidence of acute
exacerbation in the hospital and the patient was restarted on
his home regimen once he returned to ___ and hypotension
resolved.
- preload: continued on Lasix 40mg PO daily
- afterload: continued home lisinopril
- contractility: initially started on metoprolol in CCU later
transitioned to home carvedilol and labetalol on ___
- strict I's and O's
- low salt diet
- daily standing weights
# Hypotension: Became hypotensive in ED with SBP in ___ in the
setting of afib RVR (rates in 150s). Improved with IVF and
conversion to NSR as above. Patient asymptomatic and mentating
well throughout. No further episodes of hypotension throughout
his hospital stay.
# ___: Patient's creatinine elevated to 1.3 on admission likely
in the setting of Afib with RVR and transient hypotension and
dehyrdation. Resolved with IVF and returned to baseline of 0.9
upon discharge.
#Anxiety: The patient suffers from significant anxiety
especially in the hospital environment. Maintained on his home
dose of Ativan 0.5mg qid with prn doses as needed. Will need
further management following discharge.
CHRONIC ISSUES:
# CAD s/p DES ___: Continued ___, and restarted
labetolol and carvedilol upon discharge
# PAD s/p bilateral iliac stents ___: Continued ___,
aspirin, and pravastatin
# Anemia: Long history of normocytic anemia with Hgb of 11.1 on
presentation, relatively stable at 10.5. Consider further
work-up as an out-patient
TRANSITIONAL ISSUES:
======================
Transitional Issues:
-Patient restarted on home Carvedilol, Labetolol, Lisinopril and
Amlodipine for resistant hypertension. Will likely need
adjustment as out-patient. Rec from Dr. ___
cardiologist) is to up-titrate the labetolol and stop the
carvedilol if possible.
-Patient has been very anxious in the hospital; maintained on
home dose of Ativan with prn doses as needed (takes 0.5mg qid at
home). Consider SSRI for better control.
-Started on COPD inhalers upon discharge
-Patient interested in smoking cessation. Would continue
conversations and pursue nicotine replacement therapy as
outpatient.
-Completed ___oxycycline and prednisone on ___
for COPD exacerbation
-Follow-up with Pulmonology Clinic for COPD management
-Follow-up with Cardiology
-Contact: ___ (wife) ___
-Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. Dabigatran Etexilate 150 mg PO BID
6. Furosemide 40 mg PO DAILY
7. Labetalol 200 mg PO BID
8. Lisinopril 40 mg PO DAILY
9. Pravastatin 40 mg PO QPM
10. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Dabigatran Etexilate 150 mg PO BID
7. Furosemide 40 mg PO DAILY
8. Labetalol 200 mg PO BID
9. Lisinopril 40 mg PO DAILY
10. Pravastatin 40 mg PO QPM
11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 neb
IH Q6H:PRN Disp #*14 Ampule Refills:*0
12. Nebulizer
COPD ___
Please give nebulizer machine for COPD management at home.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Chronic Obstructive Pulmonary Disease, Atrial
Fibrillation with Rapid Ventricular Response, Hypertension,
Anxiety
Secondary: Congestive Heart Failure with Preserved Ejection
Fraction, Coronary Artery Disease, 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 during your stay at ___
___. You were admitted to the
hospital for shortness of breath due to your underlying COPD. In
the emergency room, it was found that your heart was in an
irregular rhythm (atrial fibrillation) and you were transferred
to the medical intensive care unit for further management. You
were given nebulizer treatments to help with your breathing and
medications to treat your heart rate. Your symptoms improved
significantly and you were transferred to the medical ward for
further management. Once on the floor, your heart rate remained
stable and your breathing continued to improve. You will be
discharged with the inhaler medications to help with your
breathing at home.
Because you have congestive heart failure, please weigh yourself
every morning and call the doctor if weight goes up more than 3
lbs.
Please follow-up at your appointments listed below and return to
the hospital if you begin to experience shortness of breath,
palpitations, dizziness, fevers or chills.
Best Wishes,
Your ___ Team
Followup Instructions:
___
|
19859251-DS-28 | 19,859,251 | 25,396,931 | DS | 28 | 2177-08-14 00:00:00 | 2177-08-14 21:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ old man with CAD s/p NSTEMI with DES to
LCX
and RCA in ___, pAF on amiodarone and dabigatran, ___, and
COPD presenting with dyspnea found to have atrial fibrillation
with RVR.
He reported sudden onset of dyspnea upon awakening on ___. He
denies recent fevers, chills, or chest pain/pressure. He has not
taken any of his home mediations in ___ days, including Lasix,
Amiodarone, and dabigatran. He told his wife to call ___ and he
was initially ___ to an OSH. There, he was found to be in
AFib with RVR to the 130s. Labs were notable for Troponin I
0.168, lactate 2.1, Hb 11. He was also hypoxemic and trialed on
BiPAP transitioned to a NRB mask. He was trialed on a diltiazem
drip without effect and was bloused and started on an amiodarone
drip. This did not work, and cardioversion was attempted without
success. He was therefore transferred to ___ for further
management.
Of note, he was hospitalized at ___ on ___ for about a
week
requiring CCU stay for acute pulmonary edema in the setting of
AFib with RVR. He required amiodarone loading and digoxin at
that time, and was discharged on amiodarone. This
hospitalization was also complicated by COPD exacerbation, ___,
and uncontrolled hypertension.
In the ED, initial vitals were: HR 154, BP 101/86, RR 22, SpO2
98% Non-Rebreather on a diltiazem and amiodarone drips
Exam: Poor air movement, tachycardic
Labs: WBC 17.3, H/H ___, Cr 0.9, lactate 1.2
Imaging: CXR from OSH with mild pulmonary edema
Patient was given: Continued on amiodarone drip, given 0.125mg
digoxin x 2 (21:30), and 1g acetaminophen.
Decision was made to admit to CCU for atrial fibrillation
requiring amiodarone drip
Upon transfer he converted to sinus rhythm.
On the floor, patient reported improved dyspnea, although not at
his baseline. He denied chest discomfort or palpitations.
Past Medical History:
-CAD status post LCX and RCA stenting in ___
-PAD status post bilateral iliac stents in ___
-paroxysmal atrial fibrillation with Reveal implant in ___
-HFpEF 60% ___
-hypertension
-hyperlipidemia
-small infrarenal AAA seen on angiogram in the past although
most recent CT abdomen without aneurysm
-right renal stenosis on CT abdomen
-neck arthritis
-COPD, not on any inhalers, reports he has had this diagnosis
for ___ years and tried Spiriva in the past and has had PFTs
before
Social History:
___
Family History:
His mother had heart disease in her ___. His
father had leukemia. No family history of sudden death.
Physical Exam:
ON ADMISSION:
=============
VS: T 96.5 BP 137/82 HR 62 sinus SpO2 100% on NRB
Tele: sinus rhythm/sinus bradycardia
GEN: No acute distress, lying flat comfortably in bed
HEENT: NC/AT, sclera anicteric, no conjunctival injection or
pallor, oropharynx clear
NECK: JVP at 5-6cm, no lymphadenopathy
CV: RRR, normal s1/s2, no m/r/g
LUNGS: Rales ___ up bilateral lung fields, nonlabored
respirations
ABD: Soft, nontender, nondistended, normoactive bowel sounds
EXT: Warm, well-perfused, intact pulses, no edema
SKIN: Dry, no rash
NEURO: AOx3, moves all 4 extremities equally, gait deferred
ON DISCHARGE:
=============
VS: 97.8 ___ 60's 18 98% RA
Tele: Sinus rhythm, HR 60-70's, several episodes of bradycardia
Gen: In no acute distress
Cardiac: RRR, normal s1/s2, no m/r/g
Lungs: Clear lungs bilaterally
Abd: soft, nontender, non-distended
Ext: no edema
Pertinent Results:
ON ADMISSION:
=============
___ 08:25PM BLOOD WBC-17.3* RBC-3.90* Hgb-11.0* Hct-34.8*
MCV-89 MCH-28.2 MCHC-31.6* RDW-14.7 RDWSD-47.4* Plt ___
___ 08:25PM BLOOD Neuts-94.0* Lymphs-2.0* Monos-2.9*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-16.24*# AbsLymp-0.35*
AbsMono-0.50 AbsEos-0.01* AbsBaso-0.05
___ 08:25PM BLOOD ___ PTT-26.5 ___
___ 08:25PM BLOOD Plt ___
___ 08:25PM BLOOD Glucose-195* UreaN-18 Creat-0.9 Na-135
K-3.9 Cl-101 HCO3-22 AnGap-16
___ 08:25PM BLOOD Calcium-8.2* Phos-2.5* Mg-2.4
___ 08:35PM BLOOD Lactate-1.2
PERTINENT TESTS:
================
___ CXR:
Significant improvement in the right basilar parenchymal
process. The
pulmonary vasculature remains prominent.
ON DISCHARGE:
=============
___ 06:50AM BLOOD WBC-11.8* RBC-3.51* Hgb-9.8* Hct-31.0*
MCV-88 MCH-27.9 MCHC-31.6* RDW-14.8 RDWSD-47.6* Plt ___
___ 06:50AM BLOOD ___ PTT-42.9* ___
___ 06:50AM BLOOD Glucose-116* UreaN-26* Creat-0.9 Na-140
K-3.9 Cl-105 HCO3-27 AnGap-12
___ 06:50AM BLOOD Calcium-8.7 Phos-1.9* Mg-2.___ with a PMHx of pAF, CAD s/p PCI, dCHF, PVD, and COPD
presenting with acute onset shortness of breath, found to have
rapid AFib in context of not taking all his home medications for
two weeks because he is not able to afford them. He
spontaneously converted back to sinus rhythm. We restarted his
home amiodarone and dabigatran, and he remained in sinus rhythm
throughout his hospital stay. We also diuresed him with
furosemide 40 mg IVx2, then restarted him on his home dose of
furosemide 40 mg PO before discharge.
Brief Hospital Course:
#atrial fibrillation: he was found to have rapid AFib in context
of not taking all his home medications for two weeks because he
is not able to afford them. He spontaneously converted back to
sinus rhythm. He was briefly restarted on digoxin in the ED,
however, this was discontinued and he was restarted on home
amiodarone and dabigatran in the CCU. He remained in sinus
rhythm throughout his hospital stay. He was seen by social work
during hospitalization to provide resources to help with
finances/affording medications.
#HTN: patient with known history of hypertension that has been
difficult to control in the past. Patient had episodes of HTN to
170s-180s during hospitalization. He was treated with amlodipine
10mg, lisinopril 40mg, carvedilol 25mg BID, and hydralazine 50mg
TID.
#hypoxia: Patient was initially on BiPAP. CXR from OSH showed
pulmonary edema. Likely in the setting of not taking home Lasix
and also being in atrial fibrillation. He was actively diuresed
with IV Lasix 40mg and weaned to RA. He was restarted on home
Lasix 40mg PO daily before discharge.
#acute on chronic diastolic heart failure: HFpEF 60% ___. As
above, found to have pulmonary edema and was diuresed. Likely
triggered by atrial fibrillation, lack of medication compliance.
#CAD: status post LCX and RCA stenting in ___ in the setting of
NSTEMI. continued home ASA 81mg, carvedilol. Clopidogrel 75mg
daily was discontinued as was no longer needed.
# Anemia: Long history of normocytic anemia with Hgb of 11.0 on
presentation, stable from prior. No current bleeding. Consider
further work-up as an out-patient
#COPD: continued advair, tiotropium, albuterol
***TRANSITIONAL ISSUES:***
- SBPs up to 180s during this admission, consider uptitrating
anti-hypertensive medications as an out patient
- Clopidogrel discontinued during hospitalization as no longer
needed
- Our social worker is working with the patient to ensure access
to his home medications, make sure patient is compliant with his
home medications
- If patient can not afford his medications, consider switching
him to less expensive medications
- Consider of pulmonary vein isolation as outpatient
# CONTACT: ___ (wife) ___
# CODE: full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Dabigatran Etexilate 150 mg PO BID
7. Furosemide 40 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Pravastatin 40 mg PO QPM
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob, wheeze
11. Advair HFA (fluticasone-salmeterol) 115-21 mcg/actuation
inhalation BID
12. HydrALAzine 50 mg PO TID
13. Tiotropium Bromide 1 CAP IH DAILY
14. Nicotine Patch 14 mg TD DAILY
15. Nicotine Polacrilex 2 mg PO Q2H:PRN cigarette craving
16. Lorazepam 0.5 mg PO Q8H:PRN Anxiety
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob, wheeze
2. Amiodarone 200 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Carvedilol 25 mg PO BID
6. Dabigatran Etexilate 150 mg PO BID
7. Nicotine Patch 14 mg TD DAILY
8. Nicotine Polacrilex 2 mg PO Q2H:PRN cigarette craving
9. Advair HFA (fluticasone-salmeterol) 115-21 mcg/actuation
inhalation BID
10. Furosemide 40 mg PO DAILY
11. HydrALAzine 50 mg PO TID
12. Lisinopril 40 mg PO DAILY
13. Lorazepam 0.5 mg PO Q8H:PRN Anxiety
14. Pravastatin 40 mg PO QPM
15. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Atrial fibrillation
HFpEF
SECONDARY DIAGNOSES:
Coronary artery disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because you were experiencing shortness
of breath. You were found to have a rapid heart rate, a
condition called atrial fibrillation (also known as A. Fib).
Your heart rhythm spontaneously reversed to normal while you
were in the hospital. You have not been taking your heart
medications for two weeks, which most probably precipitated the
atrial fibrillation. We restarted you on your home medications
in order to maintain a normal heart rhythm and rate. You must
take all your medications regularly. However, you no longer need
clopidogrel (Plavix),so you can stop taking it. Our social
worker is working with you in order to ensure that you have
access to all your medications at all times.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure taking care of you!
-Your ___ team
Followup Instructions:
___
|
19859524-DS-13 | 19,859,524 | 28,891,342 | DS | 13 | 2147-01-03 00:00:00 | 2147-01-04 09:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Incisional Hernia Repair, Lysis of adhesions, placement of
drain in
left adnexa
History of Present Illness:
___ with Hx ventral hernia s/p repair with mesh ___ presenting
with incarcered hernia. Patient was discharged from ED 24 hours
prior to admission with same complaint. Her hernia was manually
reduced at that time and patient was discharged. However, her
hernia recurred and she presented back to the ED. She reports
increasing pain over the last 24 hours. Pain is primarily in the
epigastrium, is non-positional. Patient did not report symptoms
of obstruction at time of admission.
Patient had similar symptoms in ___, was diagnosed with ventral
hernia by CT scan at that time. Again, hernia was manually
reduced and patient was discharged.
Past Medical History:
Asthma (prescribed 3L home O2 on last discharge ___
Obstructive Sleep Apnea (on O2 as above)
Hypertension (hx of being uncontrolled with med noncompliance)
Hyperlipidemia
CKD thought due to uncontrolled hypertension
Obesity (480lbs, BMI 76.1)
Uterine fibroids
Ovarian cyst/mass (incomplete MRI ___, rec f/u in ___
Umbilical hernia s/p mesh ___
Depression
Vitamin D deficiency
Social History:
___
Family History:
Mother: ___, HTN, epilepsy, stroke
Father: Living, oral cancer at ___
Siblings: Sister
Physical ___:
ADMISSION PHYSICAL EXAM
From ACS consult note performed by ___, MD
"98.0 80 138/68 18 96%RA
Gen alert, NAD
CV RRR
Abd soft, morbidly obese, nondistended; tender focally in
midline
at palpable mass at lower margin of ventral hernia repair
well-healed scar; no rebound tenderness or guarding
Ext WWP"
DISCHARGE PHYSICAL EXAM
Afebrile. VSS
Gen: AAOx3, NAD
HEENT: ATNC. EOMI
CV: RRR S1 and S2 without MRG
Pulm: CTA B/L.
Abd: Obese, soft, NT, ND. Incision c/d/i. JP drain sites with
minimal oozing. No discharge.
Ext: Warm without cyanosis or pallor. Mild extremity edema.
Brief Hospital Course:
Upon Emergency Department evaluation, CT of the abdomen
demonstrated ventral hernia and right adnexal mass. Acute Care
Surgery was consulted for management of recurrent ventral hernia
and OB/GYN was consulted regarding the adnexal mass. MRI of the
abdomen and pelvis which demonstrated similar findings.
Differential included benign and malignant causes. Patient was
taken to the Operating Room in joint operation with General
Surgery for management of hernia and OB/GYN for management of
adnexal mass was planned. The right adnexal mass was identified
as a tuboovarian abscess and was drained of purulent fluid. A JP
drain was placed in the right adnexal region for management of
pelvic free fluid. The ventral hernia was then closed with a
second JP drain left in a subcutaneous fluid pocket.
The patient was started on IV antibiotics postoperatively. She
was observed and diet was slowly advanced. When JP drain output
had diminished, after discussion with OB/GYN, JP drains were
discontinued. Postoperatively patient had a rise in serum
creatinine and diminished urine output. Urine electrolytes were
consistent with prerenal dysfunction and patient was managed
with IV hydration. When Cr remained, 2.0 for several days,
nephrology was consulted. Renal ultrasound demonstrated no
hydronephrosis. It was felt that acute kidney injury was likely
secondary to dehydration with accompanied postoperative toradol
and ACE inhibitors. They recommended that patient's home
lisinopril be discontinued. They also recommended that patient
not receive home chlorthalidone and that she avoid NSAIDs.
By the day of discharge, patient's Cr had begun to decline,
urine output was adequate and Foley catheter was discontinued.
She was able to void spontaneously and it was felt that it was
safe for her to return home. She was tolerating a regular diet,
was ambulating well with a walker and needed O2 only
intermittently (which she had used prior to discharge). She was
discharged on PO antibiotics (levofloxacin and metronidazole)
for a total of 2 weeks. She will follow up with her PCP, OB/GYN
and ACS.
RELEVANT IMAGING:
CT Abdomen and Pelvis ___:
"1. Limited study given body habitus resulting in significant
streak artifact.
Ventral abdominal hernia, with small bowel loops up to 3 cm in
diameter
proximal to this (upper limits of normal), but no transition
point or
significantly dilated loops to suggest obstruction.
2. Large right adnexal 9 cm multilobular hypodense lesion has
increased in
size compared to the prior CT, and has been characterized by the
prior MRI
from ___ of this year as a hydrosalpinx.
3. In the left adnexa, posterior to the uterus, there is a
6.4-cm
intermediate density abnormality, appearing increased from prior
CT. I note
that followup MRI pelvis has been previously recommended. I
would recommend
performing this at this time, given apparent change since
previous CT. Please
also note prior MRI recommendation for large bore MRI scan,
potentially with
sedation if patient requires."
MRI Abdomen and Pelvis ___
" Enlarging unilocular right ovarian cystic lesion now 8.8 cm
without overtly
concerning features. Low-grade neoplasm is not excluded, but
this could be a
simple benign cyst, with reactive enlargement due to the
inflammatory process
within the left adnexa. Continued follow up in 6 months is
recommended if
resection is not performed.
Progressive left hydrosalpinx with some fluid complexity, mural
hyperenhancement and surrounding edema. A developing pyosalpinx
is not
excluded.
Increasing free pelvic fluid, some of which appears loculated,
representing
either loculated ascites or inclusion cysts.
Likely uterine adenomyosis, with nonspecific focal mucosally
based area of
hyperenhancement within the right cornua.
Large umbilical hernia, containing multiple loops of small
bowel."
Renal Ultrasound
No hydronephrosis.
Medications on Admission:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Gabapentin 300 mg PO TID
5. Lisinopril 40 mg QD
6. Chlorthalidone 25mg PO QD
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Gabapentin 300 mg PO TID
5. Levofloxacin 750 mg PO Q48H Duration: 7 Days
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth Q48H
Disp #*4 Tablet Refills:*0
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 7 Days
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*21 Tablet Refills:*0
7. Outpatient Physical Therapy
8. Walker for endurance
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four
hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Incisional hernia, tuboovarian abscess
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital for abdominal pain. You were
found to have a hernia of your abdominal wall that contained
your ovary. A surgery was performed to fix this problem. You
were started on antibiotics. After your surgery, it seemed that
your kidneys were not functioning normally. You were given IV
hydration and your urine output was monitored. You were seen by
nephrology, the doctors who ___ in the kidneys. They
recommended that you avoid medications called NSAIDs, which
include medications like ibuprofen (Motrin), naproxen (Naprosyn)
and that we discontinue your lisinopril. You should also avoid
taking your chlorthalidone. You should follow up with your
regular doctor within the next week to discuss your blood
pressure medications.
Followup Instructions:
___
|
19859524-DS-15 | 19,859,524 | 23,248,250 | DS | 15 | 2147-05-30 00:00:00 | 2147-05-31 13:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath, hypoxemia, weight gain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F h/o pulmomary HTN, asthma, morbid obesity, OSA (home O2 at
night, does not yet have CPAP) presents with SOB and hypoxemia
from clinic. She was seen to follow up on daytime sleepiness and
chronic headaches and was noted to have O2 sat 85% ra. Initial
vital signs: HR-90-104 RR=20 BP 175/80. Pulmonary exam notable
for diffuse wheze and diminshed breath sounds. She was given 1
duoneb and her sat improbed to came up to 89 %. She desatted
soon after to ___ and was placed on 3 L NC. Pt checks her sats
at night and they can be as low as 79% on RA. She denies cough,
fevers, chest pain. She has gained a significant amount of
weight over the last several weeks. Admitted for abscess
drained/hernia repair in ___. Per patient at that time her
weight was 485 pounds; she is currently 19 lbs up from her dry
weight. In addition she has noticed ___ edema and has a hard time
wearing her shoes. She does not carry a formal dx of CHF however
she was admitted later in ___ and was hypoxemic and volume
overloaded (felt to be from too much IVF administration) and was
diuresed. However, her chlorthalidone and lisinopril were held
for the past couple of months because of ___. Verapamil
increased recently for HTN. She is also trying to arrange to get
a CPAP machine for home but hasn't gotten it yet due to
logistical issues.
In the ED initial vitals were: 97.8 80 154/86 20 91% 3L NC. Labs
were significant for BNP 601 UA pos nitr, 19 blood, few bacteria
(grew Klebsiella). CXR with pulmonary edema. Patient was given
ceftriaxone for presumed UTI, lasix 40mg IV. Vitals prior to
transfer were: 76 144/82 19 93% 2L NC. On the floor she was in
no distress and had no complaints. Review of systems were
negative for fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Asthma (Non-compliant with home O2)
Obstructive Sleep Apnea (Supposed to be on O2 as above)
Hypertension (hx of being uncontrolled with med noncompliance)
Hyperlipidemia
Obesity
Uterine fibroids
Ovarian cyst/mass (incomplete MRI ___, rec f/u in ___
Umbilical hernia s/p mesh ___
Depression
Vitamin D deficiency
Social History:
___
Family History:
Mother: ___, HTN, epilepsy, stroke
Father: oral cancer at ___
Physical Exam:
ADMISSION:
Vitals - 98.1 160/101 73 91% 2L NC Wt not obtained
GENERAL: NAD, morbidly obese
NECK: JVD elevated
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: decreased breath sounds at bases, mild crackles
appreciated at bases
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 2+ pitting edema in ___, venous stasis
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE:
Vitals: 98.1, 140/70, RR 18, HR 75, 97% 2L
GENERAL: NAD, morbidly obese
NECK: JVD decreased
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: decreased breath sounds at bases, no wheeze or crackles
appreciated
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 2+ pitting edema in ___, venous stasis
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 06:43PM BLOOD WBC-7.1 RBC-4.84 Hgb-10.5* Hct-35.5*
MCV-73* MCH-21.7* MCHC-29.6* RDW-18.9* Plt ___
___ 08:31AM BLOOD WBC-6.8 RBC-5.26 Hgb-11.4* Hct-39.3
MCV-75* MCH-21.6* MCHC-29.0* RDW-19.1* Plt ___
___ 06:43PM BLOOD Neuts-71.7* ___ Monos-5.1 Eos-3.8
Baso-0.3
___ 06:43PM BLOOD Glucose-79 UreaN-21* Creat-1.0 Na-142
K-4.6 Cl-103 HCO3-33* AnGap-11
___ 07:40AM BLOOD Glucose-91 UreaN-23* Creat-1.3* Na-140
K-3.8 Cl-99 HCO3-36* AnGap-9
___ 06:43PM BLOOD proBNP-601*
___ 06:43PM BLOOD cTropnT-<0.01
___ 07:58AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.8
___ 07:40AM BLOOD Calcium-9.8 Phos-4.5 Mg-2.0
___ 09:33AM BLOOD ___ pO2-101 pCO2-47* pH-7.46*
calTCO2-34* Base XS-8 Comment-GREEN TOP
EKG ___
Sinus rhythm. Non-specific ST-T wave changes in the inferior
leads suggest evaluation or consideration of myocardial
ischemia. Compared to the previous tracing of ___ there is
no important change.
IntervalsAxes
___
___
CXR ___
FINDINGS:
PA and lateral views of the chest provided. Cardiomegaly is
again noted with moderate pulmonary edema. No large effusions or
pneumothorax seen. A subtle superimposed pneumonia is difficult
to exclude though no asymmetric opacities are identified.
Mediastinal contour is prominent though this could be due to
technique. Bony structures are intact.
IMPRESSION:
Cardiomegaly with moderate pulmonary edema. Difficult to exclude
and a subtle superimposed pneumonia. Followup post diuresis.
Echo ___
Conclusions
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. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to high cardiac output.
No aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global left ventricular
systolic function. Mild mitral regurgitation. Indeterminate
pulmonary artery systolic pressure.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Brief Hospital Course:
___ F h/o pulmomary HTN, asthma, morbid obesity, OSA (home O2 at
night, does not yet have CPAP) presents with SOB and hypoxemia
from clinic.
#Decompensated dCHF: Preserved EF but LVH. New oxygen
requirement but OSA and obesity hypoventilation syndrome also
contributing. BNP 600 but unreliable in setting of morbid
obesity. 19 lbs weight gain on admission, CXR with moderate
pulmonary edema. ___ be dietary indiscretion and in addition her
chlorthalidone was stopped bc of ___. Diuresed and discharged on
10 mg torsemide.
#UTI: Klebsiella, sensitive to cipro, treated for five days.
#OSA: Pt does not yet have CPAP machine but she has an appt with
pulmonary to coordinate it. Used CPAP overnight. On discharge,
she had low oxygen saturations on walking, likely related to
compressed lungs from sitting. Instructed to wear your oxygen at
home and check oxygen saturation 4x/day. Discharged on 2 L O2
with goal sat >90%.
# HTN: SBP 150s. On home verapamil (recently increased),
metoprolol and lisinopril. Continued verapamil and metoprolol
and restarted lisinopril ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
3. Lisinopril 40 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Verapamil SR 240 mg PO Q24H
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 100 mcg-50 mcg/Dose 1
INH twice a day Disp #*1 Disk Refills:*0
2. Lisinopril 40 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Verapamil SR 240 mg PO Q24H
5. Ciprofloxacin HCl 500 mg PO Q12H Duration: 1 Day
Finishes course with last dose ___
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*3 Tablet Refills:*0
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
RX *albuterol sulfate 90 mcg 2 puff every six (6) hours Disp #*1
Inhaler Refills:*0
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
9. Outpatient Lab Work
CHEM 7, Mg (ICD 42___.30)
Please fax results to Dr. ___ at ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Congestive heart failure exacerbation
Secondary:
Obstructive sleep apnea
Obesity hypoventilation syndrome
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with difficulty breathing and
increased weight. We felt that you had worsening congestive
heart failure and we gave you medications to remove excess fluid
in your lungs and legs. We started a new medication called
torsemide to keep you from accumulating fluid. We also gave you
CPAP at night for your OSA. You will need to touch base with
your primary care provider about continuing this at home. We
also treated you with antibiotics for a urinary tract infection.
You should take one more dose tonight and two doses tomorrow to
complete your course.
You should follow up with your primary care provider and all of
your other appointments as detailed below.
On discharge, you had low oxygen saturations on walking, likely
related to compressed lungs from sitting. Please continue to
wear your oxygen at home and check your oxygen saturation
4x/day. Goal sat >90%.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team
Followup Instructions:
___
|
19859524-DS-16 | 19,859,524 | 20,319,227 | DS | 16 | 2147-08-13 00:00:00 | 2147-08-13 15:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F h/o pulmomary HTN, dCHF, asthma (on 3L night O2), morbid
obesity, OSA (not adherent to CPAP), and recent Right
tubo-ovarian abscess s/p drainage who presented to ___ w/ SOB
and crampy RLQ pain. With regards to SOB, pt developed
increasing SOB on ___, associated with subjective fever,
chills, sweating and fatigue. No CP, light-headedness, cough or
sick contacts. Pt used her albuterol inhaler at home, which did
not help significantly. Pt notes that her SOB felt similar to
previous asthma exacerbation. She does believe that she may be
retaining fluid in her body, but cannot say why. She thinks she
may have gained "a little" weight, but does not have a scale at
home. She also notes no worsening swelling in her ___. She
notably only takes chlorthalidone at home. She had previously
been on Torsemide 10mg/d, but this was stopped by her PCP ~2
months ago in the setting of worsening renal function.
With regards to abdominal pain, pt developed crampy abdominal
pain in RLQ starting on ___, up to ___. She has been
taking Motrin 1200mg BID for the pain since then. She notably
had a Right tubo-ovarian abscess drained in ___. Her current
pain is similar in quality, although it is more constant now as
compared with prior. ROS negative for n/v, diarrhea,
constipation or unusual vaginal discharge.
In the ED, initial VS were: 98.6 96 ___ 84%. Pt was noted
to be wheezy on exam. CBC w/ 13.5 WBC (78% PMN), CHEM w/ K 3.1,
Cr 1.2, trop <0.01, BNP 378, DDimer 666, LFTs wnl, VBG
7.40/60/51, UA w/ 3WBC, Nitr Pos. CXR showed possible RLL PNA,
but no pulmonary edema or cardiomegaly. CTA and CT A/P
attempted but scanner table could not operate properly ___ pt's
weight and had to be cancelled. Pt was given NTG SL, Duonebs,
Morphine. She was also given 500cc NS, and CXR after
interventions was consistent with pulmonary edema. Vital signs
after such interventions were 98.2 76 152/74 22 94% Nasal
Cannula. Pt was then admitted for ___ exacerbation. On
transfer, VS were 78 158/85 22 94% on NC.
On arrival to the floor, VS were: 98.3; 156/102; 83; 20; 92%
2LNC. Pt reports that her breathing is now at her baseline. She
continues to complain of abdominal pain.
Past Medical History:
___
Asthma (Non-compliant with home O2)
Obstructive Sleep Apnea but non compliant on CPAP
Hypertension (hx of being uncontrolled with med noncompliance)
Hyperlipidemia
Obesity
Uterine fibroids
Ovarian cyst/mass (incomplete MRI ___, rec f/u in ___
Umbilical hernia s/p mesh ___
Depression
Vitamin D deficiency
Social History:
___
Family History:
Mother: ___, HTN, epilepsy, stroke
Father: oral cancer at ___
Physical Exam:
On Admission:
Vitals: 98.3; 156/102; 83; 20; 92% 2LNC
Weight on admission: 214.4kg
Dry weight: 220.5kg
GENERAL: Pleasant, obese, NAD. AOx3
HEENT: NC/AT. EOMI. JVP ~8cm
CV: RRR. Normal S1/S2. No MRG
LUNGS: CTAB. No wheezes, rales, rhonchi.
ABD: Obese. Diffusely TTP, primarily in the RLQ. No rebound.
EXT: 1+ pitting edema, up to mid-shin. Chronic venous stasis
changes bilaterally. ~1cm open sore on Right anterior shin.
NEURO: CNII-XII grossly intact.
On Discharge:
Vitals: 98.7/98.4; 82-139/50-76; 64-86; ___ 93-98% RA
General: Pleasant, obese, NAD
HEENT: NC/AT. EOMI. Anicteric sclera. JVP difficult to assess
given body habitous
Lungs: CTAB. No wheezes, rales, rhonchi
CV: RRR. No MRG
Abdomen: Obese. TTP in RLQ and RUQ. No rebound.
Ext: Trace pitting edema, up to lower shin. Chronic venous
stasis changes bilaterally. ~1cm open sore on Right anterior
shin
Neuro: CNII-XII.
Pertinent Results:
On Admission:
___ 01:32AM BLOOD WBC-13.5* RBC-5.32 Hgb-12.1 Hct-38.5
MCV-72* MCH-22.7* MCHC-31.4 RDW-20.2* Plt ___
___ 01:32AM BLOOD Glucose-121* UreaN-13 Creat-1.2* Na-134
K-3.1* Cl-94* HCO3-30 AnGap-13
___ 10:30AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.8
___ 05:04AM BLOOD D-Dimer-666*
___ 01:35AM BLOOD ___ pO2-51* pCO2-60* pH-7.40
calTCO2-39* Base XS-9
On Discharge:
___ 04:40AM BLOOD WBC-7.2 RBC-4.82 Hgb-10.6* Hct-37.4
MCV-78* MCH-22.0* MCHC-28.3* RDW-19.2* Plt ___
___ 04:40AM BLOOD Glucose-77 UreaN-33* Creat-1.8* Na-139
K-4.0 Cl-93* HCO3-37* AnGap-13
___ 04:40AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.1
IMAGING:
___ CXR:
IMPRESSION:
Possible right lower lobe pneumonia. Lateral view strongly
recommended.
Increased left atrial pressure, but no pulmonary edema or
cardiomegaly.
___ Bilateral ___ Venous U/S
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
___ Transvaginal Ultrasound
IMPRESSION:
Complex cystic lesions in bilateral adnexae are redemonstrated.
Evaluation is limited on these transabdominal images. Findings
could represent neoplasm; recurrent tubo-ovarian abscess also
cannot be excluded. If further imaging is clinically warranted,
MRI pelvis in a large bore scanner may be considered.
___ MRI Pelvis:
IMPRESSION:
Bilateral hydrosalpinges. While chronic bilaterally, and
appearing better than previously on the left, the right adnexa
is markedly distended with complex contents and inflamed,
consistent with a pyosalpinx and likely tuboovarian abscess.
Extensive surrounding inflammation extends to the anterior
parietal peritoneum with mild secondary edema within the
abdominal wall musculature.
Slightly thickening urinary bladder, with small left
posterolateral
diverticula likely from chronic bladder outlet obstruction.
Brief Hospital Course:
___ F h/o pulmomary HTN, dCHF, asthma (on 3L night O2), morbid
obesity, OSA (not adherent to CPAP), and recent Right
tubo-ovarian abscess s/p drainage who presented to ___ w/ SOB
and crampy RLQ pain.
#Abdominal Pain: On presentation, pt had RLQ tenderness, but was
otherwise afebrile and had no leukocytosis. MRI pelvis was
concerning for a pyosalpinx and likely
tuboovarian abscess. Pt was seen by the gynecology service. Per
___, drainage would be difficult given pt's body habitus. Pt was
started on clindamycin/gentamycin on ___, and this was changed
to doxycycline/flagyl per recommendations of the gynecology
service. Otherwise, pt's STI panel was negative, although HIV
was pending at discharge. Pt was discharged with a plan to
complete a 14-day course of doxycycline/Flagyl and follow up
with GYN.
#Hypoxia: By the time of her admission, pt's respiratory status
was at her baseline. Her initial hypoxia was felt to be from
asthma exacerbation in the setting of obesity hypoventillation
syndrome.
#Chronic dCHF: Pt was found to have mild bilateral edema on
admission, and she was given 40mg IV lasix, which did not
significantly alter her breathing status. She was started on
torsemide 10mg PO QDay, which had been discontinued by her
outside provider in the setting of worsening renal function. Her
chlorthalidone was discontinued in the setting of soft BPs with
a plan to possibly consider restarting as an outpatient. Pt was
not discharged with torsemide.
#Hypertension: Pt's BP were soft at the time of discharge
(90's-100's), felt to be secondary to concurrent use of
chlorthalidone and torsemide. Chlorthalidone was discontinued,
pt's lisinopril was reduced to 20mg/day and verapamil was
reduced to 180mg/day.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Verapamil SR 240 mg PO Q24H
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
5. Chlorthalidone 25 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
Discharge Medications:
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Lisinopril 20 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*21 Tablet Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*32 Tablet Refills:*0
6. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*12 Tablet Refills:*0
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
8. Verapamil SR 180 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Tubo-ovarian abscess
Asthma exacerbation
Secondary:
Chronic diastolic heart failure
Obesity
Obstructive Sleep Apnea
Hypertension
Hyperlipidemia
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to ___
evaluation of abdominal pain and shortness of breath. Your
abdominal pain was caused by a tubo-ovarian abscess (an
infection in your ovary and fallopian tube). ___ were given
antibiotics, and ___ will need to keep taking them after ___
leave. ___ were also seen by our gynecologists, and ___ will
need to follow up with them as an outpatient.
Your shortness of breath was probably caused by an asthma
exacerbation. ___ were given some breathing treatments in the
emergency department, which helped your breathing.
___ are being discharged with 2 new antibiotics: doxyclycline
and Flagyl. ___ will need to take them for the next ___ days. ___
will also need to start taking torsemide again after ___ leave.
___ should STOP taking chlorthalidone, as this can cause your
blood pressure to become too low. Finally, your lisinopril and
verapamil doses are being decreased because your blood pressures
were low.
It was a pleasure to help care for ___ during this
hospitalization, and we wish ___ all the best in the future.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19859524-DS-17 | 19,859,524 | 23,927,518 | DS | 17 | 2148-05-04 00:00:00 | 2148-05-05 13:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with a history of
hypertension, hyperlipidemia, and morbid obesity who presents
with 1 week of right lower extremity cellulitis failing 4 days
of PO antibiotic therapy.
She was initially seen in the ED on ___ with knee pain and
lower extremity edema in her right lower leg. Ultrasound was
performed, which was negative for DVT or fluid collection.
She was given Keflex, but she continues to have persistent
cellulitis despite antibiotics, with pain and weeping in the
same area. She describes that she bumped her right ankle a year
ago and has had persistent circulation / dermatitis issues in
the region since. She's also had fevers and occasional night
sweats over the last several days. 12 pt ROS otherwise
negative.
Past Medical History:
___
Asthma (Non-compliant with home O2)
Obstructive Sleep Apnea but non compliant on CPAP
Hypertension (hx of being uncontrolled with med noncompliance)
Hyperlipidemia
Obesity
Uterine fibroids
Ovarian cyst/mass (incomplete MRI ___, rec f/u in ___
Umbilical hernia s/p mesh ___
Depression
Vitamin D deficiency
Social History:
___
Family History:
Mother: ___, HTN, epilepsy, stroke
Father: oral cancer at ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: temp 98, BP 140/102, HR 80, RR 12, O2 sat 98% RA
GEN: Black female, sitting up in bed, morbidly obese
HEENT: Anicteric
Cardiac: Nl s1/s2 RRR no m/r/g
Pulm: CTAB
Abd: soft NT, obese abdomen
Ext: erythematous, fluctuant skin overlying right anterior shin,
small amount of clear fluid weeping from skin
left lower extremity shows venous stasis changes
DISCHARGE PHYSICAL EXAM:
VS: 98.1 ___ 110s-140s/50s-80s ___ 98-100%2L
I/O: 620/875(8hr); ___
WEIGHT: 220 kg (standing) (220 kg ___
GENERAL: NAD, alert, interactive, very pleasant
HEENT: acanthosis nigricans on posterior neck fold
LUNGS: distant lung sounds, CTAB
HEART: RRR, distant, S1 and S2, no m/r/g
ABDOMEN: BS+, soft, NT, ND
EXTREMITIES: bilateral ___ with venous stasis changes and
improving edema, RLE with resolved erythema and areas of
compromised skin barrier
NEURO: awake, A&Ox3
Pertinent Results:
==Admission Labs==
___ 01:18PM ___ COMMENTS-GREEN TOP
___ 01:18PM LACTATE-1.4
___ 01:10PM GLUCOSE-97 UREA N-18 CREAT-1.2* SODIUM-140
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-32 ANION GAP-13
___ 01:10PM CALCIUM-9.6 PHOSPHATE-2.8 MAGNESIUM-2.0
___ 01:10PM WBC-7.7 RBC-4.90 HGB-11.0* HCT-39.4 MCV-80*
MCH-22.4* MCHC-27.9* RDW-20.3* RDWSD-57.5*
___ 01:10PM NEUTS-73.5* LYMPHS-13.6* MONOS-9.5 EOS-2.6
BASOS-0.5 IM ___ AbsNeut-5.62 AbsLymp-1.04* AbsMono-0.73
AbsEos-0.20 AbsBaso-0.04
___ 01:10PM PLT COUNT-325
==Discharge Labs==
___ 06:47AM BLOOD WBC-6.1 RBC-4.79 Hgb-10.9* Hct-38.3
MCV-80* MCH-22.8* MCHC-28.5* RDW-20.0* RDWSD-57.0* Plt ___
___ 02:50PM BLOOD Glucose-89 UreaN-31* Creat-1.4* Na-140
K-3.8 Cl-97 HCO3-34* AnGap-13
___ 06:47AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.2
==Imaging==
TTE ___
The left atrium is normal in size. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
mildly dilated with mild global free wall hypokinesis. The
aortic valve leaflets (?#) appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. No
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Dilated right ventricle
with mild global systolic dysfunction. Normal left ventricular
systolic function.
Compared with the prior study (images reviewed) of ___, the
findings are probably similar.
CTA ___
Essentially nondiagnostic study for the evaluation of pulmonary
embolism due to bolus timing, respiratory motion and body
habitus. No pulmonary embolism in the main, proximal right or
left pulmonary arteries. If clinical concern consider V/Q scan.
CXR ___ (prelim)
Film limited secondary to body habitus. Mild edema and
cardiomegaly.
Possible left pleural effusion. Retrocardiac opacity is new from
the prior exam and could reflect effusion/atelectasis/and or
edema.
CXR ___
Findings consistent with mild congestive heart failure, no overt
pulmonary edema appreciated.
___ US ___
No right leg DVT. No drainable fluid collection.
CXR ___
Mild cardiomegaly, otherwise unremarkable.
==Hemoglobin A1c==
___ 5.6
==HIV==
HIV ___ Negative
___
Positive, titer pending
==Iron Studies==
___ 02:50PM BLOOD LD(LDH)-160 TotBili-0.2
___ 02:50PM BLOOD Iron-45
___ 02:50PM BLOOD calTIBC-381 ___ Ferritn-19 TRF-293
==Arterial Blood Gas==
___ 01:42PM BLOOD Type-ART pO2-64* pCO2-51* pH-7.45
calTCO2-37* Base XS-9
==Pulmonary Function Testing==
PFTs ___
Spirometry
Pre
FVC 1.97 (59% predicted)
FEV1 1.35 (50% predicted)
FEV1/FVC 69 (83% predicted)
FEF mx 5.82 (84% predicted)
___ 7.78
Lung Volumes
TLC 3.51 (70% predicted)
FRC 1.37 (54% predicted)
RV 1.37 (82% predicted)
RV/TLC 39 (117% predicted)
VC 2.17 (65% predicted)
IC 2.14 (86% predicted)
ERV 0 (0% predicted)
Diffusing Capacity
DLCO/SB 15.07 (70% predicted)
DLCO ___ 16.09 (75% predicted)
___ 2.18 (58% predicted)
VI 2.13
Hgb 11.50
DL/VA/SB/Hgb 5.72 (130% predicted)
Brief Hospital Course:
Ms. ___ was admitted with right lower extremity cellulitis.
She had previously had a course of Keflex as an outpatient, but
her infection did not respond. She was admitted to the hospital
for intravenous antibiotics (vancomycin) for purulent
cellulitis. She was transitioned to oral clindamycin and
completed a 7 day course on ___. She was also found to have
right ventricular hypokinesis and a primarily restrictive
pattern on pulmonary function testing. She will follow up with
pulmonary and cardiology to continue her work up and treatment.
# Right lower extremity cellulitis: Pt presented with RLE pain,
erythema, edema, and skin break down. The pt endorsed a
traumatic incident to the RLE without active bleeding but with
disruption of the skin barrier. This represented the likely
portal of entry for bacteria. The pt was initially treated with
Keflex as an outpatient, but her cellulitis persisted. While
not much purulence was present on admission to the hospital, the
pt showed a picture on her phone with copious pus emanating from
her RLE. She was admitted to the hospital for IV vancomycin for
purulent RLE cellulitis that failed outpatient management. Day
1 of vancomycin was ___. On ___, she was transitioned
to oral clindamycin. She completed a 7 day clindamycin course
on ___.
# Oxygen Requirement: Pt has desaturations to ___ with
ambulation while in the hospital. She had a chest xray with
evidence of mild CHF. She had a TTE showing right ventricular
hypokinesis. She had a DDimer of 1008 and an inconclusive CTA.
Given low concern for PE and body habitus, she did not have a VQ
scan. She also had PFTs showing a restrictive pattern, possible
obstruction, and mild diffusion defect. She was evaluated by
cardiology and pulmonology. The etiology of her O2 requirement
was felt to be multifactorial including heart failure, pulmonary
hypertension, and OHS. She will have further workup and
possibly a stress test and right heart catheterization as an out
patient. She will also continue to use her CPAP as she can and
will use supplemental oxygen. She was encouraged to follow up
with bariatric surgery given concern that a large component of
her disease is due to obesity.
# Heart Failure: During the hospital course, the pt had chest
xrays showing evidence of pulmonary congestion and had ___ edema.
Her weight was over 220 kg and her most recently documented dry
weight was 213 kg. She was 220 kg on discharge. She had IV
furosemide in the hospital with good urine output. Her IV
diuresis was stopped when her creatinine increased to 1.4. She
was discharged on 20 mg PO furosemide daily. Her chlorthalidone
was held while she was undergoing diuresis. She will need outpt
monitoring of wt and volume status as well as titration of
furosemide.
# Obesity: Pt very concerned about weight and understands that
weight is contributing to various medical problems. She would
like to lose weight. Her A1c was 5.8 on ___. She is
interested in working to lose weight. She has also been
referred to the ___ Clinic to work on
weight management and encouraged to f/u with bariatric surgery.
# Chronic venous stasis: She has chronic venous stasis changes
on the bilateral lower extremities. The association between
venous stasis and infections was discussed and informational
material about venous stasis was given to the pt on discharge.
# OSA: The pt has CPAP at home but endorsed not using it
regularly. The importance of using CPAP was discussed and the
pt agreed to attempt to use CPAP with more regularity.
# HTN: Continued metoprolol, amlodipine, chlorthalidone,
lisinopril
TRANSITIONAL ISSUES:
-Iron studies pending
-Started on 20 mg PO Lasix daily
-Chlorthalidone stopped
-Completed 7 day antibiotic course for cellulitis
-Pt will require stress test as out patient
-Pt will follow up with cardiology and pulmonology
-Pt should use CPAP regularly at home
-Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Lisinopril 40 mg PO DAILY
3. Metoprolol Succinate XL 200 mg PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
5. Amlodipine 10 mg PO DAILY
6. Chlorthalidone 25 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Amlodipine 10 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Metoprolol Succinate XL 200 mg PO DAILY
5. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 20 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1
puff IH Twice Per Day Disp #*1 Disk Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Cellulitis
Secondary Diagnoses:
Venous Stasis
Obesity
Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted to
the hospital to get antibiotics for your cellulitis infection on
your right leg. You completed your antibiotic course in the
hospital. There is also some information about venous stasis in
your discharge paperwork, and using compression socks or
elevating your legs when possible can be helpful in preventing
more infections. You were also found to require extra oxygen at
home. Please resume use of your home oxygen on discharge. You
should also try to use your CPAP machine as often as possible.
You were seen by cardiology and pulmonology and you should
follow up with both of these teams for your heart and lung
problems. You were found to have extra fluid in your body and
you got medication to help you urinate. You should take 20 mg
of Lasix by mouth every day at home and you should stop taking
chlorthalidone. Finally, you have been referred to the ___
___ to work on weight management. Thank
you for allowing us to participate in your care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19859524-DS-19 | 19,859,524 | 28,328,208 | DS | 19 | 2149-01-03 00:00:00 | 2149-01-05 11:17:00 |
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, weight gain
Major Surgical or Invasive Procedure:
BiPAP initiation
History of Present Illness:
___ hx asthma, obesity, OSA, ___ (EF ___, pulmonary
hypertension, RV failure, chronic respiratory failure (3L home
O2) who presents with worsening dyspnea and weight gain.
She was seen in ___ ___ for evaluation after developing 20#
weight gain over 6 weeks. She also developed worsening rest and
exertional dyspnea. Denies worsening chest pain and leg
swelling. In ___ note, providers report that patient ran out of
her medications and had not been taking home antihypertensives
or furosemide. These medications were prescribed, and she took
20mg PO Lasix once on ___ without effect. Due to worsening
dyspnea, weight gain she presented to ED for eval.
In the ED:
- Initial VS (no temp) 81 161/92 25 92% Nasal Cannula
- Labs: Chem normal except HCO3 30, BUN/Cr ___. BNP 659. CBC,
coags, LFTs, UA unremarkable.
- Studies: CXR with "Unchanged moderate to severe cardiomegaly
with mild to moderate pulmonary edema." ECG demonstrates sinus
rhythm, ___, poor baseline but no apparent ST segment
deviations.
- Interventions:
___ 16:46 PO Aspirin 324 mg ___
___ 18:24 IV Furosemide 40 mg ___
- Consults: none
She is admitted to Cardiology for further management.
VS prior to transfer
On the floor, she recounts the history above. She complains of
HA without visual changes. She has dyspnea for years but several
weeks of worsening exertional dysnpea, decreased exercise
tolerance, and fatigue. She has ___ orthopnea at baseline
for years, which hasn't changed. She reports only intermittent
medication adherence due to her primary care doctor leaving
___ (Dr. ___ and not having a new PCP. Today, she was able
to take amlodipine and spironolactone, but has not been taking
lisinopril or metoprolol for the past several weeks.
She notes she has been on home oxygen for several years, but
does not recall anyone ever giving her a diagnosis for why she
has chronic respiratory failure. She wears O2 all the time. On
review of OMR, it appears she carries dx of pulmonary HTN
(likely made on the basis of echo), but she has not specifically
seen cardiology, pulmonology, or had RHC for this.
She also carries dx of OSA. She has had 2 sleep studies. The
first one resulted in CPAP being prescribed; she used it
temporarily but found it too burdensome. The second sleep study
resulted in her being told she required BiPAP, but she was never
able to get the machine.
Past Medical History:
- dCHF
- HTN
- OSA
- asthma
- obesity
- migraines
- anemia
- uterine fibroids
- ventral hernia
- depression
- umbilical hernia repair ___
- incisional hernia repair ___ with LOA, L adnexal drain
Social History:
___
Family History:
Relative Status Age Problem Comments
Mother ___ ___ HYPERTENSION
STROKE
EPILEPSY
Father Living ___ MOUTH CANCER Dx'd at age ___.
Sister Living
Comments: No early deaths. No cancers of the breast, lung,
colon, endometrium or ovaries. No MI.
Physical Exam:
==============
ADMISSION EXAM
==============
VS 99.3 174/117 84 24 91/3L (home O2). Repeat BP 130s systolic
Genl: morbidly obese, NAD
HEENT: PERRLA, no icterus, MMM
Neck: JVP difficult to appreciate given habitus
Cor: RRR. II/VI SEM loudest over the aortic area.
Pulm: distant breath sounds, equal air entry bilaterally. ?
crackles at bilateral lung bases.
Abd: obese, nt
MSK: 2+ pitting edema to the knee bilaterally
Neuro: alert, oriented x3. grossly nonfocal.
Skin: R shin with area of superficial skin breakdown
==============
DISCHARGE EXAM
==============
***
Pertinent Results:
==============
ADMISSION LABS
==============
___ 04:15PM BLOOD ___
___ Plt ___
___ 04:15PM BLOOD ___
___ Im ___
___
___ 04:15PM BLOOD Plt ___
___ 04:15PM BLOOD ___
___
___ 04:15PM BLOOD ___
___ 04:15PM BLOOD ___
___ 06:10AM BLOOD ___
___ 04:35PM BLOOD ___
___ 04:35PM BLOOD O2 ___
=================
PERTINENT IMAGING
=================
CXR PA AND LATERAL (___): Unchanged moderate to severe
cardiomegaly with mild to moderate pulmonary edema.
ECHOCARDIOGRAM (___): The left atrium and right atrium are
normal in cavity size. There is mild symmetric left ventricular
hypertrophy with preserved regional and global biventricular
systolic function (LVEF >55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Right ventricular chamber size is normal
with mild global free wall hypokinesis. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Moderate pulmonary artery
systolic hypertension. Mild symmetric left ventricular
hypertrophy with preserved regional and global biventricular
systolic function
Compared with the prior study (images reviewed) of ___,
moderate PA systolic hypertension is now quantified.
RLE VENOUS ULTRASOUND (___):
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. 5.2 ___ cyst on the right.
==============
DISCHARGE LABS
==============
***
Brief Hospital Course:
___ hx asthma, obesity, OSA, dCHF (EF ___, and hx
sonographic RV dysfunction who presented with worsening heart
failure symptoms. She was diuresed to euvolemia but still had
exertional desaturation to the high ___ she therefore underwent
RHC which showed normal RA pressures but mild pulmonary HTN
(mRAP 6, mPAP 26, PCWP 7, PVR 3.0 ___. She had TTE with bubble
study which had indeterminate results due to body habitus. Due
to persistent ambulatory hypoxemia (ambo SaO2 ___, she was
discharged with home oxygen.
Additionally, for OSA and obesity hypoventilation, she was seen
by Pulmonology consult. She received BiLevel nocturnal
respiratory support, and was set up for this at home. She was
also encouraged to follow up with bariatric surgery.
=============
ACTIVE ISSUES
=============
# HFpEF: Presented with 3L O2 requirement, exertional dyspnea.
Diuresed to euvolemia with IV Lasix, then started on oral
medications. TTE this admission confirmed normal EF.
- Preload: torsemide 20 daily
- see OSA below
# OSA:
# Possible pulmonary HTN:
s/p 2 sleep studies: Sleep study #1 recommended CPAP, which the
patient received and has not been using; sleep study #2
recommended BiPAP with IPAP 19 EPAP 16. She was unable to get
the BiPAP due to logistical issues. Her OSA is complicated by hx
of sonographic findings of RV overload/failure (free wall
dilation and hypokinesis), raising concern for WHO3 pulmonary
HTN.
- Pulmonology consulted for assistance with nocturnal
respiratory support
- patient started on BiPAP QHS IPAP 19 EPAP 16
- arranged this admission for outpatient nocturnal BiLEVEL
- due to persistent ambulatory desaturation to low ___
(attributed to obesity hypoventilation), she was arranged for
home oxygen therapy; by report from the nursing staff, she
declined O2 when it was delivered to her home
- had RHC after diuresis to euvolemia, showing: RA 2, RV ___ PA
___ (26) PCWP 7 CO 6.4 CI 2.27, PVR 3.0. Elevated TPG suggests
an element of pulm HTN
- RV overload: Diuretics as above. NHBK with metoprolol
succinate 75 daily. cont'd spironolactone 25 daily.
# Morbid obesity:
Patient's morbid obesity complicating her HFpEF, OSA. Likely a
significant contributor to her ambulatory hypoxemia. She has
followed with bariatric surgery in the past.
- encouraged patient to follow up with Bariatric Surgery
# HTN: Elevated on admission, likely ___ nonadherence. Pt was
resumed on a lower dose of her antihypertensives (amlodipine
10mg and lisinopril 10mg daily), to improvement of her BP.
=====================
CHRONIC/STABLE ISSUES
=====================
# ASTHMA: Continued home albuterol, fluticasone
===================
TRANSITIONAL ISSUES
===================
- follow up: CHF, Pulm (OSA, obesity hypovent), Bariatric Surg,
PCP
- needs home nocturnal resp support (set up in hospital)
- needs ambulatory oxygen supplementation due to exertional
desat to ___.
- needs further diagnosis and treatment of exertional hypoxemia
- needs to undergo weight loss to improve her cardiopulmonary
status and overall prognosis; has considered bariatric surgery
in the past
- CODE: FULL
- contact/HCP: ___, nephew, ___
- dry weight: 219 kg
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 10 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Metoprolol Succinate XL 200 mg PO DAILY
5. Spironolactone 25 mg PO DAILY
6. Fluticasone Propionate 110mcg 1 PUFF IH BID
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing sob
8. Betamethasone Dipro 0.05% Oint 1 Appl TP DAILY
Discharge Medications:
1. Torsemide 20 mg PO DAILY
RX *torsemide 10 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
2. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 25 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing sob
5. Amlodipine 10 mg PO DAILY
6. Betamethasone Dipro 0.05% Oint 1 Appl TP DAILY
7. Fluticasone Propionate 110mcg 1 PUFF IH BID
8. Spironolactone 25 mg PO DAILY
9.Outpatient oxygen
Oxygen concentrator with portable O2 via nasal cannula.
___: R09.02, E66.2, J96.11. Flow: 3 liters/minute.
Length of need: ongoing. Ordering Provider: ___ MD,
___ #: ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
- diastolic heart failure, acute on chronic
- obstructive sleep apnea
- pulmonary hypertension
- morbid obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ for shortness of breath and low oxygen
levels requiring supplemental oxygen. We discovered that you had
excess fluid overwhelming your heart; we removed this fluid with
IV medication and pills. You will need to continue some daily
medications for this issue. Please also weigh yourself every
morning, call MD if weight goes up more than 3 lbs.
We also consulted the lung doctors and set up home respiratory
support at night for your sleep apnea. This can contribute to
heart and lung problems in the future, and we encourage you to
continue to use this and follow up with the lung doctors.
___ weight affects your overall health. You will experience
much better health outcomes if you are able to lose weight --
either through diet, exercise, or surgery. Please do follow up
with the bariatric surgeons.
Finally, if you are about to run out of medications, please do
not let these lapse; rather, call ___ and ask for them
to be refilled.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
19859524-DS-20 | 19,859,524 | 29,089,743 | DS | 20 | 2149-05-29 00:00:00 | 2149-06-04 13:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx asthma, obesity, OSA, dCHF (LVEF >55% ___, pulmonary
hypertension, RV failure, chronic respiratory failure (3L home
O2) presenting with dyspnea and pleuritic chest pain. Patient
reports gradual onset of pain and dyspnea over the course of the
past few days. No nausea or vomiting. No history of PE. Has been
using her inhalers with minimal improvement. She also reports
progressive exertional dyspnea over the past several days as
well as dyspnea at rest.
Of note had an admission to ___ service ___ for CHF
exacerbation during which she was diuresed to euvolemia but
still had exertional desaturation to the high ___ she therefore
underwent RHC which showed normal RA pressures but mild
pulmonary HTN (mRAP 6, mPAP 26, PCWP 7, PVR 3.0 ___. She had TTE
with bubble study which had indeterminate results due to body
habitus. Due to persistent ambulatory hypoxemia (ambo SaO2
83-88%), she was discharged with home oxygen and torsemide 20 mg
daily.
In the ED initial vitals were:
98.1 ___ 28 87% Nasal Cannula (presumably on home 3L).
Exam notable for mild wheezing, crackles b/l lung bases, 2+ ___
edema.
EKG: sinus tachycardia. ?new TWI in III, otherwise unchanged
Labs/studies notable for:
BNP 305, trop negative, CXR: Bilateral pulmonary edema worse
than baseline
Patient was given:
___ 00:06 IH Albuterol 0.083% Neb Soln 1 NEB
___
___ 00:06 IH Ipratropium Bromide Neb 1 NEB
___
___ 00:21 IH Albuterol 0.083% Neb Soln 1 NEB
___
___ 00:21 IH Ipratropium Bromide Neb 1 NEB
___
___ 00:35 SL Nitroglycerin SL .4 mg ___
___ 00:35 IV Furosemide 20 mg ___
___ 01:39 IV Furosemide 20 mg ___
___ 01:39 IV DRIP Nitroglycerin (0.35-3.5 mcg/kg/min
ordered) ___ Started 0.35
Initially put on NRB; sats improved to low ___ but then went
back down to ___. Started on BiPAP and was satting 88% at time
of xfr. BP 152/80 and HR 88 on nitro gtt. Was felt not to be in
an asthma exacerbation due to lack of wheezing and minimal
improvement with DuoNebs. Peak flow measurement was not
obtained. Was felt not to have PE as no hx of DVT/PE and
alternate explanation for respiratory distress. UOP 1750 cc
after IV Lasix 20 x2. weight not done in ED.
Pt arrived to the CCU feeling comfortable on BiPAP and was soon
switched to NRB. Said she feels better and that her symptoms
seemed more like past HF exacerbations than past asthma
exacerbations. Feels like she has gained weight lately. Her
chest pain feels like muscle soreness. She said she was switched
to Lasix 20 daily after her last discharge ___, although
her d/c summary lists her medication as torsemide 20 daily. She
does not always take her diuretic, particularly when she will be
gone during the day. Missed about 2 doses this week. Her
lisinopril has been held since ___ for ___. Denies any sick
contacts, cough, fevers, and had her flu shot this year. Also
c/o L knee pain which she has had for weeks and is worse with
ambulation.
Past Medical History:
- ___
- HTN
- OSA
- asthma
- obesity
- migraines
- anemia
- uterine fibroids
- ventral hernia
- depression
- umbilical hernia repair ___
- incisional hernia repair ___ with LOA, L adnexal drain
Social History:
___
Family History:
Relative Status Age Problem Comments
Mother ___ ___ HYPERTENSION
STROKE
EPILEPSY
Father Living ___ MOUTH CANCER Dx'd at age ___.
Sister Living
Comments: No early deaths. No cancers of the breast, lung,
colon, endometrium or ovaries. No MI.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 37 BP 132/73 HR 97 RR 22 O2 SAT 92% on 10L NRB
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric.
NECK: Supple. unable to accurately assess JVP
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. no accessory
muscle use. Crackles to midfields b/l, no wheezing, decreased
breath sounds throughout.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. 1+ pitting edema below knees
b/l. venous stasis changes b/l.
PULSES: Distal pulses present via Doppler
DISCHARGE EXAM:
VS: T97.4 116/73 80 20 91-95/3L
Weight: 224.4 kg -> 223.2 kg -> 221.9 -> 223 kg
(dry weight 219kg on discharge in ___ with RHC in place)
I/O: ___
GENERAL: Pleasant, morbidly obese young female in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric.
NECK: Supple. JVP difficult to appreciate ___ body habitus
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. no accessory
muscle use. mild crackles, no wheezing, decreased breath sounds
throughout.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. Trace edema. Chronic venous
stasis changes b/l.
PULSES: Distal pulses present via Doppler
Pertinent Results:
ADMISSION LABS:
___ 12:09AM ___ PTT-27.0 ___
___ 12:09AM PLT COUNT-258
___ 12:09AM NEUTS-75.3* LYMPHS-14.3* MONOS-7.0 EOS-1.4
BASOS-0.4 NUC RBCS-0.9* IM ___ AbsNeut-5.28 AbsLymp-1.00*
AbsMono-0.49 AbsEos-0.10 AbsBaso-0.03
___ 12:09AM WBC-7.0# RBC-4.91 HGB-10.9* HCT-39.5 MCV-80*
MCH-22.2* MCHC-27.6* RDW-21.1* RDWSD-58.7*
___ 12:09AM CALCIUM-8.5 PHOSPHATE-2.5* MAGNESIUM-2.0
___ 12:09AM proBNP-305*
___ 12:09AM cTropnT-<0.01
___ 12:09AM estGFR-Using this
___ 12:09AM GLUCOSE-95 UREA N-14 CREAT-1.1 SODIUM-141
POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-30 ANION GAP-17
___ 12:20AM O2 SAT-62
___ 12:20AM LACTATE-1.5
___ 12:20AM ___ PO2-39* PCO2-74* PH-7.31* TOTAL
CO2-39* BASE XS-6 INTUBATED-NOT INTUBA COMMENTS-NEBULIZER
___ 12:50AM URINE MUCOUS-RARE
___ 12:50AM URINE RBC-<1 WBC-2 BACTERIA-MOD YEAST-NONE
EPI-2
___ 12:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
___ 12:50AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:00AM CALCIUM-8.6 PHOSPHATE-3.6 MAGNESIUM-1.9
___ 05:00AM GLUCOSE-92 UREA N-14 CREAT-1.0 SODIUM-148*
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-32 ANION GAP-18
==============
DISCHARGE LABS
==============
___ 05:28AM BLOOD WBC-6.3 RBC-4.97 Hgb-10.4* Hct-40.1
MCV-81* MCH-20.9* MCHC-25.9* RDW-21.1* RDWSD-60.5* Plt ___
___ 05:28AM BLOOD Plt ___
___ 04:30AM BLOOD Plt ___
___ 05:56AM BLOOD ___ PTT-29.5 ___
___ 05:28AM BLOOD Glucose-97 UreaN-34* Creat-1.4* Na-141
K-4.6 Cl-95* HCO3-34* AnGap-17
___ 05:28AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.3
============
IMAGING
============
CXR ___: In comparison with the study of ___, there
is continued enlargement of
the cardiac silhouette with moderate pulmonary edema. Possible
coalescence of
opacification in the right mid zone could be worrisome for
aspiration or
developing pneumonia in the appropriate clinical setting.
The right subclavian catheter again extends to the mid to lower
portion of the
SVC.
CXR ___:
Worsened pulmonary edema since ___. Superimposed
infection is not
excluded.
==============
MICROBIOLOGY
==============
___ URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
Brief Hospital Course:
SUMMARY: ___ with asthma, OSA, pulmonary HTN, on 3L home O2 and
___ who presents with acute on chronic diastolic heart failure.
This was thought to be triggered by medication non-compliance as
patient had not been taking her furosemide. She was diuresed
with boluses of IV furosemide with good response. After she
reached her baseline functional status and baseline O2
requirement of 3L, she was transitioned to PO torsemide 30mg
daily. She was also noted to have a transient atrial arrhythmia
on telemetry concerning for afib vs flutter, for which she was
discharged on a Ziopatch monitor. She will follow up in the
Heart Failure clinic in one week.
#Acute on Chronic Diastolic Heart Failure:
Pt presented with acute worsening of respiratory status likely
due to HF exacerbation as evidenced by 10 kg weight increase,
CXR with worsening pulm edema. Likely triggered by medicatio
nnon-compliance. She initially required BiPAP, but was able to
wean to nasal cannula on her first day in the hospital with
diuresis. She was diuresed with boluses of ___ IV furosemide
with good improvement. She was eventually transitioned to PO
torsemide 30mg daily. Continued home metoprolol succ 75 daily,
spironolactone 25 daily. Restarted lisinopril 5 as Cr at
baseline. Subsequently up-titrated lisinopril to 10mg.
# Atrial arrhythmia: Patient was noted to have a tachycardia on
telemetry concerning for Afib vs Aflutter. A ziopatch was placed
on this patient as an event monitor.
#Hypertension: BP 160/138 on initial presentation. Pt was
initially placed on a nitro gtt, which was quickly weaned. She
was continued on her home Amlodipine 10 mg PO DAILY and
Metoprolol Succinate XL 75 mg PO DAILY, and we restarted
lisinopril at 5, which was uptitrated to 10 the following day.
# UTI: Has grown sensitive E. coli and klebsiella in the past.
Presented with dirty UA and positive urine culture with
sensitive E. Coli. Treated with 7-day course of macrobid.
CHRONIC ISSUES:
#Pulmonary Hypertension
#Obstructive Sleep Apnea
Acute heart failure likely worsening underlying pulm HTN. BiPAP
at night (pt wears at home).
TRANSITIONAL ISSUES:
- Discharge weight: 221.9 kg, dry weight 219 kg (on prior
admission with RHC)
- Patient states that she does not have a scale at home and
cannot afford one. Case management explored options (including
prescription, ___ to cover a bariatric scale but we were not
able to obtain one at this time. Please continue to investigate
how to get her a scale for daily weights.
- Patient will complete 1 more day of macrobid for urinary tract
infection treatment (last day ___
- Patient started on torsemide 30mg daily. Please re-check labs
and weight at follow-up appointment and titrate as appropriate
- Patient on lisinopril 10mg daily, please re-check BP and
titrate as appropriate
- Discharged with Ziopatch monitor due to atrial arrhythmia seen
on telemetry. Will follow up in heart failure clinic
- Patient has microcytic anemia (Hb ___, MCV 80) on admission.
Please work up as appropriate
# Code status: full code confirmed and ordered
# contact: ___ (son) ___ ___
Relationship: Nephew Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing sob
2. Amlodipine 10 mg PO DAILY
3. Fluticasone Propionate 110mcg 1 PUFF IH BID
4. Metoprolol Succinate XL 75 mg PO DAILY
5. Spironolactone 25 mg PO DAILY
6. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 2
capsule(s) by mouth twice a day Disp #*2 Capsule Refills:*0
3. Torsemide 30 mg PO DAILY
RX *torsemide 10 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing sob
5. Amlodipine 10 mg PO DAILY
6. Fluticasone Propionate 110mcg 1 PUFF IH BID
7. Metoprolol Succinate XL 75 mg PO DAILY
8. Spironolactone 25 mg PO DAILY
9.bariatric weighting scale
ICD-10: E66.01
PCP: ___ Phone: ___ Fax: ___ .
Please provide with weighing scale that can measure weights >
190 KG
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Acute on chronic diastolic heart failure
Atrial arrhythmia
Urinary tract infection
SECONDARY DIAGNOSIS:
Obstructive sleep apnea
Asthma
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because you were short of breath.
This was due to fluid building up with your congestive heart
failure. We gave you Lasix to take off the fluid. You also had
an irregular heart rhythm so we gave you a monitor.
Please take note of the following:
**VERY IMPORTANT**: Please continue working to get a scale. When
you have a scale please weigh yourself every day and call the
heart failure clinic if your weight goes up by 3 pounds or more.
- Please take your torsemide every day as prescribed. This will
prevent fluid from building up and you from being hospitalized
again
- Please make sure to come to all your follow up appointments.
You will need continued care to prevent future hospitalizations
We wish you all the best!
- Your ___ care team
Followup Instructions:
___
|
19859524-DS-21 | 19,859,524 | 23,588,578 | DS | 21 | 2149-12-11 00:00:00 | 2149-12-14 21:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intra-abdominal drain placement by ___ ___
History of Present Illness:
This ___ female with a history of heart failure with
preserved ejection fraction, obstructive sleep apnea presents
emergency room today with concerns of subjective fever the last
___ days, left-sided chest pain, and also noted to be hypoxic on
a home monitor to 70%. She called the on-call ___ physician this
AM because of the fevers, chills, and feeling weak. She does not
have a thermometer so she is unsure how high her temperature has
been but she has felt warm. She also told the on-call physician
at ___ that her HR at home as been up to the 120s and her O2
level has been "struggling to stay at 90" and drops to 65-70
with walking so she was referred to the ED for evaluation. She
just recently got a pulse oximeter at home, so she is unsure
what her O2 saturation is at baseline when she is feeling well.
She also noted that the pulse oximeter was alarming when she was
sleeping on her bipap so she thinks she may need her settings
adjusted.
___ the ED, initial VS were 98.9 ___ 19. ___ the ED she
spiked a fever to 101.8 and she also desaturated requiring
supplemental O2 via NC. Basic labs, CXR, and CTA were obtained.
CTA was negative for PE, CXR showed interstitial edema, and labs
were notable for leukocytosis and UA concerning for a UTI. She
was given acetaminophen 1000mg PO x2, Furosemide 20mg IV x1, and
CTX 1g. No consults were requested. She was admitted to medicine
for UTI and CHF exacerbation.
On arrival to the floor, patient reports that she is feeling
short of breath and having lower abdominal discomfort. She said
that she was having chest pain before with deep breaths but that
it is now gone.
Past Medical History:
- dCHF
- HTN
- OSA
- asthma
- obesity
- migraines
- anemia
- uterine fibroids
- ventral hernia
- depression
- umbilical hernia repair ___
- incisional hernia repair ___ with LOA, L adnexal drain
Social History:
___
Family History:
Relative Status Age Problem Comments
Mother ___ ___ HYPERTENSION
STROKE
EPILEPSY
Father Living ___ MOUTH CANCER Dx'd at age ___.
Sister Living
Comments: No early deaths. No cancers of the breast, lung,
colon, endometrium or ovaries. No MI.
Physical Exam:
========================
Admission Physical Exam
========================
VS: 101.0PO 137 / 89L Sitting 99 18 94 4L
GENERAL: morbidly obese, NAD
HEENT: atraumatic, normocephalic, EOMI, PERRL, MMM
HEART: RRR, no murmurs, rubs, gallops
LUNGS: CTAB, no wheezes, ronchi, crackles
ABDOMEN: obese, soft, mild TTP ___ suprapubic region
EXTREMITIES: chronic venous stasis changes ___ bilateral lower
extremity edema
NEURO: A&Ox3, moving all 4 extremities with purpose, CN II-XII
grossly intact
======================
Discharge physical exam
======================
Vitals: Tcurr ___ F, 117/69 mm Hg, 78 BPM, 92% RA
GENERAL: Obese female laying ___ bed awake and alert ___ no pain
or
distress
HEART: Regular rate and rhythm, S1/S2, no murmurs, gallops, or
rubs
LUNGS: Clear to auscultation anteriorly, non-labored breathing,
no wheezes rhonchi or crackles
ABDOMEN: Obese, soft, non-distended, no guarding, 2 JP drains ___
LLQ, drains are dressed with clean appearing bandages and
minimal
serous drainage ___ both. Increased tenderness to palpation ___
left lower quadrant, worse with palpation with some withdrawal
from pain on rebound not true rebound tenderness but is a subtle
finding that the patient appears to be ___ pain on abd. movement
EXTREMITIES: venous stasis changes, warm, well perfused, PICC ___
right arm
Neuro: Awake and alert and oriented X3
Pertinent Results:
=================
Admission labs
================
___ 12:00PM BLOOD WBC-14.0*# RBC-4.74 Hgb-10.8* Hct-37.4
MCV-79* MCH-22.8* MCHC-28.9* RDW-19.6* RDWSD-54.8* Plt ___
___ 12:00PM BLOOD Neuts-81.4* Lymphs-8.8* Monos-8.9
Eos-0.1* Baso-0.2 Im ___ AbsNeut-11.37*# AbsLymp-1.23
AbsMono-1.25* AbsEos-0.02* AbsBaso-0.03
___ 12:00PM BLOOD Plt ___
___ 12:00PM BLOOD Glucose-107* UreaN-17 Creat-1.2* Na-138
K-4.1 Cl-100 HCO3-28 AnGap-14
___ 12:00PM BLOOD cTropnT-<0.01 proBNP-290*
___ 12:00PM BLOOD D-Dimer-658*
___ 12:13PM BLOOD Lactate-0.9
Microbiology
Urine culture: pending
Blood culture: pending
Imaging:
<<CT Abdomen ___
IMPRESSION:
1. Patient is known to have bilateral hydrosalpinges. The
absence of
intravenous contrast makes it difficult to fully assess
intrapelvic
structures, however there is an 8 x 8.9 cm intermediate density
rounded
structure ___ the region of the left adnexa extending towards
midline, which
demonstrates surrounding fat stranding and associated thickening
of the broad
ligament. Although assessment is limited, tubo-ovarian abscess
is not
excluded. Recommend correlation with physical exam and culture
data.
2. Large ventral hernia containing loops of nonobstructed small
bowel.
3. Bladder is under distended, and therefore difficult to fully
assess.
RECOMMENDATION(S): Patient is known to have bilateral
hydrosalpinges. The
absence of intravenous contrast makes it difficult to fully
assess intrapelvic
structures, however there is an 8 x 8.9 cm intermediate density
rounded
structure ___ the region of the left adnexa extending towards
midline, which
demonstrates surrounding fat stranding and associated thickening
of the broad
ligament. Although assessment is limited, tubo-ovarian abscess
is not
excluded. Recommend correlation with physical exam and culture
data.
<<ECHO ___
Conclusions
Very suboptimal images. The left atrium is mildly dilated.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Left ventricular systolic
function is hyperdynamic (EF = 75%). The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
<<MRI Abd: ___
IMPRESSION:
1. 10.6 x 8.7 x 10.5 cm left tuboovarian abscess, unchanged ___
size compared
to the most recent prior CT from ___. Associated
surrounding inflammatory
change including secondary thickening of the sigmoid colon.
2. Overall size and appearance right ovary has significantly
improved since
admission CT on ___. There is mild chronic inflammatory
change and a small
hydrosalpinx, but no drainable collection is identified on the
right.
3. Enlarged reactive left pelvic sidewall and common iliac lymph
nodes.
<<CT ___ Procedure report: ___
IMPRESSION:
1. Successful CT-guided placement of two ___ pigtail
catheter into the
collection. Samples were sent for microbiology evaluation.
2. Drained 140 cc of pus.
3. 3 old drainage catheters were removed as they were pulled
outside of the
abscess cavity.
Microbiology:
___ 7:25 pm ABSCESS Source: abscess.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final ___:
GRAM POSITIVE COCCUS(COCCI). GROWING ___ BROTH ONLY.
SEE ANEROBIC CULTURE FOR IDENTIFICATION.
ANAEROBIC CULTURE (Final ___:
ANAEROBIC GRAM POSITIVE COCCUS(I). RARE GROWTH.
(formerly Peptostreptococcus species).
NO FURTHER WORKUP WILL BE PERFORMED.
___ 4:49 pm ABSCESS Site: PELVIS
Source: pelvic absess ___.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Discharge Labs:
___ 06:30AM BLOOD WBC-8.1 RBC-4.00 Hgb-9.0* Hct-32.5*
MCV-81* MCH-22.5* MCHC-27.7* RDW-22.8* RDWSD-62.3* Plt ___
___ 03:34AM BLOOD Neuts-84.1* Lymphs-8.6* Monos-5.4
Eos-0.3* Baso-0.3 Im ___ AbsNeut-17.66* AbsLymp-1.80
AbsMono-1.14* AbsEos-0.07 AbsBaso-0.06
___ 09:00AM BLOOD ___ PTT-25.4 ___
___ 06:30AM BLOOD Glucose-84 UreaN-19 Creat-1.3* Na-138
K-5.6* Cl-98 HCO3-26 AnGap-14
___ 06:30AM BLOOD Calcium-8.7 Phos-4.8* Mg-1.8
___ 09:17AM BLOOD K-4.4
Brief Hospital Course:
========================================
Patient summary statement for admission
========================================
___ female with a history of heart failure with
preserved ejection fraction, obstructive sleep apnea, and asthma
who presents with UTI and hypoxia, history of TOAs found to have
recurrent tubo-ovarian abscess admitted to ICU for
hypotension/hemodynamic monitoring ___ sepsis and cardiogenic ___
setting of new afib with RVR, with course complicated by ___.
She was stabilized with attempted source control with 3 drains
placed by ___ and antibiotics with ceftriaxone/flagyl. Ms.
___ returned for drainage on ___ and ___ for retained
collections.
==========================
Acute medical/surgical issues addressed
==========================
#Severe sepsis secondary to complicated ___:
Patient presented with urinary frequency and urgency, suprapubic
pain, and fevers that had been worsening for about 2 weeks prior
to admission. She was febrile to 101.8F ___ ED and was given
Ceftriaxone 1g for presumed UTI. On admission, found to have a
UA with WBCs and bacteria. She was initially hemodynamically
stable but continued to have systemic signs of infection
including fever, chills, and end organ damage (mild ___. Urine
culture growing GNR. Renal US of right kidney did not show
hydronephrosis or fluid collection. Left kidney could not be
visualized. Has grown sensitive E. coli and klebsiella ___ the
past. Antibiotic coverage broadened from ceftriaxone to cefepime
on ___ as patient was still having fevers after 24 hours of
antibiotics and had some evidence of clinical worsening
(increased dyspnea and abdominal pain). On ___, she was
broadened to vanc/cefepime/flagyl due to continued fevers. She
had a CT A/P for abd pain that showed ?L ___ (8x9cm). Gyn
consulted on ___ and recommended ___ drainage. B/l salpingectomy
wanted to be avoided due to her OSA, HFpEF, and morbid obesity.
She underwent drainage of b/l TOAs on ___ (55cc purulent fluid
drained from right, 20cc purulent fluid drained from left), and
required medical ICU stay for hypotension and continued fevers.
Abx were switched to vanc/meropenem/doxy, with last fever ___.
On ___, CT showed continued collections despite drains ___
place. STD testing was notable for hx of HBV (w/ neg VL), neg
CT/GC/RPR/HIV. ___ cx grew gardnerella and anaerobes (formerly
peptostreptococcus). On ___, ___ was unable to place new bedside
U/S-guided drains. ___ placed drains on ___. Antibiotics were
deescalated to clindamycin and ceftriaxone then to
ceftriaxone/flagyl. MRI was performed on ___ that ___ ___ left
pelvis with multiple septations and ___ drains not ___ place. The
patient went for ___ drainage again ___ with 140cc of puss
drained. Case was reviewed at length with OB/gyn, ___, and ID.
Briefly, during surgical procedure for ventral hernia and
bilateral TOAs on ___, procedure was complex and limited by
extensive abdominopelvic adhesions. Given known extensive
adhesions, morbid obesity, as well as OSA, decision was made to
defer surgical intervention, with continued attempts at
percutaneous drainage of TOAs. She was discharged with 2 drains
___ place with plan for follow up imaging and consideration of
removal of drains with ___.
#Afib w/RVR
New diagnosis of afib during this admission, ___ setting of
sepsis ___ TOAs. Likely from sepsis and hypoxia i/s/o pulm
edema. Responsive to phenylephrine w/HR ___ (from 110-160)
and MAP improved from 50 to 70-90. Poor CO also likely
responsible for contribution to ___. Given planned procedure and
control on phenylephrine elected not to cardiovert. Patient was
placed on amiodarone and metoprolol and to sinus rhythm
following improvement ___ sepsis and pulmonary edema. No
anticoagulation was started. Amiodarone was stopped and she was
continued on metoprolol. A discussion was held with the patient
about anticoagulation. Decision was made to defer
anticoagulation at this time ___ setting of TOAs requiring
ongoing intervention.
#Chronic hypercarbic and hypoxic respiratory failure:
Patient presented with worsening dyspnea for 2 weeks prior to
admission and hypoxia on home oximeter. Patient recently got
oximeter at home so unclear how far from baseline her current O2
saturation is. Likely multifactorial including her known OSA and
likely OHS, as well as mild HFpEF exacerbation ___ the setting of
an acute infection. She is on BiPAP at home and ABG done this
admission showed chronic hypoxia and hypercarbia (similar to
previous studies ___ OMR). Patient triggered ___ for oxygen
desaturation <80 while on 2L NC and fever. CXR showed some pulm
edema unchanged from ___. Abx broadened to cefepime. Patient put
on face mask and given albuterol nebs with improvement ___ SOB
and SaO2. SOB likely secondary to current infection and a mild
asthma exacerbation may have contributed as well. On transfer to
ICU thought ___ dCHF exacerbation I/s/o tachycardia from sepsis.
Also contribution from flash edema from afib with RVR (see
below). Mild pulm edema noted ___. Had been non compliant on
home Lasix. Thought mild exacerbation I/s/o infection and afib.
Patient felt to be significantly volume overloaded and was
briefly required Lasix IV boluses PRN.
#HFpEF exacerbation:
Patient admitted with a weight of 223kg (last documented dry
weight 219kg). Patient takes Lasix 20mg daily at home but
reports frequently missing doses. CXR and CTA chest on admission
showed evidence of mild to moderate pulmonary edema. Diuresed
with 40mg IV lasix x2 this admission and near last documented
dry weight (last weight 221kg). Holding further diuresis due to
___. O2 requirement weaned during the admission. She was on O2
and nightly BiPAP. By the end of her stay she as weaned to RA
during the day. Of note, recorded weights are unreliable, with
large discrepancies ___ recorded weights, ranging from 175-223 kg
(388-492 lbs), all recorded as standing weights, from
___.
___:
Likely prerenal ___ the setting of sepsis and overdiuresis.
Creatinine improving with holding of diuresis. Patient baseline
is 1.0-1.1. She improved to 1.4 at the time of discharge. Peak
creatinine was 3.2
============================
Chronic medical/surgical issues addressed
============================
#OSA:
She reports that she was alarming on her oximeter at home for
hypoxemia when on her home BIPAP settings. Respiratory therapy
consulted and added oxygen to nightly BiPAP and patient was
without desaturation ___ oxygen overnight.
======================
Transitional issues
======================
- Furosemide, spironolactone, lisinopril, amlodipine held ___
setting of acute illness. Consider restarting when stable or if
hypertensive.
- Patient will need formal evaluation of BiPAP setting as
outpatient given history of hypoxemia at home. Current BIPAP
settings at discharge -
BiPAP: Settings:
Inspiratory pressure (Pressure support) 3 cm/H2O
Expiratory pressure (EPAP Fixed) 16 cm/H2O
IPAP 19
- Follow up with ___ for re-imaging and consideration of drain
removal.
- Follow up with ID regarding duration of antibiotics course
- Follow up with OBGYN regarding discussion of possible surgery
- ___ drain care instructions:
___ Drain Care:
-Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
-Note color, consistency, and amount of fluid ___ the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes ___ character.
-Be sure to empty the drain bag or bulb frequently. Record the
output daily. You should have a nurse doing this for you.
-You may shower; wash the area gently with warm, soapy water.
-Keep the insertion site clean and dry otherwise.
-Avoid swimming, baths, hot tubs; do not submerge yourself ___
water.
- If you develop worsening abdominal pain, fevers or chills
please call Interventional Radiology at ___ at ___
and
page ___.
-When the drainage total is LESS THAN 10cc/ml for 2 days ___ a
row, please have the ___ call Interventional Radiology at ___
at ___ and page ___. This is the Radiology fellow on
call who can assist you.
-DISCHARGE WEIGHT unclear given large discrepancies ___ recorded
weights, ranging from 175-223 kg (388-492 lbs)
#CODE: Full
#CONTACT: ___ (sister) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Spironolactone 25 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Fluticasone Propionate 110mcg 1 PUFF IH BID
7. Ibuprofen 600 mg PO DAILY:PRN Pain - Mild
8. Vitamin D ___ UNIT PO DAILY
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth Every 6 hours Disp
#*60 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth Once daily Disp #*30
Tablet Refills:*0
3. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone ___ dextrose,iso-os 2 gram/50 mL 1 50ml IV every
24 hours Disp #*21 Intravenous Bag Refills:*0
4. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth Every 8 Hours Disp
#*90 Tablet Refills:*0
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 capsule(s) by mouth Daily Disp
#*30 Capsule Refills:*0
6. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 6 hours Disp
#*40 Tablet Refills:*0
7. Senna 8.6 mg PO BID constipation
RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*60
Tablet Refills:*0
8. Sodium Chloride Nasal ___ SPRY NU BID:PRN dry nose
RX *sodium chloride [Saline Nasal] 0.65 % 1 spray ___ Daily Disp
#*1 Spray Refills:*0
9. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*0
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
11. Fluticasone Propionate 110mcg 1 PUFF IH BID
12. Vitamin D ___ UNIT PO DAILY
13. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until Your blood pressure recovers
from your current infection
14. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until your infection resolved and your
blood pressures are not at risk of being low from infection
15. HELD- Ibuprofen 600 mg PO DAILY:PRN Pain - Mild This
medication was held. Do not restart Ibuprofen until your kidney
function returns to normal
16. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until Your blood pressure recovers
from your current infection
17. HELD- Spironolactone 25 mg PO DAILY This medication was
held. Do not restart Spironolactone until Your blood pressure
recovers from your current infection
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
=============
Primary diagnosis
=============
# Severe sepsis secondary to Acute Complicated Bacterial UTI
# Hypercarbic respiratory distress
===============
Secondary diagnosis
===============
# Heart failure with reduced ejection fraction
# Obstructive sleep apnea
# Acute kidney injury
# Asthma
# Hypertension
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 ___ your care at ___.
During your hospitalization,
- We found that you had an infection ___ your urine and treated
you with antibiotics
- You had trouble breathing and we gave you oxygen and used a
machine called BiPAP to help you breathe easier.
After you leave the hospital, it is important that you:
- Take all your medications as prescribed, especially your
antibiotics
- Use your BiPAP machine at home while sleeping
- Use your oxygen as needed for your shortness of breath
- Follow-up with your primary care physician within the next
week. We will make an appointment for you.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Best wishes,
Your ___ care team
Followup Instructions:
___
|
19859524-DS-23 | 19,859,524 | 24,636,132 | DS | 23 | 2150-04-10 00:00:00 | 2150-04-16 16:09:00 |
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:
fever
Major Surgical or Invasive Procedure:
___ guided placement of drain
History of Present Illness:
Patient is a ___ with a PMHx significant for history of dCHF,
OSA, asthma, obesity, HTN, ___ abscess c/b sepsis, VRE UTI, afib
in ___, presenting with subjective fever. Patient did not
take her temp at home. She reports that starting the previous
day at 4pm she started having pain in her LLQ, nausea, vomiting
x3 (nonbloody), weakness, diaphoresis, and HA. Denies CP/SOB,
diarrhea, vaginal bleeding, abnl vaginal discharge. She had
taken Tylenol without improvement. She felt that the pain was
similar to her prior ___ episode and presented for eval.
Past Medical History:
Obstetric History: G5P4
- SVD x 1
- C-section x 3
- SAB with D&C
Gynecologic History:
- Can't recall LMP, Menses once monthly
- ___ (___), s/p recent admission with ___
drainage
- Not currently sexually active, last sexually active 2 months
ago, not on contraception
- Last Pap ___, denies history of abnormal Paps
Past Medical History:
- asthma
- obesity (BMI 76)
- dCHF
- HTN
- OSA, on BIPAP
- anemia
- ventral hernia
- depression
- osteoarthritis of knee
Past Surgical History:
- incisional hernia repair ___ with LOA, L adnexal drain
- ventral hernia repair with ? possible mesh in ___
- C-section x 3
- D&C
Social History:
___
Family History:
___ Deceased ___ HYPERTENSION
STROKE
EPILEPSY
Father Living ___ MOUTH CANCER Dx'd at age ___.
- Denies family history of breast, GYN, or colon cancers
- Denies family history of bleeding/clotting disorders, CVA or
MI
Physical Exam:
Physical Exam on Day of Admission:
97.2 ___ 26 94% RA
98.9 84 154/89 16 98% RA
80 135/77 16 98% RA
General: NAD, A&O Morbidly obese
Lungs: breath sounds distant, no wheezes
Cardiac: tachycardic. no m/r/g
Abdomen: mild to mod TTP in the LLQ, under her pannus, no TTP
over her ventral hernia, no R/G
___ no TTP
Pelvic + L>R adnexal TTP
Physical Exam on Day of Discharge:
Vital signs: Tc 98.1 Tm 99 ___ 18 983L while
sleeping,
97-98%RA during day
General: NAD, comfortable
CV: RRR
Lungs: normal work of breathing, CTAB
Abdomen: morbidly obese, soft, obese, non-distended, tender to
palpation in LLQ without rebound or guarding
Extremities: no edema, no TTP, pneumoboots in place bilaterally
Pertinent Results:
___ 01:10AM ___ PTT-27.4 ___
___ 05:23PM LACTATE-1.6
___ 05:20PM URINE HOURS-RANDOM
___ 05:20PM URINE UCG-NEGATIVE
___ 05:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-TR*
___ 05:20PM URINE RBC-2 WBC-8* BACTERIA-FEW* YEAST-NONE
EPI-4
___ 05:20PM URINE MUCOUS-RARE*
___ 05:00PM GLUCOSE-107* UREA N-12 CREAT-1.2* SODIUM-137
POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-30 ANION GAP-12
___ 05:00PM estGFR-Using this
___ 05:00PM WBC-15.6*# RBC-5.07 HGB-11.4 HCT-38.6 MCV-76*
MCH-22.5* MCHC-29.5* RDW-19.4* RDWSD-51.2*
___ 05:00PM NEUTS-82.5* LYMPHS-9.2* MONOS-7.3 EOS-0.2*
BASOS-0.3 IM ___ AbsNeut-12.87*# AbsLymp-1.43 AbsMono-1.13*
AbsEos-0.03* AbsBaso-0.04
___ 05:00PM PLT COUNT-321
___ 04:50PM WBC-UNABLE TO
Brief Hospital Course:
Ms. ___ is a lovely ___ with diastolic congestive heart
failure, morbid obesity (BMI 75), obstructive sleep apnea,
hypertension, chronic kidney disease, tuboovarian abscess
complicated by sepsis, vancomycin-resistant enterococcal urinary
tract infection, and atrial fibrillation in ___, who was
admitted with subjective fever, left lower quadrant pain,
nausea, 3 episodes of nonbloody emesis, weakness, diaphoresis
and headache. She states she last experienced these symptoms at
the time of her previous tuboovarian abscess.
CT imaging revealed 9cm left adnexal complex, multi-septated
cystic
lesion and 7.1 cm heterogeneous right cystic lesion,
demonstrating recurrent bilateral tuboovarian abscesses. She had
a leukocytosis to WBC 15.6. There was scant red blood cells on
UA and otherwise normal renal imaging on CT, therefore a low
likelihood of nephrolithiasis. Gonorrhea and chlamydia testing
was negative. Her hCG was negative and she reported she was not
sexually active. She received one dose of ampicillin,
gentamicin, and clindamycin, which was transitioned to
ceftriaxone and clindamycin given her history of chronic kidney
disease.
Patient was restarted on home metoprolol, lisinopril, and
amlodipine for chronic hypertension, Bipap for obstructive sleep
apnea, and home fluticasone and albuterol for asthma.
Interventional radiology was consulted for possible drainage of
bilateral tuboovarian abscesses.
On hospital day 2 (___), patient underwent ___ placement
of drain into left tuboovarian abscess, which drained 45cc of
purulent fluid. ___ deferred placement of right sided tuboovarian
abscess given it as unchanged from prior. Her pain was managed
on PO oxycodone and Tylenol. Infectious disease was consulted
and transitioning antibiotics from ceftriaxone and clindamycin
to Ceftriaxone and PO flagyl. Patient desaturated overnight to
89% when she was taken off oxygen. She was otherwise
asymptomatic.
On hospital day 3 (___), patient remained afebrile and
clinically well-appearing on ceftriaxone and PO flagyl. Her pain
was well controlled with Tylenol and PO dilaudid. She was weaned
off oxygen during the daytime, saturating 94% on room air in the
afternoon. Her leukocytosis resolved, with WBC 8.4.
On hospital day 4 (___), physical therapy was consulted to
assist patient in obtaining a new cane, as she misplaced hers in
the ED. Per ID and ___ recommendations, ordered CT Abd/Pelvis to
assess if right tuboovarian abscess was able to be drained for
better source control. CT Abd/Pelvis showed small, right ___,
unable to be drained, but also showed that the left ___ catheter
terminates along the periphery of a large left multiloculated
___ currently 6x6cm (prev 7.3x6.8cm). Therefore per ___ recs,
patient's left drain was flushed 3x overnight in hope to liquefy
infectious debris and aid in resolution of collection. Patient
also had markedly elevated BP yesterday of 187/96 during this
time. She was asymptomatic with all other vitals and BP
spontaneously declined 10 minutes later to 163/106. Patient was
also made NPO after midnight with IVF in case collection does
not start to drain, in which case patient would likely undergo
an ___ guided procedure to advance L catheter tip to adequately
drain ___ collection.
On hospital day 5 (___), her JP had still not had any output
therefore ___ took her to the OR for advancement of left catheter
tip further into left tuboovarian abscess to drain loculated
collection on left side. ___ attempted to advance catheter drain
however the pre-existing left pigtail catheter could not be
advanced, and was subsequently removed. An attempt to place a
new pigtail catheter was made, however unsuccessful. Fluid
culture grew E.coli and ID recommended outpatient management
with IV Ceftriaxone and PO Flagyl for ___ weeks. A PICC line was
placed and ___ services were arranged. Patient was discharge
home in stable condition with outpatient follow-up arranged with
infectious disease in ___ weeks to assess duration of IV
treatment.
Medications on Admission:
- Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
- Fluticasone Propionate 110mcg 1 PUFF IH BID
- Vitamin D ___ UNIT PO DAILY
- Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
- Multivitamins W/minerals 1 TAB PO DAILY
- Sodium Chloride Nasal ___ SPRY NU BID:PRN dry nose
- amLODIPine 10 mg PO DAILY
- Furosemide 20 mg PO DAILY
- Lisinopril 10 mg PO DAILY
- Spironolactone 25 mg PO DAILY
- Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H pain
Do not exceed 4000mg in 24 hours
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*30 Tablet Refills:*0
2. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV every
24 hours Disp #*21 Intravenous Bag Refills:*0
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
Do not drive or drink alcohol while taking this medication;
causes sedation
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
___ hours Disp #*4 Tablet Refills:*0
4. MetroNIDAZOLE 500 mg PO/NG Q8H ___
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*63 Tablet Refills:*0
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
6. amLODIPine 10 mg PO DAILY
7. Fluticasone Propionate 110mcg 1 PUFF IH BID
8. Lisinopril 10 mg PO DAILY
9. Metoprolol Succinate XL 12.5 mg PO DAILY
10. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
recurrent tuboovarian abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted with fever and found to have a tuboovarian
abscess. You were started on intravenous antibiotics and had a
drain placed into the abscess to drain the infection. You
remained without fevers and clinically well, and the drain was
removed. A PICC line was placed in order for you to receive IV
antibiotics at home. You have recovered well and the team
believes you are ready to be discharged home with the PICC line
in place. A nurse ___ come to your home daily in order to give
you antibiotics through the IV. Please call the OBGYN office
(___) with any questions or concerns. Please follow the
instructions below.
General instructions:
* Take your medications as prescribed.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* Do not drink alcohol or drive while taking narcotics.
* Please take Colace or Miralax with narcotics in order to
prevent constipation.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from drain site
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* Feeling more tired
* Swelling in the ankle legs or belly
* Discomfort/pain in the chest
* Please weigh yourself daily and call MD for any weight gain
more than 3 pounds in 1 day
Followup Instructions:
___
|
19859524-DS-26 | 19,859,524 | 20,462,426 | DS | 26 | 2151-07-23 00:00:00 | 2151-07-28 17:07:00 |
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:
Ms. ___ is a ___ female history of HFpEF
___,
morbid obesity, asthma, obstructive sleep apnea on BiPAP, and
HTN
presenting with dyspnea. Patient reports 2 weeks of URI symptoms
with runny nose and productive cough without fevers. Denies sick
contacts or anyone else sick at home. Over the last two days she
became increasingly dyspneic which got worse over yesterday. She
also endorses lower leg edema and feeling volume overload. Tried
taking nebulizer and albuterol treatments, without benefit. Of
note, per pharmacy fill records, the patient last filled a
30-day
course of Lasix in ___. But the patient says that she had
left over tablets which she was able to take until 4 days ago.
She says that she takes Lasix when she does not need to leave
her
house and doesn't otherwise. Typically she takes Lasix 40 mg QD
4
out of 7 days per week. In addition, the patient has a difficult
time abiding to a low salt diet because has lives and cooks for
5
other people in her household. She reports that last night she
had significant orthopnea waking up with dyspnea. No fever,
chills. No productive cough. No chest pain. On arrival to the
ED,
the patient is formulating sentences but is in respiratory
distress, triggered for O2 saturation at 62% for which she was
placed on BiPap. She has never been hospitalized for her asthma.
In the ED,
- Initial vitals were:
Pain 0 T 98.8 HR 131 BP 174/77 RR 40 sPO2 62% RA
- Exam notable for:
+obese
+rales bilaterally
tachypneic, retractions
- Labs notable for:
___
FluA and FluB PCR negative
proBNP 540
WBC 11.5
VBG pH 7.31, pCO2 71, HCO3 37, lactate 1.4
- Studies notable for:
___ CXR
FINDINGS:
Poorly penetrated film, likely from positioning. Bibasilar and
retrocardiac opacities are likely. Cardiomediastinal silhouette
is unchanged. The presence of pneumothorax is unlikely however
not well evaluated with quality of the film. At least small
bilateral pleural effusions are seen although again the extent
is
difficult to evaluate on this exam.
IMPRESSION:
Probable right lower lung and retrocardiac opacities. Upright
and
lateral films are recommended if patient status allows.
- Patient was given:
___ 07:43 SL Nitroglycerin SL .4 mg
___ 08:11 IV Furosemide 40 mg
___ 08:37 IV DRIP Nitroglycerin ___ mcg/kg/min ordered)
___ 09:29 IV CefTRIAXone
___ 09:59 PO Acetaminophen 1000 mg
___ 09:59 PO Ibuprofen 600 mg
___ 10:04 IV Azithromycin (500 mg ordered)
Patient urinated 1 L to the 40 IV Lasix. She was started on
nitro
gtt for systolic blood pressure in 170s. She was placed on
biPAP
for presentation with spo2 in ___ on room air. With diuresis and
trial off bipap she had desaturation to high ___. And decision
was made to transfer her the CCU for closer monitoring and
diuresis.
On arrival to the CCU, the patient endorses the history per
above. She says she still has difficulty breathing but feels a
bit better after urinating with Lasix given in the ED.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative.
Past Medical History:
PAST MEDICAL HISTORY:
Cardiac History:
- HFpEF (preserved EF on ___
- Hypertension
- PULMONARY HYPERTENSION
- PAROXYSMAL ATRIAL FIBRILLATION
Other PMH:
ASTHMA
OBESITY
OBSTRUCTIVE SLEEP APNEA, on Bipap
VENTRAL HERNIA
RECURRENT URINARY TRACT INFECTION
VENOUS STASIS ULCERS
KNEE OSTEOARTHRITIS
TUBO-OVARIAN ABSCESS AND PYOSALPINX
URINARY TRACT INFECTION - VRE ___
INCISIONAL HERNIA REPAIR ___
UMBILICAL HERNIA ___
DILATION AND EVACUATION ___
Social History:
___
Family History:
Denies family history of cardiovascular disease, pulmonary
disease, or blood clots.
Physical Exam:
Admission Physical Examination:
================================
VS: Afebrile, HR 83, BP 109/86, SpO2 94% on Bipap
GENERAL: Morbidly obese woman wearing BiPAP mask without
respiratory distress or use of accessory muscles to breathe.
Oriented x3. Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. JVP 10 cm at 60 degrees.
CARDIAC: Distant heart sounds. normal rate, regular rhythm. No
murmurs, rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Low breath sounds. No
crackles or wheezes.
ABDOMEN: Obese, Soft, non-tender, non-distended.
EXTREMITIES: Trace lower leg edema, warm, well perfused. No
clubbing, cyanosis, or peripheral edema. PVD skin changes b/l
___.
SKIN: No significant lesions or rashes.
NEURO: CNII-XII grossly normal. Moving all extremities
appropriately.
Discharge Physical Examination:
===============================
GENERAL: Morbidly obese woman on NC without respiratory distress
or use of accessory muscles to breathe. Oriented x3. Mood,
affect
appropriate.
NECK: Supple. Unable to appreciate JVD due to habitus
CARDIAC: Distant heart sounds. normal rate, regular rhythm. No
murmurs, rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Distant breath sounds.
EXTREMITIES: Trace to 1+ lower leg edema, appears worse from
yesterday. Warm, well perfused. No clubbing, cyanosis, or
peripheral edema. Chronic venous stasis changes b/l ___.
Pertinent Results:
Admission Labs:
============
___ 07:43AM BLOOD WBC-11.5* RBC-5.14 Hgb-11.6 Hct-42.3
MCV-82 MCH-22.6* MCHC-27.4* RDW-21.1* RDWSD-59.9* Plt ___
___ 07:43AM BLOOD Glucose-141* UreaN-13 Creat-1.1 Na-142
K-4.7 Cl-98 HCO3-29 AnGap-15
Discharge Labs:
================
___ 07:44AM BLOOD WBC-6.0 RBC-4.89 Hgb-11.0* Hct-40.3
MCV-82 MCH-22.5* MCHC-27.3* RDW-21.1* RDWSD-59.6* Plt ___
Brief Hospital Course:
TRANSITIONAL ISSUES:
New Medications: Warfarin, Spironolactone, Torsemide
Changed Medications: None
Discontinued Medications: Furosemide
Discharge weight: 512 lb
Discharge creatinine: 1.3
[ ] Anticoagulation: Patient started on warfarin during this
hospitalization. Will be followed in ___ clinic
after discharge
[ ] Fe Supplementation: Patient received 4 250mg doses of IV Fe
during this hospitalization
[ ] Heart Failure Management: Patient is being discharged on
Torsemide 20mg. Recommend assistance in obtaining bariatric
scale at home
[ ] Bariatric Surgery: Please ensure patient follows up for
evaluation for gastric sleeve, has appointment for orientation
at outside clinic
[ ] Labs: recommend repeat CBC and Chem-10 Panel at first PCP
appointment to ensure stability
[ ] Sleep/OSA: Encourage consistent use of Trilogy at home, has
sleep f/u in 2 weeks from discharge
[ ] Pulmonary: Recommend outpatient pulmonary f/u for daily O2
[ ] Medication Adherence: Encourage consistent adherence to
medications as able
SUMMARY STATEMENT:
=================
___ y/o woman with PMH HFpEF (>55% ___, morbid obesity,
asthma, obstructive sleep apnea on BiPAP, paroxysmal afib, and
HTN who presented ___ with dyspnea following 2 weeks of URI
symptoms, increasing lower leg swelling initially admitted to
the
CCU for CHF exacerbation requiring BiPAP with reduction in
oxygen requirement with diuresis. Patient was transferred to the
advanced heart failure service where she was managed with Lasix
gtt and transitioned to PO prior to discharge. Hospital course
otherwise notable for initiation of anticoagulation for
paroxysmal atrial fibrillation.
ACUTE ISSUES:
=============
#ACUTE ON CHRONIC DIASTOLIC CHF (HFpEF):
#Hypoxemic Respiratory Failure
Presented with hypoxia and respiratory failure, increased leg
swelling, weight 522 lbs, pro-BNP 540 (likely low due to
obesity), and pulmonary edema on CXR c/w CHF exacerbation.
Etiology likely multifactorial- medication and dietary
non-compliance as she reports inconsistent lasix usage at home
and is a ___ for multiple other people, and recent respiratory
infection. Patient initially required BiPAP on admission in the
setting of severe pulmonary edema, however, was able to be
transitioned to baseline nasal cannula ___ L) with diuresis.
She diuresed well on Lasix gtt of 5 for ___ days before being
transitioned to Torsemide 20 PO regimen at time of discharge.
Her dry weight prior to hospitalization is uncertain, however,
her weight at time of discharge was 512 lb. She was believed to
be mildly above dry weight at that time, with plan to follow up
in heart failure clinic for additional diuretic titration. She
was otherwise initiated on spironolactone for HFpEF during this
hospitalization.
#PAROXYSMAL ATRIAL FIBRILLATION: Patient is documented to have
history of paroxysmal a-fib, notably referenced in two discharge
summaries from ___, however, has never undergone outpatient
ziopatch monitoring. She was documented to have multiple short
episodes of a-fib on telemetry during this inpatient stay.
Patient was rate controlled on home metoprolol without issue.
Patient was not a candidate for DOAC therapy in setting of
elevated BMI and was started on Warfarin with extensive patient
counselling regarding the importance of medication and
compliance. She was subtherapeutic at time of discharge (1.1)
with plan to uptitrate dosage
CHRONIC MEDICAL ISSUES
======================
#HTN: Presented with systolic blood pressure in 170s without
clear symptoms of hypertensive urgency. She was initially placed
on nitro gtt in ED with minimal requirement by time of transfer
to CCU and was otherwise managed on home amlodipine and
lisinopril, with addition of spirnolactone
spironolactone.
#OSA: Patient was maintained on home trilogy and established for
follow up with sleep clinic on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB
2. amLODIPine 10 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Furosemide 40 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Metoprolol Succinate XL 12.5 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Medications:
1. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth once
a day Disp #*30 Tablet Refills:*0
2. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. ___ MD to order daily dose PO DAILY16
RX *warfarin [___] 2.5 mg ___ tablet(s) by mouth once a day
Disp #*90 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. amLODIPine 10 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Acute Heart Failure with Preserved Ejection
Fraction Exacerbation
SECONDARY DIAGNOSIS: Atrial fibrillation, Obstructive Sleep
Apnea, Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
-You were admitted because you had significant excess fluid in
your body
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
-You were admitted to the heart service and were given
medications to better optimize your fluid levels
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, seek medical attention if your
weight goes up more than 3 lbs.
-___ medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
-Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
19859532-DS-17 | 19,859,532 | 24,734,570 | DS | 17 | 2201-02-09 00:00:00 | 2201-02-16 20:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
New AML
Major Surgical or Invasive Procedure:
Bone Marrow Biopsy
History of Present Illness:
Ms. ___ is a ___ year-old otherwise healthy young woman with a
PMH menorrhagia (now off OCPs for 2 months), who presented to
the ED with worsening gingival hyperplasia, parotid swelling,
and trismus x 2 weeks. She was accompanied by her mother. She
was in her USOH up until 2 weeks ago when she began to develop
gingival swelling associated with oral mucosal discomfort. She
went to her dentist for a teeth cleaning and he prescribed her
with a 1-week course of penicillin. Her gingival swelling
continued to progress during this course with some visible
swelling of her cheeks and subsequently prompted some question a
penicillin allergy. She saw another dentist who then prescribed
her a z-pack which she took for 4 days. She saw this dentist
again on ___ for continued progression of her symptoms who
then recommended a ___ referral, however due to insurance
issues she could not be seen there. Due to ongoing worsening of
her gingival swelling, associated discomfort, and resultant
difficulty chewing and speaking she presented to the ___ ED.
Over her recent 2-week course, she has also developed
significant fatigue and has wanted to spend most of the day
sleeping, ~10+ hours/night. She has experienced drenching night
sweats, decreased appetite in combination with difficulty
chewing, and has lost 10 pounds over this 2-week period. She has
also noted pinpoint red spots on her body including on her
extremities and trunk. She had a minor episode of epistaxis from
her right nare ___ days ago which self-resolved, and her
menstrual cycle finished also ___ days ago which was not
excessively bloody or prolonged.
She otherwise denies any HA, vision changes, numbness, tingling,
weakness, chest discomfort, SOB, cough, wheezing, hemoptysis,
abdominal discomfort, nausea, vomiting, diarrhea, constipation,
hematochezia, melena, dysuria, hematuria, or joint swelling.
Past Medical History:
OTHER PAST MEDICAL HISTORY:
- car accident several years ago with need for minor surgery to
her scalp
- no other medical conditions
Social History:
___
Family History:
FAMILY HISTORY:
Denies any history of cancer, specifically including leukemia or
lymphoma.
Physical Exam:
PHYSICAL EXAM:
Vital signs: Temp 98 HR 97-107 BP 84/54 RR 16 O2sat 100%
RA
ECOG: ___
GENERAL: NAD, pale, fatigued-appearing young woman
HEENT: Prominent gingival hyperplasia, gums protrude out from
between her teeth. Anicteric sclerae, pale conjunctivae, MM
otherwise moist and pink, OP clear. floor of mouth soft
non-elevated and tender, good dentition, trismus to 25mm with
guarding, generalized diffuse mandibular/maxillary erythema and
gingival inflammation. Neck supple with significant bilateral
submandibular swelling at the inferior/posterior border of
mandible nodular, palpable lymph nodes extending towards the
clavicle and bilaterally along the cervical chain. No palpable
lymphadenopathy in the axillary, or inguinal chains bilaterally.
PULM: Symmetric breath sounds, clear bilaterally; no wheezes,
rales, or rhonchi
CV: normal rate, regular rhythm. normal S1, S2; no murmurs, rubs
or gallops
ABDOMEN: Soft, no tenderness to palpation. dullness to
percussion present in ___ space. no hepatomegaly, normal
bowel sounds
NEURO: A&Ox3. Appropriate mood and affect.
SKIN: scattered petechiae present across BUE/BLE extremities
DISCHARGE EXAM:
VS: Tm98.7 Tc97.9 HR94 BP109/58 RR 18 O2sat 100% RA
GENERAL: NAD, pale, thin, alert
HEENT:Neck supple with left triple lumen with dressing c/d/I.
PULM: CTAB, no w/r/r.
CV: RRR. normal S1, S2; no m/r/g.
ABDOMEN: Soft, NTND. BS+ No HSM.
EXT: WWP, no c/c. No ___ edema.
NEURO: A&Ox3. Affect appropriate.
SKIN: PIH on RUE, BLE, and abdomen almost completely resolved
Pertinent Results:
=========
STUDIES:
=========
___: CYTOGENETICS REPORT - Final
SPECIMEN: BLOOD, NEOPLASTIC
CLINICAL HISTORY: Suspected acute leukemia
CYTOGENETICS PROCEDURE: Unstimulated culture for Giemsa-banded
chromosome analysis.
FINDINGS: An abnormal 45,XX,-7,t(11;17)(q23;q25) female
chromosome complement with a chromosome 7 missing and a
translocation involving the distal long arms of chromosomes 11
and 17 was observed in 9 cells. 11 cells had a
46,XX,-7,+8,t(11;17)(q23;q25) chromosome complement with the
chromosome aberrations described above and an extra chromosome
8. A total of 20 mitotic cells were examined in detail.
Chromosome band resolution was 425. A karyogram was prepared on
4 cells.
CYTOGENETIC DIAGNOSIS:
45,XX,-7,t(11;17)(q23;q25)[9]/46,XX,-7,+8,t(11;17)(q23;q25)[11]
INTERPRETATION/COMMENT: Every metaphase peripheral blood cell
examined had an abnormal karyotype with monosomy 7 and a
translocation involving chromosomes 11 and 17 that FISH has
confirmed has resulted in rearrangement of the MLL gene (see
below). Two related neoplastic clones were detected. One clone
also had trisomy 8. These findings are consistent with acute
myeloid leukemia with an unfavorable prognosis.
FISH: POSITIVE for MLL REARRANGEMENT. 78% of the interphase
peripheral blood cells examined had a probe signal pattern
consistent with rearrangement of the MLL gene. MLL gene
rearrangements are usually associated with an unfavorable
prognosis in acute leukemia.
___: FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: ___, Kappa,
Lambda, and CD antigens
2,3,4,5,7,8,10,11c,19,20,23,33,34,38,56,nTdT, cMPO, cCD79a,
cCD3, cCD22, CD11b.
RESULTS: 10-color analysis with linear side scatter vs. CD45
gating was used to evaluate for leukemia. The sample viability
done by 7-AAD is 99% CD45-bright, low side-scatter gated
lymphocytes comprise 94% of total analyzed events. B cells
comprise 8% of lymphoid gated events, are polyclonal, and do not
express aberrant antigens. T cells comprise 87% of lymphoid
gated events and express mature lineage antigens CD3, CD5, CD2,
CD7. T cells have a helper-cytotoxic ratio of 1.8 (usual range
in blood 0.7-3.0). Natural killer cells comprise 3% of total
gated lymphocytes. The majority of the cells isolated from this
peripheral blood occur in the CD45-dim/intermediate side scatter
"blast" region. They express immature antigens CD38, ___
(___), myeloid associated antigens CD33, CD117 (partial),
CMPO, CD11b, CD13 (partial), monocyte-associated antigens CD4,
CD64, CD11c, lack B and T cell associated antigens, are CD10
(cALLA) negative, and are negative for CD34, nTdT, CD16, CD14.
Blast cells comprise around 50% of total gated events.
INTERPRETATION: Immunophenotypic findings consistent with
involvement by acute myeloid leukemia with monocytic
differentiation. Correlation with clinical and cytogenetic
findings and morphology. See separate pathology report
___.
Bone marrow biopsy and core aspirate ___ > ___:
HYPERCELLULAR BONE MARROW WITH EXTENSIVE INVOLVEMENT BY ACUTE
MYELOID
LEUKEMIA, SEE NOTE.
NOTE: The immature blast population represents>90% of the bone
marrow cellularity. Corresponding flow cytometry revealed
immunophenotypic findings consistent with involvement by acute
myeloid leukemia with monocytic differentiation. Cytogenetics
studies revealed evidence of a rearrangement involving the MLL
gene (see separate reports ___-___ and ___ for full
details). The morphologic, immunophenotypic and cytogenetic
findings are in keeping with involvement by acute myeloid
leukemia. Correlation with clinical and laboratory findings is
recommended.
PERIPHERAL BLOOD SMEAR: very cellular specimen with abundant
blasts as evidenced by large cells with high N:C ratio with
large and prominent punched out nucleoli and scant cytoplasm. n
odefinite Auer rods appreciated. multiple large cells of
monocytic differentiation appear present. significant
thrombocytopenia with occasional large and giant platelets
present.
==========
IMAGING:
==========
CT CHEST ___:
1. Interval placement of right internal jugular catheter with
tip terminating in the right atrium.
2. Otherwise unchanged appearance of the chest since the recent
CT of 7 days earlier with no findings to suggest active
infection or the intrathoracic malignancy.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST ___:
The paranasal sinuses are normally aerated, and there is
moderate mucosal thickening of the left maxillary sinus,
improved from the CT scan from ___. The other
visualized paranasal sinuses are clear. The ostiomeatal units
are patent. The cribriform plates are intact. There is no nasal
septal defect. The nasal septum is midline. The anterior clinoid
processes are not pneumatized. The lamina papyracea are intact.
The sphenoid sinus septum is multipartite with insertion upon
the bilateral carotid grooves. The visualized brain is
unremarkable. IMPRESSIONS: Moderate left maxillary mucosal
thickening, improved from prior CT.
ULTRASOUND ___:
FINDINGS: There is normal flow with respiratory variation in
the bilateral subclavian vein. The right internal jugular and
axillary veins are patent, show normal color flow and
compressibility. There is a PICC within the basilic vein, and
the basilic vein is not compressible. No color flow is
demonstrated around the PICC in the basilic vein. The right
brachial and cephalic veins are patent, compressible and show
normal color flow and augmentation.
IMPRESSION: Thrombus around the PICC within the right basilic
vein.
CT Sinus ___:
1. Near complete opacification of the left maxillary sinus with
aerosolized debris in the inferior left frontal sinus and
opacification of left frontal ethmoidal recess.
2. ___ tooth 14 extends into the left maxillary sinus floor.
Clinical correlation with odontogenic sinusitis is recommended.
3. No peripherally enhancing fluid collections to suggest
abscess formation.
4. Enlarged level 2A lymph nodes as well as the adenoids and
palatine tonsils compatible with patient's given history of AML.
ULTRASOUND ___:
FINDINGS: There is normal flow with respiratory variation in
the bilateral subclavian vein. The right internal jugular and
axillary veins are patent, show normal color flow and
compressibility. There is a PICC within the basilic vein, and
the basilic vein is not compressible. No color flow is
demonstrated around the PICC in the basilic vein. The right
brachial and cephalic veins are patent, compressible and show
normal color flow and augmentation.
IMPRESSION: Thrombus around the PICC within the right basilic
vein.
CT Sinus ___:
IMPRESSION:
1. Near complete opacification of the left maxillary sinus with
aerosolized debris in the inferior left frontal sinus and
opacification of left frontal ethmoidal recess.
2. ___ tooth 14 extends into the left maxillary sinus floor.
Clinical correlation with odontogenic sinusitis is recommended.
3. No peripherally enhancing fluid collections to suggest
abscess formation.
4. Enlarged level 2A lymph nodes as well as the adenoids and
palatine tonsils compatible with patient's given history of AML.
TTE ___:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Left ventricular
systolic function is hyperdynamic (EF = 75%). Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. There is mild
posterior leaflet mitral valve prolapse. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
CHEST CT ___:
IMPRESSION: Normal Chest CT. No evidence of active
intrathoracic infection or malignancy.
ABD/PELVIS CT ___:
IMPRESSION:
1. No acute process in the abdomen or pelvis. No evidence of
infection.
2. No abnormal lymphadenopathy within the abdomen or pelvis.
3. Rounded hypodensity arising from the left lobe of the liver
likely
represents a cyst.
4. Please see separate chest CT report for details of intra
thoracic findings.
CXR ___:
IMPRESSION: Right PICC still passes into the right neck and out
of view. Lungs are fully expanded and clear. Cardiomediastinal
and hilar silhouettes pleural surfaces are normal.
Panorex ___:
FINDINGS: Single Panorex image provided. The mandible appears
intact. The teeth
contain numerous fillings though there is no very a focal
lucency or obvious dental erosion.
IMPRESSION: Unremarkable exam.
CXR ___:
FINDINGS: The lungs are clear without focal consolidation. No
pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are unremarkable. IMPRESSION: No acute
cardiopulmonary process.
IMAGING:
CT CHEST ___:
1. Interval placement of right internal jugular catheter with
tip terminating in the right atrium.
2. Otherwise unchanged appearance of the chest since the recent
CT of 7 days earlier with no findings to suggest active
infection or the intrathoracic malignancy.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST ___:
The paranasal sinuses are normally aerated, and there is
moderate mucosal thickening of the left maxillary sinus,
improved from the CT scan from ___. The other
visualized paranasal sinuses are clear. The ostiomeatal units
are patent. The cribriform plates are intact. There is no nasal
septal defect. The nasal septum is midline. The anterior clinoid
processes are not pneumatized. The lamina papyracea are intact.
The sphenoid sinus septum is multipartite with insertion upon
the bilateral carotid grooves. The visualized brain is
unremarkable. IMPRESSIONS: Moderate left maxillary mucosal
thickening, improved from prior CT.
ULTRASOUND ___:
FINDINGS: There is normal flow with respiratory variation in
the bilateral subclavian vein. The right internal jugular and
axillary veins are patent, show normal color flow and
compressibility. There is a PICC within the basilic vein, and
the basilic vein is not compressible. No color flow is
demonstrated around the PICC in the basilic vein. The right
brachial and cephalic veins are patent, compressible and show
normal color flow and augmentation.
IMPRESSION: Thrombus around the PICC within the right basilic
vein.
STUDIES:
___: CYTOGENETICS REPORT - Final
SPECIMEN: BLOOD, NEOPLASTIC
CLINICAL HISTORY: Suspected acute leukemia
CYTOGENETICS PROCEDURE: Unstimulated culture for Giemsa-banded
chromosome analysis.
FINDINGS: An abnormal 45,XX,-7,t(11;17)(q23;q25) female
chromosome complement with a chromosome 7 missing and a
translocation involving the distal long arms of chromosomes 11
and 17 was observed in 9 cells. 11 cells had a
46,XX,-7,+8,t(11;17)(q23;q25) chromosome complement with the
chromosome aberrations described above and an extra chromosome
8. A total of 20 mitotic cells were examined in detail.
Chromosome band resolution was 425. A karyogram was prepared on
4 cells.
CYTOGENETIC DIAGNOSIS:
45,XX,-7,t(11;17)(q23;q25)[9]/46,XX,-7,+8,t(11;17)(q23;q25)[11]
INTERPRETATION/COMMENT: Every metaphase peripheral blood cell
examined had an abnormal karyotype with monosomy 7 and a
translocation involving chromosomes 11 and 17 that FISH has
confirmed has resulted in rearrangement of the MLL gene (see
below). Two related neoplastic clones were detected. One clone
also had trisomy 8. These findings are consistent with acute
myeloid leukemia with an unfavorable prognosis.
FISH: POSITIVE for MLL REARRANGEMENT. 78% of the interphase
peripheral blood cells examined had a probe signal pattern
consistent with rearrangement of the MLL gene. MLL gene
rearrangements are usually associated with an unfavorable
prognosis in acute leukemia.
___: FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: ___, Kappa,
Lambda, and CD antigens
2,3,4,5,7,8,10,11c,19,20,23,33,34,38,56,nTdT, cMPO, cCD79a,
cCD3, cCD22, CD11b.
RESULTS: 10-color analysis with linear side scatter vs. CD45
gating was used to evaluate for leukemia. The sample viability
done by 7-AAD is 99% CD45-bright, low side-scatter gated
lymphocytes comprise 94% of total analyzed events. B cells
comprise 8% of lymphoid gated events, are polyclonal, and do not
express aberrant antigens. T cells comprise 87% of lymphoid
gated events and express mature lineage antigens CD3, CD5, CD2,
CD7. T cells have a helper-cytotoxic ratio of 1.8 (usual range
in blood 0.7-3.0). Natural killer cells comprise 3% of total
gated lymphocytes. The majority of the cells isolated from this
peripheral blood occur in the CD45-dim/intermediate side scatter
"blast" region. They express immature antigens CD38, ___
(___), myeloid associated antigens CD33, CD117 (partial),
CMPO, CD11b, CD13 (partial), monocyte-associated antigens CD4,
CD64, CD11c, lack B and T cell associated antigens, are CD10
(cALLA) negative, and are negative for CD34, nTdT, CD16, CD14.
Blast cells comprise around 50% of total gated events.
INTERPRETATION: Immunophenotypic findings consistent with
involvement by acute myeloid leukemia with monocytic
differentiation. Correlation with clinical and cytogenetic
findings and morphology. See separate pathology report
___.
Bone marrow biopsy and core aspirate ___ > ___:
HYPERCELLULAR BONE MARROW WITH EXTENSIVE INVOLVEMENT BY ACUTE
MYELOID
LEUKEMIA, SEE NOTE.
NOTE: The immature blast population represents>90% of the bone
marrow cellularity. Corresponding flow cytometry revealed
immunophenotypic findings consistent with involvement by acute
myeloid leukemia with monocytic differentiation. Cytogenetics
studies revealed evidence of a rearrangement involving the MLL
gene (see separate reports ___ and ___ for full
details). The morphologic, immunophenotypic and cytogenetic
findings are in keeping with involvement by acute myeloid
leukemia. Correlation with clinical and laboratory findings is
recommended.
PERIPHERAL BLOOD SMEAR: very cellular specimen with abundant
blasts as evidenced by large cells with high N:C ratio with
large and prominent punched out nucleoli and scant cytoplasm. n
odefinite Auer rods appreciated. multiple large cells of
monocytic differentiation appear present. significant
thrombocytopenia with occasional large and giant platelets
present.
TTE ___:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Left ventricular
systolic function is hyperdynamic (EF = 75%). Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. There is mild
posterior leaflet mitral valve prolapse. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
CHEST CT ___:
IMPRESSION: Normal Chest CT. No evidence of active
intrathoracic infection or malignancy.
ABD/PELVIS CT ___:
IMPRESSION:
1. No acute process in the abdomen or pelvis. No evidence of
infection.
2. No abnormal lymphadenopathy within the abdomen or pelvis.
3. Rounded hypodensity arising from the left lobe of the liver
likely
represents a cyst.
4. Please see separate chest CT report for details of intra
thoracic findings.
CXR ___:
IMPRESSION: Right PICC still passes into the right neck and out
of view. Lungs are fully expanded and clear. Cardiomediastinal
and hilar silhouettes pleural surfaces are normal.
Panorex ___:
FINDINGS: Single Panorex image provided. The mandible appears
intact. The teeth
contain numerous fillings though there is no very a focal
lucency or obvious dental erosion.
IMPRESSION: Unremarkable exam.
CXR ___:
FINDINGS: The lungs are clear without focal consolidation. No
pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are unremarkable. IMPRESSION: No acute
cardiopulmonary process.
Brief Hospital Course:
___ with newly diagnosed AML with adverse cytogenetics,
induction with 7+3, s/p BM Bx at Day 14 (___), awaiting BM
transplant.
# New AML with adverse cytogenetics: On admission, patient
presented with prominent gingival hyperplasia a/w submandibular
LAD, parotid swelling, and trismus x 2 weeks. Found to have WBC
50 in the setting of anemia, thrombocytopenic, and numerous
circulating blasts on peripheral smear, concerning for
monocytic/monoblastic subtype. No e/o tumor lysis or
leukostasis. CT Torso otherwise normal, TTE normal. Bone marrow
aspirate and biopsy confirmed AML with monocytic differentiation
and MLL rearrangement. BM > 90% blasts. Cytogenetics negative
for FLT3, PMR/RARa. Cytogenetics positive for
45,XX,-7,t(11;17)(q23;q25)[9]/46,XX,-7,+8,t(11;17)(q23;q25)[11].
G6PD negative on ___, so can give rasburicase if needed. Flow
34-, myeloid markers, many immature cells, blasts are 34-, 33+,
cytoplasmic MPO. Has MLL rearrangement, worse-risk
translocation. s/p BM Bx on ___ (day 14), results pending.
s/p Lupron given risk of thrombocytopenic bleeding (D1: ___,
next dose in 4 weeks). BM match screening of siblings (has
sister and brother). s/p Induction with 7+3: Daunorubicin 120
mg IV Days 1, 2 and 3 (___), Cytarabine 130 mg IV Days
1, 2, 3, 4, 5, 6 and 7 (___), Lorazepam 0.5-1 mg IV
Q6H:PRN anxiety, Ondansetron 8 mg IV Q8H:PRN nausea and vomiting
Hydrea 2g BID ___ ___ > 1g BID on ___ ___ > d/c ___ AM ,
Allopurinol ___ mg daily (dc'ed on ___, uric acid wnl)
# Fever and neutropenia: On ___, patient with new URI symptoms
but no fever. On ___, Tm 100.1. Persistent fevers, concern for
infection vs thrombosis vs malignancy vs chemotherapy. On ___,
Tmax 101.2 with ANC of 0. DDX: infection vs malignancy. On
admission, Tmax in the ED of 101 in setting of ANC < 1000.
Patient continued to spike intermittently, tx with prn
acetaminophen with good effect. Treating empirically with
cefepime/vanc/flagyl, source likely left-sided odontogenic
sinusitis vs mucositis. CT sinus on ___ showed left-sided
odontogenic sinusitis, CT a/p/c negative. On ___, patient
spiked fever to 101.2 coincident with development of thrombus
around RUE PICC in the R basilica vein as detected on
ultrasound. RUE ___ dc'ed on ___ and replaced with triple
lumen central line. Repeat sinus CT on ___: Moderate left
maxillary mucosal thickening, improved from prior CT. Patient
had second episode of febrile neutropenia which resolved after
removal of right IJ.
# Coagulopathy: Patient presented on admission in ___. INR on
___, started vitamin K. Patient presented on admission
with isolated prolonged ___ ___ with elevated fibrinogen
345 and normal PTT. Likely vitK deficiency given poor
nutritional intake, -10lb weight loss, therefore gave patient
vitamin K and trend for improvement. However, given trend in ___
labs, concern for DIC vs evolution to APML given downward
trending fibrinogen, upward trending coags, elevated D-Dimer.
Extremely elevated D-Dimer expected in patients with AML, but
also concerning for DIC. Improved and normalized prior to
discharge.
# Severe anemia: Presented with an H/H 6.5/23.6 with MCV 99.
Retic 0.3 low. She received transfusions as needed for platelets
less than 10 and Hgb less than 7.
# Thrombocytopenia: On admission, plt 17. In setting of concern
for DIC, transfused for plt < 10 due to the increased risk of
spontaneous bleeding.
# Thrombosis: Stable. On ___, RUE ultrasound showed stable
clot. On ___, patient developed increasing erythema around RUE
___ site extending up to R shoulder. Patient with occlusive
clot around RUE ___ with erythema and tenderness developing on
___. Spiked a fever on ___ at ___ to 100.6 likely d/t clot.
Clot stable, will hold off on anticoagulation in the setting of
thrombocytopenia. s/p temporary triple lumen on ___. s/p R
PICC dc'ed
# GERD: Stable. Patient c/o bloating and reflux after meals.
Miralax prn. Simethicone. Omeprazole BID transitioned to daily.
Bowel regimen with senna and colace
# Coping/psychosocial: Patient appears to be coping well, has
good social supports. On ___, patient purchased a white cap
as her hair has begun to fall out. Her best friend, ___ came
to visit her on ___. On ___, patient became very despondent
and tearful when her mother could not visit her due to illness.
On admission, patient and mother understood her dx of acute
leukemia, requiring a prolonged hospital course lasting weeks
with IV chemotherapy. Patient anxious, concerned about being a
financial burden to family.
# Rash: Resolved. Likely drug exanthem (cytarabine vs
allopurinol vs flagyl). On ___, RUE rash pruritic and spread
to abdomen and BLE, improved with clobetasol and Benadryl. On
___, new papular eruption spreading from antecubital fossa
near old ___ site to R upper shoulder, mildly pruritic. On
___, papular pruritic eruption under the chin. Rash on chin
resolved on ___ with discontinuing facial wash and
hydrocortisone. Chin rash likely contact dermatitis given
chronicity and a/w new topical facial wash.
# Dysmenorrhea: Resolved. On ___, developed lower abdominal
pain a/w spotting, responsive to oxycodone. On ___, period
started, cramps severe, improved on ___. s/p Lupron on ___
and ___.
# Mucositis: Resolved prior to discharge. On ___, new ulcer.
On ___, patient complaining of odynophagia. On exam, OP with
several mucosal ulcers and erythema of the posterior pharynx.
# Gingival hyperplasia: Resolved. On clinical exam,
submandibular swelling in posterior mandible consistent with
inflamed lymph nodes, generalized diffuse mandibular and
maxillary erythema and inflammation of gingiva throughout
dentition. Presented on admission with chronic gingival
swelling, associated discomfort, and resultant difficulty
chewing and speaking. Per OMFS, does inflammation of gingiva not
odontogenic in origin.
TRANSITIONAL ISSUES:
# LUPERON ADMINISTERD ___
# CODE: FULL CODE
# EMERGENCY CONTACT: Mother ___ (___)
# PCP: ___ MD
# Oncologist: ___ ND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Scalp Prosthesis
Scalp Prosthesis
ICD-9 code: ___
Diagnosis: Acute myeloid leukemia
Name: Dr. ___ information: ___
2. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every 8 hours Disp
#*90 Tablet Refills:*0
3. Omeprazole 20 mg PO DAILY reflux
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
4. Fluconazole 400 mg PO Q24H
RX *fluconazole 200 mg 2 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute myeloid leukemia
Right UE catheter associated thrombus
Catheter associated infection
GERD
Pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on ___ with gum changes and were
found to have leukemia. We started treatment with chemotherapy
and we are preparing for a bone marrow transplant. While you
were here we found that you had a blood clot associated with one
of your access line as well as an infection. We had to remove
these lines and treat you with antibiotics. Additionally we gave
you an injection to stop you from having your period to prevent
anemia. Lastly we gave you medication to stop your heartburn and
to treat your pain, we are sending you home on acyclovir and
fluconazole which are medications to help prevent you from
getting an infection. Please take all medications as prescribed
and attend all of your follow up appointments. It was an honor
to take part in your healthcare. Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
19859532-DS-20 | 19,859,532 | 22,116,947 | DS | 20 | 2201-05-01 00:00:00 | 2201-05-01 16:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with monocytic AML with unfavorable cytogenetics (monosomy
7, MLL rearrangement and trisomy 8) who is s/p induction
chemotherapy with 7+3, one cycle of consolidation with HiDAC and
now day +33 of Allo stem cell transplant (Day 0: ___ who
presented with 3 days of diarrhea after increasing her PO Mg
intake.
She was in ___ when seen in clinic on ___ at which point
persistent hypomagnesemia was noted; she was instructed to
increase her Mg oxide from 400mg daily to BID at that point. The
following day she did so, and she developed loose stools, only
___ episodes of loose stools, non-bloody no tarry stools and not
watery, over the weekend. Then yesterday she developed some
abdominal cramping which preceded bowel movements, and diarrhea
became more liquidy. She states yesterday in total including ED
course she had 4 episodes of diarrhea, one large volume the
other
small volume. Still no blood. Other than mild cramping which to
her seems consistent with prior diarrheal episodes she has had
in
the past (prior to transplant) she has no abdominal pain or
nausea/vomiting. No headaches. No fevers or chills at home. Her
mother has also been preparing high magnesium foods for her and
since her clinic appointment she has been specifically eating
primarily only high magnesium foods, including pumpkin seeds and
nuts. No other sick contacts.
ED COURSE:
T 99.1 HR 119, BP 108/70 RR 18 98%RA. Labs with WBC 10.8 up
from
6 in clinic, Hct 23.7, PMNs 55%, ANC 5960, plts 231. LFTs
including Tbili reassuring. Lactae 1.7. SHe was given 1L IVF.
On arrival to the floor states she feels well, cramping appears
to have subsided, and regardless she states it is very short
lived when it does occur. At the moment denies any abdominal
pain
or cramping or chills or nausea. No dysuria or pain anywhere
else
either. She is comfortable and alert and interactive and
pleasant.
Past Medical History:
PAST ONCOLOGY HISTORY
___: Presented to ___ ED with several week history of
gingival hyperplasia and fevers. WBC 49.5 with 60% blasts. MLL
rearranagement, monosomy 7, trisomy 8.
___: BM biopsy confirmed AML (100% hypercellularity, 93%
blasts
with AML monocytic phenotype).
BM cytogenetics were similar to PB findings.
FLT3, NMP1, CEBPA mutations not detected.
Echo demonstrated normal EF.
___: 7+3 initiated with daunorubicin 90 and cytarabine.
___: Day +14 BM demonstrated aplasia with no blasts.
___: BM biopsy performed after recovery of counts demonstrated
morphologic remission.
FISH studies detected the previously observed monosomy 7 in 7%
of
interphase cells and the previously observed MLL rearrangement
in
5% of interphase cells.
___: Received HiDAC consolidation cycle 1 as inpatient.
Tolerated well without any complications.
___: ___ confirms remission with FISH negative for both
monosomy 7 and MLL rearrangement both previously observed on
___ and ___.
PAST MEDICAL HISTORY:
None
Social History:
___
Family History:
Her parents are alive and in good overall health. Her father has
hypertension. She does not know of any family members who have
had cancer.
Physical Exam:
PHYSICAL EXAM on ADMISSION:
VITAL SIGNS: T 97.9 Bp 106/62 HR 102 RR 18 100%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, NTND, no masses or hepatosplenomegaly.
Completely
nontender
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
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.
PHYSICAL EXAM on DISCHARGE:
Vitals: Tm 98.2 BP 92-120/50-66 P 72-105 R 18 SatO2 98-100/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
Abd: BS+, soft, NTND, no masses or hepatosplenomegaly.
Non-tender to palpation over all quadrants. No rebound or
guarding.
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
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.
Pertinent Results:
LABS on ADMISSION:
___ 10:12PM BLOOD WBC-10.8*# RBC-2.48* Hgb-7.8* Hct-23.7*
MCV-96 MCH-31.5 MCHC-32.9 RDW-16.2* RDWSD-55.1* Plt ___
___ 10:12PM BLOOD Neuts-55.0 Lymphs-18.8* Monos-16.2*
Eos-9.2* Baso-0.3 Im ___ AbsNeut-5.96# AbsLymp-2.03
AbsMono-1.75* AbsEos-0.99* AbsBaso-0.03
___ 10:12PM BLOOD Plt ___
___ 06:04AM BLOOD ___ PTT-31.6 ___
___ 10:12PM BLOOD Glucose-143* UreaN-11 Creat-0.6 Na-141
K-4.0 Cl-103 HCO3-24 AnGap-18
___ 10:12PM BLOOD ALT-14 AST-37 AlkPhos-104 TotBili-0.4
___ 10:12PM BLOOD Lipase-25
___ 10:12PM BLOOD Albumin-4.4 Calcium-10.7* Phos-4.9*
Mg-1.6
___ 09:05AM BLOOD Cyclspr-97*
___ 10:00AM BLOOD Cyclspr-98*
___ 10:24PM BLOOD Lactate-1.7
LABS on DISCHARGE:
___ 12:00AM BLOOD WBC-4.5 RBC-2.80* Hgb-8.7* Hct-26.5*
MCV-95 MCH-31.1 MCHC-32.8 RDW-15.6* RDWSD-53.4* Plt ___
___ 12:00AM BLOOD Neuts-43.3 ___ Monos-17.3*
Eos-14.1* Baso-0.2 Im ___ AbsNeut-1.93 AbsLymp-1.11*
AbsMono-0.77 AbsEos-0.63* AbsBaso-0.01
___ 12:00AM BLOOD Plt ___
___ 12:00AM BLOOD ___ PTT-31.8 ___
___ 12:00AM BLOOD Glucose-77 UreaN-12 Creat-0.5 Na-139
K-3.9 Cl-106 HCO3-25 AnGap-12
___ 12:00AM BLOOD ALT-12 AST-35 LD(LDH)-235 AlkPhos-90
TotBili-0.3
___ 12:00AM BLOOD Albumin-4.0 Calcium-9.7 Phos-5.0* Mg-1.6
___ 09:30AM BLOOD Cyclspr-264
MICRO:
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.
FEW POLYMORPHONUCLEAR LEUKOCYTES.
FECAL CULTURE (Final ___:
NO SALMONELLA OR SHIGELLA FOUND.
NO ENTERIC GRAM NEGATIVE RODS FOUND.
CAMPYLOBACTER CULTURE (Preliminary):
NO CAMPYLOBACTER FOUND ; CONFIRMATION PENDING.
Reported to and read back by ___ ___
11:50AM.
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.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
CMV Viral Load (Final ___:
CMV DNA not detected.
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___. ___ (___)
AT 12:03
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification.
BLOOD CULTURE (___): pending
Brief Hospital Course:
___ with monocytic AML with unfavorable cytogenetics (monosomy
7, MLL rearrangement and trisomy 8) who is s/p induction
chemotherapy with 7+3, one cycle of consolidation with HiDAC and
now day +33 of Allo stem cell transplant (Day 0: ___ who
presented with 3 days of diarrhea after increasing her PO Mg
intake, found to have C. diff (on vanco PO).
ACTIVE ISSUES:
# Diarrhea - Improving. C. Diff positive. On admission, pt
without fever, BRBPR or melena, and clear time course coinciding
exactly to the date with up-titration of magnesium oxide after
clinic visit 5 days prior to admission. Symptoms initially
thought likely attributable to magnesium ingestion, compounded
by intake of Magnesium enriched foods. However, the patient was
found to be C. diff positive. There is concern for possible
development of GVHD in the setting of this infection, which can
serve as an immunological trigger for GVHD. Further concerning
that cyclosporine level of 97 on ___ and 98 on ___, which was
subtherapeutic and can lead to GVHD. Cyclosporine level on ___. Of note, the patient's WBC was elevated to 10.8 on
admission, down-trending to 5.7 on ___. Patient is norovirus
negative, CMV VL not detected. Stool cultures showed no O&P,
campy, shigella, salmonella, enteric GNRs, vibrio, Yersinia, E.
coli 0157:H7. Patient was started on Vancomycin Oral Liquid ___
mg PO/NG Q6H (day 1: ___, for 14 days). F/u blood cultures from
___ (pending ___.
# AML- monocytic AML with unfavorable cytogenetics (monosomy 7,
MLL rearrangement and trisomy 8) who is s/p induction
chemotherapy with 7+3, one cycle of consolidation with HiDAC and
now day +32 of Allo stem cell transplant/ Pt had bone
marrow biopsy on ___ prior to admission confirming remission
(FISH was negative for both monosomy 7 and MLL rearrangement
both previously observed on ___ and ___. Cyclosporine
level (___) was 95 (last level 441 goal 150-250, recently
decreased to 50mg bid. Her CSA level has been somewhat erratic
will follow w/ labs). Cyclosporine level ___ was 165, and 264 on
___. We increased cyclosporine 75 mg Q12H. Patient continued
ppx: acyclovir, fluconazole and Bactrim (started on
___. Last dose of Lupron given on ___.
# Anemia: Baseline for past two months appears to be Hbg
___. This is likely due to recent transplant,
chemotherapy, and anemia of inflammatory block. No evidence of
blood loss, BP stable, has mild tachycardia at baseline per
review of OMR. Denies melena or BRBPR. Trend hct.
# Hypomagnesemia - has needed repletion, taking Mg Oxide as
outpatient. Monitored and repleted prn with IV formulation as
suspect diarrhea related to aggressive po mg supplementation.
TRANSITIONAL ISSUES:
- Follow up with PCP and oncologist within 1 week of discharge.
- Trend cyclosporine level (increased from 50 mg to 75 mg Q12H
due to level at 165)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
3. Famotidine 20 mg PO BID
4. Fluconazole 400 mg PO Q24H
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Ursodiol 300 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. FoLIC Acid 1 mg PO DAILY
9. Magnesium Oxide 400 mg PO BID
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
RX *cyclosporine modified [Neoral] 25 mg 3 capsule(s) by mouth
every 12 hours Disp #*84 Capsule Refills:*0
3. Famotidine 20 mg PO BID
4. Fluconazole 400 mg PO Q24H
5. FoLIC Acid 1 mg PO DAILY
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. Ursodiol 300 mg PO DAILY
8. Vancomycin Oral Liquid ___ mg PO/NG Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*48 Capsule Refills:*0
9. Docusate Sodium 100 mg PO BID
10. Magnesium Oxide 400 mg PO BID
11. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
C. difficilis
Secondary Diagnoses:
AML
Allo stem cell transplant (Day 0: ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
because you had worsening diarrhea. You were admitted to the ___
service and you were found to have C. diff. We gave you PO
vancomycin, which you should take for a total of 14 days (last
day on ___.
We monitored your level of cyclosporine, and increased it from
50 mg to 75 mg every 12 hours because the cyclosporine level was
165.
Please continue to keep hydrated (take plenty of fluids) and
monitor the number of times that you have diarrhea, as well as
the quantity. If your diarrhea worsens, please go to the ER as
soon as possible.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
19859576-DS-5 | 19,859,576 | 27,268,735 | DS | 5 | 2153-08-09 00:00:00 | 2153-08-09 15:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
bloody cough
Major Surgical or Invasive Procedure:
-Bronchoscopy ___
History of Present Illness:
In brief, this is a ___ M COPD, active tobacco, DM2, CAD s/p DES
on ASA/Plavix admitted for hemoptysis.
-On ___, patient performed Heimlich maneuver on his
girlfriend 3 days ago when she knocked a tooth out. Initially he
didn't notice anything until the following day. Patient states
that he filled up ___ pink kidney shaped containers' worth of
blood on the ___. Hemoptysis tapered subsequently.
-Patient confirms taking penicillin q2H for 3 days in hopes of
improving the hemoptysis.
-Patient confirmed increased SOB above baseline and general
weakness as well.
-Patient also confirmed one black bowel movement on the ___.
Past Medical History:
OSA
HTN
DM2
COPD
Hyperlipidemia
CHF with diastolic dysfunction. EF 64%.
Bipolar d/o, stopped meds
CAD. Per his report, h/o MI x 3 (as above, allergic rxn to fire
ants, dog bite and falling out of bldg)
Tobacco abuse
recently diagnosed PAF
None
Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension
.
Cardiac History: CABG, in anatomy as follows: none
.
Percutaneous coronary intervention, in anatomy as follows: ___.
No report available
.
Pacemaker/ICD, in: none
Social History:
___
Family History:
Mother had brain tumor, HTN, h/o MI. Father also ahd MI, HTN,
hyperlipdiemia and died of suicide.
Physical Exam:
ADMISSION EXAM:
===============
Vital Signs: 98.6 140/78 62 18 98% 4L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: NLB on RA, diffuse expiratory wheezes
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact grossly, ___ strength upper/lower
extremities, grossly normal sensation, gait deferred.
DISCHARGE EXAM:
===============
Vital Signs: 98 133/77 68 18 96RA
General: Alert, oriented, no acute distress
Neuro: face grossly symmetric and moving all limbs with purpose
against gravity
Psych: pleasant mood
HEENT: Sclera anicteric, EOMI
Lungs: wheezes heard bilaterally. p
CV: rrr
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm, well perfused, no edema
Pertinent Results:
ADMISSION LABS:
===============
___ 06:30PM BLOOD WBC-6.6 RBC-4.47* Hgb-13.3* Hct-40.2
MCV-90 MCH-29.8 MCHC-33.1 RDW-13.3 RDWSD-43.7 Plt ___
___ 06:30PM BLOOD ___ PTT-32.6 ___
___ 06:30PM BLOOD Glucose-173* UreaN-11 Creat-0.8 Na-140
K-4.2 Cl-103 HCO3-24 AnGap-17
___ 06:30PM BLOOD Calcium-9.8 Phos-3.1 Mg-1.8
DISCHARGE LABS:
===============
___ 05:03AM BLOOD WBC-10.4* RBC-4.07* Hgb-11.8* Hct-37.0*
MCV-91 MCH-29.0 MCHC-31.9* RDW-13.3 RDWSD-44.2 Plt ___
___ 09:30AM BLOOD ___
___ 05:03AM BLOOD Glucose-282* UreaN-18 Creat-0.8 Na-137
K-4.0 Cl-101 HCO3-26 AnGap-14
___ 05:03AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0
MICROBIOLOGY:
=============
NONE
PERTINENT STUDIES:
==================
___ CXR:
1. Small metallic foreign body projects over the right lower
lobe bronchi and remains in unchanged position compared to the
chest CT from ___.
2. There is no distal lung collapse/subsegmental atelectasis or
pleural
effusions.
___ CT CHEST: DONE AT OSH. NO OFFICIAL READ AT ___
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
======================
___ M with PMHx COPD, DM2, CAD s/p stent DES ___ admitted for
hemoptysis. Imaging revealed what is likely the tooth that he
dislodged prior to admission in his right lower lobe bronchi.
Interventional pulmonology attempted to retrieve the tooth via
bronchoscopy; however, given the amount of blood, granulation
tissue, and distal location, was unable to retrieve tooth.
Patient was then assessed by thoracic surgery for possible
surgical resection. Fortunately, patient remained clinically
stable, his H&H remained stable, and stopped coughing up blood,
and so, surgical resection was deferred. Patient was discharged
on augmentin, steroids, tesselon pearls. holding his Plavix
until repeat bronch. Plan is for patient to have repeat
bronchoscopy with IP in following week with pulmonary imaging
and testing in the interim.
ACUTE ISSUES:
=============
#Hemoptysis:
#Foreign body aspiration (tooth):
tooth seen on CXR and CT chest, likely cause of hemoptysis. IP
consulted and attempted bronchoscopy. Unsuccessful retrieval
given distal location of tooth. IP, however, was able to
aspirate some of the blood clots and granulation tissue. Patient
on floor continued to have small amounts of hemoptysis but
clinically stable, improved over course of admission with
resolution of hemoptysis. Thoracic consulted for consideration
of surgical resection, recommended outpatient PFTs and repeat IP
attempt prior to more invasive intervention. Per IP recs:
prednisone 40mg x 7 days, augmentin 875 BID x7 days, Benzonatate
TID, holding aspirin and Plavix. Per IP recs: CT chest with
super D protocol on ___, PFTs with tentative repeat bronch.
Plan is to have patient follow up as outpatient with IP for
extraction tooth via repeat bronchoscopy on ___. On day of
discharge, patient's H&H was stable and had not had episode of
hemoptysis for 24 hours.
#CAD/PCI s/p 5 stents. Most recent stent in ___, per patient.
Patient's metoprolol and nitroglycerin SL PRN, and atorvastatin
were continued. However, given setting of hemoptysis, decision
was made by interventional pulmonology team and primary team to
hold aspirin and Plavix given significant bleeding risk and
pending procedures. Per IP recommendations, patient was
discharged on baby aspirin but Plavix was held given risk of
rebleed and pending bronchoscopy on ___. Patient's aspirin
and Plavix will need to be readdressed after successful removal
of tooth.
CHRONIC ISSUES:
===============
#COPD: wheezing on exam, exacerbated by foreign body on
underlying COPD. Oxygen saturations wnl, continued on home
regimen of montelukast, iptratropium-albuterol.
Budesonide-formoterol was not on formulary and given
fluticasone-salmeterol while inpatient. Patient however stated
his HR races on fluticasone-salmeterol. Given patient's good
respiratory condition on ipra-alb and montelukast, held on long
acting beta agonist-steroid inhaler. Patient was satting in the
mid to high 90's on room air and discharged without no changes
to home regimen, no wheezing on exam prior to discharge.
#HTN: continued lisinopril and isosorbide home regimen with no
changes upon discharge.
#DM2: held metformin and glipizide home regimen and placed on
ISS. Patient discharged with no changes to home regimen.
#Chronic hip pain: controlled on home regimen. Standing
acetaminophen, gabapentin 600 qHS and oxycodone PRN for pain.
Patient discharged with no modifications to home regimen.
#GERD: continued home regimen of omeprazole with no changes to
home regimen
#Tobacco use: declined nicotine replacement
TRANSITIONAL ISSUES:
====================
[]repeat bronchoscopy on ___ with interventional
pulmonology
[]complete 7 day course of augmentin and prednisone (last dose
on ___. Patient will continue taking Tessalon Perles
(benzonatate) until appointment with interventional pulmonology.
[]Patients' aspirin was reduced to 81mg daily and Plavix was
held given hemoptysis and pending bronchoscopy. Patient's
aspirin and Plavix regimen will need to be reassessed once tooth
is extracted
[]CT chest with super D protocol on ___.
[]PFTs to be done before seeing interventional pulmonology as
well. These have been ordered.
[]follow up with his PCP as soon as possible
NEW MEDICATIONS:
================
-Amoxicillin-Clavulanic Acid (augmentin) 875 mg PO 1 tab twice a
day. Last dose on ___
-Benzonatate (tessalon perles) 100 mg PO 1 tab three times a
day. Continue taking until you see interventional pulmonology.
-PredniSONE 40 mg PO 1 tab daily. Last dose ___
CHANGED MEDICATION DOSING TO:
=============================
-Aspirin 81mg one tab daily. Interventional pulmonology will
make changes after seeing patient.
STOPPED MEDICATIONS:
====================
-Clopidogrel (Plavix) pending repeat bronchoscopy.
Interventional pulmonology will make changes after seeing
patient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 severe allergic
reactions
2. Lisinopril 40 mg PO DAILY
3. Hydrocortisone Cream 2.5% 1 Appl TP DAILY:PRN lesions on
forearms
4. Gabapentin 600 mg PO QHS
5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB
6. Metoprolol Succinate XL 25 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Fluticasone Propionate NASAL 2 SPRY NU BID
9. Atorvastatin 20 mg PO QPM
10. Montelukast 10 mg PO DAILY
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN CP repeat up to 3 tabs
the call ___. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Moderate
14. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
15. Clopidogrel 75 mg PO DAILY
16. Omeprazole 40 mg PO DAILY
17. Aspirin 325 mg PO DAILY
18. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation Q4H:PRN
19. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
20. GlipiZIDE XL 10 mg PO DAILY
21. Lidocaine 5% Ointment 1 Appl TP DAILY hip pain
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*11 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*10 Tablet
Refills:*0
3. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
4. PredniSONE 40 mg PO DAILY Duration: 7 Days
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*10 Tablet
Refills:*0
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation Q4H:PRN
6. Atorvastatin 20 mg PO QPM
7. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
8. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 severe allergic
reactions Duration: 1 Dose
9. Fluticasone Propionate NASAL 2 SPRY NU BID
10. Gabapentin 600 mg PO QHS
11. GlipiZIDE XL 10 mg PO DAILY
12. Hydrocortisone Cream 2.5% 1 Appl TP DAILY:PRN lesions on
forearms
13. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q4H
14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
15. Lidocaine 5% Ointment 1 Appl TP DAILY hip pain
16. Lisinopril 40 mg PO DAILY
17. MetFORMIN (Glucophage) 1000 mg PO BID
18. Metoprolol Succinate XL 25 mg PO DAILY
19. Montelukast 10 mg PO DAILY
20. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN CP repeat up to 3 tabs
the call ___. Omeprazole 40 mg PO DAILY
22. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Moderate
23. HELD- Aspirin 325 mg PO DAILY This medication was held. Do
not restart Aspirin until after speaking with interventional
pulmonology
24. HELD- Clopidogrel 75 mg PO DAILY This medication was held.
Do not restart Clopidogrel until after speaking with
inteventional pulmonology
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
-Hemoptysis
- foreign body aspiration
SECONDARY DIAGNOSES:
====================
-Dislodged tooth
-COPD
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 you come to the hospital?
-You were concerned because you were coughing up blood
What did you receive in the hospital?
-We imaged you which revealed that there was indeed something
lodged in your right lung airway, likely the tooth that was
dislodged before you came into the hospital.
-We attempted to retrieve the tooth with a scope, but it was too
far down.
-We took you off your aspirin and Plavix given your bloody
cough.
-We put you on a couple of new medications as described below.
-We monitored you for continued blood loss, and fortunately, you
stopped coughing blood during your hospitalization.
What should you do when you leave the hospital?
-Please continue taking your new medications as prescribed
below.
-Please note we have made changes to your aspirin and Plavix as
described below.
- You will be called with the date & time of your lung tests. If
you haven't received a call by ___, please call ___
to confirm
- You have a CT scan of your lungs scheduled on ___. This
will be at ___. You must get this scan before your
procedure. If you have not received a call with the time of this
appointment by ___, please call ___ to confirm
- You have another scope procedure on ___. Don't
eat or drink anything after midnight on ___ before the
procedure. Come to the ___ Building at ___ for this
procedure.
- Please return to the Emergency Room if you begin coughing up
blood again.
NEW MEDICATIONS:
================
-Amoxicillin-Clavulanic Acid (augmentin) 875 mg PO 1 tab twice a
day. Last dose on ___
-Benzonatate (tessalon perles) 100 mg PO 1 tab three times a
day. Continue taking until you see interventional pulmonology.
-PredniSONE 40 mg PO 1 tab daily. Last dose ___
CHANGED MEDICATION DOSING TO:
=============================
-Aspirin 81mg one tab daily. Interventional pulmonology will
make changes after seeing patient.
STOPPED MEDICATIONS:
====================
-Clopidogrel (Plavix) pending repeat bronchoscopy.
Interventional pulmonology will make changes after seeing
patient.
Followup Instructions:
___
|
19859733-DS-12 | 19,859,733 | 25,811,835 | DS | 12 | 2129-10-04 00:00:00 | 2129-10-04 20:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD ___
Large volume para ___
Endoscopy ___
History of Present Illness:
Mr. ___ is a ___ man with EtOH cirrhosis decompensated by
varices (last variceal bleed ___, h/o ___ tears,
EtOH use disorder c/b withdrawal seizures, PTSD, and Bipolar who
is presenting with two days of hematemesis, melena, worsening
abdominal pain and distention in the setting of recent EtOH
relapse.
Mr. ___ states that he has been sober for the past ~10
months
as he was recently incarcerated. He was released from prison ~1
week ago, and due to a number of social stressors (mother
recently had a stroke, wife is actively drinking, PTSD from
being
in the military and recent incarceration) he started drinking
heavily ___ days ago (estimates >20 nips yesterday). He notes
that since he relapsed, he has had worsening abdominal pain,
distention, hematemesis and melena for the past ___ days. His
wife found him in his hotel room "passed out" and with "blood
all
over the sheets," and subsequently called EMS where he was taken
to ___.
He describes his hematemesis as a "tablespoon" of blood with
emesis every ___ hrs. Otherwise notes that his stools have been
"black and tarry". Notes that his abdominal distention is
significant and that he has never seen it so swollen. States
that
he was previously on spironolactone, furosemide, nadolol,
thiamine, folic acid, MVI, and prilosec but stopped taking his
medications once he was released from prison.
He denies fevers/chills, no chest pain, sick contacts, or
productive cough. Does note dyspnea since his abdominal swelling
has worsened. No known head injury.
Previously received care at ___ and ___. Reports
last EGD in ___ at ___ which showed esophageal varices,
has occasional small amount of hematemesis, but last significant
bleeding in ___.
In the ED,
- Initial Vitals: 99.8, 120, 161/99, 20, 97% RA; later became
febrile to 100.4F
- Exam:
Gen: Uncomfortable-appearing
HEENT: No icterus
Abd: Abd markedly distended, diffusely tender to palpation w/
guarding, no rebound, +fluid wave, +BS
Ext: No edema
Neuro: A&O to place and ___, though not year. Unable to
spell "WORLD" backward. No asterixis.
Rectal: guaiac + stool
- Labs Notable for: WBC 6.2, Hb 14-> 12.5 -> 11.7, Plt 47->36 ->
27, AST 100, ALT 70, ALP 131, T bili 3.3, lipase 18, Bicarb 17,
Na/K/Cl normal, Cr 0.9, Lactate 8.1-> 6.0 -> 4.6, Peritoneal
fluid: 172 WBC with 5% poly, 345 RBC, flu pending
- Imaging:
---NCHCT: No acute intracranial process.
---RUQUS:
1. Cirrhotic liver with moderate ascites and splenomegaly to
18.0
cm. The portal vein is patent.
2. Status post cholecystectomy.
- Consults:
---Hepatology:
___ with h/o Alc cirrhosis with active alcohol use, as per
patient h/o variceal bleed in the past, coming in with emesis
with some bright red blood in setting of alcohol use, some
melena, no emesis or BM in the ED ehre, Hb 14, VSS. Mild
confusion. Ascites on exam, diagnostic para not showing SBP.
Impression:
Given normal Hb, stable VS, most likely this is ___
vs
gastritis vs portal hypertensive gastropathy vs GAVE. Low
likelihood of variceal hemorrhage. Although patient was
dehydrated on exam so Hb 14 is likely hemoconcentrated. Will
admit for potential EGD, management of Alc Hep.
-NPO
-iv access 16G x 2
-Expect Hb to drop since getting iv fluids so will monitor for
signs of active bleeding
-PPI iv BID
-Ceftriaxone 1gm for SBP Prophylaxis
-Octreotide infusion
-RUQ US
-Diagnostic para
-Start lactulose
-___ DF 12, good prognosis of alc hep
-Will plan EGD likely tomorrow
- Interventions: Pantoprazole 40mg x1, Octreotide 50mcg/hr,
Ceftriaxone 1g, Lactulose 30mL x1, IV Morphine 7mg total (2mg,
1mg, 4mg), Zofran 4mg x3, 1L NS, 25g 5% Albumim
Past Medical History:
-Alcohol Use disorder, active, complicated by withdrawal
seizures
and ?DTs vs. Alcoholic hallucinosis
-Alcoholic cirrhosis decompensated by varices and now massive
ascites; no h/o HE, HPS, HRS
-H/o ___ tears
-PTSD
-Bipolar Disorder: previously tried on a variety of
anti-psychotics w/o success
-Abdominal hernias (3; w/o bowel incarceration)
-R Inguinal hernia
-H/o cholecystectomy
Social History:
___
Family History:
-Mother: gastric ulcers, stroke
-Father: unknown
-Sister: diverticulitis requiring colectomy
-Brother: healthy
-Two children: healthy
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Reviewed in OMR
GEN: Tremulous middle-aged man, appears intermittently
uncomfortable, pleasant and conversant
EYES: Anicteric sclerae, +mild scleral injection
HENNT: +white tongue discoloration, +dried blood on lips
CV: +tachycardic, no m/r/g
RESP: +Diminished at R base, but otherwise clear and w/o
wheezes,
rhonchi, or crackles
GI: +BS, +large distention, +Quite TTP along epigastric to
suprapubic, negative rebound, +fluid wave
SKIN: +Spider angiomata on chest, no BLE edema
NEURO: AOx3 (self, ___, ___, no asterixis
PSYCH: Good eye contact, mildly pressured speech
DISCHARGE PHYSICAL EXAM:
VS: 24 HR Data (last updated ___ @ 829)
Temp: 98.0 (Tm 99.0), BP: 130/85 (119-142/72-89), HR: 85
(81-92), RR: 18 (___), O2 sat: 98% (94-98), O2 delivery: Ra,
Wt: 186.8 lb/84.73 kg (186.8-189.6)
GEN: in no acute distress, A/Ox3
HEENT: sclera anicteric, MMM
CV: RRR, no mgr
LUNGS: CTAB, no wrr
ABD: NABS, soft, moderately distended, nontender, no
rebound/guarding, engorgement of superficial veins noted,
umbilical hernia noted
EXT: wwp, no edema
NEURO: A/Ox3, moves all extremities with intent, no asterixis
SKIN: spider angiomata noted
Pertinent Results:
ADMISSION LABS:
___ 01:07PM BLOOD WBC-6.2 RBC-4.68 Hgb-14.0 Hct-39.8*
MCV-85 MCH-29.9 MCHC-35.2 RDW-15.6* RDWSD-47.5* Plt Ct-47*
___ 01:07PM BLOOD Neuts-83.2* Lymphs-10.2* Monos-5.4
Eos-0.2* Baso-0.5 Im ___ AbsNeut-5.12 AbsLymp-0.63*
AbsMono-0.33 AbsEos-0.01* AbsBaso-0.03
___ 01:07PM BLOOD ___ PTT-27.7 ___
___ 01:07PM BLOOD Glucose-103* UreaN-16 Creat-0.9 Na-138
K-3.9 Cl-97 HCO3-17* AnGap-24*
___ 01:07PM BLOOD ALT-70* AST-100* AlkPhos-131*
TotBili-3.3*
___ 01:07PM BLOOD Albumin-4.0 Calcium-8.2* Phos-2.5* Mg-1.7
___ 01:07PM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
___ 01:17PM BLOOD Lactate-8.1*
DISCHARGE LABS:
___ 05:42AM BLOOD WBC-1.9* RBC-3.51* Hgb-10.4* Hct-30.8*
MCV-88 MCH-29.6 MCHC-33.8 RDW-14.6 RDWSD-45.8 Plt Ct-31*
___ 05:42AM BLOOD ___ PTT-25.2 ___
___ 05:42AM BLOOD Glucose-111* UreaN-7 Creat-0.9 Na-140
K-3.5 Cl-99 HCO3-27 AnGap-14
___ 05:42AM BLOOD ALT-47* AST-49* LD(LDH)-204 AlkPhos-90
TotBili-1.6*
___ 05:42AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.4*
============================================================
IMAGING:
CHEST CXR (PORTABLE AP)
Lungs are fully expanded and clear. Cardiomediastinal and hilar
silhouettes
and pleural margins are normal.
LIVER U/S
1. Cirrhotic liver with moderate ascites and splenomegaly to
18.0 cm. The
portal vein is patent.
2. Status post cholecystectomy.
CT HEAD W/O CONTRAST
There is no evidence of infarction, hemorrhage, edema, or mass.
There is
prominence of the ventricles and sulci suggestive of
involutional changes.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
MICRO:
No positives
Brief Hospital Course:
SUMMARY:
==================================================
___ w/ PMH EtOH cirrhosis (decompensated by variceal bleed
___, alcohol use disorder w/ prior withdrawal seizures,
prior
___ tear, bipolar disorder presented with 2 days of
melena and hematemesis c/f variceal bleed requiring banding. He
developed ascites i/s/o holding diuretics for which he underwent
therapeutic paracentesis. His ongoing alcohol use was discussed
extensively with plan for him to live with his mother and enroll
in an alcohol treatment program after discharge.
ACUTE ISSUES
============
#Hematemesis
#Acute variceal hemorrhage
He presented with hematemesis and underwent EGD on ___ with
banding of a nonbleeding varix that was seen. He was placed on
octreotide gtt for 72 hours, and started on ceftriaxone for SBP
prophylaxis, which was switched to ciprofloxacin for a total of
7 d(D1 on ___ date of ___. After banding his diet was
advanced and he had no further bleeding. He was given sucralfate
2g BID and BID PPI.
#Decompensated EtOH cirrhosis
#Alcoholic hepatitis
On admission MELD 15, DF 19 on admission. His RUQ US w/
cirrhotic liver but w/o portal vein clot. He had a therapeutic
paracentesis on ___ with no evidence of SBP and removal of 3L.
His fluid reaccumulated in the setting of holding diuretics
I/s/o bleed. His diuretics 80mg Lasix and 150mg spironolactone
were restarted prior to discharge with some decrease in
abdominal swelling so no further paracentesis was performed. He
was counseled on a low sodium diet. He was restarted on nadolol
as well. He had no evidence of encephalopathy this admission and
was continued on thiamine/folate/MVI.
#Alcohol use disorder
S/p phenobarbital load in the ICU but he had no evidence fo
withdrawal. He explained that he has long struggled with alcohol
use and had gone on a bender prior to admission. He had recently
been in prison and so had had a period of sobriety. He was
motivated to quit drinking and met with our social worker for
counseling and resources. His plan on discharge was to live with
his mother and attend a rehab program at the ___. His
wife did appear to have her own struggles with alcohol use and
we discussed this extensively with the patient - his plan was
not to return to her apartment at this time.
#Pancytopenia: Anemia improved with iso acute GI bleed and
transfusion of 3u of pRBCs. His thrombocytopenia was likely ___
cirrhosis. He did develop a low WBC count I/s/o acute illness
which was starting to recover and should be trended.
#TRANSITIONAL ISSUES:
=====================================
[] f/u in clinic with Dr. ___ with repeat EGD planned given
recent banding
[] Abstinence plan was to live with his mother and attend an
alcohol treatment program through the ___. Please continue to
follow closely with the patient.
[] repeat CBC as outpatient to ensure WBC recovery
[] Ongoing counseling regarding med and low sodium diet
adherence.
[] f/u final peritoneal fluid and blood cultures, at discharge
prelim read was no growth to date
[] Complete Cipro course through ___ for total of 7d for SBP
prophylaxis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Spironolactone 150 mg PO DAILY
2. Furosemide 80 mg PO DAILY
3. Nadolol 20 mg PO DAILY
4. Thiamine 100 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Psyllium Powder 1 PKT PO DAILY
9. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*5 Tablet Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*0
3. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Sucralfate 2 gm PO BID
RX *sucralfate 1 gram 2 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*0
5. Ferrous Sulfate 325 mg PO DAILY
do not take at same time with ciprofloxacin
6. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Furosemide 80 mg PO DAILY
RX *furosemide 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Multivitamins 1 TAB PO DAILY
9. Nadolol 20 mg PO DAILY
RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Psyllium Powder 1 PKT PO DAILY
11. Spironolactone 150 mg PO DAILY
RX *spironolactone 50 mg 3 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
12. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
#Variceal bleed
SECONDARY:
#Alcoholic cirrhosis
#Alcohol use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you had bleeding in
the GI tract.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had a procedure called BANDING to clamp the vessel that
was causing bleeding
- You were given blood
- You had a paracentesis
- You were monitored for further bleeding
- You improved and were ready to leave the hospital
- We gave you an antibiotic to prevent infections
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please avoid alcohol. Even 1 drink could be very harmful.
- Please enroll in AA and work with your primary care doctor to
determine the best strategy to help you stay sober
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
19859733-DS-13 | 19,859,733 | 24,769,832 | DS | 13 | 2129-10-22 00:00:00 | 2129-10-22 22:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall
Alcohol withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ man with EtOH cirrhosis decompensated by esophageal varices
w/recent banding ___, h/o ___ tears, EtOH use
disorder c/b withdrawal seizures, PTSD, and Bipolar, presents as
a transfer from an outside hospital with a fall.
This afternoon, pt remembers trying to get out of bed. Pt woke
up
on ground with R side pain. He was unsure of what happened and
if
he sustained a headstrike. No blood thinners. Pt called ___ and
was taken to OSH. Pt had a CT scan of head and neck which was
negative. CXR negative. Pt transferred to ___ for further
management.
In ED pt complaining of L rib pain, ___. Denies HA, visual
changes, neck pain, SOB, abd pain, pain in arms or legs. Denies
hematemesis, black or tarry stools, bloody stools. Patient
denies
any recent fevers. Complained of BRBPR intermittently at home,
BM
in ED with brown stool however was guiac positive.
Pt reports drinking ___ nips per day. He reports that he uses
EtOH to cope with PTSD as it helps him stay calm. He worked as a
___ in the ___ for ___ yrs. He has had periods of abstinence,
most recently Feb until a few weeks ago as pt was in jail. Upon
release has been drinking nips rather than 12 beers as he did
prior to jail. Has been admitted for EtOH w/d in the past which
have required ICU care and seizures. Last seizure ___ yrs ago.
Of note, patient recently admitted from ___ with
hematemesis, melena. Patient underwent an EGD with banding of a
nonbleeding varices. At that time patient was also status post
phenobarbital load in the ICU for etoh withdrawal. During
admission pt received 3 units of packed red blood cells.
Past Medical History:
-Alcohol Use disorder, active, complicated by withdrawal
seizures
and ?DTs vs. Alcoholic hallucinosis
-Alcoholic cirrhosis decompensated by varices and now massive
ascites; no h/o HE, HPS, HRS
-H/o ___ tears
-PTSD
-Bipolar Disorder: previously tried on a variety of
anti-psychotics w/o success
-Abdominal hernias (3; w/o bowel incarceration)
-R Inguinal hernia
-H/o cholecystectomy
Social History:
___
Family History:
-Mother: gastric ulcers, stroke
-Father: unknown
-Sister: diverticulitis requiring colectomy
-Brother: healthy
-Two children: healthy
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: 24 HR Data (last updated ___ @ ___)
Temp: 98.5 (Tm 99.1), BP: 119/70 (119-123/70-76), HR: 82
(71-82), RR: 18, O2 sat: 96% (93-96), O2 delivery: Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated,
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, no ascities
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, no asterixes
DISCHARGE PHYSICAL EXAM:
======================
VS: 98.3 ___
GEN: Alert, oriented, in no acute distress
HEENT: Sclerae anicteric, MMM
CV: RRR, no mgr
PULM: no respiratory distress, CTAB, no wheezing or crackles
ABD: NABS, soft, non-tender, non-distended, no rebound/guarding
EXT: wwp, no edema
SKIN: Warm, dry, no rashes or notable lesions, no jaundice
NEURO: A/Ox3, moves all extremities, no asterixis
Pertinent Results:
ADMISSION LABS:
============================================
___ 05:00AM BLOOD WBC-4.2 RBC-4.48* Hgb-13.2* Hct-38.5*
MCV-86 MCH-29.5 MCHC-34.3 RDW-15.8* RDWSD-48.9* Plt Ct-49*
___ 05:00AM BLOOD Neuts-67.9 ___ Monos-9.7 Eos-0.2*
Baso-0.7 Im ___ AbsNeut-2.86 AbsLymp-0.90* AbsMono-0.41
AbsEos-0.01* AbsBaso-0.03
___ 07:10AM BLOOD ___ PTT-28.2 ___
___ 05:00AM BLOOD Glucose-146* UreaN-10 Creat-0.7 Na-143
K-3.8 Cl-105 HCO3-20* AnGap-18
___ 05:00AM BLOOD ALT-58* AST-113* AlkPhos-128 TotBili-1.9*
___ 05:00AM BLOOD Albumin-3.9 Calcium-8.2* Phos-2.2*
Mg-1.5*
___ 05:00AM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS:
============================================
___ 05:35AM BLOOD WBC-2.0* RBC-3.79* Hgb-11.2* Hct-32.3*
MCV-85 MCH-29.6 MCHC-34.7 RDW-15.0 RDWSD-46.6* Plt Ct-21*
___ 05:35AM BLOOD ___ PTT-26.7 ___
___ 05:35AM BLOOD Glucose-119* UreaN-7 Creat-1.0 Na-142
K-3.6 Cl-99 HCO3-31 AnGap-12
___ 05:35AM BLOOD ALT-43* AST-62* LD(LDH)-191 AlkPhos-103
TotBili-1.8*
___ 05:35AM BLOOD Calcium-9.0 Phos-1.8* Mg-1.8
MICROBIOLOGY:
============================================
___ urine and blood cx NO GROWTH
___ C diff NEGATIVE
IMAGING:
============================================
___ C-SPINE
OSH - no report
___ CHEST
OSH - no report
___ ABD & PELVIS WITH CONTRAST
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates a nodular and cirrhotic
morphology with
heterogeneous hypoenhancement consistent with hepatic steatosis.
A right
hepatic lobe hypodensity measuring 1.2 cm is again seen and
unchanged
corresponding to hepatic cyst seen on prior ultrasound. There
is no evidence
of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is
surgically absent. Trace abdominal ascites is demonstrated
predominantly
perihepatic and perisplenic in nature. The portal vein, SMV,
and splenic vein
are all widely patent. Multiple portosystemic varices are
demonstrated
including esophageal, paraesophageal, and rectal.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen is enlarged measuring up to 19.6 cm though
demonstrates
normal attenuation throughout, without evidence of focal
lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
A plate like hypodensity in the lower pole of the left kidney
measures up to
2.3 cm and could represent a laceration though no surrounding
hematoma is
present though could also represent scarring. There is no
evidence of
hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber, wall thickness, and enhancement throughout.
Colonic
diverticulosis is noted throughout predominantly in the
transverse and
ascending colon thickening of the large bowel is demonstrated
throughout most
consistent with portal colopathy. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are
unremarkable.
LYMPH NODES: A borderline porta hepatis node measures 9 mm
(02:48). There is
no retroperitoneal or mesenteric lymphadenopathy by CT size
criteria. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: An umbilical hernia containing fluid is noted.
IMPRESSION:
1. Left lower renal platelike hypodensity could represent
scarring versus
laceration though no associated fracture or surrounding hematoma
identified.
Otherwise no traumatic injury identified within the abdomen or
pelvis. No
fracture identified.
2. Cirrhotic and steatotic liver with stigmata of portal
hypertension
including splenomegaly, trace abdominal ascites, portal
colopathy, and
multiple portosystemic varices. Patent portal vein.
3. Diverticulosis of findings diverticulitis.
Brief Hospital Course:
SUMMARY:
===============
Mr. ___ is a ___ man with EtOH cirrhosis decompensated by
varices (last variceal bleed ___, h/o ___ tears,
EtOH use disorder c/b withdrawal seizures, PTSD, and Bipolar who
is presented with EtOH withdrawal and a fall during etoh use
while at home.
ACTIVE ISSUES:
--------------
# EtOH withdrawal
# Hypomagnesima
# Hypophosphotemia
Pt with chronic ongoing EtOH use presents s/p fall. EtOH serum
237 at OSH. Pt started withdrawing in ED, received diazepam 20
IV
and lorazepam 2 and 4mg IV. After getting lorazepam on the ___
protocol on the day of discharge he was not requiring any
further lorazepam. We also repleted with IV thiamine and had
social work see him to assist in arranging an inpatient stay at
a alcohol treatment/substance use treatment disorder. On the day
of discharge he was informed to go to the ___ to self
present for a priority admission.
#EtOH Cirrhosis
Decompensated by portal HTN and prior esophageal variceal bleed.
MELD 13 on admission.
- VOLUME: continued home Lasix and spironolactone
- INFECTION: no Hx of SBP, no ppx needed, trace ascites not
tapped since it was only a trace amount
- BLEEDING: Hx of varices s/p banding ___. Continued home
Nadolol 20mg PO daily and home PPI
- ENCEPHALOPATHY: No hx of HE. Not treated with lactulose on
this hospital stay.
- SCREENING: CT ___ w/o e/o HCC lesions
# ?Melena/BRBPR
Pt is inconsistent regarding recent BMs. Hgb has been stable.
Had
BM in ED which was brown. Pt has recent hx of variceal banding.
No signs of bleeding on his stay and his hemoglobin was stable
no objective data of bleeding.
# Pancytopenia
Likely secondary to cirrhosis, at baseline.
Transitional Issues:
[] will need inpatient alcohol detoxification at an inpatient
substance use facility
[] continued his home diuretics Lasix/aldactone and will need
outpatient BMP in 1 week to ensure Cr. is stable
(appeared euvolemic on day of discharge)
DISCHARGE Hgb: 11.2
DISCHARGE Cr. 1.0
DISCHARGE CODE: FULL CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 80 mg PO DAILY
2. Nadolol 20 mg PO DAILY
3. Spironolactone 150 mg PO DAILY
4. Thiamine 100 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Sucralfate 2 gm PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Psyllium Powder 1 PKT PO DAILY
10. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 80 mg PO DAILY
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Nadolol 20 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Psyllium Powder 1 PKT PO DAILY
8. Spironolactone 150 mg PO DAILY
9. Sucralfate 2 gm PO BID
10. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Etoh withdrawal
# Mechanical Fall
# cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___ on your hospital
stay.
Why was I admitted?
- You were admitted to the hospital for a fall that you had at
home while you were intoxicated from alcohol.
What happened while I was in the hospital?
- You were treated with medicine to help with your alcohol
withdrawal
- You received thiamine to help with your malnutrition in the
setting of alcohol use
- You had tests done to look for an infection which were not
showing any infection at the time of your discharge
What do I need to do once I leave the hospital?
- It is very important that you try to get assistance in an
___ medical addiction treatment center
- You should stop drinking alcohol
- You should take all of your medicines as prescribed
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19859757-DS-8 | 19,859,757 | 20,202,199 | DS | 8 | 2155-07-18 00:00:00 | 2155-07-19 14:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / Penicillins
Attending: ___.
Chief Complaint:
Syncopal fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is an ___ year old female with a history of afib on
warfarin who transferred from OSH for management of a left
flank hematoma with active extravasation. Per daughter at
bedside, patient had an unwitnessed fall 4 days ago. Today,
the patient had a syncopal episode. She was seen in the ED
at the OSH and found to have a left flank hematoma with
active extravasation. INR at OSH was 6.7. She was treated
with vitamin K 10 mg and 2 units PRBC and transferred for
further evaluation. Here, the patient notes left flank pain.
She denies any chest pain or difficulty breathing.
Past Medical History:
Past Medical History:
breast cancer
COPD
Hypertension
Afib
Occipital CVA
Hypothyroidism
subclavian stenosis
gait imbalance
Orthostatic hypotension
Past Surgical History:
laporoscopic cholecystectomy
Left breast lumpectomy & LND
Bilateral shoulder surgery
Back surgery
Social History:
___
Family History:
noncontributory
Physical Exam:
==============================
ADMISSION PHYSICAL EXAMINATION
==============================
Temp: 97.9 HR: 57 BP: 128/62 Resp: 18 O(2)Sat: 95 Low
Constitutional: Comfortable, awake and alert
HEENT: Normocephalic, atraumatic
Chest: Clear to auscultation, normal effort
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: large left sided flank hematoma with tenderness,
no rebound or guarding
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent, moving all extremities
==============================
DISCHARGE PHYSICAL EXAMINATION
==============================
***
Pertinent Results:
LABS ON ADMISSION:
================
___ 12:55PM BLOOD WBC-13.4* RBC-3.08* Hgb-9.6* Hct-28.0*
MCV-91 MCH-31.2 MCHC-34.3 RDW-12.6 RDWSD-41.6 Plt ___
___ 12:55PM BLOOD Neuts-85* Bands-0 Lymphs-8* Monos-6 Eos-1
Baso-0 ___ Myelos-0 AbsNeut-11.39* AbsLymp-1.07*
AbsMono-0.80 AbsEos-0.13 AbsBaso-0.00*
___ 12:55PM BLOOD ___ PTT-27.1 ___
___ 12:55PM BLOOD Glucose-112* UreaN-10 Creat-0.7 Na-120*
K-4.3 Cl-86* HCO3-21* AnGap-17
___ 04:57PM BLOOD ALT-17 AST-18 LD(LDH)-125 AlkPhos-84
TotBili-0.6
___ 12:55PM BLOOD cTropnT-<0.01
___ 12:55PM BLOOD Calcium-8.0* Phos-3.9 Mg-1.8
___ 05:23PM BLOOD Osmolal-258*
___ 01:26PM BLOOD Lactate-1.5
IMPORTANT LABS:
==============
___ 07:33AM BLOOD TSH-2.1
___ 05:23PM BLOOD Osmolal-258*
___ 12:12AM BLOOD Osmolal-258*
___ 07:54AM URINE Osmolal-400
___ 11:02AM URINE Osmolal-524
___ 07:54AM URINE Hours-RANDOM UreaN-344 Creat-64 Na-44
K-34 Cl-53
___ 11:02AM URINE Hours-RANDOM Creat-78 Na-107
MICRO LABS:
==========
___ 03:10PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
IMAGES:
======
CXR (___): Compared to chest radiographs ___. No
definite pneumonia pulmonary edema. Pleural effusions small if
any. Heart size normal. No pneumothorax. Although no acute
fracture or other chest wall lesion is seen, conventional chest
radiographs are not sufficient for detection or characterization
of most such abnormalities. If the demonstration of trauma to
the chest wall is clinically warranted, the location of any
referrable focal findings should be clearly marked and imaged
with either bone detail radiographs or Chest CT scanning.
DISCHARGE LABS:
==============
***
Brief Hospital Course:
This is a ___ year old female with a past medical history of
cerebrovascular disease, chronic obstructive pulmonary disease,
atrial fibrillation (on Coumadin) & vertebrobasilar
insufficiency who presented with a fall and a syncopal episode
and was found to have an elevated INR to 6.67, hyponatremia, and
a large left abdominal wall hematoma.
When the patient presented, she was hemodynamically stable. She
received KCentra in the ED and 2 u PRBC and interventional
radiology was consulted and did not think embolization was
indicated. The patient was then admitted to the TSICU for serial
hematocrits and close monitoring (which were stable). Labs were
notable for a sodium of 120 on admission and the family reported
polydipsia at home and poor appetite prior to presentation. On
HD2 the patient was called out to the floor as she was
hemodynamically stable. She was then transferred to the medicine
service for further management of her hyponatremia and
anticoagulation. For her hyponatremia, renal was consulted and
believed that her hyponatremia was secondary to poor PO (tea and
toast phenomenon) as well as polydipsia with free water. She
received ensure TID with meals and her sodium was 131 upon
discharge. For her fall and syncope, she had a workup that was
notable for negative orthostatic vital signs, and tele and EKG
without significant bradyarrhythmia or tachyarrythmia. For her
paroxysmal atrial fibrillation (she was in sinus here), once she
was stabilized she was started on a heparin gtt and bridged to
warfarin since she has a history of stroke and high CHADS2Vasc
(6). Her atenolol was also decreased from 25 mg qd to 12.5 mg qd
(her HR was in the ___. Her aspirin 81 mg was held given her
presentation of abdominal hemorrhage.
TRANSITIONAL ISSUES:
==================
-She will follow-up with trauma surgery as well as her primary
care physician.
-New medications: Tylenol for pain. Enoxaparin 50mg BID as
bridge for warfarin therapeutic adequacy.
-Changed medications: atenolol 25 mg qd was decreased to 12.5 mg
qd. Warfarin increased from 3mg to 4mg daily.
-Held medications: ASA 81, restarted prior to discharge.
-Sodium was 131 upon discharge.
-Labs: Please check a sodium and INR at her next clinic visit.
Her hyponatremia was thought to be due to poor PO intake.
-Communication: ___ (___) ___, (___)
___
-Code status: Full
=============
ACTIVE ISSUES
=============
#Abdominal wall hematoma:
#Anemia:
On presentation, she had a normocytic anemia, which was
stabilized after KCentra and 2U PRBC. This was likely secondary
to her fall and abdominal hematoma in the setting of INR 6. Her
initial CT at the other hospital showed extravasation, but given
her stability, ___ did not want to intervene at this time. Her
cbc remained stable throughout the rest of her hospital stay.
#Fall/Syncope:
She first fell at home (she says she hit a chair) and then
syncopized in front of her daughter without ___. She has
a history of vertigo and presyncope and she says that she felt
dizzy prior to the first fall. She had normal orthostatics and
telemetry (she was in NSR without bradyarrhythmias or
tachyarrhythmias). She has a history of a CVA/TIA but normal
strength testing, CVA felt unlikely. Her fall was less likely
mechanical or cardiac (normal cardiac exam).
#Hyponatremia:
Her sodium was 120 on admission, likely in the setting of
polydipsia and poor solute intake. She was given ensure TID with
meals and her sodium improved to 131 upon discharge.
#Atrial fibrillation: Supratherapeutic INR on arrival,
initially reversed with Kcentra. Bridged on heparin gtt. Put
on enoxaparin 50mg BID prior to discharge.
- Enoxaparin as above.
- Atenolol decreased to 12.5mg daily (from 25) for borderline
HR's in the 60___s.
- Warfarin 4mg daily.
# Anxiety: She was continued on her home benzo. She was reviewed
in the PMP after discharge, which was only notable for Rx for
her chronic benzo.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atenolol 12.5 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. LORazepam 1 mg PO BID:PRN anxiety
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Warfarin 6 mg PO DAILY16
7. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Enoxaparin Sodium 50 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 300 mg/3 mL 50 mg subcutaneous twice a day Disp
#*10 Vial Refills:*0
3. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1
capsule inhaled every six (6) hours Disp #*30 Capsule Refills:*0
4. Warfarin 4 mg PO DAILY16
5. Aspirin 81 mg PO DAILY
6. Atenolol 12.5 mg PO DAILY
7. Levothyroxine Sodium 88 mcg PO DAILY
8. LORazepam 1 mg PO BID:PRN anxiety
RX *lorazepam 1 mg 1 pill by mouth BID:PRN Disp #*14 Tablet
Refills:*0
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
Left abdominal wall hematoma
Fall
SECONDARY:
Atrial fibrillation
Supratherapeutic INR
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___. You were transferred to ___ because you
developed a big bruise in your left abdominal wall. You likely
got this bruise from your recent fall, but it got bigger because
your warfarin levels were too high. At our hospital, we also
found one of the salt levels (sodium) in your blood were low.
You were given two blood transfusions at the previous hospital
due to the extent of your bruise; after that, your blood counts
remained stable. Your warfarin level was lowered with medicine,
and we sent you to rehab with a new blood thinner medication for
your atrial fibrillation ("enoxaparin").
Please follow-up with your primary care doctor as well as trauma
surgery at the number listed below.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
19860038-DS-19 | 19,860,038 | 22,947,358 | DS | 19 | 2139-01-06 00:00:00 | 2139-01-07 14:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Hydrochlorothiazide / Lisinopril / Benicar
Attending: ___
Chief Complaint:
dizziness, nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
no code stroke called
___ Stroke Scale Score: 2
t-PA administered:
[] Yes - Time given: __
[x] No - Reason t-PA was not given or considered: outside of
window
Thrombectomy performed:
[] Yes
[x] No - Reason not performed or considered: no LVO
NIHSS performed within 6 hours of presentation at: ___
time/date
___
NIHSS Total: 2
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: 2
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
REASON FOR CONSULTATION: nausea, vomiting, vertigo
HPI:
___ is a ___ year old right handed lady with history of heart
failure with preserved ejection fraction, AS, MR, multifactorial
gait disorder, hypothyroidism who presents with acute onset
nausea, vomiting and vertigo last night.
History somewhat limited as she is a vague historian and has
trouble detailing stepwise events. She has been in her usual
state of health without recent illness, fevers, or chills. She
reports that last night at 12A she was sitting in bed and
suddenly developed nausea and vomiting. She could not stop
throwing up. She got up to get out of bed with her walker and
suddenly felt like the room was spinning. She fell to the ground
but did not hit her head. She was able to pull herself up by the
bed and with the walker. She had a lot of trouble walking with
her walker to the bathroom. She had no other symptoms of
tingling, numbness, vision changes, speech changes. She did feel
weak "all over". Today she continued to have nausea and vomiting
throughout the day. She stayed still all day because this
relieved her vertigo if she was completely still. However,
because she continued to have vomiting and was unable to eat or
drink, she decided to call ___ to come to the emergency
department.
In the ED she was given Zofran and 500 cc NS. Her orthostatics
(taken after fluid) were normal. At time of my interview she
reports that she still is quite nauseous and vertiginous with
any
movement of her head. She denies prior episodes like this, prior
strokes. She does tell me she does not take any of her
prescribed
medications. She reports only taking Tylenol daily. She walks
with a walker for many years after a hip replacement. She has
help to cook, clean. She can bathe and dress on her own. Per
outpatient PCP notes there was significant concern she could no
longer take care of herself at home. She currently denies
changes
in vision, double vision, change in voice, slurred speech,
tingling, numbness, chest pain, shortness of breath, recent
cough, diarrhea, abdominal pain. She is hard of hearing at
baseline.
Past Medical History:
Hypothyroidism, hyperlipidemia, coronary artery disease, asthma,
osteoporosis, small fiber polyneuropathy, recurrent LLE edema,
questionnable aortic and mitral valve insufficiencies,
hyponatremia.
Social History:
___
Family History:
CHF
Recurrent epistaxis
CAD, mod aortic and mild mitral valve insuff,
Asthma
GERD
Heart Disease: Y - HLD
HTN
Hypothyroidism
Osteoporosis
SMALL FIBER POLYNEUTOPATHY, recurrent LLE edema, hx
hyponatremia,
hx dizziness and unsteady gait, severe pulm HTN
Physical Exam:
Admission exam:
Vitals: 97.9 °F
(36.6 °C)
Temporal
Artery
84 18 150/69
MAP: 96.0
94
Room Air
General: Awake, cooperative, frail older lady
HEENT: NC/AT, no scleral icterus noted
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: some mild lower ext edema
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to ___, ___
___.
Takes a long time to identify the department. Very vague
historian and has difficulty with timeline of events and
frustrated with questioning. Unable to do days of the week.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Able to name
both high frequency objects but not cactus or hammock Able to
read without difficulty. No dysarthria. Able to follow both
midline and appendicular commands. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
PERRL 3 mm irregular and NR, post-surgical. ___ with right
beating nystagmus on right gaze and left beating nystagmus on
left gaze. Upbeating nystagmus on upgaze. VFF full to finger
wiggle. No vertical skew. Facial sensation intact to light
touch.
No facial droop, facial musculature symmetric. Hearing intact to
finger-rub bilaterally. No corrective saccade on head impulse.
Palate elevates ___ strength in trapezii
bilaterally. Tongue protrudes in midline with good excursions.
Strength full with tongue-in-cheek testing. Did not tolerate ___
due to ongoing nausea.
-Motor: No pronator drift. No adventitious movements, such as
tremor or asterixis noted.
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 ___ 5 5 5
*giveway throughout
-Sensory: No deficits to light touch, pinprick, prop diminished
for moderate excursions bilaterally (basically guesses). No
extinction to DSS.
-Reflexes: Diminished throughout, 1+ patellar, absent Achilles
Plantar response was flexor bilaterally.
-Coordination: There is bilateral intention tremor as well as
right >left dysmetria for FnF and mirroring.
-Gait: unable to test due to patients symptoms
Discharge Exam:
24 HR Data (last updated ___ @ 757)
Temp: 97.8 (Tm 98.4), BP: 115/73 (101-121/51-81), HR: 84
(63-85), RR: 20 (___), O2 sat: 94% (92-97), O2 delivery: Ra,
Wt: 106.9 lb/48.49 kg (106.9-107.4)
Exam
General: Awake, cooperative, slight distress
HEENT: NC/AT, no scleral icterus noted. Erythema/swelling over
face, particularly below the eyes.
Pulmonary: Normal work of breathing
Skin: Erythematous, maculopapular rash over the entire torso,
back > anterior chest, without mucosal involvement. spread to
distal arms and leg.
Neurologic:
-Mental Status: Alert, oriented Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
PERRL 3 mm irregular and NR, post-surgical. EOMI with few beats
of gaze-evoked nystagmus. Facial sensation intact to light
touch.
No facial droop, facial musculature symmetric. ___ strength in
trapezii bilaterally. Tongue protrudes in midline with good
excursions.
-Motor: No pronator drift. No adventitious movements, such as
tremor or asterixis noted. Full strength throughout.
-Sensory: deferred
-Reflexes: Deferred
-Coordination: Deferred
-Gait: Deferred
Pertinent Results:
___ 08:45PM URINE HOURS-RANDOM
___ 08:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___:45PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 08:45PM URINE RBC-3* WBC-4 BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 08:45PM URINE HYALINE-5*
___ 07:25PM cTropnT-<0.01
___ 03:38PM LACTATE-1.3
___ 03:23PM GLUCOSE-137* UREA N-28* CREAT-0.9 SODIUM-144
POTASSIUM-4.4 CHLORIDE-94* TOTAL CO2-34* ANION GAP-16
___ 03:23PM ALT(SGPT)-11 AST(SGOT)-21 ALK PHOS-70 TOT
BILI-0.3
___ 03:23PM ALBUMIN-4.2 CALCIUM-10.3 PHOSPHATE-3.3
MAGNESIUM-2.5
___ 03:23PM TSH-2.1
___ 03:23PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 03:23PM WBC-7.6 RBC-4.05 HGB-12.1 HCT-38.5 MCV-95
MCH-29.9 MCHC-31.4* RDW-13.8 RDWSD-48.1*
___ 03:23PM NEUTS-86.5* LYMPHS-6.9* MONOS-5.4 EOS-0.1*
BASOS-0.7 IM ___ AbsNeut-6.55* AbsLymp-0.52* AbsMono-0.41
AbsEos-0.01* AbsBaso-0.05
___ 03:23PM PLT COUNT-247
CTA head and neck ___:
1. No acute intracranial abnormality by unenhanced CT. No
hemorrhage.
2. Inferiorly projecting 2-3 mm aneurysm or infundibulum arising
from the
distal left supraclinoid/communicating intracranial ICA.
3. Mild calcified plaque bilateral intracranial ICAs,
mild-to-moderate luminal narrowing.
4. Remaining circle of ___ vasculature is unremarkable.
5. Calcified plaque at the carotid bulbs causes 33 % left ICA
luminal
narrowing by NASCET criteria. No right ICA luminal narrowing.
Moderate
luminal narrowing, origin left vertebral artery. Otherwise,
cervical
vertebral and carotid arteries are widely patent.
6. Mild sinus disease, left maxillary sinus.
MR ___:
1. No evidence of acute infarction or intracranial hemorrhage.
2. Mild parenchymal volume loss.
3. Findings of chronic small vessel ischemic disease.
4. Left maxillary sinus disease.
Brief Hospital Course:
Ms. ___ is a ___ right handed lady with history of
HFpEF, AS, MR, multifactorial gait disorder, and hypothyroidism
who presented to the ED with acute onset nausea, vomiting and
vertigo. Of
note, this vertigo led to a backwards fall with no head strike.
#neuro
Her exam was notable for unremarkable orthostatics, gaze-evoked
nystagmus, and mild truncal ataxia. MRI was negative for stroke.
Physical therapy did full vestibular evaluation with no
elucidation of symptoms, therefore making benign paroxysmal
positional vertigo less likely. Patient has a known history of
vestibular dizziness and labyrinthitis and this is likely the
origin of her symptoms.
#Cardiac
Patient with past history of CAD, HFpEF, AS, MR found to have
low blood pressure on home metop. Cardiology consulted given low
BPs in setting of complicated cardiac history. Determined low
BPs likely secondary to hypovolemia given her mild AR and
moderate AS. Small amount of fluids started and Lasix stopped
temporarily. Plan to restart outpatient at follow up.
#dermatology
Her course more recently has been complicated by a diffuse
maculopapular rash over the entire torso. Not improving with
changing gown, sheets,
etc. No improvement with steroid cream, Benadryl or hydroxyzine.
Dermatology consulted and reported likely a viral exanthem.
Suggested adding cetirizine and hydroxyzine though will likely
have to self resolve over time.
Assessed daily by ___ and determined she would be served best
by some time in ___ rehab.
Transitional issues:
-follow up with neurology outpatient
-follow up with dermatology regarding lesion on chest
-follow up with cardiology outpatient
-follow up with PCP and restart ___ once creatinine normalizes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO QPM
2. Ranitidine 150 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
DO NOT apply to face, axilla or groin
3. Cetirizine 10 mg PO DAILY
4. Famotidine 20 mg PO Q24H
5. Hydrocortisone Oint 2.5% 1 Appl TP BID rash
apply to face, axilla and groin
6. HydrOXYzine 12.5 mg PO QHS:PRN Itching
7. Metoprolol Tartrate 6.25 mg PO BID
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Ranitidine 150 mg PO DAILY
10. Simvastatin 20 mg PO QPM
11. HELD- Furosemide 40 mg PO DAILY This medication was held.
Do not restart Furosemide until creatinine is rechecked on ___
and has returned to baseline of 0.9
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
vestibular neuritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of severe dizziness and
nausea and were worked up for concern for new acute ischemic
stroke, a condition where a blood vessel providing oxygen and
nutrients to the brain is blocked by a clot. You were admitted
to the stroke service, however your CT and MRI images of your
brain did NOT show a stroke. Physical therapy saw you and did
various maneuvers to determine if the dizziness was position
related and it did not seem as though this was the case. It is
thought at this point that your symptoms were secondary to
vestibular neuritis likely caused by a virus. While you were
inpatient, you were also found to have some low blood pressure.
Cardiology was consulted. Your home Lasix was stopped
temporarily and we gave you a small amount of fluids which
improved things. Additionally, you developed a rash for which
dermatology was consulted and determined to be a rash secondary
to a virus which likely will self resolve. They recommended
several medications for your symptoms of itchiness.
The following medication changes were made:
-Lasix was held while you creatinine level goes down. It can be
restarted once creatinine is rechecked and it has returned to
baseline
-Cetirizine was started for your rash and can be stopped when
rash resolves
-hydroxyzine was started for your rash and can be stopped when
rash resolves
-betamethasone (for body) and hydrocortisone (for face) cream
has been started to be applied until rash resolves
-aspirin 81 was started
-famotidine was started
-simvastatin 20 should be continued
-metoprolol was changed from your home dose of 25mg daily to
6.25mg twice a day given some low blood pressures while in the
hospital
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19860038-DS-20 | 19,860,038 | 21,195,941 | DS | 20 | 2139-08-07 00:00:00 | 2139-08-07 17:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Lisinopril / Benicar
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a lovely ___ year old Farsi speaking female with a
history of HFpEF, AS, MR, multifactorial gait disorder, and
hypothyroidism presenting with lethargy and dyspnea from
___.
Ms. ___ was in her usual state of health until evening of ___
when she required a new oxygen requirement of 2L. She had a CXR
performed at her living facility that showed mild pulmonary
edema, left pleural effusion and possible PNA. She was initiated
on Azithromycin on ___, and increased home Bumex dose of 1mg
to
2 mg daily and duonebs TID x 5 days.
This morning, when nursing staff entered her room, she was found
to be more lethargic and somnolent, falling asleep mid
sentences.
They also found her to have increased work of breathing and
effort.
She complains today only of weakness and dyspnea, and is unable
to provide a history otherwise.
Past Medical History:
Hypothyroidism, hyperlipidemia, coronary artery disease, asthma,
osteoporosis, small fiber polyneuropathy, recurrent LLE edema,
questionnable aortic and mitral valve insufficiencies,
hyponatremia.
Social History:
___
Family History:
CHF
Recurrent epistaxis
CAD, mod aortic and mild mitral valve insuff,
Asthma
GERD
Heart Disease: Y - HLD
HTN
Hypothyroidism
Osteoporosis
SMALL FIBER POLYNEUTOPATHY, recurrent LLE edema, hx
hyponatremia,
hx dizziness and unsteady gait, severe pulm HTN
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
24 HR Data (last updated ___ @ ___)
Temp: 98.4 (Tm 98.4), BP: 126/60, HR: 93, RR: 18, O2 sat: 97%,
O2
delivery: 3l
GENERAL: Elderly woman in NAD. Oriented x1-?2. Intermittently
having myotonic jerks.
HEENT: Normocephalic atraumatic. R pupil more reactive than L
pupil. ?lateral nystagmus? Conjunctiva were pink. Mallampati IV.
NECK: JVP not seen.
CARDIAC: Regular rate and rhythm. Normal S1, S2. ___ ejection
murmur. No rubs or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Bibasilar inspiratory
crackles. No wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
DISCHARGE EXAM
================
24 HR Data (last updated ___ @ 1203)
Temp: 98.0 (Tm 98.4), BP: 120/70 (114-138/67-73), HR: 80
(78-89), RR: 18 (___), O2 sat: 97% (71-98), O2 delivery: 2l
(0.5L-2L), Wt: 100.5 lb/45.59 kg
Telemetry: Sinus Rhythm in ___
Gen: elderly lady, responsive to verbal stimuli and rigoring,
but
not oriented to person/place/time.
Heart: systolic murmur at LUSB and RUSB. Normal rate/rhythm.
Lung: Crackles B/L posterior ___ way up
Abd: soft, non-tender
Legs: non-edematous
Pertinent Results:
ADMISSION LABS
==============
___ 03:00PM BLOOD WBC-7.6 RBC-4.13 Hgb-12.5 Hct-41.7
MCV-101* MCH-30.3 MCHC-30.0* RDW-13.2 RDWSD-48.9* Plt ___
___ 06:33AM BLOOD WBC-7.1 RBC-3.96 Hgb-12.0 Hct-40.4
MCV-102* MCH-30.3 MCHC-29.7* RDW-13.2 RDWSD-49.6* Plt ___
___ 10:22AM BLOOD ___ PTT-34.1 ___
___ 12:45PM BLOOD Glucose-108* UreaN-22* Creat-1.3* Na-134*
K-7.4* Cl-90* HCO3-32 AnGap-12
___ 06:33AM BLOOD Glucose-94 UreaN-26* Creat-1.1 Na-141
K-5.7* Cl-95* HCO3-34* AnGap-12
___ 10:22AM BLOOD Glucose-83 UreaN-24* Creat-1.2* Na-140
K-5.4 Cl-93* HCO3-37* AnGap-10
___ 08:10PM BLOOD Glucose-80 UreaN-24* Creat-1.1 Na-140
K-4.7 Cl-89* HCO3-36* AnGap-15
___ 07:05AM BLOOD Glucose-113* UreaN-26* Creat-1.1 Na-147
K-4.0 Cl-89* HCO3-39* AnGap-19*
___ 06:33AM BLOOD ALT-8 AST-21 LD(LDH)-257* AlkPhos-65
TotBili-<0.2
___ 12:45PM BLOOD cTropnT-0.26* proBNP-6075*
___ 04:11PM BLOOD CK-MB-3
___ 04:11PM BLOOD cTropnT-0.28*
___ 06:33AM BLOOD cTropnT-0.22*
___ 10:22AM BLOOD CK-MB-3 cTropnT-0.20*
___ 06:33AM BLOOD Albumin-3.7 Calcium-8.9 Phos-5.3* Mg-2.1
___ 10:22AM BLOOD Calcium-9.2 Phos-4.8* Mg-2.1
___ 08:10PM BLOOD Calcium-9.2 Phos-3.8 Mg-1.8
___ 06:33AM BLOOD TSH-1.6
___ 06:33AM BLOOD T3-52* Free T4-1.0
___ 10:45AM BLOOD ___ pO2-58* pCO2-99* pH-7.21*
calTCO2-42* Base XS-7 Comment-GREEN TOP
___ 08:12PM BLOOD ___ pO2-96 pCO2-77* pH-7.34*
calTCO2-43* Base XS-11 Comment-GREEN TOP
___ 12:55PM BLOOD Lactate-1.7 K-6.7*
___ 04:11PM BLOOD K-5.3
___ 10:45AM BLOOD Lactate-1.2
___ 08:12PM BLOOD Lactate-1.3
___ 07:10AM BLOOD Lactate-1.1
DISCHARGE LABS
===============
___ 07:05AM BLOOD WBC-6.4 RBC-4.05 Hgb-12.0 Hct-40.3
MCV-100* MCH-29.6 MCHC-29.8* RDW-13.2 RDWSD-47.8* Plt ___
___ 08:10PM BLOOD WBC-7.1 RBC-4.13 Hgb-12.4 Hct-40.9
MCV-99* MCH-30.0 MCHC-30.3* RDW-13.2 RDWSD-47.8* Plt ___
___ 07:05AM BLOOD Glucose-113* UreaN-26* Creat-1.1 Na-147
K-4.0 Cl-89* HCO3-39* AnGap-19*
___ 10:22AM BLOOD CK-MB-3 cTropnT-0.20*
___ 07:05AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.8
CXR
====
Compared to chest radiographs ___.
Moderate cardiomegaly and mild to moderate pulmonary edema
unchanged. Lung
volumes are low and therefore left basal consolidation could be
either
atelectasis or pneumonia. Likely small pleural effusions
unchanged. No
pneumothorax.
NCTCT
======
1. Study degraded by motion and dental artifact.
2. Within limits of study, no definite evidence of acute
intracranial
hemorrhage or acute large territorial infarct. Please note MRI
of the brain
is more sensitive for the detection of acute infarct.
3. Atrophy, probable small vessel ischemic changes, and
atherosclerotic
vascular disease as described.
Brief Hospital Course:
___ year old Farsi speaking female with a history of HFpEF, AS,
MR, multifactorial gait disorder, and hypothyroidism presenting
with ethargy and dyspnea from ___ being admitted to ___
for HFpEF exacerbation. Being treated for aspiration pneumonia
vs HFpEF exacerbation.
ACUTE ISSUE
============
# HFpEF Exacerbation
# Possible Aspiration PNA
# Altered mental status
Patient with history of HFpEF (last EF 55% in ___ found to
be dyspneic at her nursing home with new oxygen requirement. CXR
significant for moderate edema and possible left lower lobe
consolidation. Bibasilar crackles present on exam with a new
oxygen requirement likely representing CHF exacerbation. Could
also be PNA in setting of aspiration given fluctuating mental
status. She was noted to be hypercarbic as well. A CXR was
performed which did not show any new process aside from known
edema. A NCHCT was negative for any acute changes. Troponins and
BNP were elevated, likely in the setting of demand ischemia.
A bumex drip was initiated, with boluses in addition to help
with diuresis, and over the 24 hours that she was here, her
mental status did slightly improve however she became
progressively hypercarbic.
Her HCP was notified of the situation, and did NOT want the
patient to receive supplemental positive pressure ventilation.
She was therefore diuresed as aggressively as possible to aid in
her oxygenation. We did continue broad treatment for aspiration
PNA vs CAP as the patient was noted to be continuously
aspirating while here, and after further conversation from the
living facility, she has been aspirating for some time.
The patients HCP requested a transfer back to ___ with
hospice services as she expressed that the patient would not
want to be in the hospital at all, even if we were to be able to
remove additional volume with IV diuresis as the hypercarbia
needs positive pressure ventilation and this is not within her
goals of care, and that she wanted the patient to be transferred
back to ___ as expeditiously as possible. IV access was lost
overnight in the hospital as the patient was and was not
replaced in keeping with her goals of care.
A careful and thoughtful review of her medications was done with
the pharmacist, patient's daughter and the hospice agency in
order to maximize the smoothest transition.
================
CHRONIC ISSUES:
===============
#Coronary artery disease
#Hyperlipidemia
Discontinue home aspirin and statin
#Hypothyroid
- Continue home levothyroxine
#GERD
Discontinue home famotidine (dose reduced given CrCl)
#B12 deficiency/nutrition
Hold Cyanocobalamin 1000 mcg IM/SC QMONTHLY
Discontinue Multivitamins W/minerals 1 TAB PO DAILY
CODE: DNR/DNI/NO TRANSFER TO THE ICU. NO ESCALATION OF CARE
CONTACT: Daughter ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Metoprolol Tartrate 6.25 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Famotidine 20 mg PO BID
5. Atorvastatin 10 mg PO QPM
6. Cyanocobalamin 1000 mcg IM/SC QMONTHLY
7. Bumetanide 2 mg PO DAILY
8. Docusate Sodium 200 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH BID
11. TraZODone 25 mg PO TID
12. Zaditor (ketotifen fumarate) 0.025 % (0.035 %) ophthalmic
(eye) QHS
13. GuaiFENesin 10 mL PO QHS
14. Mirtazapine 22.5 mg PO QHS
15. melatonin 5 mg oral QHS
16. Senna 8.6 mg PO QHS
17. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
18. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
19. Fleet Enema (Saline) ___AILY:PRN constipation
20. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Third Line
21. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
Discharge Medications:
1. Morphine Sulfate (Oral Solution) 2 mg/mL 5 mg PO Q3H:PRN
Pain - Mild
RX *morphine 10 mg/5 mL 2.5 ml by mouth q3 prn Disp #*20
Milliliter Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
4. Bumetanide 2 mg PO DAILY
5. Docusate Sodium 200 mg PO DAILY
6. Fleet Enema (Saline) ___AILY:PRN constipation
7. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH BID
8. GuaiFENesin 10 mL PO QHS
9. Levothyroxine Sodium 50 mcg PO DAILY
10. melatonin 5 mg oral QHS
11. Metoprolol Tartrate 6.25 mg PO BID
12. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Third Line
13. Mirtazapine 22.5 mg PO QHS
14. Senna 8.6 mg PO QHS
15. TraZODone 25 mg PO TID
16. Zaditor (ketotifen fumarate) 0.025 % (0.035 %) ophthalmic
(eye) QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Heart failure exacerbation
Aspiration pneumonia
SECONDARY DIAGNOSIS
====================
Constipation
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at ___.
WHY WERE YOU ADMITTED?
========================
You were brought to the hospital with confusion. We believe that
the confusion was caused by your trouble breathing from all of
the fluid in your lungs.
WHAT HAPPENED WHILE I WAS HERE?
=================================
We treated you for pneumonia, in case you also have a pneumonia.
We gave you medications to help eliminate the fluid from your
lungs.
You were discharged back to ___ where you have been living.
We wish you the very best,
Your ___ Care team
Followup Instructions:
___
|
19860347-DS-7 | 19,860,347 | 23,210,780 | DS | 7 | 2193-06-22 00:00:00 | 2193-06-22 14:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Levofloxacin / Norvasc / Pollen/Hayfever
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
- R inguinal lesion biopsy ___
- Temporary HD line placement ___
History of Present Illness:
___ with hx of IDDM2, CKD stage IV, hypertension presenting
with dry cough x1 month and 25 lb weight loss x6 weeks. Pt
endorses onset of dry cough with associated unintentional weight
loss in the preceding ___ weeks. He initially presented to
urgent
care, where he a CXR raised concern for lung metastases. He
denies night sweats, chest pain, SOB, abdominal pain, diarrhea,
constipation, melena, hematochezia, hematuria, F/C. He has a
remote and relatively brief history of cigarette use in the
1970s, and more recently smoked ___ small cigars per day x ___
years. He has regular colonoscopies, last ___ was
unremarkable. Pt also describes a firm nodule at inferior aspect
of RLQ, nontender, appeared approx. 1 month prior to
presentation.
In the ___ ED:
VS 97.0, 82, 130/66, 95% RA
WBC 13.3, Hb 12.6, Plt 308, Na 139, K 5.9->5.3, BUN 59, Cr 2.8
ALT 25, AST 43, Alk phos 418, Tbili 0.7, LDH 810, uric acid 9.3
CXR with multiple pulmonary nodules concerning for metastatic
disease
Received IVF, furosemide, insulin 48u, simvastatin, omeprazole
On arrival to the floor, pt reports feeling fatigued, and has
ongoing cough. He has no other complaints.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI
Past Medical History:
IDDM2
CKD stage IV
Hypertension
HLD
GERD
BPH
Anxiety
Anemia
Gout
Obesity s/p sleeve gastrectomy in ?___, lost 140 lbs
HFpEF
Social History:
___
Family History:
Family History: Two brothers died from kidney disease.
Physical Exam:
Admission physical exam
VS: 98.5 PO 146 / 82 80 19 94 RA
GEN: alert and interactive, obese, comfortable, no acute
distress
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, moist mucus membranes
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, obese, diffuse mild TTP most pronounced at RUQ,
without
rebounding or guarding, nondistended with normal active bowel
sounds. There is a rubbery, superficial nodule at RLQ/R inguinal
region, nontender.
EXTREMITIES: no clubbing, cyanosis, or edema
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: grossly intact
PSYCH: normal mood and affect
Discharge Exam:
Exam:
Vital signs reviewed in flowsheet. AF HR ___,
90s-150s/50s-70s 90-94% on 4L, ___
UOP 105
GENERAL: Alert but drowsy and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Somewhat dry MMs
CV: RRR no m/r/g
RESP: CTAB no c/r/w on limited exam
GI: S BS+ mild TTP of R side and epigastrium
Extr: wwp mild edema
NEURO: sensation/strength grossly symmetric, oriented to
location
and year but not Month
Discharge physical exam
Pertinent Results:
Admission labs
___ 06:40PM BLOOD WBC-13.3* RBC-4.15* Hgb-12.6* Hct-39.2*
MCV-95 MCH-30.4 MCHC-32.1 RDW-14.6 RDWSD-50.4* Plt ___
___ 01:57PM BLOOD ___ PTT-29.2 ___
___ 06:40PM BLOOD Glucose-115* UreaN-59* Creat-2.8* Na-139
K-5.9* Cl-98 HCO3-22 AnGap-19*
___ 06:40PM BLOOD ALT-25 AST-43* LD(LDH)-810* AlkPhos-418*
TotBili-0.7
___ 06:40PM BLOOD Albumin-3.4* Calcium-9.2 Phos-3.7 Mg-2.0
CT CHEST ___:
IMPRESSION:
1. Innumerable large bilateral pulmonary masses are identified
affecting every
lobe of the lungs. A large left perihilar mass is seen
measuring up to 3 cm,
could be accessible by bronchoscopy for biopsy.
2. Moderate right pleural effusion.
3. Severe mediastinal and hilar lymphadenopathy, concerning for
metastasis and
involvement of the underlying neoplastic process.
4. Moderate right pleural effusion.
CT ABD ___
IMPRESSION:
Limited evaluation due to the lack of intravenous contrast.
Within these
limitations:
1. Multiple hypodense liver lesions, with dominant mass
involving the central
right hepatic and caudate lobes.
2. Extensive periportal and retroperitoneal adenopathy as well
as subcutaneous
masses.
Overall, findings are in keeping with metastatic disease to the
liver, lymph
nodes, and subcutaneous tissues. A multifocal hepatocellular or
biliary
malignancy with metastatic spread could also be a differential
consideration,
given a dominant liver mass. Other differential considerations
could include
lymphoma or a primary cutaneous/subcutaneous malignancy such as
melanoma.
Percutaneous biopsy of the large subcutaneous right flank mass
would likely be
feasible under ultrasound guidance for tissue diagnosis.
Chest CT ___. Overall increase in the size and number of the numerous
pulmonary
metastases. No pulmonary edema, pericardial effusion or evidence
of venous
occlusion.
2. Increase in the size of a moderate right pleural effusion and
atelectasis
at the right lung base.
3. Unchanged severe mediastinal and left hilar lymphadenopathy
in keeping with
metastatic disease.
4. No suspicious lytic or sclerotic osseous lesions or acute
fractures are
identified, however bone scan or FDG PET-CT is more specific for
early osseous
metastatic disease.
5. Please see the separately dictated abdominal CT report from
___ for a complete description of subdiaphragmatic findings.
ECHO:
The left atrium is elongated. There is symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. There is an anterior space
which most likely represents a prominent fat pad.
IMPRESSION: Technically-limited study. Hyperdynamic
biventricular systolic function. No major valvular disease seen.
Pathology
Right groin lymph node biopsy:
Poorly differentiated adenocarcinoma, favor gastrointestinal
origin, see note.
No lymphoid tissue seen.
Note: Tumor cells are positive for Keratin cocktail, CK20, CDX2,
CEA (non-canicular pattern) and
negative for Hepar1, Glypican, CD10, P40, TTF-1, Napsin, CK7,
CD30, PAX8 and OCT3/4.
Brief Hospital Course:
___ with hx of IDDM2, CKD stage IV, hypertension presenting with
dry cough x1 month and 25 lb weight loss x6 weeks, found to have
metastatic poorly differentiated GI origin malignancy with
significant lung and liver burden. His course was complicated
by febrile episode, and new ARF on CKD with mild hyperkalemia,
hypoxemic respiratory failure and encephalopathy. Dialysis
initiated for support on ___. Due to rate of tumor growth
chemotherapy was not felt to be a viable option and in
discussion with patient and family he was discharged to a
hospice house.
#Poorly differentiated AdenoCA of GI origin with metastasis to
lung, liver, LN
#Acute renal failure requiring HD - hypoperfusion +/- tumor
lysis
#Metabolic encephalopathy - multifactorial, primarily uremia
#Acute hypoxic respiratory failure (primarily due to lung mets)
#Chronic diastolic heart failure (not diuretic responsive)
#Diabetes (no longer requiring insulin)
#Hypertension (not requiring antihypertensives)
#Gout
Biopsy confirmed poorly differentiated adenocarcinoma most
likely of GI origin. High uric acid and LDH and imaging with
rapid growth of tumor. Ultimately felt that chemotherapy not an
option due to rate of cancer growth. Dialysis was initiated
largely to help clear mental status to involve patient in
decision making, which was somewhat effective, although patient
still preferred to defer decision making to his family. Given
the poor prognosis and primary goal of comfort, it was felt that
hospice without continuation of dialysis would be the best plan.
Medications were narrowed to only those with direct comfort
benefit. Some medications with potential comfort benefit but
with potential toxicity with poor renal clearance were
discontinued (allopurinol and gabapentin). MOLST completed prior
to discharge.
>30 minutes spent inpatient care and coordination of discharge
on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Gabapentin 300 mg PO DAILY
4. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN
BREAKTHROUGH PAIN
5. Omeprazole 20 mg PO BID
6. Simvastatin 40 mg PO QPM
7. Furosemide 80 mg PO DAILY
8. guanFACINE 2 mg oral QHS
9. Losartan Potassium 25 mg PO DAILY
10. Metoprolol Succinate XL 200 mg PO DAILY
11. vardenafil 20 mg oral ONCE:PRN
12. Detemir 38 Units Breakfast
Detemir 48 Units Bedtime
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen [8 Hour Pain Reliever] 650 mg 1 tablet(s) by
mouth every 6 hours as needed Disp #*30 Tablet Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 Unit IH Four times
dailu as needed Disp #*60 Vial Refills:*0
3. Benzonatate 100 mg PO TID
RX *benzonatate [Tessalon Perles] 100 mg 1 capsule(s) by mouth
three times daily as needed Disp #*90 Capsule Refills:*0
4. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 ml by mouth
four times daily as needed Refills:*0
5. Ipratropium Bromide Neb 1 NEB IH Q6H
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 Unit IH four times
daily as needed Disp #*30 Ampule Refills:*0
6. Ondansetron ODT 4 mg PO TID nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth three times daily as
needed Disp #*90 Tablet Refills:*0
7. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe
RX *oxycodone 10 mg 1 tablet(s) by mouth every four hours as
needed Disp #*120 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth daily as needed Refills:*0
9. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp
#*60 Tablet Refills:*0
10. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice daily Disp #*60
Capsule Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic poorly differentiated adenocarcinoma with metastasis
to the lung and liver, likely gastrointestinal origin
Acute hypoxemia respiratory failure
Acute renal failure
Acute metabolic encephalopathy
Type 2 diabetes mellitus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were hospitalized due to a new cancer, which most likely
started in your gastrointestinal tract and then spread to the
lungs and the liver. Unfortunately the cancer was so
fast-growing that treatment with chemotherapy was not going to
be helpful. As a result of the cancer you also developed kidney
failure and received several sessions of dialysis. You will be
discharged with hospice care to focus on comfort. Please contact
our staff with any questions relating to your admission to the
hospital.
Followup Instructions:
___
|
19860678-DS-8 | 19,860,678 | 29,059,642 | DS | 8 | 2173-01-17 00:00:00 | 2173-01-17 13:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Darvon
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
===============================================================
Oncology Hospitalist Admission
Date: ___
================================================================
PRIMARY ONCOLOGIST: ___., MD
PRIMARY DIAGNOSIS: Recurrent uterine carcinosarcoma w/
carcinomatosis
TREATMENT REGIMEN: awaiting initiation of
lenvima/pembrolizumab
CHIEF COMPLAINT: Chest Pain
HISTORY OF PRESENT ILLNESS:
___ PMH of Depression, T2DM, Recurrent uterine carcinosarcoma w/
carcinomatosis c/b malignant ascites (awaiting initiation of
lenvima/pembrolizumab) p/w chest pain, admitted for workup
Pt reports that she developed right sided chest pressure
yesterday at 3pm which was ___ in intensity, non radiating, not
associated with SOB/palpitations/nausea/vomiting. She noted that
she had never had anything like this before. Reported
intermittent non-productive cough, but no fever or chills. Has
family history of heart disease but no personal history, never
had a stress test, and is not a smoker. She noted that she tried
TUMS to no effect. Reported that she has baseline anxiety but
doesn't feel like she is having a panic attack.
In the ED, initial vitals: 98.1 106 116/57 18 97% RA. WBC 9.1,
Hgb 9.0, plt 380, ALT 45, AST 65, AP wnl, CHEM w/ HCO3 18, Cr
1.3, Trop <0.01x2
EKG: Sinus tachycardia, Qwave in III/AVF suggestive of old
inferior infarct, no STEMI
Repeat EKG: Difficult to assess given wavering baseline, but
appears grossly unchanged without e/o STEMI
CTA Chest:
-No evidence of pulmonary embolism or aortic abnormality.
-Similar appearance of abdominal metastatic disease and enlarged
left anterior epicardial lymph nodes to prior CT abdomen pelvis
from ___.
-No specific evidence of metastatic disease in the chest
CXR:
Similar pattern of atelectasis in the lower lungs. No signs of
pneumonia or edema.
Patient was given 325 ASA, SL NTG x1, Tylenol, Ativan, IVF then
admitted. I asked that cardiology be consulted for question of
unstable angina given her e/o old inferior infarct on EKG which
suggests that she has CAD, and fact that she was without
alternate etiology of chest pain per review of labs/imaging but
ED team declined my request and admitted without such
consultation.
Past Medical History:
Breast Cancer, DM, hypothyroidism, arthritis
PSH: cholecystectomy, neck surgery, right breast lumpectomy, D&C
OB-Gyn hx: G1P1, menarche at age ___, menopause in early ___,
last pap smear ___ NIL, HPV negative, denies h/o abnormal
pap
smears.
Social History:
___
Family History:
Family history is significant for a paternal aunt with breast
cancer, maternal ___ cousin with ovarian cancer, and a father
with lymphoma. She is of ___ descent.
Physical Exam:
Temp: 98.1 (Tm 98.1), BP: 119/72, HR: 76, RR: 18, O2 sat:
99%, O2 delivery: RA, Wt: 139.8 lb/63.41 kg
GENERAL: laying in bed, appears fatigued but is not in acute
distress
EYES: PERRLA, anicteric
HEENT: OP clear, MMM
NECK: supple, normal ROM
LUNGS: CTA b/l no wheezes/rales/rhonchi, normal RR, no
increased
WOB, no cough
CHEST: No palpable abnormalities over right chest and no
tenderness
CV: RRR normal distal perfusion, no peripheral edema
ABD: Soft, NT, slightly distended, hypoactive BS, no rebound or
guarding
GENITOURINARY: No foley or suprapubic tenderness
EXT: warm, no deformity, normal muscle bulk
SKIN: warm, dry, no rash
NEURO: AOX3, fluent speech
ACCESS: PORT dressing c/d/I on left side
Pertinent Results:
___ 08:37AM BLOOD WBC-8.4 RBC-3.03* Hgb-8.7* Hct-28.0*
MCV-92 MCH-28.7 MCHC-31.1* RDW-13.4 RDWSD-45.8 Plt ___
___ 08:37AM BLOOD Neuts-78.2* Lymphs-13.5* Monos-6.3
Eos-1.0 Baso-0.6 Im ___ AbsNeut-6.57* AbsLymp-1.13*
AbsMono-0.53 AbsEos-0.08 AbsBaso-0.05
___ 08:37AM BLOOD Plt ___
___ 08:37AM BLOOD ___ PTT-25.1 ___
___ 08:37AM BLOOD Glucose-150* UreaN-30* Creat-1.2* Na-136
K-4.0 Cl-104 HCO3-18* AnGap-14
___ 08:37AM BLOOD ALT-33 AST-39 LD(LDH)-358* CK(CPK)-25*
AlkPhos-49 TotBili-0.2
___ 08:37AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 12:35AM BLOOD cTropnT-<0.01
___ 09:41PM BLOOD cTropnT-<0.01
___ 08:37AM BLOOD Calcium-7.6* Phos-4.6* Mg-1.6
___ 09:41PM BLOOD Albumin-3.0*
Brief Hospital Course:
TRANSITIONAL ISSUES:
[ ] will need an outpatient pharmacologic stress test to assess
for ischemia (ordered, will need follow-up), and primary care
follow-up for the same
[ ] will need QTc monitoring given history of prolongation and
risk of prolongation upon starting lenvantinib. Last QTc 486 on
___.
[ ] will need follow-up oncology appointments with DFCI and with
Dr. ___ at ___ (already scheduled)
[ ] we are holding metformin for 48 hours in the setting of
contrast, will resume ___
[ ] patient had elevated Cr to 1.3 after receiving contrast,
which down-trended to 1.2 on discharge after IV albumin
BRIEF HOSPITAL COURSE:
___ depression, T2DM on metformin, recurrent uterine
carcinosarcoma with peritoneal carcinomatosis and pelvic masses
s/p ___ and brachytherapy, ccb malignant ascites
requiring paracentesis, awaiting initiation of
lenvantinib/pembrolizumab, presenting with chest pain.
#chest pain
CTA negative for PE, infection, or metastatic disease. EKG was
without STEMI and troponins were negative x 3. EKG shows
inferior q waves that were present on prior EKG suggestive of
prior MI. She has risk factors for ischemic disease including
age, DM. Chest pressure was atypical in description (lasting for
>24 hours, non-radiating, right-sided, non-exertional, did not
respond to SL nitroglycerin but improved with Tylenol and
Ativan). Her blood pressure did not tolerate further NTG or
metoprolol. She was started on aspirin ASA 81mg daily and
Tylenol and her home Crestor was continued. She was maintained
on telemetry without events. A pharm stress Echo was ordered for
inpatient workup. However, the patient adamantly wished to
attend her outpatient oncology appointment at ___ on
___ and therefore we had a shared decision making process with
her outpatient oncologist Dr. ___ inpatient oncology team,
the patient, and the patient's proxy. The decision was made to
pursue the stress test as an outpatient. The patient was given
the number ___ to call if she did not hear from them.
#recurrent uterine carcinosarcoma w/ carcinomatosis ccb
malignant ascites, awaiting initiation of
pembrolizumab/lenvantinib
Patient will have second opinion at ___ at noon prior to
starting therapy on pembrolizumab/lenvantinib. Spoke to Dr. ___
___ oncologist who agrees with our plan.
___
Patient's creatinine increased to ___ s/p IV contrast for CTA,
down-trended to 1.2 after receiving IV albumin
#DM
Metformin was held in setting of CT scan and ___. This should be
resumed on ___.
#hypothyroidism
Home Synthroid was continued
#depression/anxiety
Home sertraline and lorazepam were continued
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
2. lenvatinib 10 mg oral DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Metoclopramide 10 mg PO QIDACHS
6. Rosuvastatin Calcium 20 mg PO QPM
7. Sertraline 100 mg PO DAILY
8. FoLIC Acid 1 mg PO Q12H
9. Cyanocobalamin 1000 mcg PO DAILY
10. LORazepam 0.5 mg PO Q6H:PRN insomnia, anxiety, nausea,
vomiting
Discharge Medications:
1. Acetaminophen 650 mg PO TID mild pain
2. Aspirin 81 mg PO DAILY
3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. FoLIC Acid 1 mg PO Q12H
6. lenvatinib 10 mg oral DAILY
7. Levothyroxine Sodium 100 mcg PO DAILY
8. LORazepam 0.5 mg PO Q6H:PRN insomnia, anxiety, nausea,
vomiting
9. Metoclopramide 10 mg PO QIDACHS
10. Rosuvastatin Calcium 20 mg PO QPM
11. Sertraline 100 mg PO DAILY
12. HELD- MetFORMIN (Glucophage) 500 mg PO BID This medication
was held. Do not restart MetFORMIN (Glucophage) until ___
Discharge Disposition:
Home
Discharge Diagnosis:
chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for chest pressure
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We did two EKGs (test of electrical activity in the heart)
which were not significantly changed from your prior EKG and
suggested a possible old and resolved heart attack
- We checked blood tests for heart injury which were normal (x3)
- A chest X-ray of your lungs was normal
- We did a CT scan of your chest with contrast that did not show
any evidence of pulmonary embolism (clot in the lungs)
- We found that your kidney function was slightly worse and we
gave you some IV albumin. Your kidney function then improved.
- We gave you Tylenol and your chest pain improved
- In normal circumstances, we would have kept you in the
hospital to do a stress test with imaging to evaluate for
reversible blockages in your heart. However, after a candid
discussion with both you, your health care proxy, your
outpatient oncologist Dr. ___ our inpatient team, we
decided that you would pursue this test as an outpatient. The
reason is that you had an important second opinion oncology
appointment at ___ that you wanted to prioritize over
obtaining cardiac imaging.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments. We have held your metformin in the setting of
having a CT scan, please re-start this medication on ___.
- You will need to do a cardaic stress echo as an outpatient. We
have ordered this and you should hear from them. Please call
___ to arrange if you do not hear from them in the
coming days.
- It is okay to take Tylenol ___ three times a day for mild to
moderate pain
- Please make an appointment with your primary care doctor to
follow-up on discharge and on the cardiac stress test.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19860832-DS-7 | 19,860,832 | 22,953,527 | DS | 7 | 2131-07-25 00:00:00 | 2131-07-25 15:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Intraparenchymal hemorrhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is an ___ y/o male with uncomfirmed PMHx who was
found down outside his car in a pool of vomit and brought into
___, where he was found to have a right frontal IPH
with possible SAH component. He was subsequently transferred to
___ for neurosurgical evaluation. In the ED, he was noted to
be agitated and AAOx1.
Past Medical History:
(per OMR note from ___ from GI)
- dysphagia
- stomach ulcer NOS
- PUD
- benign neoplasia of the large bowel
- diverticulosis of the colon
- cirrhosis of the liver NOS
- ? heart disease
- achalasia
Social History:
___
Family History:
mother had GI cancer, primary unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
O: T: 98.6 BP: 108/87 HR: 98 R 20 O2Sats 100% on 2LNC
Gen: slim elderly male lying in bed, agitated
HEENT: C-collar on
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awakens to loud voice or sternal rub
Orientation: Oriented to person in that he responds to his name
but is unable to answer his name when asked
Language: Unable to assess as pt only says "what" or "Uh-huh"
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric on
passive movement, but pt unable to cooperate with formal
testing.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. MAEE and very vigorously, but pt unable to cooperate
with formal strength exam
Sensation: Intact to noxious throughout
Reflexes: B T Br Pa Ac
Right ___ 1 1
Left ___ 1 1
Toes mute bilaterally
Coordination: Patient unable to cooperate with FNF testing.
Discharge PE:
The patient did not appear to be in distress.
Pertinent Results:
ADMISSION LABS:
___ 11:23PM BLOOD WBC-12.9*# RBC-4.34* Hgb-12.8* Hct-39.0*
MCV-90 MCH-29.4 MCHC-32.7 RDW-13.8 Plt ___
___ 11:23PM BLOOD Neuts-86.0* Lymphs-7.6* Monos-6.1 Eos-0.1
Baso-0.3
___ 10:38PM BLOOD ___ PTT-27.8 ___
___ 10:38PM BLOOD Glucose-157* UreaN-15 Creat-1.1 Na-146*
K-3.1* Cl-100 HCO3-27 AnGap-22*
REPORTS:
CT head
Limited study due to motion again (despite repetition)
demonstrates a 2.1 x 1.6 cm right frontal parenchymal hemorrhage
with
subarachnoid extension and new intraventricular extension.
Additionally,
hyperdense material now layers along the posterior right
occipital lobe in the region of the right transverse sinus and
may be representative of a prominent transverse sinus or a small
subdural hematoma.
NOTE ADDED IN ATTENDING REVIEW: Though both studies demonstrate
focally
increased soft tissue-attenuation within the left parietovertex
scalp
extending to overlie the mastoid portion of the left temporal
bone, this does not clearly represent a subgaleal hematoma, as
has attenuation of only 40-45 ___. However, this may be seen in
an anemic or anticoagulated patient.
This should be closely correlated with more detailed clinical
information,
including trauma and medication history. Otherwise, this
constellation of
findings, in an elderly patient, is otherwise strongly
suggestive of cerebral amyloid angiopathy, though
intraventricular component is somewhat unusual in that setting.
There is no evidence of progressive ventricular dilatation to
suggest developing hydrocephalus.
___ MRI C-spine: 1. STIR hyperintensity in facets at C4-C5 on
the right side with synovial effusion in the right C4-C5 facet
joint which likely represent degenerative changes. There is also
STIR hyperintensity in the posterior paraspinal soft tissues at
this level on the right, which likely represent edema. There is
no evidence of fluid collection.
2. Multilevel degenerative change in the cervical spine, most
notable at
C5-C6 level.
3. Multilevel neural foraminal stenosis.
4. Heterogeneous nodule within the left lobe of thyroid, which
requires
further evaluation with ultrasound of thyroid if not already
performed.
___ CXR: In the image marked ___ Dobhoff Attempt, the feeding
tube with a wire stylet in place ends in the right lower lobe
bronchus. In the image marked ___ Dobhoff Attempt, there is no
feeding tube visible. Dr. ___ was paged 30 seconds after
finding was recognized, at 4:48 p.m. ET tube is in standard
placement. Right lung is clear. A band of atelectasis crosses
the left lower lung. There is no pneumothorax or pleural
effusion. Cardiomediastinal silhouette is normal.
___ CT T-spine: IMPRESSION:
1. No acute fracture in the thoracic spine. Wedge deformity of
T7 and T12 as well as degenerative changes in the lower thoracic
spine.
2. Bilateral pleural effusions.
3. Secretions within the esophagus.
NOTE ADDED AT ATTENDING REVIEW: The T7 compression fracture
appears to be most likely acute, rather than chronic. There is a
tiny osseous fragment slightly retropulsed into the canal
(approximately 2-3mm). there is mild angular kyphosis at this
level. The pedicles and posterior elements appear intact, but
the anterior and posterior vertebral body cortex is disrupted.
The T12 wedge deformity is chronic. There is flowing anterior
longitudinal
ligament ossification from T11 to L1.
___ CT C-spine: IMPRESSION: No evidence of fracture or
subluxation. Moderate degenerative changes.
___ CT L-spine: IMPRESSION: 1. Compression deformity of the L4
vertebral body which is chronicity indeterminate due to lack of
comparisons. There is no associated retropulsion. However,
there is irregularity of the endplates. Differential includes
possible infectious process such as discitis, collapsed
hemangioma or multiple myeloma. Wedge deformity of T12 also age
indeterminate. Multilevel degenerative changes.
2. Small bilateral pleural effusions with overlying
atelectasis.
3. Calcification within the right kidney, which may be vascular
or small
nonobstructing stone.
4. Diverticulosis without diverticulitis.
NOTE ADDED AT ATTENDING REVIEW: The L4 fracture and irregular L3
inferior
endplate appear chronic and have not changed since an abdominal
Ct of ___. Thus, these findings do not raise a concern
of recent fracture or of infection.
___ CXR: The ET tube tip is approximately 7.8 cm above the
carina. The Dobbhoff tube tip is not seen and might be
potentially coiled in the oropharynx. Heart size and
mediastinum are stable. Lungs are essentially clear except for
minimal bibasilar atelectasis.
___ ECG: Sinus rhythm. Non-specific lateral ST-T wave changes.
Borderline low voltage in the limb leads. Compared to the
previous tracing of ___ premature beats are absent. R wave
transition occurs later which may be due to lead positioning.
___ CXR: Endotracheal tube tip is 6.2 cm above the carina.
Ill-defined and faint, right lower lung opacity is new and the
minor fissure is mildly thickened and distinctly seen,
suggesting aspiration or atelectasis or asymmetrically mild
pulmonary edema. Upper lungs are clear. Heart size is normal.
Mediastinal and hilar contours are unremarkable. There is no
pleural abnormality.
___ CXR: IMPRESSION: New right upper lobe partial collapse and
contour abnormality of the left main stem bronchus suggests the
possibility of mucous plugging causing the atelectasis. A
bronchoscopy may be helpful to identify and clear potential
mucous plugging.
___ CT Head: IMPRESSION: Slightly increased size of right
frontal intraparenchymal hematoma, with a similar degree of
subarachnoid, subdural, and intraventricular hemorrhage. There
is no new mass effect, or acute territorial infarction.
___ CXR: Right perihilar opacity has markedly worsened, is a
combination of pleural effusion layering in the fissure and
adjacent atelectasis, superimposed infection cannot be excluded.
Moderate-to-large bilateral pleural effusions have increased.
Cardiac size is accentuated by the projection. There is mild
vascular congestion. ET tube is in standard position. There is
no pneumothorax.
CHEST (PORTABLE AP) Study Date of ___ 3:32 AM
FINDINGS: As compared to the previous radiograph, the patient
has been
extubated. As a consequence, the lung volumes have decreased.
The size of the cardiac silhouette is constant. Unchanged
minimal pulmonary fluid
overload, unchanged small left pleural effusion. Unchanged
partial shoulder replacement.
No newly appeared focal parenchymal opacities.
Radiology Report UNILAT LOWER EXT VEINS LEFT PORT ___: No deep
vein thrombosis seen in the left arm.
SHOULDER 1 VIEW LEFT Study Date of ___ 1:53 ___
Possible greater tuberosity fracture with coritcal irregularity
of the
proximal humeral metadiaphysis concerning for additional or
contiguous fx;
however these are not well evaluated likely due to difficulties
in positioning the patient and are age indeterminate. Old mid
humeral fx. Prior images would be helpful in determining the
chronicity of these findings.
LEFT ANKLE X-RAY ___:
FINDINGS: There is a healed fracture deformity involving the
distal fibular shaft. No definite acute fracture is seen.
There is soft tissue swelling, lateral greater than medial.
There is slight widening of the medial ankle mortise. Calcaneal
spur is present. Vascular calcifications are also seen.
LEFT SHOULDER X-RAY ___ (3 views):
FINDINGS: The visualized left lung and ribs are unremarkable.
Prior left
shoulder hemiarthroplasty. Cerclage wires are noted around the
proximal
humerus metadiaphysis. Either heterotopic ossification versus
old fracture of the greater tuberosity. Post-traumatic
deformity of the diaphysis distal to the prosthesis. Unchanged
AC joint degenerative changes.
CXR ___:
FINDINGS: A single portable AP chest radiograph was obtained.
A nasogastric tube loops in the mid esophagus. Moderate
pulmonary edema is unchanged. Left basilar opacity and small
effusion are unchanged. A right sided PICC line tip terminates
in the mid SVC.
CXR ___:
FINDINGS: As compared to the previous radiograph, the
malpositioned
nasogastric tube has been removed. The right PICC line is in
unchanged
position. Unchanged appearance of the lung parenchyma. No
pneumothorax.
CXR ___:
FINDINGS: There is a right-sided PICC line whose distal lead tip
is at the mid-to-distal SVC. Cardiac silhouette is upper limits
of normal. There is a persistent left retrocardiac opacity and
left-sided pleural effusion which is stable. Mild prominence of
pulmonary interstitial markings is again seen. Overall, these
findings are all stable.
Brief Hospital Course:
___ is an ___ yo male with uncomfirmed PMHx found down,
with a R frontal IPH. On the day of admission patient was
agitated with an otherwise non-focal neurological exam. He was
loaded with fosphenytoin, given platelets and made NPO. In the
ICU he was more awake and purposeful on ___. His wife confirmed
use of omeprazole and vitamins but did not know his PMH. OMR
notes from ___ were used for clinical reference. He was not
oriented enough to clear his C-spine so he was intubated and
taken to the MRI for a C-spine image. In addition, he had whole
spine imaging that showed multiple fractures (at T7, T12 and L4)
of questionable chronicity, with the T7 fracture likely new and
the T12 and L4 likely subacute or chronic. On ___ he had a
dilantin level that corrected to 15. Dr ___
NeuroRadiology was consulted to evaluate the role of
vertebroplasty. He recommended TLSO brace at this time, and
reconsult if worsening once he was more stable and OOB. Mr ___
was also noted to have thick secretions therefore was not
cleared for extubation. On ___ the patient was noted to have
decreased movement in the left UE, Dr ___ was made aware but
no intervention was necessary. He was also noted to have
decreased urine output so he was given multiple boluses of IVF
and subsequent lasix. His cough and gag were decreased and CXR
revealed worsening so he was bronched and noted to have a LUL
collapse.
On ___, patient began to open eyes to voice, and was moving all
4 extremities spontaneously. He was successfully extubated and
had a PICC line placed. The patient was fitted for a TLSO brace.
On ___, GI was consulted for enteral access and recommended PEG
tube. The Dilantin level was 11.9. On exam, The patient opened
eyes to voice and was oriented to self. The patient followed
commands in all extremities.
On ___, The patient was febrile to 101.2 and the patient was
pancultured. There was unknown source of fever and the Dilantin
was changed to Keppra. On exam the patient opened eyes to
sternal rub, the patient localized with upper extremities and
moved lower extremities to sternal rub. The family requested a
family meeting and stated taht the patient would not want to be
dependent on others and made the patient DNR/DNI. A pallative
care consult was made as the patient's family would like to move
toward care and comfort measures possibly and required guidence.
The family was clear with their wishes that the patient would
not want a Gtube for feedings.
On ___, the family met with Palliative care and after
thoughtful consideration the patient was made CMO given the
wishes to not proceed with a feeding tube. His cervical collar
was removed and medications were discontinued per palliative
care. Medications to promote comfort were prescribed. He was
transferred to the floor.
On ___, the patient showed improved mental status but continued
to cough with PO intake. He remained comfortable and did not
appear to be in distress or pain.
On ___, the patient had a fever of 101.3 and was given Tylenol.
Given the goals of care, no cultures were obtained at the time.
He was offered a bed at ___ and was
transfered there on ___.
Medications on Admission:
omeprazole/mvi
Discharge Medications:
1. morphine 10 mg/5 mL Solution Sig: ___ mg PO Q1H (every hour)
as needed for pain.
2. hyoscyamine sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual Q4H (every 4 hours) as needed for
secretions.
3. acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for pain.
4. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO Q4H (every 4 hours).
5. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: ___ mg Injection
Q6H (every 6 hours) as needed for nausea/vomiting.
6. lorazepam 2 mg/mL Syringe Sig: 0.5-2 mg Injection Q2H (every
2 hours) as needed for anxiety/distress/seizure.
7. morphine 5 mg/mL Solution Sig: ___ mg Injection Q2H (every 2
hours) as needed for Pain.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right frontal IPH
C4 TP fracture
T12 wedge fracture
Dysphagia
Discharge Condition:
Neurologically stable
Discharge Instructions:
General Instructions ******
Pain medications should be given as needed for comfort.
Followup Instructions:
___
|
19860951-DS-14 | 19,860,951 | 25,275,183 | DS | 14 | 2141-01-01 00:00:00 | 2141-01-01 20:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zithromax Z-Pak / Penicillins / clarithromycin
Attending: ___.
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
___: AV Fistulogram w/thrombectomy
History of Present Illness:
Mr. ___ is a ___ year old man with a history of ESRD on
HD ___, presenting from interventional radiology with
hyperkalemia.
The patient was at dialysis session on ___ (Th), when he was
noticed to have non-functioning LUE AVF. His AVF was created
about ___ years ago and he was initiated on HD ___ years ago, with
one prior complication due to LUE AVF clot. He was found to have
another clot and initially came to ___ for
fistulogram/thrombectomy procedure with ___.
At the procedure, he was noted to have elevated K to 6.3. In the
___ office, he was given insulin IV 10 Units and dextrose 1amp,
and his repeat K was 5.7. As he was still hyperkalemic, his
procedure was postponed, Dr. ___ a femoral
temporary dialysis line, and he was transferred to the ED for
further management of his hyperkalemia. His ___
fistulagram/thrombectomy was also postponed.
The patient states that he has been well throughout this entire
process, without any notable symptoms. He at baseline makes some
urine still and last completed a dialysis session prior to
admission on ___. He did have shaking, overall discomfort
due to hypoglycemia (FSBG of 35) during his ___ procedure as he
did not receive lantus that morning. He is a T1 Diabetic and has
had prior hospitalizations for DKA.
In the ED, initial vital signs were 98.8 82 142/86 20 99% RA.
Physical exam was remarkable for LUE fistula with still palpable
thrill and +bruit. His EKG was notable for mildly peaked T
waves, otherwise unremarkable. He underwent 2 emergent dialysis
session (once on ___ and once on ___, both limited by
hypotension (per patient). He also underwent delayed fistulogram
and thrombectomy on ___ prior to admission to the floor with
successful recannulation of his LUE AVF.
On transfer to the floor, the patient was well, citing pain in
his R groin ___ placement of HD line as well as his R shoulder
(irritation of known rotator cuff tear during HD line
placement). Otherwise, he denies any f/c/r, chest pain, SOB, abd
pain, N/V, dysuria, or increased ___ swelling.
Past Medical History:
-DM1 with Nephropathy, Retinopathy and Neuropathy
-ESRD on T, Th, ___ HD
-Hyperparathyroidism
-Bipolar
-COPD
-Sleep Apnea
-HTN
Social History:
___
Family History:
Non contributory
Physical Exam:
Admission Exam
==================
Vitals: 99.4, 115/41, 118, 18, 99% RA
General: well appearing in NAD, sitting up in bed
HEENT: NC/AT, EOMI, PERRLA, MMM, tongue midline on protrusion,
symmetric palatal elevation
Neck: symmetric, supple, no cervical LAD or supraclavicular LAD
CV: RRR, ___ SEM best heard at LUSB
Lungs: CTAB with decreased breath sounds and fine crackles at
bilateral bases; no rhonchi or wheezing
Abdomen: Soft, ND, NTTP, BS+ (hypoactive); no r/g, no abd scars
GU: No foley in place
Ext: Warm, well perfused, no pitting edema b/l; LUE AVF without
palpable thrill but bruit appreciated on auscultation
Neuro: A&Ox3, appropriate on exam; CN exam as above with
symmetric smile and eyebrow raise; CN5 intact and symmetric
along all divisions; b/l strength ___ in UE and ___ (LLE limited
by pain)
Discharge Exam
===============
Vitals: 98.7, 127/67, 91, 18, 100% RA
General: well appearing in NAD, sitting up in bed
HEENT: NC/AT, EOMI, PERRLA, MMM, tongue midline on protrusion,
symmetric palatal elevation
Neck: symmetric, supple, no cervical LAD or supraclavicular LAD
CV: RRR, ___ SEM best heard at LUSB
Lungs: CTAB with decreased breath sounds and fine crackles at
bilateral bases; no rhonchi or wheezing
Abdomen: Soft, ND, NTTP, BS+ (hypoactive); no r/g, no abd scars
GU: No foley in place
Ext: Warm, well perfused, no pitting edema b/l; LUE AVF with
palpable thrill and bruit appreciated on auscultation
Neuro: no focal deficits
Pertinent Results:
Admission Labs
================
___ 08:30AM BLOOD WBC-5.0 RBC-4.01* Hgb-12.3* Hct-36.8*
MCV-92 MCH-30.7 MCHC-33.4 RDW-12.7 RDWSD-42.5 Plt ___
___ 08:30AM BLOOD ___
___ 08:30AM BLOOD Creat-11.9* Na-137 K-6.3* Cl-97
___ 12:10AM BLOOD Calcium-9.5 Phos-3.4 Mg-2.0
Potassium Trend
==================
___: 6.3
___ 5.7
___ 6.6
___ 5.0
___ 5.0
___ 4.5
___ 4.6
Other Pertinent Labs
=====================
___ 07:00AM BLOOD Ret Aut-1.7 Abs Ret-0.07
___:00AM BLOOD LD(___)-135 TotBili-0.4
___ 07:00PM BLOOD %HbA1c-6.5* eAG-140*
___ 01:59AM BLOOD ___ pO2-56* pCO2-36 pH-7.44
calTCO2-25 Base XS-0
___ 06:17AM BLOOD Glucose-361.* Na-130* K-4.8 Cl-92*
calHCO3-22
___ 03:04AM BLOOD Glucose-390* Na-132* K-4.7 Cl-91*
calHCO3-22
Discharge Labs
================
___ 07:00AM BLOOD WBC-5.0 RBC-3.79* Hgb-11.5* Hct-35.4*
MCV-93 MCH-30.3 MCHC-32.5 RDW-12.4 RDWSD-43.1 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-180* UreaN-77* Creat-10.7* Na-136
K-4.6 Cl-95* HCO3-28 AnGap-18
___ 07:00AM BLOOD LD(___)-135 TotBili-0.4
___ 07:00AM BLOOD Calcium-9.7 Phos-6.0*# Mg-2.4
Procedures
===========
AV Fistulogram ___
FINDINGS:
1. Complete thrombosis of the left upper extremity AV fistula.
2. Severe (>90%) stenosis of outflow vein with improvement
following
angioplasty to 8 mm.
3. Mild stenosis of the juxta-anastamotic segment (~50%), with
improvement
following angioplasty to 6 mm.
4. No central venous stenosis.
5. Postprocedure ultrasound of the graft shows a patent fistula
with v olume
flow of 880 cc/min
Brief Hospital Course:
Mr. ___ is a ___ y/o man with history of ESRD on HD
___, T1DM, and recent AVF thrombus, transferred to ED from
___ where he was planned to have AV Fistulogram and thrombectomy
for hyperkalemia. He is now s/p urgent HD via femoral HD
catheter x2 sessions with improvement in hyperkalemia and
successful thrombectomy of LUE AVF, admitted to medicine for
further monitoring.
# T1DM/hyperglycemia: Patient with T1DM, with most recent A1c
reported to be 7 per patient, as of a couple weeks prior to
admission. However, patient does have ESRD and neuropathy as a
result. The patient was briefly hypoglycemic in setting of
aggressive insulin administration in setting of hyperkalemia. At
home, he is on lantus 32u qAM, regular insulin 10u qAM, and
regular insulin 4u qPM. Blood sugar was in 300-400's during
admission, with no obvious cause. No symptoms of DKA, no
acidosis and/or anion gap. Patient's home insulin regimen was
resumed on ___ and sugars subsequently improved on ___. Patient
was continued on his home gabapentin for neuropathy, in addition
to home Lisinopril. Discharged on outpatient insulin regimen
with plan for close blood sugar monitoring and follow up with
primary doctor in prison.
# Hyperkalemia: Patient was transferred to ED from ___ for
hyperkalemia with signs of TW peaking on EKG. He was
asymptomatic. Patient received IV insulin and 2 sessions of HD
and potassium normalized.
# AVF thrombosis: Patient noted on ___ to have
non-functioning AVF. He underwent AV fistulogram and successful
thrombectomy with ___ on ___.
# ESRD on Hemodialysis: Patient with ESRD secondary to DM and
was initiated on HD about ___ years ago. As above, received 2
session of dialysis via femoral HD catheter (placed by ___ due to
thrombosed AVF). Patient underwent successful fistulogram with
thrombectomy on ___ as above and fistula now okay for
dialysis. Patient to resume outpatient dialysis on ___ as
scheduled. While inpatient he was continued on home Lasix and
started on Sevelamer for elevated Phos.
# HTN: Patient was continued on home metoprolol and lisinopril.
He remained normotensive throughout admission.
Transitional Issues
[ ] Patient's blood sugars elevated to 300-400's during
admission. Discharged on home insulin regimen; please ensure
close monitoring of blood sugars.
[ ] Patient was admitted with asymptomatic hyperkalemia. ___
consider routine electrolyte monitoring as outpatient in setting
of ESRD.
[ ] Patient due for HD on ___. Please ensure he has dialysis
as outpatient.
[ ] Patient initiated on treatment with Sevelamer during
admission for elevated phos. Patient's renal provider may
determine need for continuing this medication in the future.
Code: Full
Emergency Contact: Prison phone number ___. Identity
number ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 30 mL PO BID:PRN constipation
2. Acetaminophen 650 mg PO Q8H:PRN pain
3. Lisinopril 5 mg PO QHS
4. Gabapentin 300 mg PO QAM
5. Metoprolol Tartrate 50 mg PO Q12H
6. calcium polycarbophil 625 mg oral DAILY
7. Docusate Sodium 200 mg PO QAM
8. DiphenhydrAMINE 50 mg PO Q8H:PRN itching
9. Atorvastatin 40 mg PO QPM
10. Furosemide 20 mg PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO QHS:PRN pain
12. Glargine 32 Units Breakfast
Regular 10 Units Breakfast
Regular 4 Units Dinner
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Docusate Sodium 200 mg PO QAM
3. Furosemide 20 mg PO DAILY
4. Gabapentin 300 mg PO QAM
5. Glargine 32 Units Breakfast
Regular 10 Units Breakfast
Regular 4 Units Dinner
6. Lactulose 30 mL PO BID:PRN constipation
7. Lisinopril 5 mg PO QHS
8. Metoprolol Tartrate 50 mg PO Q12H
9. Acetaminophen 650 mg PO Q8H:PRN pain
10. calcium polycarbophil 625 mg oral DAILY
11. DiphenhydrAMINE 50 mg PO Q8H:PRN itching
12. OxycoDONE (Immediate Release) 5 mg PO QHS:PRN pain
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis:
Hyperkalemia
Hyperglycemia
Secondary Diagnosis:
Type 1 Diabetes Mellitus
End Stage Renal 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 caring for you at ___. You were admitted
because your potassium levels were high. You were treated with
insulin and sugar and your potassium level normalized. During
your admission you had a procedure with interventional radiology
to remove a clot from the fistula in your arm. The procedure was
successful and you are able to receive dialysis through your
fistula as usual.
During your admission your blood sugars were found to be high.
This may have been due to your body's stress response to the
procedure in combination with your home insulin regimen being
held in the beginning of your admission. You were re-started on
your home insulin and your blood sugars improved.
You should be seen by your primary doctor within 48 hours of
discharge. Please monitor your blood sugars closely to ensure
they remain in a safe range (<300).
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19861136-DS-21 | 19,861,136 | 21,820,005 | DS | 21 | 2155-01-14 00:00:00 | 2155-01-19 10:19:00 |
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:
Patient is ___ gentleman with no past medical history
who
presents to the emergency department from PCPs office with
abnormal EKG and concern for STEMI. One week ago, pt first
noticed some left lower chest discomfort which he felt was
similar to muscle strains he has had in the past. He plays
tennis
multiple times per week and frequently strains muscles. This
pain
resolved without intervention, but then migrated to his anterior
chest wall. He did not try any medications to improved his
chest
pain. This then migrated to his left shoulder. It was sharp in
nature, did not worsen with physical activity, and did get worse
with deep breaths. It was not associated with any dyspnea,
nausea, vomiting or diaphoresis. On the day of admission, he
woke
up this morning and went to see his PCP and had ___ EKG done which
show elevations in V3 V6, so he was transferred here for
concerns
of STEMI. Received 324 mg aspirin prior to arrival to the ED.
On arrival in the ED, patient states he is asymptomatic. Denies
any chest discomfort, shortness of breath. No nausea or
vomiting.
He otherwise denies any recent illness, fevers or chills. No
recent travels or surgeries. Never had any cardiac problems in
the past. Not a smoker.
Past Medical History:
none
Social History:
___
Family History:
non contributory
Physical Exam:
ADMISSION EXAM:
===============
VITALS: ___ 1628 Temp: 98.3 PO BP: 121/73 L Sitting HR: 86
RR: 16 O2 sat: 97% O2 delivery: Ra
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate. Lying comfortably in bed.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE EXAM:
===============
VITALS: ___ 0444 Temp: 98.0 PO BP: 133/75 L Lying HR: 81
RR: 18 O2 sat: 94% O2 delivery: Ra
GENERAL: Lying comfortably in bed. NAD
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
=============
___ 09:13AM BLOOD WBC-8.9 RBC-4.35* Hgb-13.8 Hct-42.4
MCV-98 MCH-31.7 MCHC-32.5 RDW-12.1 RDWSD-43.8 Plt ___
___ 09:13AM BLOOD Neuts-80.6* Lymphs-6.2* Monos-11.5
Eos-1.0 Baso-0.2 Im ___ AbsNeut-7.15* AbsLymp-0.55*
AbsMono-1.02* AbsEos-0.09 AbsBaso-0.02
___ 09:13AM BLOOD Glucose-135* UreaN-26* Creat-1.0 Na-140
K-4.7 Cl-101 HCO3-28 AnGap-11
___ 07:30AM BLOOD ALT-16 AST-20 LD(LDH)-249 AlkPhos-73
TotBili-0.9
___ 07:30AM BLOOD Albumin-3.7 Calcium-8.8 Phos-2.7 Mg-1.8
___ 09:13AM BLOOD CRP-136.1*
DISCHARGE LABS:
==============
___ 07:30AM BLOOD WBC-9.4 RBC-4.43* Hgb-14.1 Hct-43.3
MCV-98 MCH-31.8 MCHC-32.6 RDW-12.2 RDWSD-44.5 Plt ___
___ 07:30AM BLOOD Neuts-79.7* Lymphs-6.4* Monos-9.7 Eos-3.6
Baso-0.3 Im ___ AbsNeut-7.44* AbsLymp-0.60* AbsMono-0.91*
AbsEos-0.34 AbsBaso-0.03
___ 07:30AM BLOOD Glucose-93 UreaN-22* Creat-1.0 Na-141
K-5.0 Cl-101 HCO3-27 AnGap-13
TTE:
===
IMPRESSION: Mild symmetric left ventricular hypertrophy with
nromal cavity size and regional/ global systolic function. Mild
aortic regurgitation. Mild mitral regurgitation. Moderate
tricuspid regurgitation. Mild pulmonary artery systolic
hypertension.
Brief Hospital Course:
___ gentleman with no past medical history who presents
to the emergency department from ___ office with EKG findings
concerning for STE in V4-6, found to have diffuse ST elevations
and likely pericarditis.
#Acute pericarditis: Pleuritic chest pain, sharp in nature with
diffuse ST elevations on EKG not in vascular territory very
consistent with acute pericarditis, with CRP elevated to 100s
supporting this diagnosis as well. Given non-exertional
symptoms, no risk factors for CAD, negative trops x 2, very low
concern for ischemic etiology of chest pain. Unclear as to the
etiology of the pericarditis. No recent viral infectious
symptoms whatsoever on review of systems. Even so, most likely
etiology is indolent viral infection. Nothing to suggest lupus,
autoimmune or
other infectious cause. Diagnostically, TTE with no effusion.
Therapeutically, will start colchicine 0.5mg PO BID for 3
months, as well as Ibuprofen 600mg TID for 2 weeks. Will need a
follow up TTE in one week.
Transitional issues:
====================
[] Please get follow up TTE in one to two weeks to ensure no
accumulation of effusion
[] Discharged on Colchicine 0.6mg PO BID for 3 months, Ibuprofen
600mg PO TID for one week
[] Omeprazole 20mg PO daily for one week for GI prophylaxis (no
need to continue when not on NSAID any longer)
Medications on Admission:
None
Discharge Medications:
1. Colchicine 0.6 mg PO BID
RX *colchicine 0.6 mg 1 tablet(s) by mouth Twice daily Disp
#*180 Tablet Refills:*0
2. Ibuprofen 600 mg PO Q8H Duration: 1 Week
RX *ibuprofen 600 mg 1 tablet(s) by mouth Three times daily Disp
#*21 Tablet Refills:*0
3. Omeprazole 20 mg PO DAILY Duration: 1 Week
RX *omeprazole 20 mg 1 capsule(s) by mouth Daily Disp #*7
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pericarditis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because:
- You were having some chest pain at home
- You went to your primary care office and your EKG was
concerning
- In the ED, you were thought to have pericarditis and you were
started on
While you were here:
- You had an echocardiogram which did not show any fluid around
the heart
- You had lab work which did not show any damage to the heart
muscle
- You were diagnosed with acute pericarditis the cause of which
is unclear
- You were started on medications to help resolve the
pericarditis
When you leave:
- Please take all of your medications as prescribed
- Please attend all of your follow up appointments as arranged
for you
It was a pleasure to care for you during your hospitalization!
- Your ___ care team
Followup Instructions:
___
|
19861211-DS-17 | 19,861,211 | 20,604,911 | DS | 17 | 2194-12-12 00:00:00 | 2194-12-14 17:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Gluten / Gentamicin
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
EP study with VT ablation
History of Present Illness:
___ year old male with a past medical history of hypertension,
CAD status post CABG in ___, diabetes presenting with acute
onset of shortness of breath at 2pm yesterday. Preceded by
carrying 5 heavy bags up multiple flights of stairs. Also
reports associated palpitations. Shortness of breath started
suddenly, then was continuous over approximatelv 30 hours. No
exacerbating or relieving factors.
.
Associated symptoms: No fevers or chills, no headache, no neck
pain, no presyncope, no chest pain or cough, no abdominal pain,
no nausea vomiting or diarrhea, no focal numbness tingling or
weakness, no dysuria. The patient has no history of arrhythmias.
The patient is not on any anticoagulation. Also denies any new
medications or recent changes to medications, denies any dietary
inconsistencies.
.
In the ED, EKG showed evidence of SVT with abberancy based on
brugada criteria. The patient was given ASA 325 mg, adenosine 6
mg, repeated again at 12 mg, and then again at 18 mg with no
changes in rhythm. The patient was then bolused with Amiodarone
and drip was started. However, amiodarone was then stopped and
patient was started on procainamide drip 20mg/min, total of 1g.
.
On transfer to the floor, the patient was asymptomatic with HR
120-150s, systolic BPs in the ___. Denies any current symptoms,
reports feeling a little anxious.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: CAD s/p CABG in ___
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-DLBC Lymphoma s/p 5 x R-CHOP and 1xRCVP (completed in ___
-MDS
-___ type 2
-Hypertension
-Zoster esophagitis
-Vestibular nerve damage secondary to gentamicin
-BPH status post laser surgery
-Spinal stenosis status post laminectomy in ___
-Celiac disease
-Elevated PSA
-Small bowel perforation with CMV inclusion bodies on the bowel
biopsy after two cycles of R-CHOP in ___
-Left uveitis status post biopsy of the left vitreous body in
___
-S/p intrathecal ara-C on ___ febrile reaction
Social History:
___
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Pt's son was diagnosed with thyroid cancer at age ___, doing
well
now. Brother with prostate cancer. No other known cancers in
the family. Pt's mother died of an MI. Pt's father also had
diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
GENERAL: pleasant gentleman, NAD, laying comfortably in bed.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no JVP appreciated
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Tachycardic, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: +BS, soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: wwp, no c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: Carotid 2+ DP 2+ ___ 2+ Left: Carotid 2+ DP 2+
___ 2+
.
DISCHARGE PHYSICAL EXAM:
GENERAL: pleasant gentleman, NAD, laying comfortably in bed.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no JVP appreciated
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Tachycardic, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: +BS, soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: wwp, no c/c/e. No femoral bruits, moderate, soft
left groin hematoma that appears to be resolving.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: Carotid 2+ DP 2+ ___ 2+ Left: Carotid 2+ DP 2+
___ 2+
Pertinent Results:
ADMISSION LABS:
.
___ 08:10PM BLOOD WBC-7.6# RBC-4.34* Hgb-14.4 Hct-41.7
MCV-96 MCH-33.3* MCHC-34.6 RDW-14.0 Plt ___
___ 08:10PM BLOOD Neuts-54.4 ___ Monos-5.8 Eos-1.0
Baso-0.2
___ 08:10PM BLOOD Glucose-155* UreaN-27* Creat-1.2 Na-141
K-4.5 Cl-106 HCO3-23 AnGap-17
___ 08:10PM BLOOD Calcium-9.7 Phos-3.2 Mg-1.8
.
PERTINENT LABS:
.
___ 08:10PM BLOOD cTropnT-0.07*
___ 04:49AM BLOOD CK-MB-5 cTropnT-0.07*
___ 08:10PM BLOOD TSH-3.2
.
DISCHARGE LABS:
.
___ 06:00AM BLOOD WBC-4.3 RBC-3.60* Hgb-11.7* Hct-34.9*
MCV-97 MCH-32.6* MCHC-33.6 RDW-13.5 Plt Ct-89*
___ 06:00AM BLOOD Glucose-111* UreaN-16 Creat-1.0 Na-143
K-3.6 Cl-108 HCO3-27 AnGap-12
___ 06:00AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.7
.
MICRO/PATH:
.
MRSA SCREEN (Final ___: No MRSA isolated.
.
IMAGING/STUDIES:
.
ECG ___:
Wide complex tachycardia with right bundle-branch block and
marked right axis deviation. Atrial activity is not seen on the
current tracing. Compared to the previous tracing of ___ the
rhythm, rate and intraventricular conduction delay with right
bundle-branch block pattern and marked right axis deviation are
all new.
.
CXR ___:
IMPRESSION: Hiatal hernia, otherwise unremarkable study.
.
EP STUDY ___:
Conclusions:
1. Clinical VT (RBBB, right superior axis) induced with triple
extrastimuli. A second, non-clinical VT was also induced with
triple extra-stimuli (RBBB, right inferior axis).
2. LV voltage mapping demonstrated a small dense scar on the
basal posterolateral wall.
3. Pace mapping identified a fair pace match to the clinical VT
along the lateral aspect of the scar.
4. Successful substrate ablation of the posterolateral scar.
Brief Hospital Course:
___ with hx of DLBC Lymphoma in remission, hypertension, CAD
status post MI and CABG in ___, and diabetes presenting with
acute onset of shortness of breath found to have wide complex
tachycardia consistent with ventricular tachycardia emanating
from site of old cardiac scar now s/p VT ablation.
.
ACTIVE DIAGNOSES:
.
# Symptomatic Ventricular Tachycardia From Old Ischemic Scar:
Mr. ___ has a history of CAD s/p CABG and is now presenting
with symptomatic wide complex tachycardia diagnosed as
ventricular tachycardia. He was treated with procainamide in the
ED with good success and transferred to the CCU for further care
and monitoring. TSH was wnl's and he did not have EKG findings
or cardiac enzymes concerning for acute ischemia. He underwent
an EP study and VT substrate ablation (for full details please
see EP study report) complicated by moderate left groin hematoma
which was treated with local pressure and did not progress in
size or cause a drop in blood counts or symptoms for the
patient. Following the procedure, he had frequent PVC's and
occasional runs of trigeminy on telemetry but no frank runs of
NSVT or VT and no symptoms. He was discharged home with
follow-up in clinic and was given strict instruction to seek
urgent medical cafe if he experienced similar symptoms going
forward.
.
CHRONIC DIAGNOSES:
.
# Hx Diffuse Large B-Cell Lymphoma in Remission: Stable. He was
instructed to continue his regular outpatient follow-up.
.
# CAD s/p remote CABG: Stable. He was continued on his home
statin.
.
# Zoster esophagitis: con't acyclovir 400 mg BID
.
# NIDDM Type 2: Stable. His home oral hypoglycemics were held in
place of HISS while in-house but were continued on discharge.
.
# Celiac Sprue: Stable. Continued on home gluten-free diet.
.
# Chronic Pain: Stable. Continued on home oxycontin and
oxycodone.
.
TRANSITIONAL ISSUES:
-He will follow-up with Dr. ___ in clinic in ___ weeks and
will need an echocardiogram prior (already ordered in OMR)
Medications on Admission:
-acyclovir 400 mg Tablet by mouth twice a day
-glipizide 2.5 mg Tablet Extended Rel 24 hr daily
-nr oxycodone 10 mg Tablet Extended Release 12 hr bid
-nr oxycodone 5 mg Tablet 1 to 2 Tablet(s) by mouth q6h prn pain
-ranitidine HCl 150 mg Tablet by mouth Twice daily
-simvastatin 20 mg Tablet by mouth Daily
-cholecalciferol (vitamin D3) 1,000 unit Tablet by mouth daily
-cyanocobalamin (vitamin B-12) 500mcg daily
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*30 Tablet(s)* Refills:*0*
4. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a
day.
5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
7. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO once a
day.
8. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day.
9. oxycodone 5 mg Tablet Sig: ___ Tablets PO every six (6) hours
as needed for pain.
10. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular Tachycardia s/p EP ablation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you. You were admitted to ___
for evaluation and treatment of shortness of breath. You were
found to have an abnormal heart rhythm called ventricular
tachycardia or VT likely related to a scar in your heart from
your old heart attack. You underwent an EP study in which the
area of the heart that is thought to be responsible for this
abnormal rhythm was ablated with the hope that this rhythm would
not return.
Following the study, you have not had any abnormal heart rhythms
on our cardiac monitors. If you feel shortness of breath without
good cause, light-headedness, chest pain, or palpitations,
please seek medical attention urgently as there is a chance this
rhythm could come back.
As a result of the procedure, you have a moderately sized
hematoma (blood collection under the skin) in your left groin
which has been decreasing in size. The skin on your groin or
thigh may develop a discoloration (red, purple, yellow, or blue)
which should not concern you unless you have a significant
amount of pain in your groin or leg.
The following changes have been made to your medications:
-START Metoprolol Succinate 50mg by mouth once daily
-START Colace 100mg by mouth twice daily
-START Senna 1 tab by mouth twice daily as needed for
constipation
-Continue taking your other home medications as directed.
.
Please follow-up with the appointments below. We are scheduling
you for an echocardiogram as an outpatient in the near future.
Followup Instructions:
___
|
19861211-DS-22 | 19,861,211 | 22,502,881 | DS | 22 | 2201-06-03 00:00:00 | 2201-06-03 13:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Gluten / Gentamicin
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ year-old gentleman with history of
HFrEF(iCMP, EF 31%), MDS and relapsed high-grade ___ lymphoma
with Burkitt-like features, last treated with R-EPOCH (___) presenting following a fall with headstrike found to be
neutropenic with low grade temperatures.
Per report Mr. ___ was in his usual state of health until
this morning when he walked to the bathroom wearing loose socks.
His daughter heard a thud on the floor and found him conscious
with epistaxis which resolved with pressure. A small laceration
in the bridge of the nose was noted as well as an abrasion in
the left shin. He was seen in ___ clinic this morning where he
did not recall tripping on anything. He reported having frequent
bowel movements upon discharge a couple of days ago which
improved. In clinic he had a temperature to 99.5F and was sent
in to ED for further work-up, initiation of IV antibiotics and
admission.
ED initial vitals were 98.6 84 121/63 19 100% RA
Prior to transfer vitals were 98.4 94 110/64 17 98% RA
Exam in the ED showed : "1 cm abrasion/laceration to the bridge
of this nose. No hemotympanum. No septal hematoma. 8 cm abrasion
to the left anterior shin. skin tear with xeroform on left
anterior shin."
ED work-up significant for:
-CBC: WBC: 0.4*. HGB: 8.0*. Plt Count: 82*. Neuts%: 70
-Chemistry: Na: 142 . K: 4.3 . BUN: 23*. Creat: 1.1. Ca: 8.5.
Mg:
1.7. PO4: 2.0*.
-Lactate: 2.5
-LFTs: ALT: 12. AST: 15. Alk Phos: 109. Total Bili: 0.7.
-UA: RBC 1, WBC 1
-CT head/neck: No acute intracranial process or C-spine fracture
ED management significant for:
-Medications: Vancomycin 1g, Cefepime 2g
-Procedures: Nasal bridge abrasion closed with dermabond
On arrival to the floor, patient reports that his fall was
purely mechanical by slipping on oversized sock. He reports
recalling the whole event and not having any
syncopal/presyncopal symptoms.
Patient denies fevers/chills, night sweats, headache, vision
changes, dizziness/lightheadedness, weakness/numbnesss,
shortness of breath, cough, hemoptysis, chest pain,
palpitations, abdominal pain, nausea/vomiting, diarrhea,
hematemesis, hematochezia/melena, dysuria, hematuria, and new
rashes.
Past Medical History:
- Type II diabetes mellitus
- HLD
- Hypertension
- CAD status post CABG (___)
- VT ablation ___
- HFrEF
- MDS
- Zoster esophagitis
- Vestibular nerve damage secondary to gentamicin
- BPH status post laser surgery
- Spinal stenosis status post laminectomy in ___
- Celiac disease
- Small bowel perforation status post resection and repair with
CMV inclusion bodies on the bowel biopsy after two cycles of
R-CHOP
Social History:
___
Family History:
Son was diagnosed with thyroid cancer at age ___, doing well now.
Brother with prostate cancer. No other known cancers in the
family. Mother died of an MI in ___. Father also had diabetes,
died of unknown cause in ___.
Physical Exam:
ADMISSION EXAM
============================
VS: ___ Temp: 98.9 PO BP: 111/65 L Sitting HR: 95 RR:
18 O2 sat: 98% O2 delivery: RA
GENERAL: Well- appearing gentleman in no distress sitting in bed
comfortably.
HEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx
clear.
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: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Alert and oriented, good attention, linear thought
process. CN II-XII intact. Strength full throughout. Sensation
to
light touch intact.
SKIN: small abrasion in bridge of nose and ___ fold,
2x2cm well-healing erosion in dorsum of L foot w/o erythema or
secretion, 1x1cm similar in dorsum of R foot, 1x2cm similar in
back of left foot. New left shin erosions with significant
serous
drainage covered with damp gauze.
DISCHARGE EXAM
============================
VITALS: 98.4 104 / 69 92 18 95 Ra
GENERAL: Older appearing man, comfortable, lying in bed
NEURO: Oriented to location, month, year. Moving all four
extremities, follows commands. Pupils equal and reactive
bilaterally.
HEENT: Mild abrasion over nasal bridge. No JVD
CARDIAC: Very distant heart sounds, RRR, no murmurs
PULMONARY: Decreased breath sounds bilaterally at the bases
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: 1+ pitting edema bilaterally, both feet are wwp
SKIN: No significant rashes but abrasions on shins and right
dorsal foot
Pertinent Results:
ADMISSION LABS ___:
============================
WBC-0.4* RBC-2.71* Hgb-8.0* Hct-26.0* MCV-96 MCH-29.5 MCHC-30.8*
RDW-15.8* RDWSD-54.3* Plt Ct-82*
Neuts-70 Bands-0 ___ Monos-4* Eos-1 Baso-0 ___ Metas-0
Myelos-0 AbsNeut-0.28* AbsLymp-0.10* AbsMono-0.02* AbsEos-0.00*
AbsBaso-0.00*
___ PTT-26.8 ___
UreaN-23* Creat-1.1 Na-142 K-4.3
ALT-12 AST-15 LD(LDH)-180 AlkPhos-109 TotBili-0.7
Albumin-3.2* Calcium-8.5 Phos-2.0* Mg-1.7 UricAcd-5.7
BLOOD Lactate-2.5*
URINE Color-Yellow Appear-Clear Sp ___
URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
PERTINENT LABS
============================
___ tTG-IgA-5 antiDGP-1
___ cTropnT-0.03*
___ cTropnT-0.03*
___ CK-MB-1 cTropnT-0.01
___ Hapto-345*
___ TSH-2.0
___ ___
___ Ret Aut-3.1* Abs Ret-0.08
___ calTIBC-143* ___ Hapto-352* Ferritn-2636*
TRF-110*
___ %HbA1c-6.5* eAG-140*
___ Triglyc-199* HDL-24* CHOL/HD-5.4 LDLcalc-66
___ CK-MB-<1 cTropnT-0.06* ___
___ cTropnT-0.05*
DISCHARGE LABS ___:
============================
WBC-9.1 RBC-2.85* Hgb-8.1* Hct-25.9* MCV-91 MCH-28.4 MCHC-31.3*
RDW-19.3* RDWSD-63.3* Plt ___
Glucose-87 UreaN-20 Creat-1.1 Na-144 K-4.6 Cl-103 HCO3-28
AnGap-13
Calcium-8.5 Phos-3.2 Mg-2.2
PERTINENT MICRO
============================
ALL BLOOD AND URINE CULTURES WITH NO GROWTH TO DATE
___ 4:15 am STOOL CONSISTENCY: NOT APPLICABLE
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).
PERTINENT STUDIES
============================
CT HEAD (___)
No acute intracranial process.
CT C-SPINE (___)
No fracture is identified.
CT HEAD (___)
1. No acute intracranial abnormality on noncontrast head CT.
Specifically no
evidence of intracranial hemorrhage or acute large territory
infarct.
2. Additional findings described above.
CXR (___)
Heart size is enlarged. Hiatal hernia is large. There is mild
vascular
congestion. There is no appreciable pleural effusion. There is
no
pneumothorax.
CXR (___)
There is a new right-sided PICC line with distal tip at the
cavoatrial
junction. Heart size is prominent but stable. Opacity along
the right heart
border is due to a very large hiatal hernia. There are no
pneumothoraces.
CXR (___)
Right PIC line ends in the right atriumd approximately 3 cm
below the
estimated location of the superior cavoatrial junction.
Small to moderate right pleural effusion and large
gastrointestinal hiatus
hernia projecting to the right of midline, are long-standing.
The hernia
exaggerates the size of mildly to moderately enlarged heart.
Upper lungs are
clear. There is pulmonary edema and no pneumothorax.
CXR (___)
Bilateral lower lobe collapse unchanged. Small right pleural
effusion
decreased. No pneumothorax. Mild cardiomegaly stable. No
pulmonary edema or mediastinal widening. Right PICC line ends in
the upper right atrium as before.
CT HEAD (___)
Atrophy.
No significant changes since ___.
No evidence of hemorrhage.
RENAL US (___)
No hydronephrosis.
ECHO (___)
IMPRESSION: Suboptimal image quality. Left ventricular cavity
enlargement with regional and global systolic dysfunction
suggestive of multivessel CAD or other diffuse process. Mild
aortic regurgitation.
Compared with the prior study (images reviewed) of ___,
the severity of mitral regurgitation is reduced (may be due to
technical quality rather than a true change).
CT CHEST (___)
-Bilateral small layering pleural effusions are larger since
prior, right
greater the left. Adjacent consolidations, left greater than
right are likely due to aspirations, particularly in the
presence of large hiatal hernia.
-Increased fat stranding surrounding the partially imaged left
kidney could
represent infection, for clinical correlation.
CXR (___)
There is bilateral lower lobe atelectasis, similar to previous.
Superimposed pneumonia cannot be excluded. There is pulmonary
vascular congestion. There is a small right pleural effusion,
not significantly changed. There may be a trace left effusion.
There is mild cardiomegaly, similar to previous. The tip of the
right PICC appears stable in position. Sternal wires appear
intact.
CXR (___)
1. Interval increase in bilateral interstitial opacities,
consistent with
worsening pulmonary edema.
2. Focal increase in opacification at the right lower lobe,
which may
represent superimposed infection, aspiration, or asymmetric
edema.
3. Small bilateral pleural effusions, right greater than left.
CT ABD/PELVIS (___)
1. Stable mild stranding involving the omentum on the right
complete similar to the CT findings from ___. Mild increased perinephric stranding on the left, no evidence
of
hydronephrosis. Recommend clinical correlation to exclude
underlying
infection.
3. No other interval change.
CT CHEST (___)
1. No evidence of lymphadenopathy.
2. Stable airspace opacification in the left lower lobe
suggestive of
consolidation. New small scattered areas of ground-glass
opacities in the
right upper and middle ___ represent infectious etiology.
Clinical
correlation recommended.
3. Mild interval increase in bilateral pleural effusions which
are moderate. Stable bibasilar passive atelectasis.
MRI HEAD (___)
Multiple (approximately 7) bilateral punctate supra and infra
tentorial acute infarct. These are most likely embolic in
nature. No hemorrhagic
transformation. No intracranial hemorrhage or mass. Generalized
cerebral atrophy with white matter microangiopathic changes.
CXR (___)
A new right PICC line projects over the mid SVC. Bilateral
pleural effusions with subjacent atelectasis/consolidation.
CTA HEAD/NECK (___)
The study is degraded by incorrect bolus timing and motion
artifact.
No acute hemorrhage or large territorial infarct.
Known bilateral punctate supra and infratentorial acute
infarctions are better appreciated on prior MRI head done ___. These infarcts are most likely embolic in nature. Within
the limits of the study there is no intracranial arterial
aneurysm or occlusion. No ICA occlusion. No obvious ICA
stenosis by NASCET criteria. Increased soft tissues surrounding
the junction of V3 and V4 segment of the right vertebral artery
may be secondary to accompanying veins or may represent
dissection, these cannot be differentiated due to poor contrast
bolus timing and repeat CTA is advised.
CXR (___)
Comparison to ___. Stable low lung volumes. Stable
bilateral pleural effusions of moderate extent. Stable
subsequent bilateral areas of
atelectasis. Today's radiograph shows signs of mild pulmonary
edema.
Unchanged alignment of the sternal wires. Unchanged right PICC
line.
BEDSIDE ECHO (___)
There is moderate-severe regional left ventricular systolic
dysfunction with severe hypokinesis/ akinesis of the basal to
mid inferoseptum, inferior, and inferolateral walls and the
distal inferior wall (see
schematic) and severe global hypokinesis of the remaining
segments. The visually estimated left ventricular ejection
fraction is ___. Mildly dilated right ventricular cavity with
mild global free wall
hypokinesis. There is mild [1+] aortic regurgitation. There is
mild [1+] mitral regurgitation.
IMPRESSION: Adequate image quality. Compared with the prior TTE
of (images reviewed) of ___ , the findings are similar
(right ventricle also appeared borderline/ mildly dilated).
LEFT VENTRICLE (LV) Visual Ejection Fraction: ___ (nl
M:52-72;F:54-74)
LEFT VENTRICLE (LV): Moderate-severe focal systolic dysfunction.
The visually estimated left ventricular ejection fraction is
___.
RIGHT VENTRICLE (RV): Dilated cavity. Mild global free wall
hypokinesis.
AORTIC VALVE (AV): Mild [1+] regurgitation.
MITRAL VALVE (MV): Mild [1+] regurgitation.
Brief Hospital Course:
SUMMARY:
___ man with PMHx notable for myelodysplastic syndrome
and relapsed high-grade ___ lymphoma with Burkitt-like
features, most recently on R-EPOCH (___), as well as HFrEF
(LVEF 31%) and ischemic cardiomyopathy, and recent admission for
MSSA bacteremia now re-admitted for mechanical fall with course
complicated by neutropenic fever / sepsis, rapid a-fib, acute
in-hospital delirium, and acute cardioembolic CVAs.
ACTIVE ISSUES:
# ___ LYMPHOMA WITH BURKITT'S FEATURES
Relapsed, s/p R-EPOCH (___). Complicated by neutropenic
fever, discussed above. Following count recovery Neupogen was
discontinued. He was maintained on acyclovir for HSV
prophylaxis, and his Atovaquone was switched to Bactrim given
improvement in renal function. Repeat staging CT torso
demonstrated stability in his disease.
# SEPSIS
# NEUTROPENIC FEVER
Hospital course complicated by development of fevers, altered
mental status, and hypotension with intermittent lactic
acidosis. Occurred in setting of profound neutropenia given
recent cycle of EPOCH chemotherapy. Overall most consistent with
sepsis / septic shock for which he received aggressive fluid
resuscitation and broad spectrum antibiotics. Source was unclear
and possibly multifactorial from healing leg wounds, mucositis,
pneumonia, gut translocation, and/or urinary tract. CT torso
with evidence of possible pneumonia and perinephric stranding.
Multiple BCx were negative. Hemodynamics improved with fluid
resuscitation alone and did not require vasopressor support. He
completed a 10 day course of meropenem on ___.
# EMBOLIC CVAs
Given altered mental status and possibly new aspiration obtained
MRI brain which demonstrated multiple, small infarcts most
likely to be cardioembolic given concurrent atrial fibrillation.
Initially anti-coagulation was contraindicated due to severe
thrombocytopenia, though once recovered was able to be started
on heparin gtt and transition to oral apixaban by ___. He has
no residual deficits.
# ACUTE ON CHRONIC SYSTOLIC HEART FAILURE
# ISCHEMIC CARDIOMYOPATHY / CAD s/p ___ course complicated by new O2 requirement with evidence
of volume overload on exam. Presumed due to aggressive fluid
resuscitation in setting of sepsis, discussed above. Remained
warm & wet without evidence of cardiogenic shock. Repeat TTE
with LVEF 30%, overall unchanged from prior. Continued diuresis
with intermittent Lasix boluses with improvement in O2
requirement and volume status. Despite persistence of 1+ lower
extremity edema, Lasix has not been given since ___ due to blood
pressure limitations. Aspirin was held due to severe
thrombocytopenia and subsequently discontinued given addition of
apixaban to medication regimen. Prior to discharge, he was
restarted on a maintenance furosemide at 20mg once daily (lower
than original dose of 40mg).
# ___ course complicated by conversion in to rapid a-fib.
Most likely due to increased sympathetic tone in setting of
sepsis. Successfully rate controlled with up-titration of
metoprolol. Anti-coagulation was initially contraindicated due
to severe thrombocytopenia, later resumed once platelets >50k.
Later complicated by acute cardioembolic CVAs, discussed above.
# TYPE II NSTEMI:
Patient was borderline hypotensive (90s/60s) and tachycardic
(low 100s) near the end of his hospital stay in the setting of
titrating his diuresis and metoprolol. Troponins were elevated
to 0.06 and 0.05, presumably in the setting of demand from
hypotension. EKG and ECHO were unchanged from prior. His
pressure and heart rates stabilized on his current discharge
doses.
# TOXIC METABOLIC ENCEPHALOPATHY
Course complicated by acute onset confusion and disorientation
most consistent with delirium. Precipitating factors included
sepsis / neutropenic fever, prolonged hospitalization,
stress-dose steroids (while septic), hypernatremia. Initially
required intermittent anti-psychotics due to severe agitation,
later weaned off. Delirium improved over ___ days without
ongoing requirement for pharmacologic measures.
# NORMOCYTIC ANEMIA:
Likely multifactorial, secondary to ___ lymphoma, poor
nutrition and infection. Hemoglobin slowly trending down, and he
was given 1unit pRBC on the day prior to discharge for a
hemoglobin of 7.5 given recent ischemic stroke and ischemic
cardiomyopathy. He was transfused a total of 4units of red cells
throughout hospitalization.
# POSSIBLE ASPIRATION
Course notable for concern of aspiration. CT chest further
demonstrated RLL opacification consistent with possible
aspiration. Overall most likely to have occurred in setting of
acute toxic-metabolic encephalopathy. Symptoms improved with
clearing of mental status and was cleared for 1:1 PO intake by
speech & swallow.
# ACUTE KIDNEY INJURY
Course complicated by acute rise in serum Cr consistent with
___. Workup notable for large volume retained urine in setting
of Foley removal due to severe agitation. Foley replaced with
drainage of 1+ L urine. ___ improved, overall consistent with
obstructive / post-renal ___.
# ACUTE URINARY RETENTION
History notable for bladder diverticulectomy in ___ and open
simple retropubic prostatectomy for BPH with urinary retention
on ___ ___ at ___. His course here was
complicated by development of acute urinary retention requiring
cystoscopy and balloon dilation by urology for placement of
foley catheter due to a severe ureteral stricture and BPH.
Subsequently removed during episode of severe agitation with
recurrent retention, again resolved with Foley placement though
without difficulty. He also required replacement on ___ due to
catheter leakage and this replaced immediately without
difficulty. He will require outpatient follow up with urology
for further management of urinary retention.
# MECHANICAL FALL
Initially presented following mechanical fall at home (slipped
on a sock). No loss of consciousness. CT head and C-spine
without acute injury. Exam notable for scabbed over abrasions on
the bridge of his nose as well as his lower extremities and
feet. Evaluated by physical and occupational therapy who
recommended discharge to a short term rehabilitation facility.
Wounds monitored by wound care nursing.
# DIARRHEA: ___ episodes loose stools. C. diff negative.
Symptoms resolved.
# OROPHARYNGEAL CANDIDIASIS: Nystatin Oral Suspension 5 mL PO
QID with effect.
CHRONIC/STABLE ISSUES
# CELIAC DISEASE: Requires a gluten free diet.
# TYPE 2 DIABETES: HbA1c 6.5 (___) Not on medication prior to
admission. Required standing insulin and sliding scale.
# GERD: restarted ranitidine at discharge.
# ANXIETY: Lorazepam held during admission and not restarted at
discharge.
TRANSITIONAL ISSUES
=================================
Code Status: DNR, okay to intubate
Contact/HCP: ___, daughter - ___
Admission weight: 77.1kg
Discharge weight: ___.3kg
Discharge creatinine: 1.1 mg/dL
Discharge hemoglobin: 8.1 gm/dL
- Embolic cerebral vascular accidents
[] Neurology stroke follow up as above
[] Continue apixaban 5mg PO BID: reduce to 2.5mg PO BID in the
event of significant weight loss (60 kg or less) or acute kidney
injury (serum creatinine 1.5 mg/dL or higher).
- Acute on chronic systolic heart failure
[] Please weigh patient each morning after he urinates. If his
weight increases by 3 or more kgs in 2 days, or 5kgs in 1 week,
please give additional dose of Lasix 20mg PO. If his weight
continues to increase, consider increasing his dose to 40mg once
daily if his blood pressures can tolerate it.
[] Note that patient is not on an ACE-I or ___ due to soft
blood pressures
- Ischemic cardiomyopathy, coronary artery disease s/p CABG
- Type II NSTEMI
- Atrial fibrillation
[] Continue Metoprolol succinate 75mg once daily.
[] Consider starting patient on Atorvastatin as tolerated
[] Continue Apixaban as above
- ___ lymphoma with Burkitt's features
[] Follow up with outpatient oncology
[] Consider maintenance Rituximab in ___ months if patient can
tolerate
- Normocytic anemia
[] s/p 1unit pRBC prior to discharge for hemoglobin 7.5 gm/dL
[] Repeat CBC by ___ to ensure that his hemoglobin is stable
- Acute kidney injury
[] Discharge creatinine 1.1
[] Repeat chemistry by ___ to ensure stable creatinine and
electrolytes
- Acute urinary obstruction
[] For now, keep foley catheter in place
[] If accidentally removed or needs to come out (e.g. leaking),
please use urojet and replace ASAP to avoid closure of the
urethral stricture
[] Urology follow up as above
- Mechanical fall: wound care
[] Please see attached RN note regarding wound care (bilateral
shins, feet)
- Celiac disease
[] Strict gluten free diet
[] His favorite food is Gluten-Free Pumpernickel bread & butter
___ or ___ :)
- Type II Diabetes
[] Continue insulin scale
[] Consider trialing metformin in order to decrease insulin
requirements
- Anxiety/Depression
[] Hold Lorazepam given high risk of delirium
[] Consider initiation of an SSRI or mirtazapine if indicated
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atovaquone Suspension 1500 mg PO DAILY PCP ___
2. Filgrastim-sndz 480 mcg SC Q24H
3. Doxycycline Hyclate 100 mg PO Q12H
4. Acyclovir 400 mg PO Q12H
5. Metoprolol Succinate XL 12.5 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Levofloxacin 500 mg PO Q24H
8. Ranitidine 150 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
12. LORazepam 0.5 mg PO Q8H:PRN nausea
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Apixaban 5 mg PO BID
3. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
4. Docusate Sodium 100 mg PO BID
5. Furosemide 20 mg PO DAILY
6. Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Metoprolol Succinate XL 75 mg PO DAILY
9. Acyclovir 400 mg PO Q12H
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
11. Ranitidine 150 mg PO BID
12. Senna 8.6 mg PO BID:PRN constipation
13. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
-------------------
___ lymphoma with Burkitt's features
Sepsis
Neutropenic Fever
Embolic cerebral vascular accidents
Acute on chronic systolic heart failure
Ischemic cardiomyopathy
Coronary artery disease status post coronary artery bypass graft
Atrial fibrillation, new
SECONDARY:
-------------------
Type II NSTEMI
Toxic metabolic encephalopathy
Normocytic anemia
Acute kidney injury
Acute urinary retention
Benign prostatic hypertrophy
Ureteral stricture
Mechanical fall
Diarrhea
Oropharyngeal candidiasis
Celiac disease
Type II Diabetes
Gastroesophageal reflux disease
Anxiety
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 ___.
Why you were in the hospital:
- fall at home
- fever
What was done for you in the hospital:
- you were treated for severe infection using IV antibiotics
- you were transfused blood products while your blood counts
were low following your latest cycle of chemotherapy
- you were given heart medications and blood thinners to treat
atrial fibrillation
- you underwent an MRI of your brain that showed evidence of
strokes, possibly due to your atrial fibrillation
- you underwent repeat CT scans of your chest and abdomen to
assess for progression of your lymphoma, these demonstrated that
your lymphoma is stable
What you should do after you leave the hospital:
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Please take your medications as detailed in the discharge
papers. If you have questions about which medications to take,
please contact your oncologist to discuss.
- Please go to your follow up appointments as scheduled in the
discharge papers. Most of them already have a specific date &
time set. If there is no specific time specified, and you do not
hear from their office in ___ business days, please contact the
office to schedule an appointment.
- Please monitor for worsening symptoms. If you do not feel like
you are getting better or have any other concerns, please call
your oncologist to discuss or return to the emergency room.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19861375-DS-15 | 19,861,375 | 22,659,450 | DS | 15 | 2168-04-30 00:00:00 | 2168-04-30 17:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Carotid Stenosis
Major Surgical or Invasive Procedure:
___ Left CEA
History of Present Illness:
Mr. ___ is a ___ yo M known to the neurosurgical service. He
was seen by Dr. ___ in clinic today for known L carotid
stenosis and consultation for CEA planning. After the
appointment
today patient was in the car with his daughter around 3:30 pm
had
sudden onset of aphasia, R facial droop, R sided hemiparesis.
Daughter brought patient to ___ for evaluation. Upon arrival
there most of the symptoms had subsided except R facial.
Daughter
reports symptoms lasted for about 5 mins. A NCHCT was done there
which was negative for any acute intracranial abnormality. He
was
evaluated by Neurology there who discussed transfer to ___
with
Dr. ___ expedited CEA planning. Upon arrival here patient
denies HA, nausea, visual changes, weakness, numbness or
tingling.
Past Medical History:
R ICA stenosis s/p CEA
History of TIA
History of CVA
Known L carotid stenosis
GI bleed
Hypertension
Social History:
___
Family History:
NC
Physical Exam:
=============
ON ADMISSION
=============
PHYSICAL EXAM:
O: T: 97.7 BP: 163 /70 HR:69 R 16 O2Sats 98% on RA
Gen: WD/WN, comfortable, NAD. ___ speaking only- daughter
interpreting
___: 4-3mm EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date
Language: ___ speaking only
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
=============
ON DISCHARGE
=============
___ speaking only, EO spontaneous, AxO x 3, PERRL ___,
___, no pronator drift, MAE ___, incision with mild swelling &
Steris CDI
Pertinent Results:
=============
IMAGING
=============
___ MRI
1. No acute infarct or intracranial hemorrhage.
2. FLAIR hyperintense white matter signal with associated CSF
intensity foci in the right basal ganglia to centrum semiovale
likely represents a
combination of prior lacunar infarcts and prominent perivascular
spaces.
Cortical FLAIR hyperintense signal the right postcentral gyrus
is also
compatible with sequela prior infarct.
3. Decreased flow related signal of the visualize left internal
carotid artery and left MCA segments are noted, corresponding to
MR ___ findings from outside hospital ___.
4. Dependent fluid in the left maxillary sinus may represent
acute
inflammatory process. Clinical correlation is recommended.
CTA HEAD AND CTA NECK Study Date of ___ 5:44 AM
IMPRESSION:
1. No evidence of hemorrhage, edema, mass effect, or acute
infarction.
2. There is moderate predominantly noncalcified atherosclerotic
disease in the left common and internal carotid arteries
resulting in severe long segment narrowing of the cervical
internal carotid artery and minimal flow in the intracranial
portion of the left internal carotid artery which is heavy
calcified. The left carotid terminus and A1 and M1 branches are
irregular and severely diminutive. The left M2 branches are
small and there is paucity of more distal left middle cerebral
artery branches. The A2 segment of the left anterior cerebral
artery is supplied from the contralateral side by the anterior
communicating artery.
3. The right cervical internal carotid artery is patent and
shows no stenosis by NASCET criteria. Confluent calcifications
along the cavernous and supraclinoid right internal carotid
artery result in at least moderate focal narrowing just distal
to the take-off of the ophthalmic artery.
4. The vertebral arteries are within normal limits.
CTA HEAD AND CTA NECKStudy Date of ___ 5:18 AM
IMPRESSION:
1. No acute intracranial abnormality. Chronic right basal
ganglia infarct.
2. Changes from a left carotid endarterectomy with improvement
of the caliber of the cervical portion of the left internal
carotid artery, however with a large left-sided neck hematoma
extending from the level of the angle of the mandible inferiorly
to the thoracic inlet, with rightward displacement of the
cervical airway, with up to moderate narrowing at the
supraglottic level. No evidence of active extravasation. The
hematoma compresses on the left internal jugular vein, which
demonstrates very minimal scattered segment of opacification.
3. Occlusion of the left internal carotid artery terminus with
the left ACA and MCA territories likely supplied by the anterior
communicating and left posterior communicating arteries.
Diminutive left A1, M1 and M2 segments are unchanged, likely
secondary to atherosclerotic disease.
4. Remainder of the intracranial vasculature is patent without
additional
areas of occlusion, or aneurysm.
5. Patent cervical vasculature without significant stenosis,
occlusion, or
dissection.
6. 8 mm right thyroid lobe nodule. The ___ College of
Radiology
guidelines suggest that in the absence of risk factors for
thyroid cancer, no further evaluation is recommended.
CHEST (PORTABLE AP) Study Date of ___ 10:53 AM
IMPRESSION:
In comparison with the study of ___, there is an
placement of a
nasogastric tube that extends at least to the mid portion of the
stomach,
where it crosses the lower margin of the image. Endotracheal
tube tip is in the clavicular region, approximately 8 cm above
the carina. Little change in the appearance of the heart and
lungs. Hyperexpansion of the lungs with prominence of
interstitial markings that could reflect chronic lung disease,
elevated pulmonary venous pressure, or both.
Brief Hospital Course:
Mr. ___ is a ___ year old ___ speaking gentleman who is
known to Dr. ___ with a history of carotid stenosis who
presented with right sided weakness and TIA symptoms. The
patient was at an outpatient appointment with Dr. ___ on
___ for planning of left CEA and immediately after his
appointment his daughter noted right sided weakness and TIA
symptoms. It was decided that the patient should be admitted to
expedite surgical planning.
#Carotid stenosis: Once admitted to ___ the patient remained
on Aspirin 325 mg po daily, and his Plavix was stopped in
preparation for surgical planning. Consent was obtain with a
___ interpreter, pre-operative planning was completed and
the patient was taken to the operating room on ___. He
tolerated the procedure well and post-operatively was monitored.
His PTT was monitored and he was placed on a Heparin drip
post-operatively, which was stopped when area of firmness was
noted on neck. On ___ AM patient develped an episode of speech
arrest, and was found to have neck and face more swollen with
increasing induration/firmness concern for hematoma. STAT CT/CTA
showed no obvious stroke but large neck hematoma with tracheal
deviation. Patient developed stridor, and was taken emergently
to the OR for exploration neck hematoma. Patient had generalized
oozing but no primary feeder identified. JP drain was left in
place and patient was transferred to the TICU post-operately. He
remained intubated overnight. On ___, he was extubated without
complication and on ___ was transferred to the ___ and his JP
drain was removed. He received 1 unit of PRBC for low H&H and
his post transfusion hematocrit was improved. NG tube was
removed and his diet was advanced per speech and swallow
recommendations. He remained neurologically stable on exam and
on ___ was transferred the to floor. He was evaluated by
physical therapy who recommended rehab. He was discharged to
rehab on ___ in good condition and was given follow up
instructions and prescriptions as needed.
Medications on Admission:
Lipitor, Protonix, Aspirin, Plavix
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
2. Aspirin 325 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Atorvastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Carotid Stenosis
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:
___ BRAIN ANEURYSM INSTITUTE
Carotid Endarterectomy
Discharge Instructions
Call your neurosurgeons office for:
Worsening headache
Any new problems with your vision, speaking, or strength in
arms or legs
If you have a hard time swallowing
Swelling, drainage, or redness of your incision
Fever greater than 100.5 F degrees
Stiff or painful neck
Nausea, vomiting, lethargy (unable to stay awake)
Any problems with side effects from medications, you can also
call your pharmacy.
A follow-up appointment for ___ weeks after discharge
Activity:
No sexual activity for one month.
Do not operate any motorized vehicle for one month
No heavy lifting or bending for one month, then slowly
increase your activity at your own pace
Do not operate any motorized vehicle nor drink alcohol while
on pain medications
Incision Care:
You have absorbable sutures that will not need suture removal
Typically your dressing is removed day 1 post operatively
Leave the white strips in place; if your strips have not fallen
off after 14 days, you may carefully take them off.
When you are allowed to shampoo your hair, (typically ___ days
post operatively), let the shampoo run off the incision line and
do not rub, scrub, scratch, or pick at any scabs on the incision
line.
Do not use creams or ointment on your incision; keep it clean
and open to air unless otherwise instructed
Common Problems:
Pain medicine and inactivity can cause constipation (straining
when passing stool).
Prevent constipation by:
o Drinking plenty of fluids
o Eating vegetables, prunes, high fiber breads & cereals
o Getting enough exercise.
o Take stool softeners like Docusate sodium (Colace) per package
directions, usually three times a day
o Take bowel stimulants like Senna or Bisacodyl (Dulcolax) per
package directions, usually twice a day:
If you have loose stools: slowly reduce the bowel stimulants.
For constipation: take Milk of Magnesia, Magnesium Citrate or
Miralax per package directions.
When you start to move around and need less pain medications,
slowly stop taking the stool stimulants, and then decrease the
stool softeners.
Fatigue/Pain/ Swelling:
Fatigue: will slowly resolve, over days to weeks
Pain over incision or loss of sensation: resolves in ___
months
Facial/ carotid swelling: slowly resolves over the next few
weeks
Followup Instructions:
___
|
19861375-DS-16 | 19,861,375 | 23,725,146 | DS | 16 | 2168-06-02 00:00:00 | 2168-06-03 11:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Slurred speech
Major Surgical or Invasive Procedure:
Cerebral angiogram (___)
History of Present Illness:
Mr. ___ is an ___ yo M well known to the Neurosurgical
service s/p ___ Left CEA, s/p ___ wound exploration
hematoma evacuation. He presented today to ___ after episode of
dysarthria. Patient's daughter reports today at 12pm she was
driving the patient and noted slurred speech and L facial droop.
She reports "it lasted for longer than his other episodes" but
is
unable to say how long it last. She also reports a similar, but
shorter episode also happened on ___ but they did not seek
medical attention at that time. At ___ a CT head and CTA head
and
neck were done which were concerning for possible L carotid
dissection. He was given aspirin 325mg and started on a hep gtt
@
1400u/hr and transferred to ___ for Neurosurgical evaluation.
Past Medical History:
R ICA stenosis s/p CEA
History of TIA
History of CVA
Known L carotid stenosis
GI bleed
Hypertension
Social History:
___
Family History:
Non-contributory
Physical Exam:
===================================
ADMISSION PHYSICAL EXAM
===================================
O: T:98.0 BP: 137/84 HR:62 R 18 O2Sats 99%
Gen: WD/WN, comfortable, NAD. Elderly male lying on stretcher.
___ speaking only
HEENT: Pupils: PERRL EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: unable to assess secondary to language barrier
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift.
===================================
DISCHARGE PHYSICAL EXAM
===================================
SBP 130s-180s.
Orthostatics SBP 150s laying and 128 standing. After 1L IVF,
General and neurologic exam normal and non-focal.
Pertinent Results:
========
LABS
========
___ 07:00AM BLOOD ___ PTT-30.5 ___
___ 07:00AM BLOOD WBC-4.3 RBC-3.27* Hgb-8.6* Hct-28.0*
MCV-86 MCH-26.3 MCHC-30.7* RDW-15.6* RDWSD-49.0* Plt ___
___ 07:00AM BLOOD Glucose-96 UreaN-14 Creat-0.9 Na-142
K-3.7 Cl-109* HCO3-24 AnGap-13
___ 03:36PM BLOOD ALT-52* AST-44*
___ 07:00AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.0 Iron-PND
___ 06:38PM BLOOD cTropnT-<0.01
___ 12:43PM BLOOD cTropnT-<0.01
========
IMAGING
========
CEREBRAL ANGIOGRAM (___):
Left supraclinoid internal carotid artery occlusion. Filling of
the left
hemisphere via pial collaterals from the left anterior cerebral
artery.
MRI BRAIN WITHOUT CONTRAST (___):
1. There are few left periatrial and temporal lobe deep white
matter subacute infarcts.
2. There are stable chronic infarcts, and stable significantly
diminished left ICA, MCA flow voids, better evaluated on CTA
head and neck ___.
Brief Hospital Course:
Mr. ___ presented with transient right facial drop (upper motor
neuron pattern) and aphasia; symptoms resolved and MRI was
negative for new infarct. CTA and cerebral angiogram showed left
supraclinoid internal carotid artery occlusion (with filling of
the left hemisphere via pial collaterals from the left anterior
cerebral artery). Continued on aspirin, Plavix and Atorvastatin
for secondary stroke prevention. Counseled family on permissive
hypertension (goal SBP 110-140, may run up to 180) to prevent
stroke as pt is collateral dependent. Pt advised to maintain
adequate hydration and eat a normal amount of salt with his
diet.
Of note, on the day prior to discharge, pt was found to be
mildly orthostatic. He was asymptomatic with SBP 150s sitting to
130s standing. He was given IVF and then developed left armpit
pain and SBP 200s. This resolved. EKG and troponins x3 were
unremarkable. He was discharged home in stable condition (SBPs
130s-170s on day of discharge); physical therapy cleared pt for
home prior to discharge.
============================
TRANSITIONS OF CARE
============================
-Pt should have long term permissive hypertension (goal SBP
110-140, may run up to 180) to prevent stroke as pt is
collateral dependent. Pt advised to maintain adequate hydration
and eat a normal amount of salt with his diet.
-Iron studies pending at discharge for normocytic anemia. PCP to
___.
=
=
=
=
=
=
=
=
================================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
=
=
=
=
=
=
=
=
================================================================
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? () Yes (LDL = ) - (X) No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (X) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Docusate Sodium 100 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
6. Pantoprazole 40 mg PO Q24H
7. Clopidogrel 75 mg PO DAILY
8. dextran 70-hypromellose 0.1-0.3 % ophthalmic BID
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
4. Atorvastatin 40 mg PO QPM
5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
6. dextran 70-hypromellose 0.1-0.3 % ophthalmic BID
7. Docusate Sodium 100 mg PO BID
8. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
TIA
Secondary diagnosis:
Left supraclinoid internal carotid artery occlusion. Filling of
the left hemisphere via pial collaterals from the left anterior
cerebral artery.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of temporary difficulty
speaking and a right facial droop resulting from an TRANSIENT
ISCHEMIC ATTACK or "TIA", a condition where a blood vessel
providing oxygen and nutrients to the brain is temporarily
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms. Fortunately, the MRI of your brain did
NOT show a NEW stroke so these symptoms likely represented a
TIA.
TIA can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
-Blocked blood vessels in the brain due to atherosclerosis or
plaque
-High cholesterol
Please take your medications as prescribed:
-Aspirin 81mg daily, Plavix 75mg daily, Lipitor 40mg daily
Please also allow your blood pressure to run high (goal SBP
110-140, may run up to 180). Please ensure you stay hydrated and
eat a normal amount of salt, as your blood pressure dropped
slightly while standing on your day of discharge from the
hospital.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19861402-DS-12 | 19,861,402 | 27,840,398 | DS | 12 | 2163-10-03 00:00:00 | 2163-10-03 18:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
EGD with NJ tube placement ___
Liver biopsy ___
History of Present Illness:
Ms. ___ is a ___ woman with history of iron
deficiency anemia due to menorrhagia, fatty liver who presented
to an outside hospital with jaundice, found to have
hyperbilirubinemia and ___ and transferred for further
evaluation.
History is taken from the patient and her husband, who is at the
bedside. They report that about a year ago she was found to have
severe iron deficiency anemia secondary to menorrhagia, and she
was started on IV iron transfusions. At that time, labs were
checked and she was told she had mildly elevated liver enzymes.
In ___, she developed dyspnea on exertion and was again found
to have severe anemia and received additional IV iron
transfusions, which she has been receiving as recently as a few
weeks ago. She had been planned for hysterectomy, but her
surgeon
was reportedly concern about her elevated LFTs and declined to
perform the surgery.
Beginning about a week prior to admission, the patient's husband
noted that the whites of her eyes seemed slightly yellow, but he
examined her in the light and was not sure. The patient also
reports a fever about a week prior to admission, but none since.
However, beginning about ___ days prior to admission her scleral
icterus and jaundice became more noticeable. The patient also
began to note dark urine and pale stools. She felt extremely
fatigued. She has noted abdominal bloating and distention, but
not abdominal pain. She also notes a small amount of bright red
blood on her stool. No nausea or vomiting. She denies any fevers
or chills in over a week. No shortness of breath, but she has
developed a dry cough in the last days. No chest pain or
palpitations. No dysuria. The patient takes no medications
regularly at home, although she notes that she has been taking
ibuprofen 400 mg Q4H recently due to menstrual cramping. She has
not taken any Tylenol. No herbal supplements. No injection drug
use. She used to drink more in her youth, perhaps ___ drinks on
each weekend night, but she reports rare alcohol use over the
past several years. Her husband corroborates that she drinks
perhaps a half a beer one or two times per week.
The patient initially presented to ___. There, she was
afebrile and hemodynamically stable. Exam notable for distended,
mild upper abdominal ttp. Labs notable for WBC 17.7, Hb 10, plt
255, INR 1.3, Na 128, K 3.2, Cl 88, HCO2 19, BUN/Cr 63/4.0. AST
107, ALT 37, AP 270, Tb 14 (Db 9.0), lipase 94. UA with
bilirubin. Toxicology screen with negative salicylates,
acetaminophen, ethyl alcohol. Hepatitis serologies sent: Hep A
IgM negative, Hep Bc IgM Ab negative, Hep Bs Ag negative, Hep C
Ab negative. Imaging notable for abdominal ultrasound with
normal
kidneys, hepatic steatosis. RUQUS with hepatic steatosis, normal
CBD. Patient was given ceftriaxone 1 gm, ertapenem 1 gm, 1L NS,
1L LR. She was transferred to ___ for further care.
In the ED, vitals: 97.7 82 126/33 18 95% RA
Labs notable for; AST 106, ALT 32, AP 288, Tb 11.9 (Db 9.9),
lipase 152, INR 1.6
Imaging notable for: RUQUS
Patient given: 1L NS, albumin 12.5 g 25%
Consults: Hepatology
On arrival to the floor, the patient reports that she feels
fatigued and slightly pruritic. She feels like she has mucous n
the back of her throat. She denies any abdominal pain at
present.
No other complaints.
Past Medical History:
- Iron deficiency anemia on IV iron infusions
- Menorrhagia
- Fatty liver
Social History:
___
Family History:
Uncle died of liver problem at ___; reportedly
drank alcohol. Aunt on the liver transplant list for unknown
indication. No known family history of autoimmune disease.
Physical Exam:
ADMISSION EXAM:
VITALS: 98.6 117 / 65 76 18 92 Ra
GENERAL: Alert and in no apparent distress
EYES: +Icteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, distended, mildly tender to palpation in right
upper quadrant. Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted; jaundiced; telangectiasas
on chest
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout, no asterixis
PSYCH: Very pleasant, appropriate affect
DISCHARGE EXAM:
GENERAL: Alert and in no apparent distress
EYES: +Icteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
NJ tube with bridle in place. Oropharynx without visible
lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored, symmetric expansion.
GI: Abdomen soft, nt, +bs
GU: No CVA tenderness
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted; jaundiced; telangectiasas
on chest
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout, no asterixis
PSYCH: Very pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 07:10AM BLOOD WBC-11.3* RBC-2.68* Hgb-7.6* Hct-24.3*
MCV-91 MCH-28.4 MCHC-31.3* RDW-29.6* RDWSD-89.6* Plt ___
___ 07:30AM BLOOD Neuts-81.8* Lymphs-7.3* Monos-6.6
Eos-0.7* Baso-0.6 NRBC-0.2* Im ___ AbsNeut-7.81*
AbsLymp-0.70* AbsMono-0.63 AbsEos-0.07 AbsBaso-0.06
___ 07:10AM BLOOD ___ PTT-38.1* ___
___ 07:10AM BLOOD Ret Aut-1.6 Abs Ret-0.04
___ 07:10AM BLOOD Glucose-84 UreaN-58* Creat-2.1* Na-135
K-3.3* Cl-97 HCO3-18* AnGap-20*
___ 07:10AM BLOOD ALT-27 AST-85* LD(LDH)-226 AlkPhos-231*
TotBili-10.6*
___ 07:10AM BLOOD Albumin-2.9* Calcium-6.9* Phos-7.0*
Mg-2.8* Iron-49
___ 07:10AM BLOOD calTIBC-118* Hapto-216* Ferritn-723*
TRF-91*
IMPORTANT INTERIM RESULTS:
___ 07:10AM BLOOD HBsAb-NEG
___ 07:10AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 07:10AM BLOOD ___
___ 07:10AM BLOOD IgA-305 IgM-135
___ 09:49PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
MICRO:
___ 5:08 am URINE Source: ___.
**FINAL REPORT ___
REFLEX URINE CULTURE (Final ___: NO GROWTH.
Blood culture NGTD
IMAGING
-------
RUQUS ___:
1. Dilated CBD up to 8 mm, with the distal portion is not well
assessed. Findings are new compared to prior CT abdomen pelvis
performed ___ and further evaluation with dedicated
MRCP is recommended.
2. Mildly distended gallbladder containing sludge without
specific sonographic findings to suggest acute cholecystitis.
3. Coarsened hepatic parenchyma without evidence of focal liver
lesion. There is probable underlying cirrhosis with evidence of
portal hypertension including trace ascites and splenomegaly.
CHEST XRAY ___:
Congestive pulmonary vasculature with associated
right-greater-than-left bilateral pleural effusion and bibasal
volume loss.
MCRP ___:
1. No cholelithiasis or cholecystitis. No intrahepatic or
extrahepatic biliary ductal dilation.
2. Hepatomegaly, splenomegaly and recanalization of the
umbilical vein, which most likely represents early cirrhosis and
underlying portal hypertension.
EGD ___:
An NJ tube was placed past the third portion of the duodenum.
The tube was moved from the mouth into the nose bridled at 98
cm.
The tube flushed without difficulty.
Multiple antral ulcers including one large ___ 2A ulcer,
suggestive of recent bleed. Successful dual endoscopic therapy.
CT abdomen ___:
1. No evidence of hematoma, perihepatic fluid, or organized
fluid
collections in the abdomen or pelvis.
2. Trace low-attenuation free fluid in the pelvis.
Liver biopsy ___:
Liver, nontargeted, core needle biopsy:
1. Advanced fibrosis/ cirrhosis with prominent sinusoidal
fibrosis (trichrome stain evaluated).
2. Frequent ballooning degeneration with prominent
intracytoplasmic hyalin and lobular neutrophils seen. Mild
macrovesicular steatosis. Occasional lobular apoptotic
hepatocytes.
3. Mild intrahepatocyte cholestasis.
4. Moderate portal/septal mixed inflammation comprised of
lymphocytes, neutrophils and rare plasma cells. Focal
lymphocytic cholangitis with bile duct damage.
Septal bile duct proliferation associated with neutrophils.
5. Iron stain demonstrates no significant iron deposition.
Note: Overall the findings are consistent with toxic/metabolic
injury. Clinical correlation recommended
DISCHARGE LABS:
___ 06:55AM BLOOD WBC-8.7 RBC-2.54* Hgb-8.3* Hct-27.6*
MCV-109* MCH-32.7* MCHC-30.1* RDW-24.3* RDWSD-95.3* Plt ___
___ 07:00AM BLOOD ___ PTT-38.6* ___
___ 06:55AM BLOOD Glucose-139* UreaN-10 Creat-0.6 Na-144
K-3.9 Cl-109* HCO3-25 AnGap-10
___ 06:55AM BLOOD ALT-65* AST-103* AlkPhos-141*
TotBili-3.2*
___ 06:55AM BLOOD Calcium-8.4 Phos-2.4* Mg-1.9
___ 06:30AM BLOOD calTIBC-151* Ferritn-531* TRF-116*
Brief Hospital Course:
Ms. ___ is a ___ woman with history of iron
deficiency anemia due to menorrhagia, fatty liver who presented
to an outside hospital with jaundice, found to have
hyperbilirubinemia and ___, with labs and imaging concerning for
cirrhosis w/ acute liver decompensation. Course complicated by
acute on chronic anemia secondary to gastric ulcer.
ACUTE/ACTIVE PROBLEMS:
# Transaminitis
# Hyperbilirubinemia/cholestasis
# Hepatic steatosis
# Likely alcoholic cirrhosis
# Alcoholic hepatitis
# Confusion, resolved
Patient presenting with jaundice and abdominal distention, found
to elevated LFTs in cholestatic pattern with high total
bilirubin to 14 at ___. Patient with leukocytosis, but no
fevers and no clinical or radiographic evidence of cholecystitis
or cholangitis. Of note, hepatitis A/B/C serologies negative at
___. Tylenol level negative. Patient reports drinking
alcohol both nights on the weekends, however recently was on
vacation and had significantly more than that. She has multiple
family members with liver failure and an aunt on the transplant
list (patient and husband don't know etiology), which raised
concern for familial condition such as autoimmune hepatitis.
Autoimmune serologies negative for likely autoimmune cause of
cirrhosis/hepatitis. Hepatitis A/B/C serologies negative. MRCP
negative for obstruction. Presumed diagnosis was acute alcoholic
hepatitis, with probable background cirrhosis. She was started
on lactulose for reported confusion and likely mild hepatic
encephalopathy. Liver biopsy confirmed alcoholic hepatitis with
cirrhosis, likely from alcohol. She will need to closely follow
up with Hepatology. She was instructed to no longer drink
alcohol, that any insult would be damaging to her liver and
health. She was seen by social work and provided with list of
resources for EtOH cessation, but was not interested in
enrolling in any programs or medications at this time.
# Acute blood loss anemia
# Gastric ulcers: Noted vaginal bleeding and dark stools, with
continued hemoglobin drops, nadir of 6.2. She has received 5
units PRBCs total over hospital course. Hemoglobin at time of
discharge 8.3. Hematology consult obtained, no indication for
IV iron as patient not truly iron deficient. CT abdomen showed
no bleeding from liver biopsy site, other bleeding. Patient has
received IV iron as outpatient. Spoke with outpatient
hematologist, Dr. ___, who agrees with current
management. It was explained to patient and husband that
transfusion is the recommended treatment for blood loss,
especially when acute, and that iron is not recommended when
someone is not iron deficient. EGD showed a gastric ulcer with
evidence of recent bleeding, which explained continued drop in
hemoglobin. Iron level was low normal, ferritin level high.
B12 819 and reticulocyte count was 0.11. She was placed on an
IV PPI for 72 hours, and then transitioned to a PO PPI BID x 2
weeks, then daily. H. pylori stool antigen not detected, serum
IgG pending at time of discharge- although this was performed
after she was already on PPI. She will need a repeat EGD in four
weeks to assess again. Discussed to avoid NSAIDs.
# Coagulopathy: Suspect synthetic dysfunction due to liver
disease. S/p oral vit K x 1 on ___, with modest reduction in
INR. INR on discharge 1.5
# Leukocytosis (RESOLVED): Patient noted to have leukocytosis to
17 at outside hospital prior to transfer. She is afebrile and
hemodynamically stable without any clear localizing signs or
symptoms of infection. U/A from BI-P with pansensitive E. coli
and Klebsiella, however repeat here negative and denied urinary
symptoms.
# Pre-renal Acute kidney injury:
# Anion gap acidosis:
Patient with creatinine of 4 on admission; unknown baseline but
presumed to be normal. Patient appears euvolemic on exam, but
does have mild pulmonary edema on chest x-ray. Ultrasound at
outside hospital showed normal kidneys without hydronephrosis.
Urine lytes w/ Na of 52. She received albumin, with significant
improvement in creatinine. On discharge was down to 0.6
# Acute hypoxia:
# Pulmonary edema:
CXR with mild pulmonary edema, requiring placement of 1L NC O2.
Diuresed gently with furosemide with improvement, on day of
discharge on room air.
# Family issues: during course of hospitalization, husband has
been very involved. He often would talk over patient and state
things for patient, that upon asking the patient for their
wishes, were not congruous, specifically regarding wishes for
transfusion. Social Work saw the patient to evaluate the
situation and met with the patient several times. Patient
denied physical abuse. It should be emphasized that patient
make decisions for herself unless she specifically says her
husband should for her.
TRANSITIONAL ISSUES:
====================
[] Please recheck CBC and LFT at PCP follow up appointment;
discharge Hgb 8.3
[] She will require Hepatitis A and B vaccinations
[] Close follow up with hepatology Dr. ___
pending at discharge)
[] Please continue to encourage EtOH cessation and consider
acamprosate or baclofen; patient not interested in medications
at this time
[] Can begin cycling tube feeds as outpatient: Jevity 1.5 @
90ml/hr x
16hr
[] Repeat EGD in 4 weeks
[] PO Pantoprazole 40 mg BID x 2 weeks (until ___, then daily
[] Patient plans on transitioning to new PCP (Dr. ___,
will need to self-register
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q4H:PRN Pain - Mild
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Lactulose 30 mL PO BID
3. Pantoprazole 40 mg PO Q12H
4. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Alcoholic cirrhosis
Alcoholic hepatitis
Acute blood loss anemia
Gastric ulcer
Vaginal bleeding
Malnutrition
Coagulopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your recent
hospitalization. You came to the hospital with jaundice and
abdominal pain. Further testing showed that you have evidence
of alcoholic hepatitis, as well as cirrhosis of the liver
thought to be related to alcohol use. You also had a feeding
tube placed for nutrition. You showed evidence of blood loss,
and were found to have a stomach ulcer that looked as if it had
recently bled.
It is important that you continue to take your medications as
prescribed and follow up with the appointments listed below. It
is also very important that you stop drinking alcohol, as this
will damage your liver further.
Please take care, we wish you the very best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19861544-DS-6 | 19,861,544 | 26,711,329 | DS | 6 | 2110-05-28 00:00:00 | 2110-06-02 14:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Throat pain, L peritonsillar abscess
Major Surgical or Invasive Procedure:
- Drainage of left peritonsillar abscess
History of Present Illness:
Mr. ___ is a ___ gentleman with a history of left
rotator cuff repair one month prior who was transferred from
___ with a left peritonsillar abscess.
Mr. ___ lives ___ the ___, ___ and is ___ ___ for
a funeral. On ___, after arriving ___ ___, he
developed fevers and sore throat. He was seen at ___
___, where he received a throat analgesic. He had ongoing
fevers and chills and represented to ___ on ___, where a
CTA revealed a a 1.6 x 1 cm left peritonsillar abscess.
Additional work-up included a negative rapid strep test, lactate
of 5.9, WBC 2.1, negative influenza, negative UA, and a CXR
showing increased lung markings concerning for pneumonitis.
On arrival to the ___ ED, Mr. ___ vital signs were:
99.9 86 107/64 16 100% RA. Labs showed: WBC 6.4 (76% N, 19%
bands, 5% metas), H/H 12.0/36.4, lactate 2.9, ALT 44, AST 46,
Tbili 1.9, INR 1.7, bicarb 21, and UA with few bacteria without
signs of infection. Blood cultures x 2 and urine culutres were
sent. ENT was consulted, and they drained the abscess of 1 cc of
purulent fluid, which was also sent for culture. He was given
vancomycin 1 g IV and clindamycin 600 mg IV. VS prior to
transfer were: 101.5 82 110/71 27 99%.
On arrival to the floor, vitals were 99.8, 100/87, 80. He denied
any pain and was very comfortable. He is currently denying any
hoarseness, difficulty swallowing, or drooling. Denies any
reccent history of cough, SOB, or DOE.
Past Medical History:
- S/p left shoulder orthoscopy 1 month ago
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
VS: 99.8, 100/87, 80, 18 98%RA
GENERAL: well appearing though fatigued
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, small
incision on the left peritonsilar area, no uvular displacement.
No cervical, axillary lymphadenopathy.
NECK: supple, no LAD
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use, no significant findings ___ the RLL
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, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
DISCHARGE EXAM:
VS: 98.6 58 135/74 18 98 RA
GENERAL: Well appearing, NAD
HEENT: MMM, white area on L hard palate with surrounding
erythema. L tonsil still markedly erythematous, uvula not
displaced. R tonsil mildly erythematous but otherwise
unremarkable. No cervical, axillary lymphadenopathy. No
tenderness to palpation of external neck.
LUNGS: LCTAB, no w/r/r appreciated
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
NEURO: Awake, alert
Pertinent Results:
ADMISSION LABS
___ 06:00PM BLOOD WBC-6.4 RBC-3.75* Hgb-12.0* Hct-36.4*
MCV-97 MCH-32.0 MCHC-33.1 RDW-12.4 Plt Ct-99*
___ 06:00PM BLOOD Neuts-76* Bands-19* ___ Monos-0
Eos-0 Baso-0 ___ Metas-5* Myelos-0
___ 06:00PM BLOOD ___ PTT-29.6 ___
___ 06:00PM BLOOD Glucose-86 UreaN-12 Creat-1.2 Na-140
K-3.7 Cl-108 HCO3-21* AnGap-15
___ 06:00PM BLOOD ALT-44* AST-46* LD(LDH)-152 AlkPhos-54
TotBili-1.9* DirBili-1.2* IndBili-0.7
___ 06:20AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-POSITIVE HAV Ab-NEGATIVE
___ 10:00AM BLOOD HIV Ab-NEGATIVE
___ 06:11PM BLOOD Lactate-2.9*
___ 08:02AM BLOOD Lactate-1.7
___ 06:20AM BLOOD HCV Ab-NEGATIVE
MICROBIOLOGY
___ HBV Viral Load: HBV DNA detected, less than 20 IU/mL
___ Blood Culture: PENDING
___ Blood Culture: PENDING
___ HIV-1 Viral Load: Negative
___ Urine Culture: No growth
___ Left Peritonsillar Abscess Culture:
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >=3 COLONY TYPES) CONSISTENT WITH
OROPHARYNGEAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture..
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
___ Blood Culture: PENDING
___ Blood Culture: PENDING
___ ___ Blood Culture:
1. STREPTOCOCCUS CONSTELLATUS
___ M.I.C.
------ ------
CEFTRIAXONE - MIC S 0.50
VANCOMYCIN-MIC S 1
PENICILLIN-MIC S 0.125
STUDIES
___ CTA NECK:
Multislice soft tissue neck CT obtained ___ the axial plane
following IV administration of nonionic contrast media.
Reformatted coronal and sagittal images also generated. Soft
tissue and bone windows reviewed. Pharynx partially obscured by
streak artifact from patient's dental hardware. Nasopharynx is
normal. Left palatine tonsil is swollen and enlarged with 1.6 cm
x 1 cm low-density collection within or adjacent to the gland
compatible with a small abscess. Collection is partially
obscured by streak artifact. Right palatine tonsil is normal.
Epiglottis and aryepiglottic folds unremarkable. Vocal cords are
normal. No evidence of significant lymphadenopathy ___ the neck.
Parotid and submandibular salivary glands are symmetrical and
normal ___ appearance. Thyroid gland grossly unremarkable.
Visualized lung
apices are clear.
___ CXR:
Mildly increased interstitial lung markings suggesting
interstitial/viral pneumonitis. ? Developing right lower lobe
infiltrate.
___ Cardiac ECHO:
The left atrium and right atrium are normal ___ cavity size. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
estimated pulmonary artery systolic pressure is high normal.
There is no pericardial effusion.
IMPRESSION: Trace aortic regurgitation with normal valve
morphology. Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Dilated
thoracic aorta.
CLINICAL IMPLICATIONS:
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, a follow-up echocardiogram
is suggested ___ ___ years.
___ CXR:
Uncomplicated repositioning of right-sided PICC such that the
tip
lies ___ lower SVC. Final internal length is 41 cm. The line is
ready to use.
DISCHARGE LABS
___ 07:00AM BLOOD WBC-7.0 RBC-3.88* Hgb-12.2* Hct-37.0*
MCV-95 MCH-31.5 MCHC-33.1 RDW-12.9 Plt ___
___ 07:00AM BLOOD ___ PTT-29.9 ___
___ 07:00AM BLOOD Glucose-83 UreaN-8 Creat-0.9 Na-137 K-3.7
Cl-104 HCO3-24 AnGap-13
___ 07:00AM BLOOD ALT-27 AST-25 LD(LDH)-128 AlkPhos-51
TotBili-0.5
___ 07:00AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ gentleman with no significant past
medical history who was transferred to ___ from ___
___ with several days of fevers, sore throat, and imaging
findings concerning for a left peritonsillar abscess. Blood
cultures revealed an alpha-hemolytic strep bacteremia.
--------------------
ACTIVE ISSUES
--------------------
1. Left Peritonsillar Abscess and Bacteremia: Patient's abscess
is the most likely etiology of his sore throat, fevers,
bandemia, and bacteremia. A 1.0 x 1.4 cm left peritonsillary
abscess was identified on CTA at ___, and it was
successfully drained of 1 cc purulent fluid ___ the ___ ED by
ENT. Patient was initially started on vancomycin and clindamycin
___ the ED. He was transitioned to unasyn upon admission to the
floor. On day 1 of admission, ___ blood cultures
grew GPC's ___ pairs and chains ___ 3 bottles. Patient was
broadened to vancomycin and unasyn. Sensitivities showed a
pan-sensitive organism, and patient was started on Ceftriaxone 2
g daily. After discharge, cultures speciated as streptococcus
constellatus.
It is not clear what precipitated patient's infection, but
immunodeficiency or an early presentation of malignancy should
be considered by outpatient providers. He reports that a
colonoscopy ___ years ago showed benign polyps and ___
follow-up was recommended. An HIV antibody test was negative.
2. Strep Bacteremia: As above, patient had an alpha-hemolytic
strep bacteremia that ultimately speciated as streptococcus
constellatus. The most likely source was his L peritonsillar
abscess. Given gram-positive bacteremia, a TTE was performed to
rule out endocarditis and it showed no signs of vegetations. His
antibiotic regimen was ultimately transitioned to Ceftriaxone,
home infusion arranged, and he was discharged with plans for at
least 14 days of therapy (d1 = ___, last day = ___.
Patient was counseled that any recurrent/worsening infectious
symptoms must be urgently evaluated and that it is possible he
will require a longer course.
3. Thrombocytopenia/Anemia: Patient's labs revealed anemia (Hgb
nadir 10.5) and thrombocytopenia (platelet nadir 73). His PCP
reported that baseline labs are normal. These abnormalities were
most likely secondary to acute infection and bacteremia;
however, given severity of infection ___ this previously healthy
gentleman, an outpatient malignancy work-up should be
considered. Hemoglobin and platelets trended up by time of
discharge, but remained below the normal range.
4. Hepatitis B Serologies: Given question off immunosuppression,
a hepatitis panel was sent. Patient is HBsAg and HBsAb negative
but HBcAb positive, suggesting four possible Hep B statuses: 1.
Recovering from acute HBV infection; 2. Distantly immune (test
not sensitive enough to detect very low level of anti-HBs); 3.
Susceptible with a false positive anti-HBc; 4. Chronically
infected with undetectable levels of HBsAg. A Hep B viral load
was sent and showed and did detect Hep B DNA, though at very low
levels. Patient instructed to follow-up with PCP as an
outpatient for further work-up and management.
5. Electrolyte Abnormalities: Patient has no history of abnormal
electrolytes per his PCP but required repletion of K, Mg, and
Phos upon admission.
6. Possible Pneumonia: Patient had a CXR at ___
suggestive of possible pneumonia. Patient had no respiratory
symptoms and an unremarkable lung exam. He received two doses of
levaquin at ___. His antibiotic regimen was adjusted
as per #1 above. He did not develop respiratory symptoms.
7. Elevated Lactate: Likely due to dehydration ___ the setting of
poor PO intake. Resolved after IV fluids.
8. Elevated LFTs: Noted at ___. Patient had no RUQ
pain and LFT's normalized without intervention.
9. Elevated INR: Patient's INR was elevated upon presentation,
which may have been related to poor PO intake over the past few
days. He received 5 mg PO vitamin K and coagulopathy resolved.
CHRONIC ISSUES:
1. Left Rotator Cuff Tear: S/p surgical repair.
--------------------
TRANSITIONAL ISSUES
--------------------
- Continue Ceftriaxone 2g daily through ___ (to complete 13
day course). If patient has any further infectious
- Patient's TTE showed no endocarditis but the incidental
finding of mild dilation of his ascending aorta. He will need a
repeat ECHO ___ ___ years.
- Please consider work-up for underlying malignancy or
immunodeficiency
- Follow-up possible hepatitis B infection
- Needs ENT follow-up ___ next 4 weeks
- Needs repeat CBC and electrolytes at PCP appointment on
___
- Thereafter needs weekly labs until completion of antibiotic
course.
- Will need surveillance blood cultures drawn after finishing
Ceftriaxone
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 2 g IV daily Disp #*26 Gram Refills:*0
2. OxycoDONE Liquid 10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL 5 mL by mouth Every 4 hours Disp #*100
Milliliter Refills:*0
3. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat pain
RX *phenol [Chloraseptic Throat Spray] 1.4 % 5 sprays to throat
Every 2 hours Disp #*1 Bottle Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
- Peritonsillar Abscess
- Bacteremia
Secondary Diagnoses:
- Hepatitis B
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 during your admission to the
___. As you know, you were
admitted with a peritonsillar abscess, or infection ___ the back
of your throat. You were also found to have bacteria ___ your
blood, which is most likely from your throat infection.
You had an echocardiogram, which showed no evidence of
endocarditis, or an infection of your heart valves. Your
echocardiogram did show a mild dilation of your ascending aorta,
and you should have a repeat echocardiogram for monitoring ___
___ years.
Because of the infection ___ your blood, you need to take at
least two weeks of IV antibiotics. You are being discharged with
a PICC line and should continue to take Ceftriaxone 2 g daily IV
through ___, unless your doctors ___ ___ instruct you to
take it for a longer period. Your home infusion company will
deliver the Ceftriaxone to your house on the morning of ___.
We have scheduled you for follow-up at your PCP office on
___ (please see details below). At that visit, it is very
important that you have repeat blood work, including a CBC with
differential and an electrolyte panel.
You also need to schedule an appointment with your doctor ___ two
weeks (i.e. after you finish Ceftriaxone). At that visit, you
should have another complete set of labs and you should also get
a set of blood cultures (to ensure the infection has cleared
completely).
You and your primary care doctor ___ decide together whether
you would benefit from seeing an infectious disease specialist
___ ___ to guide your therapy.
If you have any of the alarm symptoms listed below, including
fevers, chills, worsening throat pain, confusion, or any other
symptoms that concern you, it is crucial that you immediately
call your doctor or go to the Emergency Room. These symptoms
could be a sign of a more complicated infection, such as
endocarditis, and would need emergent evaluation.
It is also important that you schedule follow-up with an Ear,
Nose, and Throat (ENT) specialist ___ the next four weeks. Your
PCP suggested Dr. ___ (___).
During your hospitalization, you also had evidence of Hepatitis
B infection. Please discuss further management with your PCP.
We made the following changes to your medications:
- START Ceftriaxone 2 g IV daily (last day is ___
- START Oxycodone liquid 5 mg q4H as needed for pain for the
next 3 days. DO NOT DRIVE OR OPERATE MACHINERY WHILE TAKING THIS
MEDICINE. IT MAY CAUSE DROWSINESS
- START Chloroseptic spray as needed for throat pain
Followup Instructions:
___
|
19862292-DS-11 | 19,862,292 | 23,319,646 | DS | 11 | 2173-03-25 00:00:00 | 2173-03-31 17:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ yo M with a history of valvular disease (no local
records), afib on coumadin, presenting with progressive new
onset dyspnea and lower extremity edema for the last 3 weeks,
with a 20 lb weight gain (203 here, 183 in ___. Pt is here
from ___, arrived on ___. He fell 7 days ago on his L
knee, that knee has been swollen and sore since then. He has no
other known cardiac history, never been on a diuretic. He has
been taking Excedrin for his knee pain and eats a salty diet. He
denies frothy urine.
In the ED intial vitals were: 97.7 66 157/62 22 98% RA. Labs
notable for BNP ___, hct 26, INR 5.7, trop neg x1. Stool brown,
guiaic pos. CXR showed right basilar opacity of unclear
significance or etiology. 2 PIVs were placed. EKG with afib w/o
RVR, nonspecific lateral ST depressions (this EKG was not
available on admission).
Patient was given: 10mg IV vitamin K, 1 unit FFP.
Vitals on transfer: 98.1 72 139/73 22 100% RA
On the floor pt is without acute complaints.
ROS: On review of systems, he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools (though cannot see the
stool color with macular degeneration). 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,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: Afib on coumadin, valvular disease of
unclear etiology without replacement
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Prostate cancer, s/p distant resection
s/p bilateral hernia repair
s/p tonsillectomy
s/p appendectomy
s/p partial colon resection for large polyp (not cancerous on
path)
Social History:
___
Family History:
Mom died at ___ without significant medical problems, dad died of
brain aneurysm
Physical Exam:
EXAM ON ADMISSION:
VS: T=98.3 137/81 107 17 99% on RA
Weight 92 kg (203 lbs) dry weight 183lbs at urologist office ___
weeks ago
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 14+ cm.
CARDIAC: PMI laterally displaced. Irregularly irregular, normal
S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Pulsus 18
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles ___ way up
from bases, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits. +BS
EXTREMITIES: anasarcic, 4+ edema from feet to hips bilaterally,
L>R
L knee with warmth, no erythema, full ROM
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ bilateral DP, ___
EXAM ON DISCHARGE:
Vitals: T 98.3 BP 109/62 (104-126/59-73) HR 76 (60s-150s) RR 18
O2 93RA
I/O 180/300 since midnight, ___ yesterday
Wt: 92.4kg-> 91.5kg-> 89.4kg->87.5kg (192lbs)->85.7kg->81.5kg
(179.7lbs)->80.0kg-> 79.1kg -> 79.1kg -> 78.2kg
Tele: afib rates 60-70s over past few days, this morning with
frequent bursts into 150s-160s
General: older gentleman lying flat in bed, speaking in full
sentences, in no acute distress
HEENT: PERRL, MMM, +pale conjunctiva, good dentition
Lungs: clear bilaterallt, no crackles wheezes or rhonchi
CV: irregularly irregular, no murmurs, rubs, gallops, JVP below
clavicle at 90 degrees
Abdomen: obese, soft, non distended, non tender to deep
palpation, +BS
Ext: warm, well perfused, no edema
Pertinent Results:
LABS ON ADMISSION:
___ 03:30PM BLOOD WBC-5.4 RBC-3.37* Hgb-7.4* Hct-26.7*
MCV-79* MCH-22.1* MCHC-27.9* RDW-18.6* Plt ___
___ 03:30PM BLOOD Neuts-61.8 ___ Monos-9.6 Eos-1.6
Baso-0.5
___ 03:30PM BLOOD ___ PTT-49.6* ___
___ 03:30PM BLOOD Glucose-100 UreaN-26* Creat-1.0 Na-138
K-4.6 Cl-102 HCO3-29 AnGap-12
___ 10:13PM BLOOD ALT-18 AST-21 LD(LDH)-172 AlkPhos-60
TotBili-0.4
___ 03:30PM BLOOD ___ 03:30PM BLOOD cTropnT-<0.01
___ 10:13PM BLOOD TotProt-5.4* Albumin-3.4* Globuln-2.0
Iron-18*
PERTINENT LABS:
___ 03:30PM BLOOD cTropnT-<0.01
___ 10:13PM BLOOD CK-MB-4 cTropnT-<0.01
___ 10:13PM BLOOD TotProt-5.4* Albumin-3.4* Globuln-2.0
Iron-18*
___ 10:13PM BLOOD calTIBC-393 VitB12-265 TRF-302
___ 10:13PM BLOOD TSH-0.79
___ 06:38AM BLOOD IgA-210
___ 03:41PM BLOOD HIV Ab-NEGATIVE
DISCHARGE LABS:
___ 06:20AM BLOOD WBC-4.8 RBC-3.38* Hgb-7.9* Hct-27.6*
MCV-82 MCH-23.3* MCHC-28.5* RDW-23.5* Plt ___
___ 06:20AM BLOOD ___ PTT-28.6 ___
___ 06:20AM BLOOD Glucose-83 UreaN-40* Creat-1.5* Na-137
K-3.8 Cl-96 HCO3-33* AnGap-12
___ 06:20AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.2
STUDIES:
EKG ___:
Atrial fibrillation with a controlled ventricular response and
frequent
ventricular ectopy. Low limb lead voltage. No previous tracing
available for
comparison.
IntervalsAxes
___
___
- CXR ___:
FINDINGS:
Heart size is mildly enlarged. Mediastinal and hilar contours
are
unremarkable. The pulmonary vasculature is not engorged. Hazy
ill-defined
opacity is noted within the left mid lateral lung field. Small
bilateral
pleural effusions, right greater than left are demonstrated.
Streaky linear opacities within the right lung base likely
reflect atelectasis. There is no pneumothorax. Right type 3 AC
joint separation history is age indeterminate.
IMPRESSION:
1. Hazy ill-defined opacity in the left mid lateral lung field.
This may
reflect pneumonia, and followup radiographs after treatment are
recommended to
ensure resolution of this finding.
2. Small bilateral pleural effusions.
3. Right basilar atelectasis.
- TTE ___:
The left atrium is moderately dilated. The right atrium is
markedly dilated. No atrial septal defect is seen by 2D or color
Doppler. The estimated right atrial pressure is at least 15
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function
(LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). The right
ventricular cavity is markedly dilated with mild global free
wall hypokinesis. There is abnormal septal motion/position
consistent with right ventricular pressure/volume 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. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Moderate [2+] tricuspid regurgitation is
seen. There is severe pulmonary artery systolic hypertension.
There is an anterior space which most likely represents a
prominent fat pad.
IMPRESSION: Markedly dilated right ventricle with mild free wall
hypokinesis. Mild symmetric left ventricular hypertrophy with
preserved global/regional systolic function. Mildly dilated
thoracic aorta with mild aortic regurgitation. Mild mitral
regurgitation. Severe pulmonary hypertension.
- V/Q SCAN ___:
FINDINGS:
Nonsegmental area within the left mild lateral lung field
demonstrates decreased activity on both ventilation and
perfusion which is somewhat larger then opacity seen on recent
chest radiograph.
Additional nonsegmental defects seen in the right lung on both
ventilation and perfusion which match.
Fluid is seen within the major fissure bilaterally as well as
decreased
perfusion in the lower lobes concerning for some degree of
cardiac failure. Chest x-ray shows left mid lung opacity, small
bilateral pleural effusions, and right lower lobe atelectasis.
IMPRESSION: 1. Low likelihood of pulmonary embolism. 2.
Nonsegmental area within left mild lateral lung field
demonstrates decreased activity on both ventilation and
perfusion which is somewhat larger then opacity seen on recent
chest radiograph which may represent evolving pneumonia. 3.
Evidence of cardiac failure.
- Bilateral Lower Extremity Ultrasound ___:
FINDINGS:
There is normal compressibility, flow and augmentation of
bilateral common
femoral, femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins
bilaterally.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the either leg.
- L Knee Xray ___:
FINDINGS:
No fracture, dislocation, or marked degenerative change is
detected. Small spur is noted at the patella. No suspicious
lytic or sclerotic lesion is identified. No joint effusion is
seen. No soft tissue calcification or radio-opaque foreign body
is detected.
IMPRESSION:
No evidence of left knee fracture or joint effusion.
- CT chest noncon ___:
IMPRESSION:
No evidence of interstitial or obstructive lung disease.
Mild pulmonary artery dilatation. Multi chamber cardiomegaly,
vertical right ventricular enlargement.
Coronary atherosclerosis.
General thoracic aortic ectasia. Maximum diameter 48 mm
fusiform ascending thoracic aorta.
Possible asbestos related pleural plaques. No evidence of
asbestosis.
- Catheterization ___:
R heart cath showed normal right sided heart pressures with
mildly elevated left sided heart pressures (RA 6, PA ___ (21),
PCWP 16, CO 5.3)
INTERPRETATION: This was an ___ year old man with A fib, HTN and
HLD,
who was referred to the lab from the inpatient floor for an
evaluation
of exertional dyspnea in the setting of new CHF. He exercised
for 4.5
minutes of a Gervino protocol ___ METs) and stopped due to
fatigue. This
represents a poor functional capacity for his age. He denied any
chest,
arm, neck or back discomforts, inappropriate shortness of
breath,
palpitations or symptoms of exercise intolerance throughout the
study.
There was 0.5-1mm ST segment flattening in the inferolateral
leads noted
near peak exercise, however these changes occured in the setting
of
atrial fibrillation at a rapid ventricular response (171bpm).
The rhythm
was A fib with occasional isolated PVC's and rare ventricular
couplets/triplets seen during exercise. The blood pressure
responded
appropriately to both exercise and recovery. The heart rate
response to
exercise was varied due to the presence of atrial fibrillation.
IMPRESSION: No anginal type symptoms reported. Non-specific ST
segment
changes noted. Atrial fibrillation with RVR. Poor functional
capacity
demonstrated. Echo report sent separately.
Resting images were acquired at a heart rate of 89 bpm and a
blood pressure of 112/60 mmHg. These demonstrated regional left
ventricular systolic dysfunction with focal hypokinesis of the
basal to mid inferior wall. The remaining segments contracted
well (LVEF = 50-55 %). There is no pericardial effusion. Doppler
demonstrated trivial mitral regurgitation with no aortic
stenosis, aortic regurgitation or significant resting LVOT
gradient. The estimated pulmonary artery systolic pressure is
normal.
Echo images were acquired within 56 seconds after peak stress at
heart rates of 142-130 bpm. These demonstrated no new regional
wall motion abnormalities. Baseline abnormalities persist with
appropriate augmentation of other segments.
IMPRESSION: Poor functional exercise capacity. No ECG changes
with 2D echocardiographic evidence of prior myocardial
infarction without inducible ischemia to achieved workload.
Normal hemodynamic response to exercise. Suboptimal study -
sub-optimal image quality during post-exercise acquisitions.
- TTE ___:
The patient exercised for 4 minutes and 30 seconds according to
a Gervino treadmill protocol ___ METS) reaching a peak heart rate
of 171 bpm and a peak blood pressure of 144/60 mmHg. The test
was stopped because of fatigue. This level of exercise
represents a poor exercise tolerance for age. In response to
stress, the ECG showed no diagnostic ST-T wave changes (see
exercise report for details). There were normal blood pressure
and heart rate responses to stress.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with history of afib,
unknown valvular disease presenting with 3 weeks worsening
dyspnea on exertion, lower extremity edema, exam with elevated
JVP, crackles, labs with elevated BNP ___, cxr with small
bilateral pleural effusions concerning for new onset heart
failure. TTE with EF >55% with RV hypokinesis and severe
pulmonary hypertension concerning for pulmonary artery
hypertension and right heart failure. However, patient had only
mild pulmonary artery systolic hypertension (PASP 36 mmHg) on
right heart cath. No evidence of interstitial lung disease. Will
complete PFTs and sleep study at home. Likely that heart failure
was caused by hypertension and LVH with gradual volume overload.
#Right Heart Failure: Patient with no known history of heart
failure presenting with dyspnea on exertion, volume overload,
elevated BNP up 20lbs from dry weight 183 concerning for new
onset heart failure. TTE showing RV failure with elevated PA
pressures concerning for PAH, lung parenchymal process. LENIS
negative for DVT, V/Q scan low prob for PE, no evidence of
CTEPH. DDx remained broad with class 1, 2, 3, 5 PAH possible
etiologies. Patient may have left sided heart failure leading to
RH failure, evidence of LVH but not significantly so. Consider
OSA as patient has history of snoring per daughter and noted to
have O2 desaturations to mid 80% overnight. Workup for PAH
included: negative HIV, normal TSH. Negative ___, and
SSC70. Right heart cath with normal right sided heart pressures
and mildly elevated left sided heart pressures and mild
pulmonary artery systolic hypertension (PASP 36 mmHg). CT chest
without evidence of interstitial lung disease. Patient had
desaturations at night and should have sleep study as well as
PFTs as outpatient. Patient continued on metoprolol uptitrated
to 100mg daily, discontinued home hctz and lisinopril with low
normal blood pressures. Diuresed patient with lasix gtt,
2.5mg/hr->7.5mg/hr with weight 92kg-> 78kg (172lb)on discharge.
Patient discharged on 10mg torsemide daily.
#Atrial Fibrillation: Patient with history of atrial
fibrillation, CHADS2 score 3, on coumadin. INR 5.7 on admission,
given vitamin K and FFP given concern for GI bleed with Hgb 7.4
and guaiac positive stool. Patient remained hemodynamically
stable, started heparin gtt for bridge, restarted coumadin after
right heart catheterization. INR on discharge 1.3 and pt felt
not to need bridge. Patient rate controlled with metoprolol
succinate as outpatient and switched to tartrate while
inpatient. He had asymptomatic episodes of afib with RVR,
uptitrated to tartrate 37.5mg PO BID, transitioned to succinate
100mg PO prior to discharge.
#Anemia: Patient with Hct 26.7 on admission with no history of
bleeding, elevated INR 5.7, guaiac positive stool. Patient has
history of large polyp s/p partial colectomy, though had
colonoscopy ___ year ago with benign polyps removed per patient
report. Given brown stool that was guiaic positive, raising
concern for upper GI bleed, started on pantoprazole 40mg PO BID.
Evidence of iron deficiency anemia with low iron, low ferritin
suggestive of long standing iron deficiency, Tsat 4%, no
evidence of hemolysis. Given degree of iron deficiency, patient
iron deficit 3g, started parenteral ferrous gluconate 125mg IV
QOD (received 3 doses), would need 24 doses for 3g iron deficit,
transitioned to PO iron supplementation at discharge. Also with
low normal B12 262, started oral repletion 1000mcg PO daily. As
patient remained hemodynamically stable, no urgent indication
for EGD/colonscopy. TTG for celiac was negative. Patient
monitored closely with daily labs, no active signs of bleeding.
Patient will need repeat CBC and follow up with gastroenterology
for potential EGD/colonoscopy as outpatient.
#Lower extremity edema: Bilateral. Presented with
supratherapeutic INR 5.7, lower extremity ultrasound negative
for DVT. Consistent with acute heart failue, diuresed as above,
wrapped legs and recommended elevation while in bed and seated
in chair. Improved upon discharge.
======================
CHRONIC MEDICAL ISSUES:
======================
#HTN: Initially held home ACEi and HCTZ given concern for GI
bleed and low normal blood pressures.
#CAD: Patient with history of HLD, no history of chest pain or
angina, trop negative x2, no ischemic changes on EKG. Continued
home statin.
#Macular Degeneration- Occuvite not on outpatient med list per
PCP, consider starting as outpatient.
# CODE STATUS: FULL confirmed with patient
# CONTACT: Patient, HCP daughter ___ ___
local daughter ___ ___
=====================
TRANSITIONAL ISSUES:
=====================
- Dry weight 172 lb
- Started torsemide 10mg daily, please monitor weight and adjust
accordingly as outpatient
- Right Heart Failure: R heart cath showed normal right sided
heart pressures with mildly elevated left sided heart pressures
(RA 6, PA ___ (21), PCWP 16, CO 5.3)
- Possible Sleep Apnea: Patient with O2 desaturations while on
continuous O2 monitoring overnight, would recommend outpatient
sleep study
- Recommend PFTs at outpatient
- Patient had CT scan which showed: No evidence of interstitial
or obstructive lung disease. But did show coronary
atherosclerosis and possible asbestos related pleural plaques.
No evidence of asbestosis
- Atrial Fibrillation- uptitrated metoprolol succinate to 100mg
PO daily, please follow up BPs as outpatient
- Anticoagulation- INR 5.7 on admission, held coumadin, bridged
with heparin gtt initially, restarted home coumadin prior to
discharge and patient was felt not to need bridging, INR was 1.3
on discharge ___, should be rechecked on ___
- Anemia- Iron deficient, low normal B12, guaiac positive stool
on admission. Did not require transfusion. Treated with IV
ferric gluconate x 4 doses, transitioned to PO iron on
discharge. Started oral B12 supplementation 1000mcg PO daily.
Patient will need outpatient gastroenterology follow up and
likely upper endoscopy and colonoscopy to determine etiology of
iron deficiency anemia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Warfarin 5 mg PO 5X/WEEK (___)
5. Warfarin 2.5 mg PO 2X/WEEK (MO,WE)
6. lovastatin 40 mg oral daily
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 2 tablets by mouth at night as
needed for constipation Disp #*30 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 17G powder(s) by
mouth daily as needed for constipation Disp #*30 Packet
Refills:*0
5. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
6. Pantoprazole 40 mg PO Q24H
Continue until you see a gastroenterologist
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
8. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. Warfarin 2.5 mg PO 2X/WEEK (MO,WE)
10. Warfarin 5 mg PO 5X/WEEK (___)
11. Torsemide 10 mg PO DAILY
start on ___
RX *torsemide 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Acute Right Heart Failure
Secondary: Iron Deficiency Anemia
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 recent
admission to ___. You came into
the hospital because of swelling in your legs and shortness of
breath. We found that you have heart failure. We treated you
with lasix (a water pill) which helped to remove the extra
fluid. Your weight on discharge is 172 lbs. It is very important
that you take your medications daily (torsemide 10mg) and weigh
yourself daily. If you gain more than 3 pounds in more than 2
days please take 2 pills (20mg torsemide) and contact your
cardiologist or primary care physician. It is likely that your
heart failure is from your high blood pressure and a build up of
fluid over time. You should have pulmonary function tests and a
sleep study to rule out other causes.
We also found that your red blood cell counts were low (you were
anemic). Your iron stores were low so we treated you with IV
iron supplementation and oral vitamin B12 supplementation. We
found that you had blood in your bowel movement which may be the
source of your anemia. You were monitored closely and did not
have any evidence of active bleeding. You will need to follow up
with your primary care physician and gastroenterology as an
outpatient and likely need further testing to determine the
cause of your anemia. Please continue to take your daily oral
iron supplementation, it may cause you to have dark stools or
constipation so please take your stool softeners as needed.
If you should develop chest pain, palpitations, shortness of
breath, lower extremity swelling, weight gain of more than 2
pounds, lightheadedness, dizziness, please contact your
cardiologist, primary care physician or report to the emergency
department.
Be well and take care.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19862388-DS-14 | 19,862,388 | 28,308,708 | DS | 14 | 2113-08-12 00:00:00 | 2113-11-01 23:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
laproscopic appendectomy
History of Present Illness:
Pt is ___ y/o F who presents with 1 day history of diffuse
abd pain. Pt initially thought the pain was due to hunger so
she
ate a large meal. However, the pain worsened and began to
localize to right lower quadrant. No fevers, chills,
nausea/vomiting, or diarrhea. Last menstrual period was 3 weeks
ago. Pt did have pelvic exam in ED which was normal.
Past Medical History:
none
Social History:
___
Family History:
non-contributory
Physical Exam:
T 98.4 P 79 BP 107/66 R 16 SaO2 100%
Gen: no acute distress
Heent: no scleral icterus
Lungs: clear
Heart: regular rate and rhythm
Abd: soft, tender in RLQ, nondistended
extrem: no edema
Pertinent Results:
___ 07:55PM GLUCOSE-97 UREA N-9 CREAT-0.7 SODIUM-137
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-26 ANION GAP-9
___ 07:55PM estGFR-Using this
___ 07:55PM LIPASE-18
___ 07:55PM URINE HOURS-RANDOM
___ 07:55PM URINE HOURS-RANDOM
___ 07:55PM URINE UCG-NEGATIVE
___ 07:55PM URINE GR HOLD-HOLD
___ 07:55PM WBC-7.8 RBC-4.03* HGB-12.4 HCT-35.9* MCV-89
MCH-30.6 MCHC-34.4 RDW-12.4
___ 07:55PM NEUTS-67.7 ___ MONOS-4.6 EOS-1.6
BASOS-0.3
___ 07:55PM PLT COUNT-190
___ 07:55PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
Brief Hospital Course:
Pt was brought to the OR for a laproscopic appendectomy. Please
see Op Note for more procedure details. Pt tolerated the surgery
well, and resumed a full diet the morning after the surgery. Pt
had normal bowel sounds, and passed flatus, with pain well
controlled prior to discharge. She will follow up with her
primary care doctor and in ___ clinic for a post-op visit.
Medications on Admission:
none
Discharge Medications:
1. oxycodone 5 mg Capsule Sig: ___ Capsules PO every ___ hours
as needed for pain: Take only for pain that does not respond to
tylenol. Do not drink alcohol or drive after taking this
medication.
Disp:*30 Capsule(s)* Refills:*0*
2. Acetaminophen Extra Strength 500 mg Tablet Sig: Two (2)
Tablet PO every ___ hours as needed for pain.
3. ibuprofen 200 mg Tablet Sig: ___ Tablets PO every ___ hours
as needed for pain. Tablet(s)
4. docusate sodium 100 mg Tablet Sig: Two (2) Tablet PO twice a
day as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the acute care surgery service for acute
appendicitis. This is an infection of your appendix. We
performed a laproscopic appendectomy, which is a surgery to
remove the appendix. The surgery went well, and it is safe for
you to return home. Please follow the attached instructions, and
take medication as prescribed.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*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 an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
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. You
may not drive or heavy machinery while taking narcotic analgesic
medications. 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:
*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:
___
|
19862541-DS-17 | 19,862,541 | 26,903,221 | DS | 17 | 2149-12-21 00:00:00 | 2149-12-12 15:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ischemic right foot
Major Surgical or Invasive Procedure:
___ CIA angiojet/stent/tPA infusion catheter
___: lysis check, completion angio, catheter removal
___: L cutdown, repair of CFA
History of Present Illness:
___ female with no reported vascular history who
presents with a chief complaint of right foot pain. Patient
reports the right food pain initially started approximately two
weeks ago, but it became acutely worse in the past several hours
which prompted her to go to the ED. She also noticed a
temperature difference of her R foot, which has become colder
than her L foot. Her pain is present with ambulation and at
rest. She was given indomethacin and prednisone for presumed
gout when she initially presented to her PCP about two weeks
ago, but did not experience any relief of her symptoms.
Past Medical History:
Migranes
Depression
Hypothyroidism (not medically treated)
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Phsyical Exam
General: AAOx3
HEENT: No scleral icterus
Cardiac: WNL
Respiratory: Breathing comfortably on room air
Abdomen: Soft, non-tender no rebound or guarding
Pulse exam:
L: P/D/D/D
R: P/D/NS/NS
Discharge Physical Exam
General: AAOx3
CV: RRR, s1/s2
Respiratory: CTAB/L, no respiratory distress
Abdomen: obese, soft, nontender, nondistended, no
rebound/guarding
Ext: right lower extremity with mottled/ischemic distal toes,
cold right foot, pain on palpation to medial aspect of right
foot
Pulse exam:
R: p/d/mono/very weak
L: p/d/d/d
Pertinent Results:
Admission labs:
___ 06:10AM BLOOD WBC-8.7 RBC-5.01 Hgb-15.4 Hct-42.7 MCV-85
MCH-30.7 MCHC-36.1* RDW-13.1 Plt ___
___ 06:10AM BLOOD Neuts-61.4 ___ Monos-5.6 Eos-1.3
Baso-0.6
___ 06:10AM BLOOD Glucose-629* UreaN-14 Creat-0.9 Na-129*
K-4.6 Cl-91* HCO3-22 AnGap-21
___ 06:10AM BLOOD Calcium-9.9 Phos-4.0 Mg-2.2
Discharge labs
___ 04:08AM BLOOD WBC-14.4* RBC-2.64* Hgb-7.8* Hct-24.4*
MCV-92 MCH-29.5 MCHC-32.0 RDW-15.8* RDWSD-51.4* Plt ___
___ 07:10AM BLOOD ___ PTT-62.4* ___
___ 04:00AM BLOOD Glucose-242* UreaN-6 Creat-0.6 Na-137
K-3.8 Cl-102 HCO3-25 AnGap-14
___ 04:00AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.9
Imaging:
CTA AORTA/BIFEM/ILIAC RUNOFF W
1. Filling defect in the right common iliac artery is
concerning for thrombus. There is occlusion of the right
internal iliac artery, with reconstitution from collateral
vessels.
2. There is abrupt occlusion of the proximal right peroneal
artery, the
distal right anterior tibial artery, as well as the right
posterior tibial artery in the region of the ankle. Given the
relative paucity of
atherosclerotic disease within the lower extremity vessels,
these areas of
occlusion are felt to be more consistent with smaller vessel
embolic
phenomenon.
3. Heterogeneous enhancement of the right kidney is most likely
consistent
with embolic phenomenon/early infarcts.
ECHO ___
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with aneuvers. The estimated right atrial pressure is
___ mmHg. Left entricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Left entricular systolic function is
hyperdynamic (EF>75%). Right ventricular chamber size and free
wall motion are normal. There is abnormal septal
motion/position. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (?#)
appear structurally normal with good leaflet excursion. There is
no valvular aortic stenosis. The increased transaortic velocity
is likely related to high cardiac output in setting of
hyperdynamic left ventricular function. No aortic regurgitation
is seen. The mitral valve leaflets are structurally normal.
There is no mitral valve prolapse. Trivial mitral regurgitation
is seen. There is no pericardial effusion.
IMPRESSION: No source of embolism identified. No PFO. Mild
symmetric left ventricular hypertrophy with normal biventricular
regional/global systolic function.
Brief Hospital Course:
Ms. ___ was admitted on ___ with complaints of
cold right foot for 2 weeks. Symptoms include claudication and
significant pain. Patient subsequently went to the operating
room for a right lower extremity angiogram. Angiojet was
performed, stent was placed ih the right common iliac artery,
angiojet thrombolysis of the right common iliac artery. There
was subsequent placement of right anterior tibial artery
microcatheters for tPA infusion.
Patient did well post-operatively and was again taken back to
the operating on ___ for ballon angioplasty of anterior
tbial/posterior tibial/angioJet thrombectomy with tPA of right
anterior tibial and posterior tibial artery. Patient's incision
was closed with a 6 ___ angioseal. Patient post-operative
course was initialyl uncomplicated. However, overnight, patient
had a 10pt hct drop, and was transfused 6 units of PRBC. Patient
subsequently had a PEA arrest, coded. Patient taken back to the
operating room on ___ for exploration of left common femoral
artery and repair of left common femoral arteriotomy.
Patient did well and was transferred to the ICU in stable
condition with no requirements for pressors. Patient was
re-started on a Hep drip and was eventually transitioned to
Coumadin. During her post-operatively recovery course, patient's
arterial and central lines were discontinued.
On ___, patient spiked a temperature of 102.5, UA, Blood
cultures were sent. Cxray was WNL. UA was positive, Cipro was
started. There was an initial discussion on an Amputation during
this hospital course, given the absence of pulses distally.
Patient will be discharged to rehab. Patient was seen by chronic
pain during her hospital course, and will follow-up with chronic
pain upon discharge. Patient will be discharged to rehab. She
will be discharged with a foley for failure to pass void trial.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
2. Amitriptyline 50 mg PO QHS
3. CarBAMazepine 200 mg PO QID
4. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*6 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
6. Duloxetine 120 mg PO DAILY
7. Enoxaparin Sodium 100 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 100 mg/mL 100 mg SC twice a day Disp #*50 Syringe
Refills:*0
8. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*50 Tablet Refills:*0
9. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Mirtazapine 7.5 mg PO QHS
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
12. Senna 8.6 mg PO BID:PRN constipation
13. Warfarin 4 mg PO DAILY16
RX *warfarin [Coumadin] 4 mg 1 tablet(s) by mouth daily Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Ischemic right foot
Discharge Condition:
Patient discharged in stable condition
No changes in mental status
Non-ambulatory, ischemic right foot
Discharge Instructions:
Mrs. ___ you were admitted to ___ on ___ due
to ischemic foot. Now you are ready for discharge. You need to
follow-up with Dr. ___ given that you have lack of
blood flow down to your foot on right side. Please follow these
instructions closely.
Here are your discharge instructions.
LOWER EXTREMITY ANGIO/PLASTY/STENT
MEDICATION:
Take Aspirin 81 (enteric coated) once daily
Take Lovenox, bridge to Coumadin ( INR goal ___
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE at ___ FOR:
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
FOR SUDDEN, SEVERE BLEEDING OR SWELLING (at the groin puncture
site):
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office at ___
If bleeding does not stop, call ___ for transfer to the
nearest Emergency Room
Followup Instructions:
___
|
19862541-DS-18 | 19,862,541 | 26,769,781 | DS | 18 | 2150-01-10 00:00:00 | 2150-01-10 18:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pleuritic left back pain
Major Surgical or Invasive Procedure:
___ line placed ___ for IV antibiotics
History of Present Illness:
___ y/o F with DM2 on insulin, s/p R below knee amputation
(___) who presents with left flank pain, worse with
inspiration beginning 3 days prior to admission.
The patient was recently discharged from rehab 1 week ago after
being discharged from BI for R BKA on ___. Her L sided pain was
pleuritic and dull. It had been getting gradually more severe
since ___. The pain was relieved sitting up; ___ ___nd
___ with movement. She denied fever, chills, anterior chest
pain, palpitations, or shortness of breath. She endorsed a dry
cough without sputum x1 day and denied sick contacts. She
endorsed some dysuria with no suprapubic tenderness.
She had a prolonged hospitalization from ___,
where she initially presented with ischemic right foot for which
she had right anterior tibial artery microcatheters for tPA
infusion and ballon angioplasty of anterior tibial/posterior
tibial/angioJet thrombectomy with tPA of right anterior tibial
and posterior tibial artery. Her course was complicated by 10 pt
hct drop, PEA arrest, transfusion of 6 units pRBC, and she was
later found to have a right common iliac thrombus. Despite
endovascular interventions, she had right toe necrosis and
underwent a right lower extremity guillotine BKA on ___ and
completion BKA with closure on ___. Since dicharge from rehab,
she has been seen by outpatient vascular surg. She was placed on
a 10 day course of cephalexin (last day ___ for right leg
cellulitis and percocet for pain. She denied any swelling or
increasing pain in the leg.
Past Medical History:
CHRONIC PAIN SYNDROME
BACK PAIN
ULNAR NEUROPATHY
CARPAL TUNNEL SYNDROME
CERVICAL RADICULITIS
THYROID GOITER
VITAMIN D DEFICIEINCY
HYPERLIPIDEMIA
ESOTROPIA
DEPRESSION
INSOMNIA
LOW LIBIDO
LEARNING DISABILITY
ABNORMAL THYROID FUNCTION TESTS
DIABETES TYPE II
H/O MENINGITIS
H/O PLANTAR FASCIITIS
H/O BACTERIAL VAGINOSIS
H/O ALCOHOL ABUSE
H/O ROTATOR CUFF TENDINITIS
H/O SKIN LESIONS
H/O TRICHOMONAS VAGINITIS
H/O TROCHANTERIC BURSITIS
Social History:
___
Family History:
Parents, brother with diabetes & cardiac disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 99.1 116/69 83 18 98% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Crackles in left lung base, no wheezes/rhonchi, good air
exchange
Back- Tenderness to palpation at L chest wall, worsens with
inspiration. No lower back pain.
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- Warm. S/p L BKA with staples at wound closure site, c/d/i
without drainage. No edema at RLE
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
Physical Exam
Vitals: TM 101.6 Tc 98.3 113/66 79 18 97%RA
General- Alert, oriented, no acute distress
HEENT- MMM, oropharynx clear
Lungs- Bibasilar crackles L>R, no wheezes/rhonchi, good air
exchange
Back- No CVA tenderness. Lidocaine patch in place over left
back. Pain worsens with inspiration. No lower back pain.
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen- Soft, non-tender, non-distended, bowel sounds
normoactive, no rebound tenderness or guarding, no organomegaly
GU- No foley
Access- PIV L arm
Ext- S/p R BKA with brace in place. LLE is warm, well perfused,
palpable DP pulses.
Neuro- CNs2-12 intact, right esotropia baseline for pt.
Pertinent Results:
ADMISSION LABS
===============
___ 12:30PM BLOOD WBC-9.5 RBC-3.80* Hgb-11.6 Hct-36.0
MCV-95 MCH-30.5 MCHC-32.2 RDW-14.7 RDWSD-51.2* Plt ___
___ 12:30PM BLOOD Neuts-73.7* Lymphs-15.8* Monos-9.1
Eos-0.7* Baso-0.4 Im ___ AbsNeut-7.00* AbsLymp-1.50
AbsMono-0.86* AbsEos-0.07 AbsBaso-0.04
___ 12:30PM BLOOD Plt ___
___ 12:30PM BLOOD Glucose-122* UreaN-10 Creat-0.6 Na-137
K-4.1 Cl-100 HCO3-26 AnGap-15
___ 12:48PM BLOOD Lactate-1.5
DISCHARGE LABS
===============
___ 05:10AM BLOOD WBC-4.9 RBC-3.51* Hgb-10.3* Hct-32.9*
MCV-94 MCH-29.3 MCHC-31.3* RDW-14.1 RDWSD-48.3* Plt ___
___ 07:45AM BLOOD WBC-6.6 RBC-3.49* Hgb-10.5* Hct-32.6*
MCV-93 MCH-30.1 MCHC-32.2 RDW-14.4 RDWSD-49.4* Plt ___
___ 05:10AM BLOOD Glucose-138* UreaN-8 Creat-0.5 Na-137
K-3.8 Cl-102 HCO3-31 AnGap-8
___ 07:45AM BLOOD Glucose-118* UreaN-8 Creat-0.5 Na-139
K-4.1 Cl-103 HCO3-27 AnGap-13
___ 07:45AM BLOOD ALT-26 AST-19 AlkPhos-173* TotBili-0.2
IMAGING
===============
___ CXR
IMPRESSION: Left lower lobe consolidation is compatible with
pneumonia in the appropriate clinical setting.
___ EKG
Sinus rhythm. Diffuse non-specific ST-T wave changes. Compared
to the
previous tracing of ___ the rate has increased. There is
ST-T wave
flattening in the limb leads. Otherwise, no diagnostic interim
change.
___ RLE US
IMPRESSION: No evidence of deep venous thrombosis in the right
leg.
___ CXR
IMPRESSION: PICC line placed with tip in appropriate location
MICRO:
===============
BCx ___: Pending but negative to date of ___
UCx (___): Negative
Brief Hospital Course:
___ year old female with insulin dependent diabetes, 1 month s/p
right below knee amputation (___) who presented with 3
days of pleuritic left back pain and was found to have an left
lower lobe HCAP pneumonia.
ACTIVE ISSUES:
===============
# Healthcare-associated pneumonia
Patient was discharged from rehab 1 week ago after being
discharged from ___ for a R BKA on ___. She described left
sided, pleuritic back pain that had become gradually more severe
beginning on ___ with CXR in the ED showed a LLL pneumonia.
Patient was treated initially with levofloxacin and vancomycin
but given her significant risk factors including recent Abx
exposure and stay in hospital was broadened to vancomycin and
cefepime beginning ___ for full HCAP treatment. A PICC line was
placed on ___ for IV vancomycin/cefepime administration (last
dose = ___. On discharge, she was afebrile without shortness
or breath. Plan for completion of antibiotics in rehab.
Follow-up CXR in 1 month to ensure resolution (___)
# S/p right below knee amputation complicated by cellulitis at
wound site:
As outpatient, patient noted to have drainage and pain at wound
site, prompting antibiotic coverage with cephalexin per vascular
surgery. There was no evidence of active infection on admission.
Given new antibiotic treatment for HCAP pneumonia, cephalexin
was discontinued. Patient was continued on Acetaminophen and
Oxycodone for pain. Follow-up as scheduled with vascular
surgery.
# Concern for possible clot:
Discharge summary from ___ visit reported a filling defect in
the right common iliac artery concerning for thrombus, occlusion
of the right internal iliac artery, with reconstitution from
collateral vessels, and occlusion of the proximal right peroneal
artery of possible embolic origin. Patient did not report
increased pain in either lower extremity, and both were warm and
well perfused. A doppler ultrasound of the right lower extremity
was performed which showed no evidence of venous thrombosis.
CHRONIC ISSUES:
================
# Insulin dependent Type 2 DM:
A1C was 7.9% in ___. Patient has long-standing peripheral
neuropathy. Continued patient's home insulin regimen. Continued
on carbamazepine for peripheral neuropathy.
# Depression:
Continue patient's Duloxetine 60 mg PO BID, and Mirtazapine 7.5
mg PO/NG QHS.
TRANSITIONAL ISSUES
====================
- Last dose of IV Vancomycin and Cefepime via a PICC line will
be on ___.
- *** Vanc trough after 4th dose (___) was low, so patient was
transitioned to Vancomycin 1250mg BID from 1000mg BID. Please
check another vanc trough before the evening dose of vancomycin
on ___. **
- Discontinued cephalexin for right left cellulitis given new
antibiotic therapy for HCAP.
- Patient will follow up with PCP ___ in 1 month to ensure
resolution of HCAP with interval CXR
- Patient will follow up with vascular surgeon Dr. ___ on
___ for follow-up of R leg below the knee amputation
Code: Full
Communication: Patient's boyfriend ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H pain
2. CarBAMazepine 200 mg PO QID
3. Docusate Sodium 100 mg PO BID
4. Duloxetine 60 mg PO BID
5. Mirtazapine 7.5 mg PO QHS
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
7. Aspirin EC 81 mg PO DAILY
8. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
9. Loratadine 10 mg PO DAILY
10. Glargine 20 Units Bedtime
11. Cephalexin 500 mg PO Q12H
Discharge Medications:
1. CefePIME 2 g IV Q12H
The last day will be ___. RX *cefepime [Maxipime] 2 gram
___ mg IV Every 12 hours Disp #*5 Vial Refills:*0
2. Vancomycin 1250 mg IV Q 12H
The last day will be ___. RX *vancomycin 1 gram 1250 mg IV
Every 12 hours Disp #*12 Vial Refills:*0
3. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
4. Acetaminophen 650 mg PO Q6H pain
5. Aspirin EC 81 mg PO DAILY
6. CarBAMazepine 200 mg PO QID
7. Docusate Sodium 100 mg PO BID
8. Duloxetine 60 mg PO BID
9. Glargine 20 Units Bedtime
10. Loratadine 10 mg PO DAILY
11. Mirtazapine 7.5 mg PO QHS
12. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Healthcare associated pneumonia
Secondary:
Status post right below knee amputation complicated by
cellulitis
Insulin dependent T2DM
Peripheral neuropathy
Depression
History of alcohol abuse
History of arterial thrombi
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 ___ Medicine Service on ___ for
left back pain worse with breathing.
In the Emergency Department, they did a Chest X-Ray which showed
a pneumonia. You were treated with two intravenous antibiotics,
Vancomycin and Cefepime. Prior to discharge, a PICC line was
placed so that you could receive intravenous Vancomycin and
Cefepime.
You will take Vancomycin and Cefepime through ___ at
rehab and then will be able to go home soon thereafter.
In the hospital, we discontinued the antibiotic Cephalexin which
you were taking for a skin infection on your right leg. You do
not need to take this anymore because you are taking Vancomycin
and Cefepime for your pneumonia. You will follow up with your
vascular surgeon, Dr. ___, on ___ as previously
scheduled.
You should follow up with your primary care physician ___
___ in 1 month to ensure that your pneumonia is resolving.
If you experience any new or worrisome symptoms, please contact
your primary care physician ___.
It was a pleasure taking care of you. We wish you the best in
your health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19862963-DS-13 | 19,862,963 | 21,657,864 | DS | 13 | 2142-06-26 00:00:00 | 2142-06-26 21:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hemoperitoneum
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with a history of transitional cell carcinoma
of the
bladder s/p cystectomy and presumed jejunal interposition
(report
not available) also with a history of RLL lung CA s/p right
lower
lobectomy. Per patient report, her alkaline phosphatase has been
rising over the past several months, followed by her PCP.
Because the etiology of this was uncertain, a liver biopsy was
performed two days prior to presentation, ___. Since the
biopsy she has had
increasing abdominal pain and malaise with decreased appetite.
She denies any syncope, fevers and ileostomy is functioning
well.
Past Medical History:
Past Medical History: hypertension, hyperlipidemia, high ostomy
output, transitional carcinoma of the bladder, RLL lung cancer
Past Surgical History: exploratory laparotomy with ileostomy,
cystectomy with presumed jejunal interposition, hysterectomy,
right lower lobectomy for lung CA
Social History:
___
Family History:
notable for bladder CA
Physical Exam:
GEN: Alert and oriented, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l
ABD: Soft, mildly tender to palpation in epigastrium and RUQ, no
rebound or guarding
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 04:47PM WBC-5.7 RBC-2.22* HGB-6.9* HCT-20.9* MCV-94
MCH-31.2 MCHC-33.2 RDW-13.5
___ 04:47PM NEUTS-69.3 ___ MONOS-3.2 EOS-2.4
BASOS-0.3
___ 02:00PM URINE RBC-48* WBC-29* BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-1
___ 01:46PM LACTATE-1.3
___ 11:45AM GLUCOSE-80 UREA N-19 CREAT-0.8 SODIUM-135
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-23 ANION GAP-10
___ 11:45AM ALT(SGPT)-46* AST(SGOT)-32 ALK PHOS-170* TOT
BILI-0.3
___ 11:45AM LIPASE-21
___ 11:45AM cTropnT-<0.01
___ 11:45AM ALBUMIN-3.9
___ 11:45AM WBC-6.6 RBC-2.53*# HGB-7.8*# HCT-23.7*#
MCV-94 MCH-31.0 MCHC-32.9 RDW-13.5
___ 11:45AM NEUTS-64.4 BANDS-0 ___ MONOS-3.4
EOS-2.3 BASOS-0.4
___ 11:45AM PLT COUNT-240
___ 02:50PM BLOOD Hct-27.7*
___ 05:45AM BLOOD WBC-6.3 RBC-2.81* Hgb-8.6* Hct-25.9*
MCV-92 MCH-30.7 MCHC-33.3 RDW-15.6* Plt ___
___ 05:55PM BLOOD Hct-28.7*
___ 11:30AM BLOOD Hct-27.7*
___ 05:05AM BLOOD WBC-4.9 RBC-2.76* Hgb-8.6* Hct-24.7*
MCV-90 MCH-31.1 MCHC-34.7 RDW-15.8* Plt ___
___ 04:27PM BLOOD Hct-29.5*
___ 10:25AM BLOOD Hct-29.0*
___ 04:00AM BLOOD WBC-5.3 RBC-2.83*# Hgb-8.7*# Hct-25.8*
MCV-91 MCH-30.8 MCHC-33.8 RDW-14.7 Plt ___
___ 12:25AM BLOOD Hct-23.1*
___ 04:47PM BLOOD WBC-5.7 RBC-2.22* Hgb-6.9* Hct-20.9*
MCV-94 MCH-31.2 MCHC-33.2 RDW-13.5 Plt ___
CT abd ___:
1. Intra-abdominal hematoma adjacent to the inferior edge of the
liver and
tracking down dependently into the pelvis with a small amount of
blood in the
left paracolic gutter. No evidence of parenchymal injury in the
liver or
active extravasation.
2. Cholelithiasis without evidence of acute cholecystitis.
3. Patent ileostomy without evidence of obstruction.
Brief Hospital Course:
Patient was admitted to the hospital after liver biopsy that led
to hemoperitoneum. A sizable amount of blood was seen on CT scan
and patient was admitted for serial hematocrits. She was
hemodynamically stable throughout the hospitalization but did
require 1 unit of red blood cells on ___ after which no
transfusions were required. Interventional radiology was made
aware of patient but no attempt at embolization was required.
She had two large bore IVs placed. She was monitored through
___ to make sure she remained hemodynamically stable and
that her hematocrit was stable. She was discharged tolerating a
regular diet.
Medications on Admission:
ASA 81mg daily, lomotil 2 tabs prn, opium 0.4mg TID,
omeprazole 20mg daily, immodium prn, calcium, MVI, atenolol
Discharge Medications:
1. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for loose stools.
2. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain for 4 days.
Disp:*40 Tablet(s)* Refills:*0*
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. opium tincture 10 mg/mL Tincture Sig: Eight (8) Drop PO TID
(3 times a day).
7. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for loose stools.
She was told to resume all home medications
Discharge Disposition:
Home
Discharge Diagnosis:
perihepatic hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital after you developed abdominal pain
after a liver biopsy. You were found to have a collection of
blood around your liver and were watched closely to make sure
this was not actively bleeding. You were watched by monitoring
your vital signs and checking your reb blood cell levels. You
required 1 unnit of red blood cells on ___ but none since.
Your vital signs and red blood cell count were all fine and so
you were discharged home.
Please follow up in the Acute Care Surgery office as listed
below.
Followup Instructions:
___
|
19862987-DS-10 | 19,862,987 | 24,588,564 | DS | 10 | 2187-03-01 00:00:00 | 2187-03-01 14:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
malaise, fatigue, and recurrent cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ man with PMH COPD, HTN, HLD who
presented with cough and generalized malaise.
He reports having an intermittent cough since ___. He
has been to the ED and urgent care at least 3 times and has been
treated with Azithromycin on 2 separate occasions, including
___.
Over the last 10 days he has been having a cough with
intermittent yellow sputum production that improves with
Tessalon
Perles. His Ventolin inhaler also helps. Because he hadn't
improved after Azithromycin x 5 days his friend told him to come
in to the ER. Over the past 2 days he has been having
generalized
malaise, fatigue. He has dyspnea with minimal exertion.
He received benzonatate, albuterol and duonebs, 1L IVF, 4g IV
Mg,
50 mg PO prednisone and Azithromycin 500 mg PO.
On my interview he reports that the nebulizers made him feel
better in the ED. He says that he has not taken prednisone
recently, just the Z-pak. He reports that he has lost 13 pounds
in the past several weeks which he thinks could be because he
eats less when he isn't feeling well. He has been on Ensure
shakes until this month for the past year because of his low
weight but he's always had bad appetite and not eaten much. He
says he eats a lot of ice cream and chocolate. He denies night
sweats. Says that he has been having some subjective fevers he
thinks but he's not sure and he doesn't have thermometer to
measure it.
He was told by his pulmonologist Dr. ___ he doesn't need
to use nebulizers anymore and that his lung testing is always
good. He reports that he hasn't had to go to the hospital in
many
years and is generally healthy.
He reports that he used to smoke cigars but quit ___ years ago
after having trouble breathing once and being taken in an
ambulance to an ER.
The main thing that is bothering him is how weak he has been
feeling and then his coughing that was getting worse.
Past Medical History:
COPD
HYPERTENSION
HYPERLIPIDEMIA
CAD s/p MI
CVA
S/p GUN SHOT WOUND
Social History:
___
Family History:
None reported
Physical Exam:
EXAM
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress, very fidgety, very
thin man
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect, somewhat anxious
Pertinent Results:
WBC 14.4, Cr 1, bicarb 19
trop neg x 1, BNP 353
Mg 1.5
Iron 40, Ferritin 161
TSH normal
pH 7.52, pCO2 28
I personally reviewed the EKG and my interpretation is: sinus
rhythm, no ST changes. I personally reviewed the CXR and found
hyper inflated lungs with no obvious evidence of pneumonia.
CTA chest: 1. No evidence of pulmonary embolism or aortic
abnormality.
2. Moderate bilateral perihilar and left lingular ground-glass
opacities with
bilateral nodules measuring up to 0.8 cm, and bilateral airway
thickening with
some secretions. Findings could represent small airways disease
or
viral/atypical pneumonia. However, malignancy is not excluded
given findings
of multiple ill-defined nodules.
3. Mild anterior height loss of the TT vertebral body of
indeterminate
chronicity. No high-grade spinal canal narrowing.
Discharge Labs
___ 07:55AM BLOOD WBC-10.2* RBC-3.74* Hgb-11.7* Hct-34.5*
MCV-92 MCH-31.3 MCHC-33.9 RDW-13.3 RDWSD-45.6 Plt ___
___ 07:55AM BLOOD Glucose-124* UreaN-16 Creat-0.7 Na-142
K-3.8 Cl-105 HCO3-25 AnGap-12
___ 09:30PM BLOOD ALT-21 AST-39 LD(LDH)-396* CK(CPK)-84
AlkPhos-108 TotBili-1.2
___ 07:55AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.0
___ 09:47PM BLOOD ___ pO2-37* pCO2-28* pH-7.52*
calTCO2-24 Base XS-0
MRSA screen and blood cultures pending on day of discharge
Brief Hospital Course:
#Cough
#Malaise, fatigue
#COPD: He has been having worsening cough and fatigue with CT-A
showing evidence of possible small airways disease or atypical
pneumonia with incidentally noted SPNs. He
is a poor eater and he has decreased his eating while feeling
sick with his "colds", with an 8 lb unintentional weight loss.
He notes issues with food insecurity and was seen by social work
for this. He doesn't have any wheezing on exam and
looks relatively well, however per ___ radiology read his CT was
consistent with bronchopneumonia. He received two days of IV
doxy and ceftriaxone and was then transitioned to augmentin and
doxy for 5 more days on discharge. His pulmonologist was made
aware of the admission by email.
CHRONIC/STABLE PROBLEMS:
#HTN: continue amlodipine
#HLD: continue atorvastatin 10 mg PO QPM
TRANSITIONAL ISSUES
[ ] should follow up with Dr. ___ regarding
recurrent LRT infections and have repeat CT of lungs in 3 months
to evaluate SPN
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 100 mg PO TID:PRN pain
2. amLODIPine 2.5 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Aspirin 81 mg PO DAILY
6. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB
7. Cyanocobalamin 500 mcg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth
twice a day Disp #*10 Tablet Refills:*0
2. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
3. Doxycycline Hyclate 100 mg PO BID
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*10 Capsule Refills:*0
4. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB
5. amLODIPine 2.5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. Cyanocobalamin 500 mcg PO DAILY
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Gabapentin 100 mg PO TID:PRN pain
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Bronchopneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with respiratory symptoms and
found to have a recurrent bacterial pneumonia. We treated you
with IV antibiotics and discharged you with instructions to take
them for 5 more days. Please follow up with your primary care
doctor and pulmonologists regarding your symptoms. You should
have a CT scan of your lungs in 3 months to follow up on
pulmonary nodules seen on your lung imaging.
Followup Instructions:
___
|
19862987-DS-9 | 19,862,987 | 28,700,620 | DS | 9 | 2186-02-25 00:00:00 | 2186-02-26 07:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
COUGH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old
man with medical history notable for COPD, HTN, HLD, CAD s/p MI,
stroke s/p recent treatment for pneumonia who presented to the
ED
with cough, nausea, and weakness and admitted for further
work-up.
Per patient, approximately 1 week ago he was seen by his PCP for
productive cough, subjective fevers, concerning for pneumonia.
He
was started on a Z pack. Throughout the week, his symptoms
persisted and he developed worsening cough, nausea, and
weakness.
He endorsed a few episodes of non-bloody, non-bilious vomiting
and decreased PO intake. Due to his ongoing symptoms, he
presented to the ED for further management.
In the ED, initial vitals were: 99.8 55 128/55 18 96% RA
Work-up was notable for: flu negative, leukocytosis to 16,
normal
lactate, CXR without acute findings.
Patient received:
___ 06:22 IVF NS
___ 06:37 IV CefTRIAXone
___ 07:23 IV Azithromycin
___ 07:23 IH Albuterol 0.083% Neb Soln
___ 07:23 IH Ipratropium Bromide Neb
___ 07:59 PO/NG amLODIPine 2.5 mg
Decision was made to admit for management of pneumonia.
VS on transfer:98.6 84 104/54 18 97% RA
On the floor, he reports that he is currently feeling somewhat
improved. He describes a history of one week of feeling malaise,
fatigue and cough. This did not improve with a Z-pack which he
completed. He has continued to feel increasingly unwell, with
one
episode of vomiting at home. He reports poor appetite over this
week. He denies chest pain, shortness of breath, abdominal pain,
diarrhea, lower extremity swelling.
Past Medical History:
COPD
HYPERTENSION
HYPERLIPIDEMIA
CAD s/p MI
CVA
S/p GUN SHOT WOUND
Social History:
___
Family History:
None reported
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.3 PO 114 / 57 74 18 95 Ra
GEN: elderly gentleman in NAD, sitting up in bed
HEENT: anicteric sclerae, adentulous, NC/AT
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
LUNGS: clear to auscultation but with poor air movements at the
bases
Abdomen: Soft, non-tender, non-distended
EXT: Warm, well perfused, 2+ pulses, no edema
NEURO: CNII-XII intact, A+O X 3
DISCHARGE PHYSICAL EXAM:
VS: 97.8 PO 116 / 62 5616 97% on RA
GEN: well-appearing elderly gentleman in NAD, lying in bed
HEENT: anicteric sclerae, adentulous, NC/AT
CV: RRR, normal S1 + S2, no murmurs
LUNGS: clear to auscultation
Abdomen: soft, non-tender, non-distended
EXT: warm, well perfused, no edema or ulcers
NEURO: CNII-XII intact, A+O X 3
Pertinent Results:
ADMISSION LABS:
___ 05:00AM WBC-16.8* RBC-4.35* HGB-13.8 HCT-39.0* MCV-90
MCH-31.7 MCHC-35.4 RDW-13.0 RDWSD-42.8
___ 05:00AM NEUTS-84.6* LYMPHS-6.1* MONOS-8.4 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-14.24* AbsLymp-1.02*
AbsMono-1.42* AbsEos-0.00* AbsBaso-0.03
___ 05:00AM PLT COUNT-227
___ 05:00AM ___ PTT-27.2 ___
___ 05:00AM ALBUMIN-4.2
___ 05:00AM LIPASE-36
___ 05:00AM ALT(SGPT)-31 AST(SGOT)-63* ALK PHOS-77 TOT
BILI-1.0
___ 05:00AM GLUCOSE-109* UREA N-14 CREAT-0.9 SODIUM-136
POTASSIUM-6.0* CHLORIDE-102 TOTAL CO2-22 ANION GAP-12
___ 06:26AM LACTATE-1.8
___ 12:26PM URINE MUCOUS-RARE*
___ 12:26PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 12:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 12:26PM URINE COLOR-Yellow APPEAR-Clear SP ___
CHEST X-RAY
IMPRESSION:
No acute cardiopulmonary abnormality.
DISCHARGE LABS
___ 05:46AM BLOOD WBC-7.5 RBC-3.99* Hgb-12.6* Hct-36.2*
MCV-91 MCH-31.6 MCHC-34.8 RDW-13.2 RDWSD-43.8 Plt ___
___ 05:46AM BLOOD Plt ___
___ 05:46AM BLOOD Glucose-89 UreaN-9 Creat-0.7 Na-140 K-4.1
Cl-101 HCO3-23 AnGap-16
Brief Hospital Course:
Mr. ___ is a ___ with COPD, HTN, HLD, CAD s/p MI, hx of
stroke who presented to the ED with cough, nausea, and weakness,
likely due to upper respiratory infection and clinically
improved with ceftriaxone/azithromycin, duonebs and symptomatic
treatment of his cough.
UPPER RESPIRATORY INFECTION WITH LEUKOCYTOSIS/COUGH: Patient
presented with fatigue/malaise, leukocytosis to 16.8 and cough,
making upper respiratory infection most likely. His Flu A/B, CXR
and UA were all negative on ___. Though his imaging and exam
were less consistent with a bacterial process and clinical
picture more suggestive of a viral infection, his leukocytosis
improved with ceftriaxone and azithromycin so were continued
inpatient. His cough and shortness of breath also improved with
symptomatic treatment including tesslon perles and duonebs. He
completed 3 days of ceftriaxone and azithromycin in-house and
was discharged on cefpodoxime 200mg Q12H for 2 additional days
as he had received a full course of azithromycin prior to
admission. He also was discharged with plan for a new nebulizer
machine, duonebs and tessalon perles at home.
#NAUSEA: Patient reported nausea that improved on admission but
this improved inpatient without intervention.
#COPD: No evidence of exacerbation. Plan for outpatient PFTs in
___. He was given duonebs in house with reported
improvement in symptoms. Also was continued on home Symbicort.
#HTN: Continued home amlodipine 2.5mg daily
#HL: Continued home atorvastatin
#CAD s/p MI + HX OF CVA: Patient with CAD s/p MI and Hx of CVA
without residual focal neurologic deficits. Continued home
aspirin and atorvastatin.
TRANSITIONAL ISSUES
- Patient will complete two additional days of cefpodoxime 200mg
Q12H due to concern for community acquired pneumonia.
- Patient being discharged on tessalon perles for cough and new
duonebs. He will have nebulizer machine delivered to his home.
He felt symptomatic relief with nebs inpatient so will encourage
until this illness resolves.
- Please follow-up final blood cultures
- Patient may benefit from further nutritional counseling and/or
supplements in the outpatient setting.
- Please consider whether patient may benefit from additional
(elder
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
2. amLODIPine 2.5 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Gabapentin 100 mg PO TID
5. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
6. Aspirin 81 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times per day
Disp #*21 Capsule Refills:*0
2. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 2 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice per day Disp
#*4 Tablet Refills:*0
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 unit
neb every 6 hours Disp #*28 Ampule Refills:*0
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
5. amLODIPine 2.5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. Gabapentin 100 mg PO TID
9. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
10. Vitamin D 1000 UNIT PO DAILY
11.NEBULIZER
DME: NEBULIZER MACHINE
DIAGNOSIS: COPD
ICD-10: J44.9
DURATION: 99 MONTHS (LIFETIME)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Upper Respiratory Infection
Secondary Diagnosis: COPD, Coronary Artery Disease,
Hypertension, 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 to care for you during your hospitalization at
___.
You were admitted due to cough, shortness of breath and fatigue.
We believe this was caused by an infection in your lungs. You
were treated with antibiotics and breathing treatments and your
symptoms improved.
Please complete your course of antibiotics (Cefpodoxime 200mg
twice daily for 2 more days) and continue to use the medicine
for cough and breathing treatments until your symptoms improved.
Also be sure to follow-up with your PCP.
We wish you the best!
Your ___ Team
Followup Instructions:
___
|
19863092-DS-15 | 19,863,092 | 28,352,005 | DS | 15 | 2111-05-03 00:00:00 | 2111-05-03 16:09:00 |
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:
none
History of Present Illness:
___ PMH diverticulitis s/p partial colectomy who presents with
___ pain and ___.
He had been seen in the ED on ___ with a similar complaint of
___ pain. He had a CT scan which did not show any clear
etiology,
but given history of diverticulitis he was given a prescription
for cipro and metronidazole which he has since completed.
He reports that he has been having ___ pain for about 2 weeks.
He
has not noticed any clear exacerbating or alleviating factors.
Previously the pain had been intermittent, but it has been
constant over the past ___ days. Because of the pain he has not
eaten solid food in 2 weeks. He has been drinking 1.5 bottles of
gatorade per day. He vomited a few times but has mostly been
nauseous. He also reports having some episodes where he felt
cold
and sweaty when the pain was severe. In addition, for the past
several days he has felt the urge to urinate but has not been
able to produce much urine. For pain medication he has taken
APAP
but has not taken any NSAIDs. He denies any new medications,
supplements or herbs.
On arrival to the ED his initial VS were 98.4 82 104/66 19 98%
RA. Basic labs were obtained and were notable for BUN/Cr 62/4.7
which is up from ___ when it was ___. Renal ultrasound and
CT
scan were obtained and did not show obstruction, hydronephrosis.
There was minimal perinephric stranding which was read as "may
relate to deceased renal function". There were no findings to
correlate with ___ pain. Renal was consulted and stated in ED
dash ___ M w/ hx of diverticulitis and colectomy, who is in the
ED with abdominal pain and was found to have a Cr 6.2 and BUN
57.
Apparently with decreased PO intake due to pain. Was in ED on
___ and had received IV contrast for a ___ could be due
to CIN." He was given 1L NS, dilaudid 0.5mg IV x2 and was then
admitted to medicine.
Upon arrival to the floor, he says that his pain has resolved
and
he is "starving" and would like to eat something.
Of note, he is here visiting a friend in ___ but lives in
___ and receives his care at ___. He says
the
partial colectomy was done in ___ for diverticulitis. He also
says that whenever he has an illness he always gets ___ and
___ improves when he gets better. He also reports being
diagnosed with eczema though he does not think he had it. He was
on cyclosporine for this but stopped it last month.
Past Medical History:
HTN
Hypothyroidism
Depression
Anxiety
Social History:
___
Family History:
Mother - deceased from an MI
Father - EtOH abuse, deceased
No known family history of kidney disease
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
GENERAL: Alert, NAD, appears stated age
HEENT: atraumatic, normocephalic, EOMI, PERRL, MMM
CARDIAC: RRR, no m/r/g
LUNGS: CTAB, no wheezes, ronchi or crackles
ABDOMEN: NABS, soft, NT to deep palpation in all 4 quadrants, no
rebound or guarding
EXTREMITIES: wwp, no edema
NEUROLOGIC: AAOx3, CN grossly intact, moving all 4 extremities
spontaneously and with purpose.
DISCHARGE PHYSICAL EXAM
=======================
VITALS: 24 HR Data (last updated ___ @ 1524)
Temp: 98.4 (Tm 98.4), BP: 108/73 (108-136/60-76), HR: 80
(64-80), RR: 18, O2 sat: 94% (94-99), O2 delivery: Ra, Wt: 149.1
lb/67.63 kg
GENERAL: Alert, NAD, appears stated age
HEENT: atraumatic, normocephalic, EOMI, PERRL, MMM
CARDIAC: RRR, no m/r/g
LUNGS: CTAB, no wheezes, ronchi or crackles
ABDOMEN: NABS, soft, mild TTP ___, no rebound or guarding
EXTREMITIES: wwp, no edema
NEUROLOGIC: AAOx3, CN grossly intact, moving all 4 extremities
spontaneously and with purpose.
Pertinent Results:
ADMISSION LABS
==============
___ 05:57PM BLOOD WBC-8.0 RBC-4.51* Hgb-12.8* Hct-39.5*
MCV-88 MCH-28.4 MCHC-32.4 RDW-15.1 RDWSD-48.6* Plt ___
___ 05:57PM BLOOD Neuts-62.5 ___ Monos-7.9 Eos-4.4
Baso-0.3 Im ___ AbsNeut-5.01 AbsLymp-1.95 AbsMono-0.63
AbsEos-0.35 AbsBaso-0.02
___ 06:23PM BLOOD ___ PTT-20.7* ___
___ 05:57PM BLOOD Glucose-78 UreaN-62* Creat-4.7*# Na-142
K-4.2 Cl-102 HCO3-22 AnGap-18
___ 05:57PM BLOOD ALT-19 AST-20 AlkPhos-79 TotBili-0.4
___ 05:57PM BLOOD Albumin-4.2 Calcium-8.8 Phos-6.0* Mg-2.6
___ 12:50PM BLOOD NA-140 K-3.6 CL-99 freeCa-1.12 TCO2-24
AnGap-17* Glucose-141* UreaN-57* CREAT-6.2* HCT-45 calcHgb-15.3
Lactate-2.5*
DISCHARGE LABS
==============
___ 05:54AM BLOOD WBC-7.2 RBC-4.54* Hgb-12.8* Hct-39.5*
MCV-87 MCH-28.2 MCHC-32.4 RDW-14.9 RDWSD-47.6* Plt ___
___ 05:54AM BLOOD Glucose-78 UreaN-44* Creat-1.7*# Na-143
K-4.2 Cl-106 HCO3-23 AnGap-14
___ 12:52PM BLOOD Creat-1.3*
___ 05:54AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.3
IMAGING
=======
CT A/P ___. No renal, ureteral, or bladder calculus seen. No
hydronephrosis or
hydroureter. Minimal subtle symmetric bilateral perinephric
stranding may
relate to decreased renal function. Otherwise, no acute CT
findings seen.
Renal US ___
Normal renal ultrasound. No hydronephrosis bilaterally.
Brief Hospital Course:
___ PMH diverticulitis s/p partial colectomy who presents with
___ pain and ___.
TRANSITIONAL ISSUES:
===================
[] Would consider renal outpatient referral given degree ___
may be consistent with underlying CKD unknown etiology. Would
also repeat Creatinine within one week following discharge
[] Patient had ongoing ___ pain with no findings on imaging.
Would benefit from further workup
[] Would recommend colonoscopy referral outpatient
[] Given ___ and normal BPs while inpatient, lisinopril and HCTZ
were held on discharge, would consider restarting these once Cr
has completely normalized if patient warrants it based on
outpatient BPs
ACUTE ISSUES:
=============
___:
He reported decreased PO intake over the past 2 weeks which
could have caused a prerenal ___. He did not appear particularly
volume overloaded on exam, but he was given IVFs in the ED so he
may have looked more hypovolemic on initial presentation. His
subtotal colectomy may also contribute to him being more
susceptible to dehydration given decreased surface area for
colonic re-absorption of fluid. CT scan did not show any
evidence of obstruction so this is unlikely. Intrinsic causes of
renal failure are also possible given that his FeNa was 1.6%. If
this was all hypovolemia then would have expected his urine Na
to be lower. He had not taken any new medications or herbal
supplements. He did not use NSAIDs, but the combination of an
ACE-I and prolonged hypovolemia could have caused ___
progressing to ATN. He had significant improvement in Creatinine
overnight following IVF and typical pre-renal BUN to Creatinine
ratio. He received 1 more L IVF and Creatinine went down to 1.3
(baseline appears to be around 1.2). We held his lisinopril and
HCTZ.
___ pain:
The cause of his ___ pain is unclear. He was prescribed
cipro/flagyl by a provider at ___ ___ but he is unsure why and
we do not have access, but presumably given his history this was
given for a presumed diagnosis of diverticulitis causing his ___
pain. It is possible that he did have diverticulitis and it had
improved with the antibiotics prior to his ED presentation on
___ so that it did not appear on imaging. Another possibility
is adhesions from his prior subtotal colectomy causing
intermittent obstruction, though he is currently having BMs.
Reassuringly, his
pain improved on arrival to the floor, his appetite had
returned, and the CT scan showed no concerning etiology for the
pain. He was tolerating POs without issues.
CHRONIC ISSUES
==============
#HTN:
HCTZ and lisinopril were held in the setting of ___. He was
continued on clonidine.
#Depression/anxiety:
He was continued on home fluoxetine and hydroxyzine
#GERD:
He was continued on home omeprazole
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. FLUoxetine 40 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. CloNIDine 0.1 mg PO QAM
6. CloNIDine 0.2 mg PO QPM
7. HydrOXYzine 25 mg PO QAM
8. HydrOXYzine 100 mg PO QPM
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. CloNIDine 0.1 mg PO QAM
3. CloNIDine 0.2 mg PO QPM
4. FLUoxetine 40 mg PO DAILY
5. HydrOXYzine 25 mg PO QAM
6. HydrOXYzine 100 mg PO QPM
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you see your
PCP
10. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until you see your PCP
___:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
___
SECONDARY DIAGNOSIS
___ pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for worsening renal function
What was done for me while I was in the hospital?
- You were given IV fluids
- Your kidney levels were monitored closely
- You were eating and drinking
- We did some images to look for a reason for your pain and did
not find anything concerning
What should I do when I leave the hospital?
- Take all of your medications as prescribed
- Go to all of your appointments
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19863296-DS-17 | 19,863,296 | 24,999,278 | DS | 17 | 2172-06-03 00:00:00 | 2172-06-03 20:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
perforated appendicitis
Major Surgical or Invasive Procedure:
___: CT-guided drainage of right lower quadrant collection
History of Present Illness:
Mr. ___ is a ___ year old man with a history of DM2 (refused
medications) who presented with abdominal pain, WBC 11.2, CT
abd/pelvis showing perforated appendicitis
with two abscesses.
Symptoms began on ___, when he noticed increased urinary
frequency. On ___ he had some generalized lower abdominal pain,
crampy, intermittent, associated with loose stools. He denies
nausea/vomiting, fevers/chills. He presented to
the ___ ED on ___, with WBC 12.4, found to be hyperglycemic
(glucose 298) and dehydrated. He was rehydrated with improvement
in his abdominal pain and discharged with plan for hydration and
good glucose control.
His pain continued throughout the week, and he scheduled an
appointment with his PCP ___. He presented to his PCP who
ordered CT abd/pelvis, which showed evidence of perforated
appendicitis with two abscesses possibly communicating (one
periappendiceal, one pelvic). He was then sent to ___ ED for
further evaluation.
At ___ ED, he was afebrile, HR 100, BP 153/104, with WBC 11.2.
Surgery was consulted to evaluate patient given his pain and
imaging findings.
Past Medical History:
Type 2 Diabetes
Social History:
___
Family History:
Noncontributory
Physical Exam:
Gen: alert and oriented, comfortable, no acute distress
HEENT: mucous membranes moist
CV: RRR
Resp: breathing comfortably on room air
Abd: soft, nontender, nondistended, no rebound or guarding,
drain x1 in place with purulent output
Ext: warm and well perfused, no edema
Neuro: CN II-XII, sensation, and motor function grossly intact
Pertinent Results:
___ 06:46AM BLOOD WBC-5.2 RBC-3.48* Hgb-10.1* Hct-29.5*
MCV-85 MCH-29.0 MCHC-34.2 RDW-11.9 RDWSD-36.4 Plt ___
___ 06:46AM BLOOD Glucose-178* UreaN-9 Creat-0.7 Na-142
K-3.6 Cl-100 HCO3-25 AnGap-17
___ 06:46AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.0
Brief Hospital Course:
The patient was admitted to the Acute Care Surgical Service for
evaluation and treatment of perforated appendicitis with two
abscesses (1 periappendicial and 1 pelvic) on ___. On (___),
the patient underwent ___ drain placement in pelvic fluid
collection, which went well without complication (reader
referred to the procedure note for details). The patient
returned to the floor NPO, on IV fluids and antibiotics. The
patient was hemodynamically stable.
Neuro: The patient received IV pain medications with good
effect and adequate pain control. When tolerating oral intake,
the patient was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Diet was advanced when appropriate, and was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Cultures grew strep
anginosus.
Endocrine: The patient's blood sugar was monitored throughout
his stay; ___ was consulted for management and to set up
outpatient followup. He refused insulin and was started on
metformin and glipizide.
Hematology: The patient's complete blood count was examined
routinely; 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.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
2. Ciprofloxacin HCl 500 mg PO BID
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
day Disp #*20 Tablet Refills:*0
3. GlipiZIDE 2.5 mg PO BID
RX *glipizide 5 mg 0.5 (One half) tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
4. Glucose Gel 15 g PO PRN hypoglycemia protocol
RX *dextrose [Dex4 Glucose] 40 % 15 g by mouth once a day Disp
#*2 Tube Refills:*0
5. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Do Not Crush
RX *metformin [Glucophage XR] 500 mg 1 tablet(s) by mouth twice
a day Disp #*60 Tablet Refills:*0
6. MetroNIDAZOLE 500 mg PO Q8H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perforated appendicitis
Type 2 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with abdominal pain and were found to
have perforated appendicitis. You were treated with IV
antibiotics and bowel rest. You taken to Interventional
Radiology and had a drain placed into the abscess. You are now
tolerating a regular diet, your pain is well controlled, and
your labs and vitals are stable. You are ready to be discharged
home to continue your recovery. You will be discharged home with
the drain.
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.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
19863368-DS-11 | 19,863,368 | 22,816,576 | DS | 11 | 2121-02-12 00:00:00 | 2121-03-29 20:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins / Ultram / Motrin
Attending: ___.
Chief Complaint:
___ s/p L-S fusion by Dr. ___ on ___ complains of fevers,
chills, and pain. Patient states he has been having pain in his
right buttocks and RLE since before his surgery. He states it
has never improved and has in fact gotten worse. He also reports
fevers to 103 at home as well as chills. His physical therapist
noted drainage from the wound. He was started on bactrim by his
pcp which he finished yesterday. He denies focal weakness,
saddle anesthesia, urinary incontinence, cough, shortness of
breath, dysuria. He does report intermittent tingling in his RLE
which he had prior to the surgery.
Major Surgical or Invasive Procedure:
None
Past Medical History:
R shoulde surgery
ORIF R ankle ___
R L5-S1 discectomy
Social History:
___
Family History:
N/C
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service.
Intravenous antibiotics were not given. His inflammatory
markers were trended and improved through his hospital admission
as did his pain. Hospital course was otherwise unremarkable.
On the day of discharge the patient was afebrile with stable
vital signs, comfortable on oral pain control and tolerating a
regular diet.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q4hours
Disp #*60 Tablet Refills:*0
2. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H
RX *oxycodone [OxyContin] 80 mg 1 tablet extended release 12
hr(s) by mouth q8hours Disp #*60 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN headache
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 900 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Postoperative fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit or stand more than ~45 minutes without 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.
___ Limit any kind of lifting.
Diet: Eat a normal healthy diet. You may have
some constipation after surgery. You have been given medication
to help with this issue.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___ 2. We are not allowed to call in or fax
narcotic prescriptions (oxycontin, oxycodone, percocet) to your
pharmacy. In addition, we are only allowed to write for pain
medications for 90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Gait training, lower extremity strengthening, balance
Treatments Frequency:
Wound assessments
Followup Instructions:
___
|
19863368-DS-12 | 19,863,368 | 21,372,089 | DS | 12 | 2122-07-28 00:00:00 | 2122-07-28 12:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / Ultram / Motrin
Attending: ___.
Chief Complaint:
Polytrauma
Major Surgical or Invasive Procedure:
___ coiling of the splenic artery
Left surgical chest tube
History of Present Illness:
___ old male who was involved in a moped vs. truck motor
vehicle accident. He was seen at an outside hospital and
underwent a CT which showed multiple right rib fractures, blood
around the liver, spleen and kidney with injuries to the liver,
right kidney and spleen. He received 1u PRBCs and was
transferred to ___ where he underwent the massive transfusion
protocol. He had reported episodes of hypotension down to
systolics of ___.
Past Medical History:
PMH:
- Chronic back pain
PSH:
- R shoulder surgery
- ORIF R ankle ___
- R L5-S1 discectomy
Social History:
___
Family History:
N/C
Physical Exam:
Admission
VITAL SIGNS: HR: 92 BP: 116/76 O2 sat: 96% on RA
Constitutional: uncomfortable secondary to pain
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: decreased bs secondary to porr resp effort pain on
palp
Abdominal: diffuse abdominal pain on palp
GU/Flank: No costovertebral angle tenderness
Neuro: Speech fluent
Discharge
VS 98.4/97.7 76 110/59 18 95%RA
Constitutional: NAD A/Ox3
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: CTAB/L
Abdominal: soft, ntnd, no rebound
GU/Flank: No costovertebral angle tenderness
Neuro: Speech fluent
Pertinent Results:
___ 06:04AM BLOOD WBC-10.6 RBC-3.27* Hgb-10.2* Hct-30.6*
MCV-94 MCH-31.2 MCHC-33.2 RDW-15.6* Plt ___
___ 02:16AM BLOOD WBC-11.6* RBC-2.68* Hgb-8.2* Hct-25.0*
MCV-93 MCH-30.5 MCHC-32.7 RDW-14.4 Plt ___
___ 01:41AM BLOOD WBC-19.4* RBC-3.04* Hgb-9.7* Hct-28.7*
MCV-95 MCH-31.9 MCHC-33.7 RDW-14.0 Plt ___
___ 01:30PM BLOOD WBC-17.5* RBC-3.05* Hgb-9.4* Hct-28.5*
MCV-94 MCH-31.0 MCHC-33.1 RDW-13.9 Plt ___
___ 02:02AM BLOOD WBC-17.6* RBC-3.12* Hgb-9.9* Hct-27.9*
MCV-89 MCH-31.6 MCHC-35.3* RDW-13.9 Plt ___
___ 10:45AM BLOOD WBC-23.6* RBC-4.15* Hgb-13.3* Hct-39.1*
MCV-94 MCH-32.0 MCHC-34.1 RDW-13.9 Plt ___
___ 06:04AM BLOOD Glucose-99 UreaN-28* Creat-0.7 Na-135
K-3.8 Cl-99 HCO3-26 AnGap-14
___ 01:37AM BLOOD Glucose-103* UreaN-36* Creat-0.8 Na-140
K-3.6 Cl-101 HCO3-27 AnGap-16
___ 02:02AM BLOOD Glucose-127* UreaN-11 Creat-1.0 Na-138
K-3.9 Cl-103 HCO3-25 AnGap-14
___ 11:20PM BLOOD Glucose-125* UreaN-13 Creat-1.0 Na-139
K-3.6 Cl-104 HCO3-26 AnGap-13
___ 10:45AM BLOOD UreaN-16 Creat-1.2
___ 02:31AM BLOOD Amylase-112*
___ 01:35AM BLOOD ALT-230* AST-222* AlkPhos-111 TotBili-0.8
___ 02:14PM BLOOD ALT-344* AST-149*
___ 11:20PM BLOOD ALT-431* AST-268* AlkPhos-63 TotBili-0.4
___ 06:04AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.2
___ 01:41AM BLOOD Calcium-8.3* Phos-2.1* Mg-2.0
___ 02:02AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.9
___ 11:20PM BLOOD Calcium-8.8 Phos-3.3 Mg-1.9
___ 02:29AM BLOOD Triglyc-412*
___ 01:35AM BLOOD Triglyc-1389*
___ 01:41AM BLOOD Triglyc-1007*
___ 05:46AM BLOOD Type-ART pO2-78* pCO2-40 pH-7.48*
calTCO2-31* Base XS-5
___ 11:24AM BLOOD Type-ART pO2-76* pCO2-55* pH-7.34*
calTCO2-31* Base XS-1
___ 12:56AM BLOOD Type-ART pO2-74* pCO2-38 pH-7.44
calTCO2-27 Base XS-1
___ 05:04AM BLOOD Type-ART pO2-60* pCO2-38 pH-7.47*
calTCO2-28 Base XS-3
___ 03:58PM BLOOD O2 Sat-90
___ 06:11AM BLOOD Hgb-11.6* calcHCT-35 O2 Sat-89
___ 05:38AM BLOOD freeCa-1.11*
___ 01:13PM BLOOD freeCa-1.03*
IMPRESSION: CXR
Mild increase in residual basal consolidation is due to
increased atelectasis
following tracheal extubation. Upper lungs are entirely clear.
There is no
appreciable pleural abnormality. No pneumothorax. Normal
cardiomediastinal
silhouette. Left PIC line ends low in the ___.
___, MD electronically signed on ___ ___ 5:46
___
IMPRESSION: CTA
1. No evidence of pulmonary embolism or aortic abnormality.
2. Complete bilateral lobe collapse. Progression of right upper
lobe pulmonary
contusions. Few scattered ground-glass densities in the left
upper lobe are
minimally progressed, also compatible with contusions.
3. New small pneumomediastinum.
4. Left-sided chest tube in place without pneumothorax. Small
simple density
right-sided pleural effusion.
5. Similar appearance of hepatic and splenic lacerations with
small
surrounding hemoperitoneum.
6. Previously noted rib fractures are not imaged on this study.
No other
fractures identified.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on
the telephone on ___ at 4:59 ___, 10 minutes after
discovery of the
findings.
CT abd pelvis
IMPRESSION:
1. Liver lacerations involving segments ___, IVb, V, VI and VIII
with injury
to greater than 25% of the liver parenchyma of the right lobe
and evidence of
active extravasation adjacent to the gallbladder fossa.
2. Large splenic laceration with adjacent hematoma with injury
to greater than
greater than 50% of the splenic parenchyma. No evidence of
active
extravasation.
3. The right kidney has a delayed nephrogram and shows multiple
wedge-shaped
hypo enhancing regions concerning for infarcts. Stranding around
the right
renal artery and parenchymal findings are concerning for
vascular injury/
dissection.
4. Focal mesenteric stranding raises concern for underlying
mesenteric injury.
5. Significant perisplenic and perihepatic hematomas tracking
into the pelvis.
6. Possible bilateral pulmonary contusions.
7. Posterior fractures of the right L3 transverse process, the
right twelfth
thoracic rib and a small right rib arising from the L1 vertebral
body.
NOTIFICATION: The findings of this study were communicated to
Dr. ___ by Dr.
___ at by telephone on ___.
BY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN
ATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE
EXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE.
___, MD
___, MD electronically signed on WED ___
9:12 AM
Brief Hospital Course:
ICU course:
Mr. ___ was admitted to the ___ service on ___
following a collision of his scooter with a truck and incurred
injuries of grade IV splenic laceration, grade III/IV liver
laceration, R anterior renal infarct, L3 spine fracture, and
right ___ and 12th rib fractures.
Patient underwent splenic artery couling by interventional
radiology ___ to curtail bleeding from the grade IV
splenic laceration. Heparin was held. On ___, he was
noted to be in respiratory distress and was intubated;
bronchoscopy did not reveal any mucus plugging. A left surgical
chest tube was placed that day for suspected pneumothorax,
likely responsible for the aforementioned respiratory
decompensation. UOP was also noted to be decreased and he was
started on IV fluid boluses as well as continuous drip. An echo
was normal.
Heparin was resumed ___ AM. The chest tube was placed to
water seal. Levaquin was also initiated due to community
acquired pneumonia; attempts the next day to decrease his FiO2
from 50% resulted in desaturations and he was suspected to be
volume overloaded. As a result, he started receiving a lasix
infusion as well as albumin boluses. By the next morning,
___, the patient was autodiuresing and the lasix was
thereafter held. He did have a fever to 101.7 in the afternoon
and cefepime was added for broader antibiotic coverage. He was
also started on tube feeds of Promote with fiber.
Diuresis was promoted with two lasix boluses followed by a lasix
drip again ___. A repeat bronchoscopy was also performed.
Antibiotics were switched to ceftriaxone on ___. Vent was
gradually weaned to pressure support on ___ but the patient
became agitated and was placed back on CMV. ___ was
remarkable for a worsening of the appearance of his chest x-ray,
and a bronch with BAL on ___ demonstrated significant mucus.
The ET tube was advanced and a CT of the abdomen and pelvis was
obtained for fevers; it was negative. The subclavian line was
exchanged.
The patient thereafter reapidly improved. On ___, he was
weaned to PSV. The CVL was removed and a PICC was placed in
its stead. The patient was also started on methadone and
clonidine given his history of narcotic abuse. He did have a
fever to 101.2 but his WBC was decreased from 21 to 17 that day
and so ceftriaxone was continued. The patient passed a SBT on
___ and was successfully extubated. The ceftriaxone was
discontinued the same day. The chest tube was also discontinued
and a post-pull x-ray was non-concerning for pneumothorax.
The patient was successfully weaned from his fentanyl drip on
___ and was tolerating a regular diet and got out of bed to
chair. He was saturating well on 2L nasal canula and was deemed
appropriate for transfer to the floor.
Once to the floor, both the Physical Therapy and Chronic Pain
services were consulted and left recommendations for the patient
to be discharged to rehab.
The pt continued to be stable on the floor. He was transitioned
back to his home medications and tolerated coming off the
methadone well.
On discharge pt is pain free and ready for rehabilitation.
Medications on Admission:
1. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
2. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H
3. Diazepam 5mg Q8h anxiety
4. hydromorphone 4mg tablet ___ Q4H pain
5. gabapentin 300mg TID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain/fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
3. CloniDINE 0.1 mg PO TID
4. Gabapentin 600 mg PO TID
5. Heparin 5000 UNIT SC TID
6. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
7. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H
8. Senna 8.6 mg PO BID constiation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Multitrauma
Grade IV splenic lac s/p splenic coiling by ___
Grade III/IV liver lac
R anterior renal infarct
L3 SP fx, rt.11, 12th rib fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Liver/ Spleen lacerations:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA.
Rib Fractures:
* Your injury caused two rib fractures which can cause severe
pain and subsequently cause you to take shallow breaths because
of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
In addition:
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:
___
|
19863368-DS-13 | 19,863,368 | 26,361,446 | DS | 13 | 2122-08-02 00:00:00 | 2122-08-09 16:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / Ultram / Motrin
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male, scooter vs truck +LOC, multitrauma on ___
with grade IV splenic lac, grade III/IV liver lac, R anterior
renal infarct, L3 spinous process fracture, R 11, 12th rib
fractures s/p splenic artery coiling. Hospitalized from
___. His course included a long ICU stay, ARDS,
pharmacologic paralysis as part of ARDS treatment, PTX s/p chest
tube placement and removal, PNA treated with ceftriaxone. He
also has a history of chronic pain and received methadone that
was d/c'd prior to discharge. He was discharged to rehab on ___
and approximately eight hours later developed abdominal pain
that moved to his left chest and has remained. It is worse with
breathing. Denies cough, dyspnea, fevers, chills, NS, pain
elsewhere.
Past Medical History:
PMH:
- Chronic back pain
PSH:
- R shoulder surgery
- ORIF R ankle ___
- R L5-S1 discectomy
Social History:
___
Family History:
N/C
Physical Exam:
Physical exam: ___: upon admission:
VS: 99.1, 93, 106/76, 20, 100% RA
Gen: diaphoretic
CV: RRR, no MRG; left sided prior chest tube wound c/d/i
Pulm: CTA b/l but decreased breath sounds
Abd: soft, nondistended, nontender
Ext: no edema, no cords, neg ___ sign
Discharge Physical Exam:
VS: 99.2, 83, 114/54, 20, 97%ra
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+/-) BS x 4 quadrants, soft, non tender to palpation,
non-distended. EXTREMITIES: Warm, well perfused, pulses
palpable, (-) edema.
Pertinent Results:
___ 07:30AM BLOOD WBC-11.2* RBC-3.51* Hgb-10.9* Hct-33.2*
MCV-95 MCH-31.1 MCHC-32.9 RDW-16.4* Plt ___
___ 07:49AM BLOOD WBC-13.6* RBC-3.57* Hgb-11.0* Hct-34.6*
MCV-97 MCH-30.9 MCHC-31.9 RDW-16.2* Plt ___
___ 11:12PM BLOOD WBC-12.7* RBC-3.60* Hgb-10.9* Hct-33.2*
MCV-92 MCH-30.3 MCHC-32.8 RDW-15.9* Plt ___
___ 11:12PM BLOOD Neuts-73.6* ___ Monos-6.5 Eos-0.9
Baso-0.4
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD ___ PTT-52.5* ___
___ 11:12PM BLOOD ___ PTT-28.9 ___
___ 08:30AM BLOOD Glucose-99 UreaN-18 Creat-0.8 Na-138
K-4.6 Cl-100 HCO3-26 AnGap-17
___ 03:15PM BLOOD cTropnT-<0.01
___ 08:30AM BLOOD CK-MB-1 cTropnT-<0.01
___ 11:12PM BLOOD cTropnT-<0.01
___ 08:30AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.0
CXR ___:
No acute cardiopulmonary process.
CTA CHEST ___:
1. Extensive bilateral lobar, segmental, and subsegmental
pulmonary emboli with borderline right heart strain.
2. Ground glass opacities in the right upper lobe concerning
for infection.
EKG:
Sinus rhythm. Inferior ST-T wave inversions. This could be
related to
ischemia. Clinical correlation is suggested. Compared to the
previous tracing of ___ the T wave inversions inferiorly
are more prominent. Otherwise, there are no significant
changes.
Brief Hospital Course:
___ s/p polytrauma admitted ___, discharged ___
representing with chest pain found to have PEs on CTA. The
patient was admitted to the Acute Care Service and started on a
heparin drip. PTT was checked every 6 hours with a therapeutic
goal of 60. Hematocrit was monitered twice a day, given his
recent splenic/liver lacerations. The patient was put on
telemetry for close heart rate and oxygen monitoring. His diet
was advanced to regular once there were no signs of bleeding
appreciated. The patient remained hemodynamically stable and
oxygenating comfortably on room air. Coumadin was started on HD1
and continued daily for the hospital stay. INR was checked
daily. The patient was seen by ___ and OT. The recommendations
were that he return to rehab. The patient was medically stable
and INR was 1.6 at time of discharge with heparin drip
therapeutic. The patient was discharged back to rehab on HD5,
with instructions to continue daily INR checks with goal INR ___
and to continue heparin drip until INR therapeutic.
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 back to ___ rehab
on a heparin drip and coumadin. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
. Acetaminophen 500 mg PO Q6H:PRN pain/fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
3. CloniDINE 0.1 mg PO TID
4. Gabapentin 600 mg PO TID
5. Heparin 5000 UNIT SC TID
6. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
7. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H
8. Senna 8.6 mg PO BID constiation
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain, fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
3. Bisacodyl 10 mg PO/PR DAILY
4. CloniDINE 0.1 mg PO TID
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 600 mg PO TID
7. Heparin IV
No Initial Bolus
Initial Infusion Rate: 2150 units/hr
Start: Today - ___, First Dose: 1500
PTT goal 60-80. d/c heparin gtt once INR ___. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
9. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO BID
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
pulmonary emboli
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were re-admitted to the hospital with left sided chest pain.
You underwent a chest x-ray which was normal. Because your
chest pain continued, you underwent a CTA of the chest which
showed pulmonary emboli. You were started on a heparin drip and
coumadin was started. Your vital signs have been stable and you
are preparing for discharge back to the rehabilitation center to
regain your strength.
Followup Instructions:
___
|
19863372-DS-10 | 19,863,372 | 20,142,634 | DS | 10 | 2164-07-13 00:00:00 | 2164-07-13 15:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Decreased vision
Major Surgical or Invasive Procedure:
Lumbar Puncture (___)
History of Present Illness:
The pt is a ___ year-old M w/ no significant PMH who presents
with acute persistent vision loss. Hx obtained from pt at
bedside.
Clinical course/associated symptoms: Pt reports that
approximately 1 month ago he was driving home when he suddenly
experienced a severe "stabbing" pain in his L eye. He had to
hold his L eye due to the pain and let family member drive him
home instead. He states that he is not sure if his vision
changed at this time as he kept his eye closed i/s/o pain. Pain
resolved by end of the day. The next day he noticed that his
visual acuity had decreased, with things appearing "cloudy".
This impairment has been persistent since that time and
gradually worsening to the point that patient is beginning to
have difficulty picking out colors and adequately identifying
objects. Early on in the course of this visual decline, pt saw
black wavy lines move through the ___ his vision in L eye,
as well as a "black streak" of vision loss for approximately 2
days. Pt also noticed some soreness in his L jaw starting a few
weeks ago which has been on and off, although denies any
difficulty or pain with chewing and swallowing. Due to these sx,
pt was seen by ophthalmologist who per report found exam to be
benign (of note, pt's eyes had been dilated night before by
optometrist). He was therefore referred to ___ for further
evaluation.
At time of interview, pt endorsed a mild headache over L
frontotemporal region but denied headaches in the recent past.
No myalgias, scalp tenderness, or fatigue. No diplopia, vertigo,
hearing changes, pain with eye movement, facial numbness, or eye
tearing/redness. No neck pain or trauma. Denies any
scintillations or TVO. No dysarthria, dysphagia or other focal
neurologic deficits. No recent hx of f/c or infectious sx. Of
note, pt is a chronic smoker as described below.
Neurologic and General ROS negative except as noted above
Past Medical History:
None
Social History:
___
Family History:
Sister-MS
___ (unknown cause)
Physical Exam:
=========
ADMISSION
=========
Vitals: T: 97.2 P: 89 BP: 115/78 RR: 18 O2sat: 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, no roughness over L temporal region
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: 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. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 5 to 3mm on R and 32 to 2mm on L,
slightly brisker on L. EOMI without nystagmus. Normal saccades.
VFF. Visual acuity ___ in R eye and ___ in L eye.
Fundoscopic exam revealed no papilledema, exudates, or
hemorrhages. Red color desaturation testing showed objects in L
eye to appear darker.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric. Slight L
sided ptosis.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Slight cupping in LUE on
pronation. No pronator drift bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
or proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, erratic stride with normal
arm swing. Able to walk in tandem with mild difficulty. Romberg
absent.
==============
DISCHARGE EXAM
==============
Essentially unchanged.
Pertinent Results:
Labs:
===============
___ 03:06PM BLOOD WBC-12.1* RBC-5.17 Hgb-14.9 Hct-45.8
MCV-89 MCH-28.8 MCHC-32.5 RDW-13.3 RDWSD-43.5 Plt ___
___ 07:56AM BLOOD WBC-10.1* RBC-4.82 Hgb-13.9 Hct-42.3
MCV-88 MCH-28.8 MCHC-32.9 RDW-13.2 RDWSD-42.5 Plt ___
___ 03:06PM BLOOD ___ PTT-35.7 ___
___ 03:06PM BLOOD Glucose-108* UreaN-10 Creat-0.9 Na-141
K-4.5 Cl-102 HCO3-26 AnGap-13
___ 07:56AM BLOOD Glucose-93 UreaN-12 Creat-0.9 Na-142
K-4.6 Cl-108 HCO3-24 AnGap-10
___ 03:06PM BLOOD ALT-15 AST-16 CK(CPK)-76 AlkPhos-90
TotBili-0.6
___ 03:06PM BLOOD cTropnT-<0.01
___ 03:06PM BLOOD Albumin-4.9 Calcium-9.9 Phos-3.2 Mg-2.4
___ 03:06PM BLOOD CRP-1.1
___ 03:06PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 07:56AM BLOOD WBC-10.1* RBC-4.82 Hgb-13.9 Hct-42.3
MCV-88 MCH-28.8 MCHC-32.9 RDW-13.2 RDWSD-42.5 Plt ___
___ 05:05AM BLOOD WBC-27.8* RBC-4.24* Hgb-12.5* Hct-37.8*
MCV-89 MCH-29.5 MCHC-33.1 RDW-13.2 RDWSD-43.6 Plt ___
___ 07:56AM BLOOD Plt ___
___ 05:05AM BLOOD Plt ___
___ 07:56AM BLOOD Glucose-93 UreaN-12 Creat-0.9 Na-142
K-4.6 Cl-108 HCO3-24 AnGap-10
___ 05:05AM BLOOD Glucose-109* UreaN-17 Creat-0.8 Na-140
K-4.8 Cl-108 HCO3-22 AnGap-10
___ 05:05AM BLOOD MYELIN OLIGODENDROCYTE GLYCOPROTEIN (MOG
IGG)-PND
___ 10:46AM BLOOD NEUROMYELITIS OPTICA
(NMO)/AQUAPORIN-4-IGG CELL-BINDING ASSAY, SERUM-PND
Lumbar Puncture:
=================
___ 10:19AM CEREBROSPINAL FLUID (CSF) TNC-5 RBC-1 Polys-0
___ Macroph-8
___ 10:19AM CEREBROSPINAL FLUID (CSF) TotProt-33
Glucose-100
___ 10:19AM CEREBROSPINAL FLUID (CSF) CSF HOLD-Test
___ 10:19AM CEREBROSPINAL FLUID (CSF) MULTIPLE SCLEROSIS
(MS) PROFILE-PND
Imaging:
=================
- ___ MRI Brain & Orbits w/wo Contrast
MRI BRAIN: There are several FLAIR hyperintense and
predominantly periventricular and deep white matter lesions,
some of which along the corpus callosum and radiating
perpendicularly from it, suggestive of a demyelinating process
such as multiple sclerosis. Some of these lesions demonstrate
hyperintensity on DWI sequence but without definitive ADC
correlate to suggest restricted diffusion. Another FLAIR
hyperintense lesion is seen in the right middle cerebellar
peduncle which demonstrates mild enhancement after contrast
administration (series 13, image 11). There is no evidence of
hemorrhage, edema, masses, mass effect, midline
shiftorinfarction. The ventricles and sulci are normal in
caliber and configuration. There is mild mucosal thickening
along the ethmoid air cells and left maxillary sinus.
MRI ORBITS: Limited evaluation of the orbits due to motion
artifact. Allowing for this limitation, the optic nerves appears
grossly symmetric without abnormal enhancement. The bony orbits
and preseptal soft tissues are normal. The globes are intact and
normal in appearance. The extraocular muscles are uniform in
size and normal in signal. The lacrimal apparatus is normal.
Retrobulbar soft tissues are normal.
IMPRESSION:
1. Several FLAIR hyperintense and predominantly periventricular
and deep white matter lesions, some of which along the corpus
callosum or radiating perpendicularly from it. Additional lesion
in the left middle cerebellar peduncle demonstrating mild
enhancement after contrast administration. Findings suggestive
of an underlying demyelinating process such as multiple
sclerosis.
2. Limited evaluation of the orbits due to motion artifact.
Allowing for this limitation, no evidence of optic neuritis.
- ___ MRI C/T/L-spine w/wo Contrast
(Final read pending. My read: Two non-enhancing T2 hyperintense
lesions in cervical and upper thoracic cord.)
Brief Hospital Course:
Mr. ___ is a ___ year old male with no significant past medical
history who presented with 1 months of rapid-onset left eye
vision loss and several weeks of left eye pain.
#Probable MS
___ exam was notable for loss of left eye visual acuity (___)
and red desaturation. Optic discs did not appear swollen
bilaterally and there is no evidence of retinal lesions. There
was a relative afferent pupillary defect. He also had extremely
brisk reflexes in the bilateral patella (3+ with extremely light
tapping of the tendon), and ___ beats of ankle clonus.
MRI brain with contrast showed multiple T2 hyperintensities, the
majority being pericallosal and periventricular. There was at
least 1 enhancing lesion in the left posterior frontal lobe.
There was no enhancement of the left optic nerve (probably due
to the long duration since symptom-onset). Given these findings
and family history, multiple sclerosis is high on the
differential. His CSF showed 5 WBCs, 1 RBC, 33 Protein, and 100
glucose. CSF sent for MS panel, serum sent for NMO and MOG. Due
to persistent pain, he was treated with a 5 day course of IV
methylprednisolone. He will follow-up in ___ clinic
with Dr. ___.
Whole spine MRI with contrast is pending.
Transitional Issues:
-F/u CSF/serum studies
-Continue outpatient steroid infusion at ___
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Left optic neuritis
Probably multiple sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you had severe visual
loss in your left eye, likely due to a condition called optic
neuritis. This is an inflammatory condition which causes injury
to the optic nerve. The imaging of your brain also showed some
small lesions suggestive of prior, and possibly one current,
inflammatory lesions. Given these findings on MRI, as well as
your optic neuritis, and family history of multiple sclerosis,
we performed a lumbar puncture to look for evidence of MS. ___
lab results are pending and will take up to a week to come back.
Multiple sclerosis is a condition where the immune system
intermittently attacks part of your nerves, specifically the
insulation surrounding long tracts of neurons which communicate
with other parts of the brain. Optic neuritis is commonly
treated with IV steroids, and can result in improvement of
vision. This may be less so because your symptoms started
several weeks ago. Nonetheless, we treated you with IV steroids
due to continued eye pain. You received 3 doses while here, and
we have arranged for you to receive the last 2 doses as an
outpatient, tomorrow and the day after (see below). We have also
arranged a follow-up appointment for you in 10 days with Dr.
___, who is one of our neuro-immunology specialists.
Thank you for allowing us to participate in your care. It was
our pleasure caring for you.
Sincerely,
___ Neurology
Followup Instructions:
___
|
19863976-DS-20 | 19,863,976 | 25,296,182 | DS | 20 | 2127-07-21 00:00:00 | 2127-07-22 07:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
___ - colonoscopy
History of Present Illness:
Mr ___ is a ___ male with pmhx significant for peptic
ulcer disease, Cirrhosis/Hep C and DM who presents with onset of
BRBPR at 1 ___ today after having colonic polypectomy on ___.
Exam notable for incontinence of gross blood per rectum and mild
lower abdominal tenderness.
In the ED, initial vitals: 97.4 110 124/87 16 97% RA. Exam
notable for incontinence of gross blood per rectum and mild
lower abdominal tenderness. Labs notable for Hgb/Hct ___,
ALT/AST 74/101, Tbili 0.4, INR 1.0. He received 2L NS and 80 mg
IV pantoprazole. Nasogastric lavage was negative.ED course
complicated by ~1L clotted blood passed per rectum, prompting
initiation of 2u pRBC transfusion. Hct dropped to 35.8. He was
seen by GI in the ED who plan to do flexible sigmoidoscopy in
the AM.
On transfer, vitals were: 90 129/85 13 98% RA
On arrival to the MICU, vitals were 87 130/104 17 98% RA. He
denies current abdominal pain, lightheadedness, fevers/chills.
Since his polypectomy, stools have been normal without blood. He
reports maybe occasional lightheadedness over the last week. He
denies fevers, chills, abdominal pain recently. Remaining
10-point ROS negative.
Past Medical History:
PUD (healed duodenal ulcers per EGD ca. ___ UGIB ___
GERD; prior H. pylori (+), treated twice)
Hepatitis C
Cirrhosis (Grade II varices and portal gastropathy)
HTN
Diabetes Mellitus
Obesity.
Left total hip replacement.
History of colitis/salmonella enteritis/gastroenteritis.
Hiatal hernia.
Social History:
___
Family History:
Brother passed away of liver failure.
Patient's eldest son passed away of liver failure as well.
Mother passed away, had CVA.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===============================
Vitals: Afebrile 87 130/104 17 98%
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, poor dentition, white exudate over
left buccal mucosa
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, notable physiologic
splitting, 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 stigmata of chronic liver disease
NEURO: CN2-12 grossly intact. Moves all extremities
spontaneously. No asterixis. AAOx3
PHYSICAL EXAM ON DISCHARGE:
===============================
Vitals: Tm 98.7, 64, 131/72, 22, 97% on RA
FSBG: 98-180
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM
NECK: supple
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1/S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: Warm, well perfused, no clubbing, cyanosis or edema
NEURO: Moves all extremities equally.
Pertinent Results:
LABS ON ADMISSION:
======================
___ 04:27PM BLOOD WBC-10.7* RBC-4.81 Hgb-14.0 Hct-41.7
MCV-87 MCH-29.1 MCHC-33.6 RDW-13.4 RDWSD-42.3 Plt ___
___ 04:27PM BLOOD Plt ___
___ 04:27PM BLOOD Glucose-258* UreaN-12 Creat-0.8 Na-131*
K-5.9* Cl-100 HCO3-18* AnGap-19
___ 04:27PM BLOOD ALT-74* AST-101* AlkPhos-106 TotBili-0.4
___ 04:27PM BLOOD Albumin-3.6 Calcium-9.6 Phos-3.1 Mg-1.8
___ 05:06PM BLOOD Hgb-14.6 calcHCT-44
LABS ON DISCHARGE:
======================
___ 06:30AM BLOOD WBC-10.1* RBC-3.89* Hgb-11.6* Hct-34.7*
MCV-89 MCH-29.8 MCHC-33.4 RDW-14.0 RDWSD-44.3 Plt ___
___ 06:30AM BLOOD Glucose-91 UreaN-6 Creat-0.5 Na-137 K-3.7
Cl-102 HCO3-25 AnGap-14
___ 06:30AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.7
___ 06:30AM BLOOD ALT-39 AST-38 AlkPhos-85 TotBili-0.4
MICRO:
========
MRSA screen pending
IMAGING:
=========
CXR ___:
IMPRESSION:
Low lung volumes without overt cardiopulmonary process.
STUDIES:
============
Colonoscopy ___:
Polyp in the transverse colon (polypectomy)
Polyp in the rectum (polypectomy)
No bleeding or major bleeding sources found.
Otherwise normal colonoscopy to cecum
Colonoscopy ___:
Findings:
- Contents: Melena was seen in the whole colon.
- Excavated Lesions A single shallow ulcer was found in the
rectum at the site of previous polypectomy with visible vessel
in the center. It was not actively bleeding. Three endoclips
were successfully applied to the distal rectum for the purpose
of hemostasis.
Impression: Blood in the whole colon
- Ulcer in the rectum (endoclip)
- Otherwise normal colonoscopy to cecum
Recommendations:
- Most likely etiology of BRBPR is post-polypectomy bleeding
from rectal site that has now been treated with clips.
- However, blood was seen throughout the colon. Although this is
likely due to reflux, but patient should continue to be
monitored closely.
CARDIOLOGY:
============
EKG (___): Sinus rhythm. There is a late transition with
small R waves in the anterior leads consistent with possible
myocardial infarction. Non-specific ST-T wave changes. Compared
to the previous tracing of ___ late transition is new.
Brief Hospital Course:
___ male with a PMHx of insulin-dependent DM,
hypertension, recurrent PUD, and HCV/cirrhosis (decompensated
only by varices on propranolol) who presented on ___ with
post-polypectomy painless rectal bleeding, found to have
bleeding from rectal ulcer now s/p clipping with hemostasis.
# Post-polypectomy bleeding
He passed 1L of blood per rectum in the ED with a drop in Hb
from 140->12 and associated tachcyardia so was given 1U pRBC and
admitted to the ICU. Nasogastric lavage negative. He underwent
colonocospy in the ICU which showed blood throughout the colon
and bleeding from the site of the polypectomy in the rectum with
underlying visible vessel. This was clipped with good
hemostasis. He has received 1U pRBC total, but he has remained
hemodynamically stable and was restarted on clears. That night,
he had a small bloody BM with Hgb drop from 12 to 10.2. After
that, his subsequent BMs were brown, and his H/H remained stable
without further bleeding. His diet was advanced and he was
restarted on his beta-blocker and anti-hypertensives. He was
seen by ___ who recommended rehab.
# EtOH/HCV Cirrhosis
Decompensated in the past by portal hypertension with grade II
varices without bleeding, is on propranolol. No signs of
decompensation currently. MELD score on admission 8. Baseline
AST/ALT in ___. MELD today 7. Held propranolol in setting of
possible hemodynamic instability and restarted on discharge.
Ursodiol continued.
# Leukocytosis: WBC elevated to 11.8 but resolved, most likely
reactive. No localizing signs of infection.
# METABOLIC ACIDOSIS:
Borderline anion gap. lactate normal. ___ be compensatory
secondary to tachypnea related to cirrhosis. Pt not appearing to
have diarrhea. Rapidly resolved.
CHRONIC ISSUES:
# Type II Insulin-Dependent
Followed at ___ on oral agents and insulin. Last A1C 9.6%.
Blood sugars were controlled on HISS while hospitalized.
Restarted home glipizide and insulin once on regular diet (30U
Lantus qAM and 12U Humalog prior to dinner)
# Hypertension: Held lisinopril and HCTZ in setting of bleeding
and restarted on day of discharge
# Glaucoma: Continued eye drops
# Transitional issues:
- Please monitor Hgb/Hct qWeek - discharge Hgb/Hct 11.6/34.7
- Please monitor potassium level q2-3 days and consider daily K+
supplements if needed.
- Full code
- Communication: HCP: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Propranolol 20 mg PO BID
3. Docusate Sodium 100 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Ursodiol 250 mg PO TID
6. Pantoprazole 40 mg PO Q24H
7. GlipiZIDE XL 10 mg PO DAILY
8. Hydrochlorothiazide 25 mg PO DAILY
9. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
10. Travatan Z (travoprost) 0.004 % ophthalmic QHS
11. Glargine 30 Units Breakfast
Humalog 12 Units Dinner
Discharge Medications:
1. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
2. Glargine 30 Units Breakfast
Humalog 12 Units Dinner
3. Pantoprazole 40 mg PO Q24H
4. Ursodiol 250 mg PO TID
5. Docusate Sodium 100 mg PO DAILY
6. GlipiZIDE XL 10 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Propranolol 20 mg PO BID
11. Travatan Z (travoprost) 0.004 % ophthalmic QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Post-polypectomy bleeding
Acute blood loss anemia
Secondary:
Insulin-dependent diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care at ___. You were
admitted because of bleeding from your rectum. You required 1
unit of blood cells. You underwent a colonoscopy in the ICU
which showed an ulcer with an underlying vessel in your rectum.
A clip was placed with good results. You had a additional
episode of bleeding but none after that and your blood counts
remained stable. You were evaluated by our physical therapists,
who recommended discharge to rehab.
Please follow-up with your primary care physician as listed
below.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
19864120-DS-18 | 19,864,120 | 20,281,605 | DS | 18 | 2147-03-11 00:00:00 | 2147-03-13 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:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ hx CHF, HTN, DM, hypercholesterolemia, transferred from
___ for hypertensive emergency.
Per report, she went to lie down at midnight and experienced
shortness of breath. EMS was called and found her to be
hypertensive and short of breath, RR 30's with bibasilar
crackles and lower extremities edema.
She was brought to ___ where CXR was c/w pulmonary edema.
OSH EKG reportedly showed sinus tachycardia with no acute
ischemic changes. She reportedly had bedside ultrasound at OSH
which showed EF ___. Trop was elevated at 0.04. FSBGs were
mid ___ on arrival. BP was noted to be 260/140.
She received ASA 325mg, Humalog 8units. She was placed on IV
nitroglycerin for management of hypertensive emergency. (At time
of transfer, nitroglycerin was at 80 mcg/min.) She was also
started on BiPAP, and subsequently weaned to 4L nasal cannula.
She was given 40mg IV Lasix with 1.2L of UOP.
On arrival, patient initially appeared comfortable off BiPAP.
Denied chest pain. She was noted to have additional UOP 400cc on
arrival. FSBG was 381. EKG showed sinus tachycardia, with
lateral TWI new from ___.
She was transferred to the MICU for further management.
At time of transfer, vital signs were 98.1 97 163/85 17
100%(4LNC).
On arrival to the MICU, patient denies having any pain. Unable
to elicit full ROS including assessment for vision change,
headache given language barrier.
Also of note, at last outpatient appointment on ___,
patient was noted to have BP 220/80. She had lower extremity
edema which appeared to be worse on Norvasc. She had not been
compliant with diuretics because of frequent urination.
Past Medical History:
CHF
HTN
DM
Hypercholesterolemia
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION EXAM:Vitals: 98.6 99 188/94 98 on 2L
GENERAL: Alert, no acute distress, lying comfortably, sleeping
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
NECK: supple, JVP not elevated, no LAD
LUNGS: mostly clear, with diminished sounds over bilateral bases
with fine crackles
CV: slightly tachy, otherwise, nl rhythm, normal S1 S2, without
appreciable 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; 1+
pitting edema up bilateral legs to knees
NEURO: alert, unable to assess orientation; unable to say where
she is
DISCHARGE EXAM:
VS: Tm 99.4 BP 139/61 HR 72 RR 18 Sa02 98% RA
I/O: --/1200 weight: 59.4 <- 58.8 kg <- 63.2 kg; dry weight =
55? (recorded in Atrius in ___. FSGs ___
General: well appearing middle aged woman in NAD
HEENT: poor dentition, dry mm
Neck: JVD to approx. 6 cm-8 cm
CV: RRR, no m/r/g, normal s1,s2
Lungs: R > L with light rales at base, no wheeze or rhonchi
Abdomen: soft, NT/ND, BS+
GU: no foley
Ext: trace edema bilaterally
Neuro: alert and oriented, good attention, CN2-12 intact
Pertinent Results:
ADMISSION LABS:
==============
___ 03:55AM BLOOD WBC-9.1 RBC-3.24* Hgb-9.0*# Hct-28.4*#
MCV-88 MCH-27.8 MCHC-31.7* RDW-14.7 RDWSD-46.8* Plt ___
___ 03:55AM BLOOD Neuts-76.5* Lymphs-18.9* Monos-3.7*
Eos-0.3* Baso-0.3 Im ___ AbsNeut-6.93* AbsLymp-1.71
AbsMono-0.34 AbsEos-0.03* AbsBaso-0.03
___ 03:55AM BLOOD ___ PTT-33.3 ___
___ 07:26AM BLOOD Ret Aut-2.6* Abs Ret-0.08
___ 03:55AM BLOOD Glucose-373* UreaN-19 Creat-1.0 Na-142
K-3.4 Cl-98 HCO3-34* AnGap-13
___ 07:26AM BLOOD ALT-27 AST-33 LD(LDH)-330* CK(CPK)-302*
AlkPhos-101 TotBili-0.4
___ 03:55AM BLOOD proBNP-3583*
___ 03:55AM BLOOD cTropnT-0.06*
___ 03:55AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.8
___ 04:02AM BLOOD ___ pO2-34* pCO2-62* pH-7.42
calTCO2-42* Base XS-12
___ 03:58AM BLOOD Lactate-2.8*
___ 04:00AM URINE Color-Straw Appear-Clear Sp ___
___ 04:00AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 04:00AM URINE RBC-5* WBC-3 Bacteri-FEW Yeast-NONE
Epi-<1
MICROBIOLOGY:
=============
___ BLOOD CULTURE - _negative
STUDIES:
=======
___ ECHO:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild global left ventricular hypokinesis (LVEF
= 45 %). Global longitudinal strain is markedly depressed (-9%)
suggestive of restrictive physiology. 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 is hypertrophied. Right ventricular
chamber size is normal with normal free wall contractility. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
Echocardiographic signs of tamponade may be absent in the
presence of elevated right sided pressures.
___ CXR: IMPRESSION:
Bilateral pleural effusions and cardiomegaly are moderate,
however improved from the prior examination.
DISCHARGE LABS
==============
___ 07:10AM BLOOD WBC-7.5 RBC-2.64* Hgb-7.4* Hct-24.0*
MCV-91 MCH-28.0 MCHC-30.8* RDW-16.0* RDWSD-51.6* Plt ___
___ 07:10AM BLOOD Glucose-107* UreaN-23* Creat-1.1 Na-141
K-4.6 Cl-102 HCO3-32 AnGap-12
___ 07:10AM BLOOD Calcium-8.9 Phos-4.8* Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ yo female with a history of
uncontrolled DM2, uncontrolled HTN who presented with dyspnea
and was found to have hypertensive emergency, new diagnosis of
CHF, and ___
#Hypertensive emergency c/b heart failure exacerbation: patient
initially presented to an OSH for SOB. There, her systolic blood
pressures were reportedly around 260s, and she was placed on a
nitroglycerin drip. Her CXR was concerning for pulmonary edema,
and bedside echo was concerning for EF around ___. She was
also placed on lasix for concern for new HF and pleural
effusion. She required BiPAP for her SOB but was not intubated.
She was subsequently transferred to ___, where she was
admitted to the ICU. She was weaned off BIPAP to NC, and
nitroglycerin gtt was weaned as well. Her blood pressures were
controlled with labetalol, valsartan, and the lasix she received
for diuresis. She was diuresed with IV lasix 80, transitioning
to 80 mg po by discharge. She did have a formal TTE that showed
EF 40-45%, moderate pulmonary artery hypertension, mild LV
concentric hypertrophy, and restrictive physiology with
depressed global longitudinal strain. EKG showing no evidence of
ischemia to suggest ischemic etiology of new heart failure.
#HFpEF with restrictive physiology: patient's
hypoxemic/hypercarbic respiratory distress, BNP 35___ at
admission, and pulmonary edema were concerning for HF
exacerbation as above. TTE was consistent with EF 40-45% and was
also notable for restrictive physiology as stated above. She may
have had HFpEF prior to this admission, although these echo
findings are new and are likely the result of hypertensive
emergency. As above, she was placed on aspirin 81, pravastatin
80 mg qHS, labetalol, valsartan, lasix 80 mg
#T2DM: Her blood sugars were controlled with NPH, which was
transitioned to glargine by the time of discharge. Of note, she
was on much higher dose of glargine (36U) in outpatient setting
than were required inpatient. The suspicion is that she has been
noncompliant with glargine as an outpatient and that her true
insulin requirements are lower. This explains her complaint of
hypoglycemia when she takes her insulin at home.
#Troponinemia: Patient noted to have troponins to 0.___hanges on EKG concerning for STEMI. This most likely
represents demand in setting of HF exacerbation, hypertensive
urgency, and ___.
She was continued on aspirin, statin, BB, ___ as above.
#Acute renal failure: Baseline Cr is 0.6. She presented with
creatinine to 1.0. This was felt to be due to hypertensive
emergency versus complication of poorly controlled diabetes. Her
___ was initially held but restarted prior to discharge.
#Anemia: Hgb 12.1 four months prior to admission, 9.0 on
presentation. Fe studies consistent with ACD most likely in
setting of DM and HTN.
#Microscopic hematuria: found on U/A, most likely secondary to
pyuria, urine cultures negative. This warrants repeat in the
outpatient setting.
Given a long history of medication noncompliance, she was set up
with ___ to help with medications, fingersticks, and BP
surveillance at least for the initial weeks following discharge.
TRANSITIONAL ISSUES:
- Discharge weight: 59.4 kg, 131 lbs
- Patient noted to have microscopic hematuria during admission.
This warrants repeat in the outpatient setting
- As above, patient required 12U glargine for blood glucose
control. Her glargine dosing was 36U as an outpatient. Most
likely, her insulin dosing was increased during office visit due
to elevated A1c and uncontrolled FSGs. However, it is suspected
that she has not actually been taking any glargine as
prescribed.
- Patient noted to have mild anemia with Fe studies concerning
for anemia of chronic disease
- Consider cardiology or endocrinology referral in the future if
her diabetes and CHF are difficult to control
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Losartan Potassium 50 mg PO DAILY
2. Labetalol 100 mg PO BID
3. Amlodipine 5 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
5. Furosemide 40 mg PO ONCE:PRN leg edema
6. Glargine Unknown Dose
7. Pravastatin 80 mg PO QPM
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Furosemide 80 mg PO DAILY
RX *furosemide 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
3. Labetalol 400 mg PO TID
RX *labetalol 200 mg 2 tablet(s) by mouth three times a day Disp
#*180 Tablet Refills:*0
4. Losartan Potassium 50 mg PO DAILY
5. Pravastatin 80 mg PO QPM
6. Glargine 12 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 12 Units before
BKFT; Disp #*1 Vial Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Hypertensive emergency
Acute diastolic congestive heart failure
Diabetes Mellitus
Acute Renal Failure
Secondary:
Anemia
Microscopic Hematuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ due to
shortness of breath. You initially were evaluated at another
hospital. There, you had dangerously high blood pressures and
you required a mask to help you breathe. The team at the other
hospital was also concerned that your heart was failing because
of these high blood pressures. You also had blood sugars that
were very high. For treatment of all of these things, you were
transferred to ___. Here, you were initially in the
ICU, and we were able to get your blood pressures down with
medication. Your heart does show some "heart failure" meaning
that it is unable to pump blood forward to the rest of your body
as well as it should. This causes fluid to back up in your lungs
and can cause shortness of breath like you experienced.
During your hospital stay, we got your blood pressures under
control, we took off some of this fluid in your lungs via
medication, and we also got your blood sugar under better
control.
Given the issues with taking medications in the past, we revised
your medication list so that you are on the fewest medications
possible. It is very important that you follow up with the
appointments we have arranged and take the medications as
prescribed so that we can get your medical problems under better
control. Because of your heart failure, there is a risk that you
will have fluid overload again. To monitor for this, please
weight yourself each morning and call your doctor if your weight
goes up more than 3 pounds (your discharge weight was 131 lbs or
59.4 kg).
It was a pleasure taking care of you at ___ ___
___.
Sincerely,
Your care team
Followup Instructions:
___
|
19864120-DS-19 | 19,864,120 | 21,830,018 | DS | 19 | 2147-04-07 00:00:00 | 2147-04-07 20:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
hypertension, visual changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a PMH significant
for hypertension (with h/o recent admission hypertensive
emergency), as well as DM-II who presented from clinic with
hypertension.
She states that her blood pressure as been labile for quite
some review. She states that she has blurry vision
intermittently for the last two months, worse over the past 3
days. She also reports some sugars labile. She also has
generalized weakness.
She was evaluated in clinic today, by her optometrist, whose
note does document severe hypertension, though no retinal
hemorrhages or evidence of papilledema.
In the ED, initial vitals were: pain ___, BP 202/96 (131), HR
66, R 14, SpO2 100%/NC
- Labs were notable for: WBC 6.4, Hb 9.8, K 3.1, BUN 21, trop-T
0.02, CK-MB 4, ALT 53: AST 34, proBNP 4069
- Patient was given: labetalol 20 mg IV x2, 400 mg PO
labetalolol, 40 mEq KCl and 20 mg IV furosemide
- CT head showed no acute intracranial process
On the floor, she reports feeling well.
Past Medical History:
CHF
HTN
DM
Hypercholesterolemia
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: T 98.5 BP 190/82 HR 60 R 16 SpO2 96%/2L NC FSG 153
weight 56.2 kg
General: Alert, oriented, no acute distress, comfortable,
laying flat in bed, on 2L NC
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, difficult to appreciate iJVD; prominent eJVD to
mid-neck at 30 degrees
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Crackles bilaterally from the bases to ___ up
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ DP pulses, no clubbing or
cyanosis; 1+ edema in bilateral LEs to knee
Neuro: face symmetric, moving all extremities well, oriented
x4, no obvious focal deficits
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 98.7 148-158/60-70 54-69 18 99RA
Wt. ? <-- 54.3 (___) <-- 53.8 <-- 56.2
I/O's: 120/BRP
General: Alert, oriented, no acute distress, comfortable, laying
flat in bed
Neck: Supple, JVP lower ___ of neck when laying flat
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Diminished breath sounds in bilateral lung bases, overall
clear with a few crackles at R base that clear with inspiration
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ DP pulses, no clubbing or cyanosis;
no edema
Pertinent Results:
ADMISSION LABS:
===============
___ 06:37PM BLOOD WBC-6.4 RBC-3.46*# Hgb-9.8*# Hct-30.5*#
MCV-88 MCH-28.3 MCHC-32.1 RDW-14.6 RDWSD-46.5* Plt ___
___ 06:37PM BLOOD ___ PTT-33.9 ___
___ 06:37PM BLOOD Glucose-110* UreaN-21* Creat-0.9 Na-141
K-3.1* Cl-101 HCO3-28 AnGap-15
___ 06:37PM BLOOD ALT-53* AST-34 CK(CPK)-199 AlkPhos-240*
TotBili-0.3
___ 06:37PM BLOOD CK-MB-4 proBNP-4069*
___ 06:37PM BLOOD cTropnT-0.02*
___ 06:37PM BLOOD Albumin-3.6 Calcium-9.7 Phos-3.8 Mg-2.0
___ 08:30AM BLOOD %HbA1c-7.8* eAG-177*
___ 07:00AM BLOOD TSH-2.8
DISCHARGE LABS:
===============
___ 08:32AM BLOOD WBC-5.8 RBC-3.10* Hgb-8.8* Hct-27.9*
MCV-90 MCH-28.4 MCHC-31.5* RDW-14.5 RDWSD-47.5* Plt ___
___ 08:32AM BLOOD Glucose-79 UreaN-36* Creat-1.1 Na-141
K-4.5 Cl-103 HCO3-29 AnGap-14
___ 06:37PM BLOOD ALT-53* AST-34 CK(CPK)-199 AlkPhos-240*
TotBili-0.3
___ 08:32AM BLOOD TotProt-5.9* Calcium-9.1 Phos-5.7* Mg-2.5
___ 08:30AM BLOOD %HbA1c-7.8* eAG-177*
___ 08:30AM BLOOD calTIBC-360 Ferritn-62 TRF-277
IMAGING:
========
CT HEAD ___
No acute intracranial process.
CXR ___
Layering bilateral effusions with associated patchy bibasilar
airspace disease likely reflecting compressive atelectasis.
Persistent mild pulmonary and interstitial edema. Cardiac and
mediastinal contours are likely unchanged. Lung volumes remain
low. No pneumothorax.
RENAL US ___
1. Mildly elevated intrarenal resistive indices bilaterally. No
evidence of renal artery stenosis.
2. A large right pleural effusion is incidentally noted.
Brief Hospital Course:
___ PMH of HTN, ___ who presented with recent admission for
hypertensive emergency presented from clinic with hypertensive
urgency.
Investigations/Interventions:
================================================
1. Hypertensive Urgency: Patient presented from clinic with
blood pressure 202/96. Creatinine at baseline. Denied vision
changes and had no nausea or vomiting. She was noted to have
acutely decompensated heart failure on based on exam and CXR
consistent with volume overload. Initially treated with IV
labetalol, then PO regimen uptitrated as needed to include
Amlodipine 10 mg daily, Valsartan 320 mg daily, Carvedilol 25 mg
bid, Chlorthalidone 25mg daily. Over the last 12 hours of
hospitalization patient's SBP remained in the 140's to 150's.
Secondary causes of HTN worked up include TSH which was normal
and renal U/S did not show e/o renal artery stenosis. Remaining
w/u deferred to outpatient setting with next apt <1 week after
discharge. Pt will need CHEM in 2 weeks ___ to ensure that
no electrolyte abnormalities occurred ___ use.
2. Acute on chronic diastolic congestive heart faiure: Volume
overloaded on presentation likely ___ uncontrolled HTN, so
diuresed with IV->PO Lasix initially. Cr increased from 0.8 to
1.2 so further diuresis held temporarily and Cr improved to 1.1.
While patient noted to have pleural effusions, did not have
peripheral edema, and was maintaining even IsOs without
diuretic. Accordingly, we felt that decompensation was ___
uncontrolled afterload, and with adequate BP control, would
improve without aggressive outpatient diuresis. That said, was
given Chlorthalidone as one of her anti-HTN medications. Volume
status will need to be re-evaluated as an outpatient and
diuresis initiated prn. (Inpatient weight after diuresis ~54kg).
3. ___ on CKD: Patient has a baseline Cr of near 0.6 as ___, which increased to 1.2 as per Atrius records in ___ and
has remained near since. ___ be ___ worsening CKD or ___
___ as outpatient. UA significant for proteinuria. Renal U/S
did not show e/o renal artery stenosis, but did have mildly
elevated intrarenal resistive indices bilaterally. Given
increase in Cr, and difficulty to control HTN, pt would benefit
from referral to outpatient nephrologist.
4. Possible iron deficiency anemia -- patient's Hb was low, as
it had been pre-admission, and it remained stable. 8.8 on the
day of discharge, normocytic. She had no history of melena, no
signs of blood loss. Hemoccults were not able to be sent
pre-discharge, and should be considered in the ambulatory
setting. Her iron studies were: iron 74, transferrin 274 (both
normal). Ferritin 62. These findings could be consistent with
iron deficiency. We recommend more evaluation as an outpatient.
Transitional Issues:
===============================================
1. Pt will need close follow up to ensure adherence to
outpatient anti-hypertensive and diabetes treatment regimens
2. Pt would benefit from outpatient w/u of secondary causes of
HTN
3. Pt needs BP checked at next outpatient appointment and BP
meds adjusted as needed. Also needs CHEM checked in 2 weeks
(___) to ensure no electrolyte abnormalities with
chlorthalidone.
4. Pt needs volume status assessed at next outpatient
appointment, with consideration of diuretic if needed (Inpatient
weight ~54kg).
5. Pt would benefit from outpatient nephrology evaluation to w/u
new/worsening CKD.
6. Pt would benefit from outpatient workup of her anemia,
including stool guaiac testing, given elevated BUN out of
proportion to Cr.
# CODE: Full (confirmed)
# CONTACT: husband, ___, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Furosemide 120 mg PO DAILY
3. Labetalol 400 mg PO TID
4. Pravastatin 80 mg PO QPM
5. Valsartan 320 mg PO DAILY
6. Glargine 12 Units Breakfast
7. Polyethylene Glycol 17 g PO DAILY
8. Amlodipine 5 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:*0
2. Aspirin 81 mg PO DAILY
3. Glargine 12 Units Breakfast
4. Polyethylene Glycol 17 g PO DAILY
5. Pravastatin 80 mg PO QPM
6. Valsartan 320 mg PO DAILY
RX *valsartan 320 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
8. Chlorthalidone 25 mg PO DAILY
RX *chlorthalidone 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Hypertensive Urgency
Acute on chronic decompensated diastolic congestive heart
failure
Secondary Diagnosis
Anemia
Type II diabetes
Refractory hypertension
Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at ___
___. As you know, you were admitted for VERY high
blood pressure which was causing fluid backup in your lungs.
Fortunately, we were able to lower your blood pressure to a
normal level by changing your drugs. It is VERY important that
you take these medications in order to prevent being
hospitalized. Please see the medication sheet for details.
You should weigh yourself every day. If your weight increases by
more than 3 pounds in 1 day or 5 pounds in 1 week please call
your doctor as you may need an adjustment in your medications.
It was a pleasure taking care of you!
Your ___ team
Followup Instructions:
___
|
19864484-DS-4 | 19,864,484 | 21,598,207 | DS | 4 | 2161-09-30 00:00:00 | 2161-09-30 10:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of alcohol abuse who presents for altered
mental status on ___.
Per report, she was on ___ at ___
___ for alcohol detox. They felt that she was acting
bizarre today so they referred her to ___. The patient seemed
to be confabulating and she was confident stating that she is to
be at a play and came from a place where they are working on a
project. She stated that she has not wearing shoes that she has
no keys or car or telephone. She wished to have those so she can
go to the play.
In the ED, initial vitals: 36.7 88 153/100 16 97% RA
- Exam notable for: AOx1 (self), hallucinating
- Labs notable for: Na 131, negative serum/urine tox, UA with
mod leuks, mod blood, 11 WBC, few bacteria, 5 epi
- Imaging notable for: normal NCHCT, normal CXR
- Patient was given:
___ 21:47 PO Multivitamins 1 TAB
___ 21:47 PO FoLIC Acid 1 mg
___ 21:55 PO Lorazepam 1 mg
___ 22:11 IV Thiamine 500 mg
- Vitals prior to transfer: 97.8 92 156/116 18 99% RA
On arrival to the floor, pt says that her last drink was 8 days
ago. She was binging for four to five days before presenting for
detox. She says that she was at detox receiving Ativan. She does
not agree with the "12 step method." Since being at the detox
center, she started hearing voices about a cousin who passed
away. These voices would keep her up at night. She says that she
has not been sleeping for the past six days and that is why she
is "out of it." Throughout our conversation, she was falling
asleep and often answering questions inappropriately. She says
that she may have had alcohol withdrawal seizures in the past
but is not sure.
Past Medical History:
She is unable to answer this question appropriately.
Alcohol abuse
HTN
Social History:
___
Family History:
Mother and father with alcohol abuse
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.4 171 / 134 84 18 94 RA
General: Alert, not oriented to place, oriented to year and
person
HEENT: Sclera anicteric, MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no cyanosis or edema, no asterixis,
no tremor with hands outstretched
Skin: Without rashes or lesions
Neuro: No nystagmus. CN ___ intact. Moving all four
extremities spontaneously.
DISCHARGE PHYSICAL EXAM
VS: 98.1
PO 100 / 61 80 16 96 RA
GEN: well appearing, no acute distress
HEENT: no scleral icterus
CV: rrr, no m/r/g
PULM: lungs clear bilaterallyl
ABD: soft, NT/ND +bs
EXT: warm, no edema
NEURO: No nystagmus. CN ___ intact. Moving all four extremities
spontaneously.
PSYCH: Sleepy, but answers questions. Oriented to person, place
(___), not time. Tangential when telling stories. Judgment
and insight not intact.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:30PM BLOOD WBC-8.4 RBC-4.34 Hgb-12.3 Hct-36.0 MCV-83
MCH-28.3 MCHC-34.2 RDW-13.7 RDWSD-39.9 Plt ___
___ 04:30PM BLOOD Neuts-56.8 ___ Monos-10.7 Eos-3.3
Baso-0.4 Im ___ AbsNeut-4.76 AbsLymp-2.40 AbsMono-0.90*
AbsEos-0.28 AbsBaso-0.03
___ 04:30PM BLOOD Glucose-115* UreaN-16 Creat-0.6 Na-131*
K-3.9 Cl-90* HCO3-27 AnGap-18
___ 04:30PM BLOOD ALT-63* AST-68* AlkPhos-50 TotBili-0.7
___ 04:30PM BLOOD Albumin-4.5
___ 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
================
___ 06:10AM BLOOD WBC-7.1 RBC-4.24 Hgb-11.4 Hct-35.6 MCV-84
MCH-26.9 MCHC-32.0 RDW-14.0 RDWSD-41.1 Plt ___
___ 06:10AM BLOOD Glucose-98 UreaN-15 Creat-0.6 Na-139
K-3.6 Cl-94* HCO3-29 AnGap-20
___ 06:10AM BLOOD ALT-59* AST-45* AlkPhos-48 TotBili-0.6
___ 06:10AM BLOOD Albumin-3.9 Calcium-9.4 Phos-5.6* Mg-2.2
___ 06:10AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative HAV Ab-Negative
___ 06:10AM BLOOD HCV Ab-Negative
IMAGING:
=========
CXR ___
IMPRESSION:
No acute cardiopulmonary process.
CT head w/o contrast ___:
IMPRESSION:
Normal study.
Brief Hospital Course:
___ with history of alcohol abuse who was sectioned 12 prior to
admission at ___. At that point she
was sectioned 12 on ___ (signed at 9AM), transferred to ___
with acute confusion and hypertension.
# ACUTE ENCEPHALPATHY: Initially, differentia diagnosis included
Wernicke encephalopathy, hospital delirium, infection, or
primary psychiatric disorder. She has no evidence of infection,
U/A was clear. The most likely etiology is underlying
psychiatric disorder, complicated by receiving high doses of
Haldol & Ativan, which made her somnolent. Her tox screen was
negative, pointing against ingetion. Na of 131 is unlikely to
cause this degree of confusion. No current evidence of
withdrawal and given that last drink was over one week ago,
unlikely. Recommend returning back to psychiatric facility for
management of primary psychiatric disorder without underlying
additional medical illness.
# ETOH ABUSE: Patient was monitored on ___, and did not score
or need benzo's on the floor. She received thiamine, folate, and
multivitamin and was counseled to stop drinking.
# Hyponatremia - Given concurrent hypochloremia, possibly due to
decreased PO intake. Received a fluid bolus, and it resolved.
# Hypertension: Continue home Labetalol 200mg BID,
Hydrochlorothiazide 25mg daily.
# Transaminitis-Likely secondary to alcohol use. Hepatitis
serologies negative for Hep A, hep B, Hep C.
# Bacterial vaginitis: Topical metronidazole ___.
TRANSITIONAL ISSUES:
======================
- Patient needs vaccination against hepatitis B.
- Encourage ETOH cessation
- Recommend transfer back to psychiatric facility for ongoing
management of psychiatric illness including hallucinations
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Thiamine 100 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Labetalol 200 mg PO BID
6. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Medications:
1. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Labetalol 200 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 40 mg PO DAILY
7. RisperiDONE 2 mg PO DAILY
8. ValACYclovir 500 mg PO DAILY:PRN herpes
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Altered mental status
Secondary diagnosis: Bipolar disorder, alcohol use disorder,
transaminitis, hypertension
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 ___ from your psychiatric facility
because you became confused. We made sure you did not have an
infection and that you were not withdrawing from alcohol. After
you got some rest, you began to feel better. You will go to a
psychiatric facility for further treatment of your bipolar
disorder and your hallucinations.
You also had an elevated blood pressure. When we restarted your
home Labetalol and Hydrochlorothiazide. Your blood pressure
improved.
Please continue all of your home medications. It was a pleasure
taking care of you.
Your ___ Team
Followup Instructions:
___
|
19864589-DS-5 | 19,864,589 | 26,439,685 | DS | 5 | 2146-01-11 00:00:00 | 2146-01-15 18:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
codeine
Attending: ___
Chief Complaint:
left sided weakness, aphasia
Major Surgical or Invasive Procedure:
___- Diagnostic cerebral angio w/ R groin access, vessels
patent
___- ___ CFA pseudoaneurysm embolization with thrombin
History of Present Illness:
Ms. ___ is a ___ left handed woman
with past medical history of prior strokes, with minimal
baseline deficits (difficulty opening jars), atrial fibrillation
on Coumadin who presented with acute onset left sided weakness
and problems with speech. She was visiting her cousin in ___
(she lives in ___ when she had acute left sided weakness,
difficulty speaking and understanding people speaking to her.
The patient was last known well at 3:30 ___. She was taken to
___ where she was noted to have a stroke scale
of 12 due to left upper and lower extremity weakness, and
attention, aphasia, and left facial droop. Noncon head CT was
done at outside hospital which showed no evidence of acute
infarct or bleeding but question of a thrombus in the ___
territory. Patient's INR was 1.48. Patient was given TPA at
1729 and was transferred to ___
for possible endovascular intervention. Patient went to ___
where the vessels were found to be open and patient was
subsequently transferred to our neurology ICU for further
monitoring.
Past Medical History:
Atrial fibrillation on coumadin
Prior CVAs- she was told these were due to afib
Anxiety
COPD
Anxiety
GERD
Social History:
___
Family History:
No prior history of CVAs in her family, no family history of
seizures. Mother and father with "heart disease".
Physical Exam:
ADMISSION EXAM:
===============
General: Tearful, anxious
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to self but not here.
Able to follow midline commands. Mild aphasia as patient unable
to fluently explain cookie jar picture. Patient able to repeat.
Neglecting left side
- Cranial Nerves: PERRL 3->2 brisk. Patient has gaze
preference
to the right difficult to cross midline but patient was able to
with multiple attempts. EOMI, no nystagmus. ___ without
deficits to light touch bilaterally. Left facial droop of the
lower face. Hearing intact to finger rub bilaterally. .
- Motor: Normal bulk and tone.
[___]
L 3 3 3 3 3 3 2 2 2 2 2 2
R 5 5 5 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
- Sensory: Appears to have decreased sensation to light touch
on
the left upper and lower extremity
- Coordination: Deferred
- Gait: Deferred
DISCHARGE PHYSICAL EXAM:
========================
General: ___ woman, sitting in bed comfortably,
becomes very upset and starts crying with conversation
HEENT: normocephalic, nontraumatic
Neck: supple, no bruits
CV: RRR, no murmurs
Lungs: non labored breathing
Abdomen: large, soft, tender at R groin site with ecchymosis
around groin extending past demarcated areas, + pulses
Ext: +femoral and distal pulses to palpation. ++tender to
palpation at R groin
Skin: right groin w/ bandage cdi, light ecchymosis
Neurologic Examination:
- Mental status: Awake, alert, oriented to self, date and this
hospital. Able to follow midline commands on right but limited
by
weakness on left. No word finding difficulty appreciated. Seems
to lose train of thought.
- Cranial Nerves: PERRL 3->2 brisk. No gaze preference. EOMI,
no nystagmus. Left facial droop of the lower face. Hearing
intact
to finger rub bilaterally.
- Motor: Normal bulk and tone. Exam effort dependent.
[___]
L 4+ 4+ 4+ 4 4 4 4 3 3 3 3 3
R 5 5 5 5 5 5 5 5 5 5 5 5
*weakness of left upper and lower extremity seemed to be
transient, when tested with quick motions patient would
initially
give good effort then extremity would fall.
Positive hoover sign.
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 2+
R 2+ 2+ 2+ 2+ 2+
- Abdominal reflexes present and symmetric
- Toes: neutral on left, up on right
- Sensory: decreased sensation to light touch on
the left upper and lower extremity as well as lower half of left
face.
- Coordination: intact finger to nose on right, poor effort on
left
- Gait: Deferred
Pertinent Results:
ADMISSION LABS:
===============
___ 09:15AM BLOOD ___
___ Plt ___
___ 12:32AM BLOOD ___
___ Plt ___
___ 12:32AM BLOOD ___ ___
___ 12:32AM BLOOD ___
___
___ 12:32AM BLOOD ___
IMAGING:
========
___ CT HEAD AND NECK
1. No evidence of acute intracranial hemorrhage or large
vascular
territorial infarction.
2. Patent intracranial and neck vasculature without evidence of
___ stenosis, dissection, or aneurysm greater than 3 mm.
+ ___ DIAGNOSTIC CEREBRAL ANGIOGRAM
Right internal carotid artery: Vessel caliber smooth. There is
no
evidence of thrombus. There is complete filling of the M2
branches as well as the anterior cerebral artery territory.
There is no evidence of distal thrombus, aneurysm, or AVM. The
venous phase is unremarkable except she appears to have a
congenital at the absent transverse sinus on the right.
___ CTA ABD/PELVIS
1. In the right adrenal region adjacent to the common femoral
vein, there is a lobulated hyperattenuating focus measuring 1.9
x
0.9 cm (series 3:380) likely representing a pseudoaneurysm.
2. No evidence of retroperitoneal hematoma or active
extravasation.
+ MRI BRAIN ___
There is no evidence of acute territorial infarction. No
intracranial hemorrhage. No mass, mass effect, edema or midline
shift. The ventricles and sulci are normal, without evidence of
hydrocephalus. The basal cisterns are patent. There is no
evidence of impending, downward herniation. There is gross
preservation of the principal intracranial vascular flow voids.
+ ECHO WITH BUBBLE ___
Normal diastolic and systolic function. EF<55%. No PFO.
MICRO:
======
DISCHARGE/INTERVAL LABS:
========================
___ 06:47AM BLOOD ___
___ Plt ___
___ 06:47AM BLOOD Plt ___
___ 06:47AM BLOOD ___
___
___ 06:47AM BLOOD ___
___ 12:32AM BLOOD ___ cTropnT-<0.01
___ 04:16AM BLOOD ___
___
___ 04:16AM BLOOD ___
___ 04:16AM BLOOD ___
Brief Hospital Course:
___ is a ___ year old woman with PMH of Afib on
Coumadin (sub therapeutic INR on admission) with ?prior stroke
(per patient, but not seen on imaging) who presented with acute
onset left sided weakness and aphasia s/p TPA on ___ at 1729
and diagnostic angiogram on ___ without evidence of vessel
occlusion with negative MRI and hospital course c/b R common
femoral pseudoaneurysm, who went with interventional radiology
for thrombin injection x2, which corrected the pseudo aneurysm.
After interventional radiology completed their procedures, she
was restarted on coumadin to treat her atrial fibrillation, and
given lovenox as a bridge until her INR is therapeutic. During
her hospital stay, her left sided weakness showed some mild
improvements. She worked with physical therapy, who recommended
home ___ and a walker. Her hemoglobin A1c was 6.2 during her
hospital stay, but may have been elevated because she had
recently finished a course of steroids for an asthma
exacerbation. She should have an A1c rechecked in 3 months.
Lipid panel showed LDL 159 and TSH 2.6.
Presenting history and exam in this left handed lady were
concerning for right MCA syndrome, especially in the setting of
her known atrial fibrillation and subtherapeutic INR, so she was
given tPA ~2 hours after her last known normal and was
transferred to ___ for endovascular intervention. She had a
CTA H/N unrevealing for vascular etiology. Diagnostic angio w/o
vessel occlusion. MRI w/o evidence of chronic or acute CVA.
Despite this, she continued to have fluctuating left sided
weakness which was effort dependent. Additionally, she had left
hemisensory loss with splitting of the midline, normal abdominal
reflexes and diffuse 2+ reflexes which were symmetric. At this
time, it would be unlikely for her deficits to be explained by a
CVA given her normal MRI findings. Additionally, it is
perplexing that her remote infarct was not apparent on MRI as
she reports she was in a wheelchair and had a rehab stint post
stroke. In terms of alternative etiologies to her stroke,
seizure is unlikely at this time given her history and the
duration of her weakness would be unlikely for a ___. She has
had no issues w/ hypo/hyperglycemia. Migraine can also mimic
stroke but this is unlikely given no history of migraine and
duration of deficits. TTE w/ bubble was negative for PFO with
normal EF, systolic/diastolic function. Resuming systemic
___ was held initially in the setting of tPA and
then held further given the development of a right common
femoral pseudoaneurysm which required embolization and
antithrombin injection on ___. She was resumed on heparin sub q
on ___ of ___. Anticoagulation was discussed (given her history
of afib and previously Rx coumadin) and she reports allergy (red
hands and tingling) with Eliquis and Xarelto. The decision was
made to start Coumadin (decision made with her PCP). In terms of
her stroke risk factors, she does not have a history of HTN, HLD
or DM. A1c was 6.3 but she previously had been on a steroid
taper for asthma, so she will need recheck as outpatient.
#RIGHT COMMON FEMORAL PSEUDOANEURYSM
She developed pain at angio site of right groin associated with
a popping sound. Her H/H was stable as were her VS. CTA
abd/pelvis showed small pseudoaneurysm w/o active extravisation
or hematoma. ___ was consulted who performed thrombin injection
on ___, but this was minimally successful. She had a repeat
Doppler of her right groin which showed persistent
pseudoaneurysm. She had significant groin pain radiating to the
back which was treated with Tylenol and ice packs. She had a
repeat thrombin injection, which resolved the pseudoaneurysm.
#PAROXYSMAL ATRIAL FIBRILLATION
History of prior CVA per patient about ___ years ago. MRI negative
for evidence of remote infarct. She had been on Coumadin prior
to onset of symptoms, but had a subtherapeutic INR on admission.
She was monitored on tele with no atrial fibrillation during her
ICU stay. Her CHA2DSVASC is tricky given the question of CVA and
is either 2 or 4. Systemic anticoagulation was held initially in
the setting of tPA, but continued to be held due to her
pseudoaneurysm and thrombin injection. She was started on subq
heparin on ___. For ongoing anticoagulation in the setting of
afib, decision was made to continue with Coumadin.
#COPD
No issues during her hospitalization. Former smoker and recently
had COPD exacerbation requiring antibiotics and steroids.
Several of her medications, Breo and Incruse, are ___.
We treated her with Advair, albuterol PRN and continued her home
singular.
#GERD
On lansoprazole and intermittent famotidine at home. She had
some reflux throughout her clinical course which responded well
to pantoprazole and famotidine.
Transitional Issues:
- Lovenox Bridge to Coumadin
- Follow up with Cardiology, PCP
- ___ OT home services
- pseudoaneurysm follow up per ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 10 mg PO DAILY16
2. lansoprazole 30 mg oral Q24H
3. Famotidine 40 mg PO QHS
4. Montelukast 10 mg PO DAILY
5. Breo Ellipta ___ mcg/dose
inhalation Q24H
6. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
Q24H
7. ALPRAZolam 1 mg PO TID:PRN anxiety
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL 1 syringe SC twice a day Disp #*10
Syringe Refills:*0
2. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth q8 hrs
prn Disp #*20 Tablet Refills:*0
3. Breo Ellipta ___ mcg/dose
inhalation Q24H
4. Famotidine 40 mg PO QHS
5. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
Q24H
6. lansoprazole 30 mg oral Q24H
7. Montelukast 10 mg PO DAILY
8. Warfarin 10 mg PO DAILY16
9. HELD- ALPRAZolam 1 mg PO TID:PRN anxiety This medication was
held. Do not restart ALPRAZolam until ___ follow up with your
primary care provider
10.Rolling Walker
Dx: R27.0
Px: Good
___: ___ mon
Discharge Disposition:
Home
Discharge Diagnosis:
TIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___ were hospitalized due to symptoms of weakness of the left
side of your body. Based on your symptoms, it appeared as if ___
were having a stroke. ___ were given TPA, and then brought to
___ for a procedure to try to remove a clot if it were
blocking a vessel in the brain. During the procedure, no clot
was seen in your brain. This is good news, because it means ___
did not suffer a stroke. The weakness ___ experienced could have
been due to a transient ischemic attack, which is decreased
blood flow to a part of the brain for a short amount of time, or
it could be due to another cause such as stress. Your INR (the
level we check to make sure coumadin is keeping your blood thin
enough to prevent clots) was too low. It is very important ___
take your coumadin as prescribed and not miss doses. We
recommend ___ take lovenox as a bridge to a therapeutic INR on
Coumadin and that ___ follow up with your PCP next week (as
already scheduled).
___ experienced a complication from the angiography procedure,
which was called a "pseudo aneurysm" of an artery in your right
leg. Interventional radiology took ___ for two procedures and
the pseudoaneurysm is secured.
We contacted your PCP, who was out of the office on vacation,
but we spoke with her nurse practitioner as well as your
cardiologist, who recommended ___ continue on coumadin for
anticoagulation for your atrial fibrillation since ___ have had
GI issues with other anticoagulants.
___ worked with physical therapy, who recommended ___ use a
walker to help ___ get around at home. ___ remained stable for
discharge home on ___, and ___ should follow up with your
primary care provider and cardiologist when ___ return to
___.
We assessed ___ for medical conditions that might raise your
risk of having stroke. In order to prevent future strokes, we
plan to modify those risk factors. Your risk factors are:
Atrial fibrillation
History of stroke
We are changing your medications as follows:
Continue with coumadin
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If ___ experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
___
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
It was a pleasure taking care of ___ and we wish ___ the best!
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19864612-DS-21 | 19,864,612 | 22,167,702 | DS | 21 | 2186-01-15 00:00:00 | 2186-01-15 19:14:00 |
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:
None
History of Present Illness:
HPI: ___ w/ PMH of seizure disorder, ADHD, alcohol use disorder
(has not had a drink in 3 months, currently on naltrexone),
depression/anxiety, and a traumatic splenic rupture in ___
managed nonoperatively presenting with abdominal pain and N/V/D
for approximately one week. Symptoms started abruptly on ___.
Symptoms were diffuse and not localized, and were worsened by
food. He was seen at an urgent care in ___ last week
for this, was thought to have viral gastroenteritis and was
prescribed ondansetron and loparamide. Since then, his vomiting
and diarrhea have resolved, but he is still with nausea and
epigastric pain, in addition to decreased energy level and
appetite. He had not had fever or chills but was sweating
enough
to need to change his clothes a few times. Finally, he also
reported ___ episodes of dark urine yesterday with decreased
urinary frequency (which he called "difficulty urinating," but
of
note, described as decreased frequency) and the day before, as
well as cramping in the bilateral lower extremities for the last
couple of weeks. He was scheduled to come in for an HCA Epi
visit on ___, at which time he had not had persistent vomiting,
but had ongoing nausea. In clinic, he was tachy to the 130s, T
99.1, and ___ with diaphoresis. Urine dipstick was
done and notable for moderate bili and small blood, with >300
protein. He was sent to the ED for further evaluation.
In the ED, initial VS were 98.2 126 147/98 18 98% RA. Labs were
notable for WBC 11.5 w/ normal diff, Hgb 16.3, plts 238, AST/ALT
146/102, Tbili 3.3 (with dbili 0.8), Lipase 45, BUN/Cr ___
(baseline Cr ___, Na 134, K 3.0, Mg 1.5, Anion gap 20,
serum
tox negative, Lactate 2.9 -> 1.3, INR 1.2. RUQ US showed
steatosis and sludge with a distended gallbladder and no other
sonographic signs of acute cholecystitis. He received 2L NS,
Ondansetron 4 mg x2, Morphine 4 mg IV x2, Potassium and
Magnesium
repletion, was started on Pip/Tazo. Surgery was consulted and
felt this presentation was unlikely to represent acute
choelcystitis and recommended a HIDA scan. The patient was
admitted for further workup. Of note, HR decreased from
___
on presentation to the ___ after IVF.
On arrival to the floor, the patient was comfortable and
reported
that his abdominal pain had improved. He had no complaints
apart
from feeling tired.
ROS: A ___ review of systems was performed and was negative
with the exception of those systems noted in the HPI.
Past Medical History:
- Seizure disorder, on levetiracetam
- ADHD, on ___
- Low back pain
- Alcohol use disorder, on naltrexone, last drink 3 months ago
- Traumatic splenic rupture in the setting of a soccer game,
___ management, no evidence of hyposplenism afterwards
and no history of infections (had an episode of strep
pharyngitis
and infectious mononucleosis in college but that's it) but did
receive encapsulated organism vaccinations.
- Depression
- Anxiety
Social History:
___
Family History:
Father had a cholecystectomy for gallbladder
sludging around age ___.
Physical Exam:
ADMISSION
VITALS: 24 HR Data (last updated ___ @ 724)
Temp: 97.9 (Tm 98.0), BP: 110/66 (___), HR: 79
(___), RR: 18 (___), O2 sat: 97% (___), O2 delivery: RA,
Wt: 187.39 lb/85.0 kg
GENERAL: Sleepy but generally alert and in no apparent distress
EYES: Anicteric, pupils equally round, 3 -> 1.5 mm bilat
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is ___
GI: Abdomen soft, mildly distended, mildly tender to palpation
in
the epigastrium. Bowel sounds present. Spleen not palpable.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs. Reports mild TTP of L
calf.
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
VS: ___ ___ Temp: 98.5 PO BP: 147/91 HR: 74 RR: 18 O2 sat:
97% O2 delivery: Ra
Gen - sitting up in bed, comfortable appearing
Eyes - EOMI, anicteric
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft, nontender, no rebound/guarding; normal bowel sounds;
no splenomegaly noted
Ext - no edema
Skin - no rashes, no jaundice;
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 05:47PM BLOOD ___
___ Plt ___
___ 07:42PM BLOOD ___ ___
___ 05:47PM BLOOD ___
___
___ 05:47PM BLOOD ___
___
___ 05:47PM BLOOD ___
___ 07:03PM BLOOD ___
DISCHARGE
___ 06:35AM BLOOD ___
___ Plt ___
___ 06:35AM BLOOD ___
___
___ 06:35AM BLOOD ___
REPORTS
RUQUS
1. Echogenic liver with no focal lesions identified. Echogenic
liver
consistent with steatosis. Other forms of liver disease and more
advanced
liver disease including steatohepatitis or significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
2. Sludge within a somewhat distended gallbladder. No other
sonographic
evidence of acute cholecystitis.
RECOMMENDATION(S): Radiological evidence of fatty liver does
not exclude
cirrhosis or significant liver fibrosis which could be further
evaluated by
___. This can be requested via the ___
(FibroScan) or the
Radiology Department with either MR ___ or US
___, in
conjunction with a GI/Hepatology consultation" *
* ___ et al. The diagnosis and management of nonalcoholic
fatty liver
disease: Practice guidance from the ___ Association for the
Study of
Liver Diseases. Hepatology ___ ___
GALLBLADDER SCAN
FINDINGS:
Serial images over the abdomen show homogeneous uptake of tracer
into the
hepatic parenchyma.
The gallbladder is not seen within the first hour of imaging.
The patient returned at 4 hours to show tracer uptake in the
gallbladder.
IMPRESSION: Abnormal hepatobiliary scan consistent with chronic
cholecystitis.
Brief Hospital Course:
This is a ___ year old male with past medical history of seizure
disorder, alcohol use disorder currently on naltrexone,
depression and anxiety admitted ___ with 1 week of
worsening nausea and abdominal pain, found to have abnormal LFTs
in a mixed pattern (AST>ALT, elevation of direct and indirect
bilirubin), thrombocytopenia, HIDA scan without acute
cholecystitis and cleared by general surgery, thought to have
had a ___ viral infection, spontaneously improving
and able to be discharged home
# Abnormal LFTs
# Generalized Abdominal Pain
In setting of generalized abdominal pain, patient was found to
have elevated LFTs in a mixed atypical pattern: ALT 102 AST 146
AP 100 Tbili 3.3 Dbili 0.8 ibili 2.5. In ED, RUQUS showed
echogenic liver consistent with steatosis, and sludge within a
somewhat distended gallbladder without signs of biliary
obstruction. Workup otherwise notable for HIDA scan showing
"The gallbladder is not seen within the first hour of imaging.
The patient returned at 4 hours to show tracer uptake in the
gallbladder." thought to represent chronic cholecystitis. Per
discussion with general surgery consult team, given atypical
LFTs and imaging, his symptoms were not felt to represent acute
cholecystitis. Suspect more likely he had acute viral infection
resulting in cramping, mild transaminitis and (given ibili
predominance without signs of intravascular hemolysis, normal
hapto) either mild extravascular hemolysis or a ___
syndrome. Patient initially given empiric antibiotics on
admission, this was stopped once HIDA results returned. His
pain and LFTs rapidly improved. Prior to discharge he was able
to tolerate a regular diet without any pain or nausea. At
discharge LFTs were ALT 59 AST 53 AP 57 Tbili 0.8. Would
consider recheck at ___. Anaplasma serologies pending at
discharge.
# Abnormal imaging gallbladder
Admission RUQUS showed mild distension of gallbladder, and
subsequent HIDA scan consistent with chronic cholecystitis. As
above, clinical picture and imaging were not felt to represent
acute cholecystitis. However, given chronic findings seen on
HIDA, general surgery recommended outpatient ___ for
discussion re: elective cholecystectomy. Scheduled at
discharge.
# Thrombocytopenia
Course notable for thrombocytopenia, nadiring at 134k. Smear
not suggestive of ongoing hemolysis, coags normal. Felt to fit
with suspected viral infection. Platelets rapidly improved to
178k prior to discharge.
# Proteinuria
Noted to have trace proteinuria on admission. Could consider
repeat UA as outpatient
# Alcohol use disorder
Held Naltrexone during admission. Of note, naltrexone can cause
mild elevations of transaminases, or abdominal pain, but would
not typically cause bilirubin elevations seen in this
patient--not felt to be related to his acute presentation.
Restarted at discharge.
# Anxiety
Continued clonazePAM
# Seizure disorder
Continued keppra
# ADHD
Continued Adderall
Transitional issues
- Discharged home with PCP ___ consider repeat check of CBC and LFTs at ___
discharge platelets were 178k; discharge LFTs were ALT 59 AST 53
AP 57 Tbili 0.8
- Incidentally noted to have mild proteinuria on admission urine
dipstick; would consider repeat at ___
- Ultrasound incidentally showed "Echogenic liver with no focal
lesions identified. Echogenic liver consistent with steatosis.
Other forms of liver disease and more advanced liver disease
including steatohepatitis or significant hepatic
fibrosis/cirrhosis cannot be excluded on this study." Radiology
recommended "Radiological evidence of fatty liver does not
exclude cirrhosis or significant liver fibrosis which could be
further evaluated by ___. This can be requested via the
___ (FibroScan) or the Radiology Department with either
MR ___ or US ___, in conjunction with a
GI/Hepatology consultation"
- Ultrasound showed "Sludge within a somewhat distended
gallbladder. No other sonographic evidence of acute
cholecystitis." HIDA scan showed "Abnormal hepatobiliary scan
consistent with chronic cholecystitis." Per discussion with
___ general surgery, recommended for outpatient ___ for
discussion re: elective cholecystectomy
> 30 minutes spent on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO DAILY
2. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
3. ___ 10 mg oral DAILY
4. ___ 30 mg oral DAILY
5. LevETIRAcetam 500 mg PO BID
6. Naltrexone 50 mg PO DAILY
Discharge Medications:
1. ClonazePAM 0.5 mg PO DAILY
2. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
3. ___ 10 mg oral DAILY
4. ___ 30 mg oral DAILY
5. LevETIRAcetam 500 mg PO BID
6. Naltrexone 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Generalized Abdominal Pain secondary to viral enteritis
# Abnormal LFTs
# Abnormal Ultrasound Liver
# Abnormal imaging gallbladder
# Thrombocytopenia
# Proteinuria
# Alcohol use disorder
# Anxiety
# Seizure disorder
# ADHD
Discharge Condition:
Mental Status: Clear and coherent.
Mental Status: Confused - sometimes.
Mental Status: Confused - always.
Discharge Instructions:
Mr. ___:
It was a pleasure caring for you at ___. You were admitted
with nausea, abdominal pain and diarrhea. You underwent testing
that showed elevation of several of your liver function blood
tests. Testing of your liver and gallbladder was reassuring you
did not have any blockages of your bile ducts or acute
gallbladder problems. You were treated with IV fluids and
nausea medications. You improved.
We think that the most likely explanation for your symptoms is
that you had a viral infection impacting your liver and GI
tract, that then resolved on its own.
You are now ready for discharge home.
Of note while you were in the hospital, testing showed that you
might have chronic problems with your gallbladder. You were
seen by surgeons who recomemended seeing them as an outpatient
to discuss having your gallbladder removed in the future.
It will be important for you to see you primary care doctor to
your blood and urine tests rechecked.
Followup Instructions:
___
|
19865076-DS-12 | 19,865,076 | 20,234,328 | DS | 12 | 2169-07-16 00:00:00 | 2169-08-14 10:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lorazepam overdose
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
___ yo M with PMH including lymphocytic myocarditis with CHF with
LVEF ___, history of polymorphic VT arrest now on LifeVest,
and polysubstance abuse who presented with alcohol intoxication
and lorazepam overdose and is now intubated (at ___ for
mental status, and on pressors.
Patient was recently prescribed lorazepam for PTSD. He broke up
with his girlfriend last night, after which he drank heavily and
took all of his lorazepam. Called his mother at 21:00. She saw
him at 21:30. Per report, he was altered but talking at that
time. EMS was called and on arrival patient's mental status was
worsening. He was brought to ___ where he was intubated
on arrival. He was initially started on propofol but this
resulted in hypotension with SBP 70-80. Sedation was switched to
Fentanyl and Versed and patient given IVF. This did not result
in significant improvment, so a RIJ was placed and patient was
started on Levophed. Notably, EtOH 480. Patient was transferred
to ___ for further management.
In the ED, initial vital signs were 97, 82, 95/43, 16, and 100%
RA. Labs were remarkable for EtOH 486 and lactate 2.5. CXR with
low lung volumes and ETT and RIJ in place. Patient was continued
on Levophed, Fentanyl, and Versed. LifeVest not present on
transfer so pacer pads were placed on patient's chest. He was
admitted to the FICU.
In the FICU, patient was unresponsive, intubated; vitals below.
Past Medical History:
Lymphocytic myocarditis
- CHF with LVEF ___
- Polymorphic VT arrest on ___ on LifeVest
- Factor V ___
- LLL PE and LLE DVT - now on rivaroxaban
- ADD, PTSD, and anxiety
- Polysubstance abuse
Social History:
___
Family History:
Melanoma in paternal grandmother.
Father has HTN, no history of blood clots or MI in the family.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
============================
VITAL SIGNS: T 98 HR 64 BP 104/52 R 20 SaO2 100% on CMV Vt 500 f
16 PEEP 5 FiO2 50%
GENERAL: intubated, sedated, no response to sternal rub
HEENT: Sclerae anicteric, MMM, oropharynx clear
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, no murmurs/rubs/gallops
ABDOMEN: soft, non-tender, non-distended, hypoactive bowel
sounds, no rebound tenderness or guarding, no organomegaly
GU: + Foley
EXTR: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: sedated, pupils equal, brisk responses to light
SKIN: warm, dry, no rashes or lesions
Discharge Physical Exam:
VS: T: 98.1 HR: 62 BP: 120/64 RR: 20 97% RA
Gen: NAD
HEENT: EOMI, PERRLA, MMM
CV: RRR nl s1s2 no m/r/g, no JVD
Resp: CTAB no w/r/r
Abd: Soft, NT, ND +BS
Ext: no c/c/e
Neuro: CN II-XII intact, ___ strength throughout
Psych: normal affect
Skin: warm, dry no rashes
Pertinent Results:
LABS ON ADMISSION:
==================
___ 05:03AM BLOOD WBC-9.5 RBC-4.35* Hgb-12.7* Hct-36.7*
MCV-84 MCH-29.1 MCHC-34.5 RDW-13.5 Plt ___
___ 01:27AM BLOOD Neuts-60.6 ___ Monos-3.2 Eos-0.5
Baso-0.5
___ 01:27AM BLOOD ___ PTT-34.4 ___
___ 01:27AM BLOOD Glucose-171* UreaN-13 Creat-1.1 Na-143
K-3.8 Cl-107 HCO3-25 AnGap-15
___ 01:27AM BLOOD ALT-35 AST-17 AlkPhos-85 TotBili-0.3
___ 01:27AM BLOOD Albumin-3.8 Calcium-7.9* Phos-2.4* Mg-2.2
___ 01:27AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CXR ___:
===============
IMPRESSION:
As compared to ___, the patient has been extubated.
Cardiomediastinal contours are normal, and lungs are clear.
TTE ___:
IMPRESSION: moderate to severe global hypokinesis with regional
akinesis as described above. No significant valvular
abnormality.
Compared with the prior study (images reviewed) of ___, the
findings are similar. The basal to mid septum was near-akinetic
on the prior study also. On both studies, the septal akinesis is
in the same distribution of late gadolinium enhancement on the
cardiac MRI.
Brief Hospital Course:
___ yo M with PMH including lymphocytic myocarditis with CHF with
LVEF ___, history of polymorphic VT arrest now on LifeVest,
and polysubstance abuse who presented with alcohol intoxication
and lorazepam overdose requiring intubation and pressors.
# Sedative overdose:
Patient presented in the setting of alcohol and benzodiazpine
overdose after break up with his girlfriend. The patient
___ presented to ___ and was intubated and
transfered to ___ for further management. On arrival patient
was intubated and sedated. Serum ethanol level noted to be 486.
QTc monitored with serial EKG's. Benzodiazpines used for CIWA
scores > 10. Patient extubated within 24 hours of admission
without complication. Toxicology consulted with reccomendations
to avoid phenobarbital given effect of myocardial depression to
be avoided given patient's underlying cardiac history.
Psychiatry and social work consulted. Patient initially placed
on ___. Pt followed by psychiatry while in house and felt
to benefit from intense outpatient program at ___ Care on
discharge. Pt left with the plan to stay with his parents until
starting his program 3 days after discharge. He was discharged
off benzodiazepenes and opiates.
# Lymphocytic cardiomyopathy:
Complicated by CHF with LVEF ___ and polymorphic VT arrest on
LifeVest at home. Pateint presented without LifeVest on and as
such was placed on telemtry with pacer pads. Amiodarane was
continued. Furosemide, lisinopril, metoprolol, and
spironolactone all initially held in setting of hypotension and
restarted prior to leaving the ICU. Patient had transient
episode of chest pain on ___ with normal EKG with pain that
was reproducible on palpation. He was placed back on his life
vest and wore it at the time of discharge. Follow up for AICD
placement arranged prior to discharge.
Chronic Issues
# Factor V Leiden: Continued rivaroxaban.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Gabapentin 600 mg PO QHS
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Lisinopril 20 mg PO DAILY
6. Lorazepam 1 mg PO QHS:PRN insomnia
7. Metoprolol Succinate XL 100 mg PO BID
8. Morphine SR (MS ___ 15 mg PO Q12H
9. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain
10. Rivaroxaban 20 mg PO DAILY
11. Spironolactone 12.5 mg PO DAILY
12. Acetaminophen 650 mg PO Q8H:PRN pain
13. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Gabapentin 300 mg PO QHS
4. Gabapentin 100 mg PO TID:PRN anxiety
5. Lisinopril 20 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO BID
7. Rivaroxaban 20 mg PO DAILY
8. Spironolactone 12.5 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Thiamine 100 mg PO DAILY
11. Acetaminophen 650 mg PO Q8H:PRN pain
12. Docusate Sodium 100 mg PO BID
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. Wellbutrin XL (buPROPion HCl) 300 mg oral DAILY
RX *bupropion HCl 300 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
15. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hous as needed
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Benzodiazapine overdose
Alcohol ingestion
Chronic Lymphocytic myocarditis
CHF with EF of ___
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 ingesting benzodiazpines
and drinking alcohol. You were found to be in respiratory
distress requiring intbation and ICU care. You were evaluated by
psychiatry who felt you would benefit from close psychiatric
care. You are being discharged home with plan to start an
outpatient psychiatric program at ___ on ___. Please
follow up closely with your therapist as well.
You were on decreasing doses of pain medications during this
hospitalization. You will taper off as planned by your primary
care physician.
You will need to be sure to follow up with your cardiologist for
ongoing management of your heart failure. In addition, you were
seen by the electrophysiologists who will arrange a visit in
clinic with them to discuss ICD implantation. Please continue to
wear your life vest at all times. If you ___ not hear from the
___ clinic in a week, please call ___ to set up an
appointment.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19865423-DS-2 | 19,865,423 | 20,038,088 | DS | 2 | 2171-10-18 00:00:00 | 2171-10-21 09:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Heart racing, tremor
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ y/o male with a history of rheumatoid arthritis,
eczema who presents with ___ weeks of heart racing and shortness
of breath. He has had a mild tremor in his hands at rest but
more recently has felt like a "full body tremor" + insomnia,
some "puffiness" in face and legs, has problems with bowels that
he attributes to lactose intolerance. No neck pain, no prior
viral URI symptoms. Progressive dyspnea on exertion. Does
sweat with exertion but he attributes that to his hip pain. His
roommate persuaded him to get evaluated for this so he went to a
___ clinic where his heart rate was found to be in the 140s,
so he was sent to the ED. HR in ED 140-150, he was given
metoprolol 25 mg.
He endorses long term heavy caffeine use - consumes about 2 pots
of coffee a day as well as caffeinated beverages. Does not
consume much water. He does not like seeing doctors and ___ not
seen one in some time.
Past Medical History:
1 Rheumatoid arthritis - diagnosed when he was in high school,
mainly affected left hip. He was advised to have a hip
replacement but he did not want to do that at a young age. Has
left hip stiffness and pain
2 eczema
3. iritis
Social History:
___
Family History:
No known thyroid disorders in family.
Physical Exam:
ADMISSION EXAM
--------------
AF 93 123/77
Gen: NAD, very pleasant
No exophthalmos
No obvious lid lag
No thyroid bruit or thyromegaly
EOM intact
Lung: CTA V
CV: Tachycardic
Abd: Obese, soft
Ext: Trace edema
+ fine resting tremor visible with outstretched hands.
Skin: + erythematous scaly patches visible on hands
DISCHARGE EXAM
--------------
VS: 98.0 124/81 102 18 98% on RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM. No exophthalmos
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, regular and tachycardic, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash. No diaphoresis noted
Neuro: non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS
--------------
___ 01:50PM BLOOD WBC-11.4* RBC-4.86 Hgb-12.9* Hct-39.7*
MCV-82 MCH-26.5 MCHC-32.5 RDW-13.4 RDWSD-39.3 Plt ___
___ 01:50PM BLOOD Neuts-71.5* Lymphs-15.7* Monos-11.9
Eos-0.2* Baso-0.3 Im ___ AbsNeut-8.15* AbsLymp-1.79
AbsMono-1.36* AbsEos-0.02* AbsBaso-0.03
___ 01:50PM BLOOD Plt ___
___ 01:50PM BLOOD ___ PTT-41.4* ___
___ 01:50PM BLOOD Glucose-86 UreaN-19 Creat-0.7 Na-137
K-4.4 Cl-98 HCO3-21* AnGap-22*
___ 01:50PM BLOOD Calcium-10.3 Phos-3.7 Mg-1.6
___ 02:06PM BLOOD D-Dimer-394
___ 01:50PM BLOOD TSH-<0.01*
___ 01:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:56PM BLOOD Lactate-1.2
___ 02:07PM BLOOD Lactate-2.5*
IMAGING
-------
CXR on admission:
No acute cardiopulmonary abnormality.
DISCHARGE LABS
--------------
___ 09:05AM BLOOD WBC-5.7 RBC-4.22* Hgb-11.2* Hct-35.1*
MCV-83 MCH-26.5 MCHC-31.9* RDW-13.3 RDWSD-40.0 Plt ___
___ 09:05AM BLOOD Glucose-135* UreaN-15 Creat-0.5 Na-142
K-3.9 Cl-105 HCO3-26 AnGap-15
___ 09:05AM BLOOD Calcium-9.4 Phos-3.3 Mg-1.7
___ 01:50PM BLOOD antiTPO-201*
Brief Hospital Course:
___ y/o male with h/o rheumatoid arthritis, iritis, eczema
presents with palpitations and shortness of breath. Labs
notable for suppressed TSH, elevated T3 and T4.
# Hyperthyroidism: No clear exophthalmos suggestive of Graves
disease; his burden of autoimmune disease makes it likely that
an auto-immune process is driving his hyperthyroidism. T3 and
T4 elevated, with TSI pending. Endocrinology was consulted and
recommended starting methimazole and propranolol. He will
follow up with Endocrine on ___, appointment time to
be arranged. Vital signs improved over course of stay.
# Dyspnea on exertion: Likely multifactorial, driven by hip
pain, deconditioning as well as tachycardia. CXR normal.
# Tachycardia: Due to hyperthyroidism, will continue
propranolol
# Rheumatoid arthritis: patient was placed on ibuprofen
# Caffeine dependence: Counselled on tapering caffeine use at
home.
# Anxiety: Has multiple stressors, but also likely worsened by
his hyperthyroid state. He was offered SW consultation which
he declined.
TRANSITIONS OF CARE
-------------------
# Follow-up: patient will follow up with a new PCP. He will
follow up with Endocrine on ___, appointment time to
be arranged.
# Code status: Full
Medications on Admission:
Celecoxib, unknown dose
Discharge Medications:
1. Methimazole 20 mg PO DAILY
RX *methimazole 10 mg 2 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Propranolol 10 mg PO TID
RX *propranolol 10 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
3. Celecoxib, unknown dose
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperthyroidism
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 during your visit to ___.
You came for further evaluation of shortness of breath and fast
heart beat. You were found to have high thyroid hormone levels
(hyperthyroidism). You were seen by Endocrinology and they
prescribed a new medication called methimazole.
It is important that you continue to take your medications as
prescribed and follow up with your appointments listed below.
Followup Instructions:
___
|
19865572-DS-11 | 19,865,572 | 28,434,964 | DS | 11 | 2185-01-15 00:00:00 | 2185-01-15 13:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro / Flagyl / codeine / Demerol / levofloxacin / Sulfa
(Sulfonamide Antibiotics) / Keflex
Attending: ___
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
ERCP with metallic CBD stent
History of Present Illness:
___ is a ___ year old female who is s/p CCY, with prior
know hemangiomas ("smaller than quarters" per patient - last
evaluated ___ years ago) initially presented to ___
___ with painless jaundice, now transferred due to findings
of transaminitis, hyperbilirubinemia and pancreatic mass with
likely metastatic disease throughout the liver.
Patient reports that she went to urgent care last week because
of dark urine and was treated for UTI with a course of Keflex.
She reported dysuria that that time. She felt like she had a
reaction to Keflex, including nausea and abdominal pain, so was
switched to Macrobid.
Over the last ___ days she has noticed yellowing of her skin, so
she presented to ___ for evaluation. While she
reports no pain currently, she does note that she has had some
moments with epigastric pain radiating around to her back. She
does report some intermittent nausea, decreased appetite..
At OSH ED she had labs notable for tbili 6.0, lipase ~4000, UA
with pos LEs and nitrites. She was given ceftriaxone for
possible UTI. CT abdomen showed likely pancreatic mass with
diffuse liver metastases, as well as intra and extrahepatic
ductal dilatation. She was transferred to ___ for further
evaluation.
ED course: AVSS, exam notable for jaundice, labs repeated
showing tbili 7.0, AST/ALT 379/607, ALP 709, lipase 1634.
Patient was admitted for further evaluation of likely new
metastatic disease and likely ERCP.
Past Medical History:
- S/p cholecystectomy
- S/p ventral hernia repair
- Hepatic hemangioma ("smaller than silver dollars" per patient)
Social History:
___
Family History:
- Mother: Died age ___ of kidney cancer
- Father: Died age ___ of COPD
Physical Exam:
ADMISSION EXAM:
Vital signs: Afebrile, BP 144/76, P 79, RR 18, O2 96% on RA
Gen: Well appearing, in no apparent distress
HEENT: NCAT, oropharynx clear, +scleral icterus
Lymph: no cervical lymphadenopathy
CV: No JVD present, regular rate and rhythm, no murmurs
appreciated
Resp: CTA bilaterally in anterior and posterior lung fields, no
increased work of breathing
GI: Liver edge palpable ~4cm below costal margin, mildly tender
to palpation in RUQ, otherwise soft, non-tender, non-distended.
GU: No suprapubic tenderness
Extremities: no clubbing, cyanosis, or edema
Neuro: no focal neurologic deficits appreciated. Moves all 4
extremities purposefully and without incident, no facial droop.
Psych: Euthymic, speech non-tangential, appropriate
DISCHARGE EXAM:
Vitals: 97.6PO 110/62 70 18 95 Ra
Gen: Well appearing, in no apparent distress
HEENT: NCAT, oropharynx clear, +scleral icterus
Lymph: no cervical lymphadenopathy
CV: No JVD present, regular rate and rhythm, no murmurs
appreciated
Resp: CTA bilaterally in anterior and posterior lung fields, no
increased work of breathing
GI: Liver edge palpable ~4cm below costal margin, mildly tender
to palpation in RUQ, otherwise soft, non-tender, non-distended.
GU: No suprapubic tenderness
Extremities: no clubbing, cyanosis, or edema
Neuro: no focal neurologic deficits appreciated. Moves all 4
extremities purposefully and without incident, no facial droop.
Psych: Euthymic, speech non-tangential, appropriate
Pertinent Results:
ADMISSION LAB RESULTS:
___ (___):
Lipase 3910
INR 0.9
PTT 27.3
ALT 833, AST 478
ALP 818
Tbili 6.3, Dbili 5.2
CBC:
8.5 > 12.74/38.7 < 285
BMP:
138 | 102 | 9
-----------------< 125
3.2 | 29 | 0.64
ESR 46
UA: large bili, trace prot, mod ___, +nitrites, ___ WBC,
+bacteria
___ (___):
ALT: 607 AP: 709 Tbili: 7.0 Alb: 3.5
AST: 379
Lipase: 1634
BMP:
138 | 101 | 6
----------------< 114
3.0 | 23 | 0.5
Ca: 8.6 Mg: 1.8 P: 3.4
CBC:
7.3 > 11.0/34.1 < 258
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-11.2* RBC-4.08 Hgb-11.6 Hct-36.7
MCV-90 MCH-28.4 MCHC-31.6* RDW-14.5 RDWSD-47.1* Plt ___
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-91 UreaN-7 Creat-0.5 Na-138 K-4.3
Cl-99 HCO3-23 AnGap-20
___ 07:50AM BLOOD ALT-542* AST-262* AlkPhos-718*
TotBili-3.7*
___ 07:50AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.7
IMAGING:
CT abd/pelvis ___ - ___ - MY READ:
Diffuse lesions throughout liver, concerning for metastatic
disease.
Abd ultrasound ___ - ___:
Liver is heterogeneous and postsurgical with multiple hepatic
masses measuring up to 4.7x4.2x4.3cm in left hepatic lobe and
7.2x3.7x4.cm in right hepatic lobe.
Multiple hepatic masses as above with peripancreatic and
para-aortic masses likely representing lymphadenopathy, cannot
exclude a pancreatic mass. Intrahepatic and extrahepatic biliary
ductal dilatation together with pancreatic ductal dilatation.
ERCP (___): ERCP (___):
The scout film showed clips from previous CCY and partial liver
resection. Duodenal narrowing was noted at the junction of teh
first and second parts of the duodenum. The scope was exchanged
for a diagnostic ERCP scope. A mass was found at the area of the
papilla. The mass caused a partial obstruction. The scope
traversed the lesion.The PD was cannulated using a Rx
sphincterotome preloaded with 0.035in guidewire. Contrast
injection showed dilated main PD at approximately 6mm. There was
no filling defects. Decision was made to place a PD stent to aid
with biliary cannulation. A ___ x 5cm ___ pancreatic stent
was successfully placed in the PD. The CBD was cannulated using
a Rx sphincterotome preloaded with 0.035in guidewire. Contrast
injection revealed very tight stricture at the lower CBD. The
common bile duct, common hepatic duct, right and left hepatic
ducts were dilated. The sphincterotome was not able to traverse
the stricture therefore a 4mm x 4cm Hurricane balloon was used
to successfully dilate the stricture up to 4mm. Brushings were
successfully obtained from the CBD stricture and sent for
cytology. A 10mm x 60mm Wallflex fully covered biliary metal
stent (___ REF ___ was
successfully placed in the CBD. Excellent bile and contrast
drainage was noted at the end of the procedure. The PD stent was
removed successfully using a snare.
CTA Pancreatic Protocol ___: Completed. Read pending.
Brief Hospital Course:
ASSESSMENT/PLAN:
___ is a ___ year old female who is s/p CCY, with prior
know hemangiomas ("smaller than quarters" per patient - last
evaluated ___ years ago) initially presented to ___
___ with painless jaundice, now transferred due to findings
of transaminitis, hyperbilirubinemia and pancreatic mass with
likely metastatic disease throughout the liver.
# HYPERBILIRUBINEMIA,
# TRANSAMINITIS, due to
# BILIARY OBSTRUCTION, from
# PANCREATIC MASS:
Patient noted increasing jaundice over the past ___ days. Found
to have hyperbili and transaminitis, as well as CT with
pancreatic mass (official report not yet available, not sent
with patient) causing biliary obstruction. CT also notable for
diffuse metastatic disease to liver. CT most consistent with
metastatic pancreatic adenocarcinoma, however will await tissue
diagnosis.
Ms ___ underwent ERCP on ___ with placement of metallic CBD
stent and good biliary flow. Due to length of procedure, EUS
with FNA was not done. The ERCP team will await for brush
cytology - and if it is undiagnostic, a follow up EUS may be
done in 1 week. CEA, ___ was sent. Multidiscplinary
pancreatic clinic visit will be arranged as an outpt. She was
given 4 day supply of Ceftin to complete 4 days of antibiotics.
CTA pancreatic protocol was done prior to discharge for surgical
planning.
# URINARY TRACT INFECTION:
Unclear if patient truly has UTI given that dark urine was
almost certainly due to hyperbilirubinemia. However she did have
dysuria and UA is positive, so she was given ceftriaxone and
discharged home on PO ceftin for infection prevention (post
ERCP) as well.
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. CefTIN (cefUROXime axetil) 500 mg oral Q12H
RX *cefuroxime axetil 500 mg 1 tab by mouth every twelve (12)
hours Disp #*8 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic mass, obstructive jaundice - concern for metastatic
pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure looking after you, Ms. ___. As you know,
you were admitted with jaundice and underwent a procedure called
ERCP to relieve the obstruction of the common bile duct. A
metallic stent was placed to maintain patency of the bile duct.
A brush biopsy was done - where the result will not return till
next week. Please call Dr. ___ ___ in 7
days for the pathology results. Dr. ___ will also
arrange for follow up regarding care of your pancreatic/liver
condition and will notify you of the needed follow up.
Please complete a 4 day course of the antibiotics (Augmentin)
to prevent infection.
We wish you the best of luck.
Your ___ Team
Followup Instructions:
___
|
19865581-DS-18 | 19,865,581 | 22,940,858 | DS | 18 | 2169-02-15 00:00:00 | 2169-02-17 15:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Vertigo, Ataxia
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
___ is a ___ old man with a history of aortic
aneurysm and recent total hip replacement who presented to an
OSH
with the acute onset of vertigo, diplopia, imbalance, nausea and
vomiting and head CT concerning for cerebellar infarct and thus
was transferred to ___ for further evaluation.
Mr. ___ underwent elective total left hip replacement two days
ago. The procedure went well and was uncomplicated. On POD 1 he
was discharged home on coumadin 1 mg daily, oxycodone and bowel
regimen and plan for ___ with mobilization. He got home around
1630 and had a good afternoon, ate dinner, watched sports on TV
and was in good spirits. At 10 ___ he had the sudden onset of a
severe headache, vertigo, and diplopia. He tried to stand up and
had significant imbalance. He cried out and his family noted
that
his speech was dysarthric. He became acutely nauseated and
vomited.
He presented to ___, where a head CT was
obtained and showed no hemorrhage but was concerning for
cerebellar hypodensity. He had persistent diplopia, nausea and
vomiting. He received valium with improvement in his symptoms.
While at ___ he was retching violently. He recalls
vomiting and then felt like his vision was going dark with
spots.
According to his wife, his eyes rolled back in his head and he
fell backwards. He was unresponsive for a period of ___
seconds
and then awoke. He was a bit sleepy and did not recall the event
itself but was oriented. She did not specifically notice any
movements of his arms or legs, though he describes
incoordination
in his left arm which prevented him from catching himself when
he
fell. He was transferred to ___ for further evaluation.
Here, he reports that he is feeling a bit better overall and his
diplopia has resolved, but his vertigo, headache, dysarthria and
nausea persist. He has not been able to get up to walk. Here he
had a CTA head and neck which demonstrated an acute L cerebellar
infarct.
He reports one episode of similar symptoms several weeks ago
while he was in ___. He had been golfing outside and that
afternoon had the sudden onset of vertigo which he attributed to
dehydration. With rest and fluids the symptoms completely
resolved.
He has a history of weekly headaches which are midline and
behind
the eyes, are not associated with aura, phonophobia or nausea.
They are triggered by hunger and improve with excedrin.
Neuro ROS was notable as above. Otherwise, the pt denies loss of
vision, blurred vision, lightheadedness or hearing difficulty.
Denies difficulties producing or comprehending speech. Denies
focal weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention.
General review of systems notable as above, he also mentions
chest pain, dyspnea on exertion, frequent night sweats where he
will have to turn his pillow over. He denies recent fever or
chills. No recent weight loss or gain. Denies cough. Last bowel
movement was the day before his surgery. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Denies rash.
Past Medical History:
PMHx:
Aortic aneurysm (thoracic)
BPH
osteoarthritis
asbestosis
PSHx
L hip arthroplasty
hernia repair
Social History:
___
Family History:
-Sister with stroke (1 week ago, unclear cause), possibly
history
of blood clot leading to the stroke although not sure of the
cause.
Physical Exam:
# Admission Exam #
General: Well-nourished man in NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing. Vesicular breath sounds
bilaterally, no wheezes or crackles appreciated.
Cardiac: S1/S2 appreciated, RRR, no M/R/G.
Abdomen: soft, nontender, nondistended
Extremities: no lower extremity edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Able to read without difficulty. Speech was not
dysarthric. Able to follow midline, appendicular, cross-body
and
gramatically complex commands. Pt. was able to register 3
objects
and recall ___ at 5 minutes. Able to calculate the number of
quarters in $1.75. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3 mm, both directly and consentually; brisk
bilaterally. VFF to confrontation with finger counting.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages, but showed difficulty in maintaining fixation.
III, IV, VI: EOMI with sustained left-beating nystagmus on
leftward gaze. Normal saccades.
V: Facial sensation intact to light touch, pinprick in all
distributions.
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, and is equal ___ strength
bilaterally as evidenced by tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ 5 4* ___ 5 5 5
R ___ ___ ___ 5 5 5 5 5
* ability to test strength limited by hip replacement
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 3 3 2 beats clonus
R 3 2 3 3 2 beats clonus
- Plantar response was mute bilaterally.
- Pectoralis Jerk were present bilaterally, and Crossed
Adductors
are present bilaterally.
-Sensory: No deficits to light touch, pinprick, cold sensation
throughout. Normal vibration sensation in great toes
bilaterally.
No extinction to DSS.
-Coordination: Intention tremor, dyssynergia on L FNF. Overshoot
on L finger following. L RAM are clumsy with impaired cadence.
Could not test L HKS due to hip replacement. R FNF, HKS, RAM are
normal. +Trunkal ataxia.
# Discharge Exam#
No significant Change
Pertinent Results:
#Labs#
___ 04:20AM BLOOD WBC-15.1* RBC-3.35* Hgb-10.3* Hct-28.8*
MCV-86 MCH-30.8 MCHC-35.8* RDW-13.0 Plt ___
___ 04:20AM BLOOD Neuts-87.8* Lymphs-7.3* Monos-4.7 Eos-0.1
Baso-0.1
___ 04:20AM BLOOD ___ PTT-26.4 ___
___ 04:20AM BLOOD Plt ___
___ 04:20AM BLOOD Glucose-138* UreaN-21* Creat-1.0 Na-138
K-4.1 Cl-100 HCO3-28 AnGap-14
___ 03:26PM BLOOD cTropnT-<0.01
___ 04:20AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.1 Cholest-189
___ 04:20AM BLOOD Triglyc-205* HDL-36 CHOL/HD-5.3
LDLcalc-112
___ 04:20AM BLOOD TSH-0.73
___ 04:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
#Images#
CTA Head/Neck ___:
IMPRESSION:
1. Hypodensity in the superior left cerebellum concerning for
infarct.
2. The left superior cerebellar artery is not well seen, which
may be due to relative small size or possible occlusion. No
other intracranial vasculature abnormality.
3. Dilation of the ascending thoracic aorta measuring 4.1 cm in
diameter
Left Lower Extremity Duplex ___: IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
MRI Head w/o Contrast ___: IMPRESSION: Areas of restricted
diffusion in the bilateral cerebral hemispheres, left greater
than right, compatible acute infarcts.
MRV Pelvis: IMPRESSION: No deep venous thrombosis identified
within the inferior vena cava or pelvic veins.
Brief Hospital Course:
___ is a ___ old right-handed man with a history of
aortic aneurysm who was POD1 from hip replacement who had sudden
onset of vertigo, diplopia, and imbalance with MRI confirmation
of bilateral (L>R) cerebellar infarction concerning for an
embolic event. Unlcear if source of embolus was a provoked dvt
and resultant paradoxical embolus vs hypercoagulable state.
#L cerebellar infarct, Likely Embolis:
- Admission CT concerning from Left cerebellar hypodensity.
Subsequent MRI head revealed with bilateral left > right
cerebellar infarction. Given the bilaterality of his strokes,
there was very high concern for an embolic event. B/l ___
ultrasound of his legs were negative. TTE with bubbles was
performed revealing PFO vs ASD with significant Left Atrial
dilatation. Lipid labs were notable for increased LDL of 112 and
triglycerides of 205. A1c was 6.1. Although small, the
stroke's position near the ___ ventricle has raised concerns for
risk of hydrocephalus but no signs of herniation were noted
in-house. Aspirin was started, and patient was bridged to
Coumadin with goal INR of ___.
Further evaluation for clot w/ MRV of the pelvis revealed no
evidence of deep venous thrombosis..Partial Hypercoagulable was
started in patient with Cardiolipin Ab, B2 glycoprotein Ab and
Lupus Anticoagulant sent. Unfortunately, Protein C+S were not
sent as patient was already on Coumadin and these labs would
likely be unreliable.
The importance of these labs is in the determination of the
length of his anticoagulation course. Should the
hypercoagulable evaluation (including genetic w/u) be negative,
this even can likely be consider a sequelae of a provoked Clot
in the setting of either recent flight or left hip surgery, and
thus short term a/c can be considered. Should hypercoagulable
w/u be positive, patient will likely require indefinite
anticoagulation.
# ASD vs PFO in setting of severe Left Atrial Enlargement.
- Detected on TTE. Cardiology recommended outpatient Holter
monitor (4 weeks) for monitoring for atrial fibrillation in
addition to outpatient cardiology follow-up. Consideration for
closure of his PFO to be deferred pending his hypercoagulable
work-up.
# Thoracic Aortic Aneurysm
- Patient scheduled for routine follow-up with Thoracic Surgery
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented (required for all patients)? (X) Yes (LDL =
112) - () No
5. Intensive statin therapy administered? () Yes - (X) No [if
LDL >= 100, reason not given: ____ ]
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
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (X) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - () Anticoagulation] - (X) No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (X) Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. fenofibrate 145 mg oral DAILY
2. Celecoxib 200 mg oral DAILY
3. Warfarin 1 mg PO DAILY16
4. alfuzosin 10 mg oral DAILY
5. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN SoB, Wheezing
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
8. Senna-S (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN
Constipation
Discharge Medications:
1. Outpatient Lab Work
Please draw INR on morning of ___ and call the result to Dr.
___ at ___ (preferred). If needed, fax to
___.
ICD-9: 433.01
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SoB, Wheezing
3. alfuzosin 10 mg oral DAILY
4. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN SoB, Wheezing
7. Aspirin 81 mg PO DAILY
Please stop this medication when your INR is between ___ (as
guided by your doctor)
8. Atorvastatin 20 mg PO QPM
9. fenofibrate nanocrystallized 145 mg oral DAILY
10. Warfarin 4 mg PO DAILY16
RX *warfarin 2 mg 2 tablet(s) by mouth at bedtime Disp #*60
Tablet Refills:*2
11. Senna-S (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN
Constipation
12. fenofibrate 145 mg oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
- Bilateral Cerebellar Strokes
- Stretched PFO/ASD present
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of dizziness (vertigo),
imbalance and incoordination resulting from an ACUTE ISCHEMIC
STROKE, a condition in which a blood vessel providing oxygen and
nutrients to the brain is blocked by a clot. Damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Atrial Septal Defect (small hole between the sides of your
heart)
We are changing your medications as follows:
- adding warfarin 4mg daily
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
19865758-DS-21 | 19,865,758 | 20,968,572 | DS | 21 | 2170-01-25 00:00:00 | 2170-01-26 12:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
doxycycline / cefoxitin / erythromycin base / Percocet /
oxycodone / tetracycline
Attending: ___.
Chief Complaint:
Fevers, chills
Major Surgical or Invasive Procedure:
Enteroscopy (___)
History of Present Illness:
___ year old female with a history of ampullary adenocarcinoma
s/p minimally-invasive pylorus-sparing radical
pancreaticoduodenectomy ___, adjuvant chemotherapy (last
___ with gemcitabine), external beam radiation therapy with
course c/b MDR E Coli intra-abdominal abscess s/p 3 weeks
ertapenem in ___, cholangitis with e coli bacteremia on
___ in the setting of PTBD placement discharged on two week
course of CTX via PICC line readmitted ___ with chills and
leakage around PTBD site found to have displaced PTBD requiring
multiple replacements. She was also been noted to have thrombus
of the R hepatic vein for which she was placed on
anticoagulation. Her course was complicated by VRE and MDR e
coli bacteremia in the setting of a PICC Line from her prior
hospitalization. She was started on daptomycin and meropenem
with clearance of her bacteremia initially on ___. She underwent
placement of a left
internal-external biliary drain and removal of the R drain, but
following drain clamping on ___, she spiked a fever and had
recurrent VRE bacteremia from peripheral cx. She was discharged
to complete a 4 week total course of daptomycin (end date
___ and ertapenem (end date ___. Since discontinuing
abx therapy the patient had one episode of the PTBD becoming
dislodged requiring balloon dilatation and replacement on ___,
at which time she presented with sudden onset abdominal pain and
rigors. Cholangiogram performed at that time noted stenosis of
her HJ anastomosis. On ___, the patient
reported decreased biliary output through her drain and that it
had migrated out, which prompted PTBD exchange on ___ with
drainage of a significant amount of bile. Beginning two days
PTA the patient noted the onset of chills and malaise
accompanied by a decrease in output through her PTBD. She denied
any overt fevers, abdominal pain, N/V, or drainage around the
catheter. She contacted her surgical team who advised she come
to the ED for evaluation.
Past Medical History:
-Ampullary adenocarcinoma s/p Whipple
-Deep vein thrombosis - LLE ___
-Hyperlipidemia
-Status post appendectomy
-History of cataract surgery
-Status post bunionectomy
Social History:
___
Family History:
- Father - COPD
- Mother - stroke
- 9 siblings, most are healthy: 1 sister with lung cancer, 1
brother with type ___ diabetes
- Daughter - type 1 diabetes mellitus
Physical Exam:
GEN: NAD lying in bed. Appears comfortable
EENT: PERRL, EOMI, sclerae anicteric, MMM, no ulcers / lesions /
thrush
NECK: supple
CARD: RRR, no murmurs / rubs / gallops
PULM: clear to auscultation bilaterally w/o wheezes / rhonchi /
rales
BACK: no focal tenderness, no costovertebral angle tenderness
ABDM: soft, nontender. Left abdominal catheter drain in place,
site nontender and nonerythematous, draining green bilious fluid
EXTR: warm and well perfused, no edema, 2+ DP pulses palpable
bilaterally
Pertinent Results:
___ 07:41PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 07:41PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 07:41PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 07:41PM URINE AMORPH-OCC
___ 07:41PM URINE MUCOUS-RARE
___ 06:24PM LACTATE-1.3
___ 06:24PM WBC-7.7 RBC-3.08* HGB-10.4* HCT-32.1*
MCV-104* MCH-33.8* MCHC-32.4 RDW-15.6* RDWSD-59.5*
___ 06:24PM NEUTS-75.5* LYMPHS-5.2* MONOS-15.8* EOS-2.7
BASOS-0.5 IM ___ AbsNeut-5.85 AbsLymp-0.40* AbsMono-1.22*
AbsEos-0.21 AbsBaso-0.04
___ 06:24PM ___ PTT-35.0 ___
___ 06:24PM PLT COUNT-269
___ 06:10PM GLUCOSE-88 UREA N-11 CREAT-0.6 SODIUM-138
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-26 ANION GAP-17
___ 06:10PM ALT(SGPT)-47* AST(SGOT)-77* ALK PHOS-966* TOT
BILI-2.4*
___ 06:10PM LIPASE-9
___ 06:10PM ALBUMIN-3.5 CALCIUM-9.4 PHOSPHATE-4.0
MAGNESIUM-1.9
Brief Hospital Course:
The patient was admitted to the ___ surgery
service on ___ for evaluation and workup of her
fevers/chills. She was initially kept NPO and was started on
___ for presumed bacteremia/cholangitis. The hepatology
service was consulted and recommended that the patient start
Ursodiol BID, which the patient began taking on this admission.
It was felt that there was no indication for a liver biopsy at
this time. The infectious disease service was consulted and
recommended that the patient receive ___ antibiotics
(___) if GI/biliary manipulation was anticipated to
prevent further episodes of bacteremia and systemic symptoms.
The patient's empiric antibiotics were held for the remainder of
her hospital course. The ERCP service was consulted in regards
to the patient's initial cholangitic picture. The patient would
undergo enteroscopy on ___, which the patient tolerated well
without any complications. She was kept NPO/IVFs for the
procedure. The enteroscopy revealed a duodeno-jejunal
anastomosis that was normal with no evidence of anastomotic
stricture. The enteroscope was advanced into the afferent
(pancreatobiliary) limb measured length approximately 40 cm. The
choledoco-jejunal anastomosis was identified and PTBD stent was
seen, the H-J anastomosis was widely opened after ___
intervention. Status post procedure, the patient resumed her
regular diet and have an uneventful hospital course. She had no
further episodes of fevers, chills, or systemic symptoms. At
discharge, the patient was tolerating a regular diet, ambulating
independently, and her pain was well-controlled.
Medications on Admission:
- Acetaminophen 1000 mg PO/NG Q8H:PRN pain
- Creon 12 3 CAP PO/NG TID W/MEALS
- Calcium Replacement (Oncology) IV Sliding Scale
- Enoxaparin Sodium 50 mg SC Q12H
- HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN pain
- Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Creon 12 6 CAP PO TID W/MEALS
3. Ursodiol 300 mg PO BID
RX *ursodiol 300 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless
specifically advised not to take a particular medication. Also,
please take any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
___ JP Orders:
JP Drain Care: To bulb suction. Cleanse insertion site with
mild soap and water or sterile saline, pat dry, and place a
drain sponge daily and PRN. Monitor and record quality and
quantity of output. Empty bulb frequently. Ensure that the JP is
secured to the patient.
Monitor for s/s infection or dislocation.
.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or ___ strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
___ Drain Care Rx:
Drain Catheter: To gravity drainage. Cleanse insertion site
with ___ strength hydrogen peroxide and rinse with saline
moistened q-tip or with mild soap and water. Apply a drain
sponge if needed. Change dressing daily and as needed. Monitor
for s/s infection or dislocation. Check the patency of tube and
that the tube and drainage bag are secured to the patient.
Monitor and record quality and quantity of output.
Followup Instructions:
___
|
19865976-DS-11 | 19,865,976 | 20,563,840 | DS | 11 | 2148-05-09 00:00:00 | 2148-05-09 08:47:00 |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
___ Cardiac catheterization
___ Coronary artery bypass grafting x2 with a left internal
mammary artery graft to left anterior descending and reverse
saphenous vein graft to the right coronary artery.
History of Present Illness:
___ year old male that developed dyspnea while moving furniture
few days prior to presentation which resolved with rest. Noted
___ chest pain but neck pain radiating to right arm. The dyspnea
progressively worsened and he presented to OSH ED.
Past Medical History:
Coronary artery disease s/p STEMI ___ ___
Developmental delay
Anxiety
Herpes Zoster
Vein stripping left leg
Additional procedures to right leg for varicose veins
Social History:
___
Family History:
family history of diabetes
father with quadruple bypass surgery at ___ at age ___
mother with triple bypass at age ___ (now deceased)
3 older siblings - ___ known heart issues
Physical Exam:
Pulse: 60 Resp: 16 O2 sat: 98 RA
B/P ___
Height: 68.9 inches Weight: 144 pounds
General: ___ acute distress resting in bed
Skin: Dry [x] intact [x] brown areas right ankle that he states
are from vein procedures
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] ___ hepatomegaly
Extremities: Warm [x] Edema trace
Varicosities: mild
Neuro: Alert and oriented x3 ___ focal deficits poor recall
Pulses:
Femoral Right: +2 Left: +2
DP Right: +1 Left: +1
___ Right: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: ___ bruit Left: ___ bruit
Discharge Examination
___ 94 RA discharge wt 64.8 kg
Alert and oriented x3 ___ focal deficits
RRR ___ murmur or rub
CTA ___ wheezes or rhonchi
Abd soft NT ND + BS BM ___dema
Sternal and right leg incision healing ___ erythema or drainage
Pertinent Results:
___ Cardiac cath: Dominance: Right
The proximal LAD has minor irregularities in the proximal
portion but was occluded within the stent in the mid vessel. The
distal LAD filled by left to left collaterals.
There was a large diagonal branch without disease. A second
diagonal branch filled by collateral.
LCx had a 40% stenosis in its proximal portion. There was a OMB1
without disease. The OMB2 had a subtotal occlusion and filled by
lefft to left collaterals. The distal RCA was a small vessel.
RCA was a hyperdominant vessel. There was an 80% stenosis in the
proximal RCA that extended for a 50-60% stenosis in the mid RCA.
The PDA had ___ lumen irregularities that supplied collaterals to
the apical LAD. There was a cascade of posterolateral branches
without disease.
.
___ Vein mapping
Bilaterally patent greater saphenous and small saphenous veins
with
measurements as indicated above. And the left leg, there are
multiple varicosities in the calf and in the thigh.
.
___ Echo: Pre-CPB:
___ spontaneous echo contrast is seen in the left atrial
appendage. Overall left ventricular systolic function is mildly
depressed (LVEF= 45 - 50 %). with borderline normal free wall
function. There is mild infero-septal HK.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and ___ aortic stenosis or aortic
regurgitation. 1+ mitral regurgitation is seen. 1+ TR is seen.
There is ___ pericardial effusion.
Post-CPB: The patient is in SR, on ___ inotropes. Unchanged
biventricular systolic fxn, Mild MR ___ AI. Aorta intact.
CXR ___
Interval removal of right IJ central venous catheter. The lungs
are well
expanded and clear. The hila and pulmonary vasculature are
normal. Left
pleural effusion is mild. ___ right-sided pleural effusion. ___
pneumothorax. The cardiomediastinal silhouette is stable.
IMPRESSION:
Small left pleural effusion. Otherwise ___ acute cardiopulmonary
process
Labs
___ 03:44AM BLOOD WBC-7.0 RBC-4.10* Hgb-12.5* Hct-35.3*
MCV-86 MCH-30.5 MCHC-35.4 RDW-13.7 RDWSD-43.1 Plt ___
___ 10:25AM BLOOD WBC-5.4 RBC-5.18 Hgb-15.5 Hct-45.2 MCV-87
MCH-29.9 MCHC-34.3 RDW-13.9 RDWSD-43.6 Plt ___
___ 02:47AM BLOOD ___ PTT-29.6 ___
___ 02:40PM BLOOD ___ PTT-31.1 ___
___ 01:51PM BLOOD ___
___ 03:44AM BLOOD Glucose-113* UreaN-11 Creat-0.5 Na-133
K-4.0 Cl-95* HCO3-31 AnGap-11
___ 02:40PM BLOOD Glucose-108* UreaN-9 Creat-0.6 Na-139
K-4.7 Cl-104 HCO3-23 AnGap-17
___ 03:44AM BLOOD ALT-27 AST-18 LD(LDH)-169 CK(CPK)-41*
TotBili-0.9
___ 05:45AM BLOOD %HbA1c-4.8 eAG-91
Brief Hospital Course:
Transferred from outside hospital for cardiac evaluation which
include cardiac catheterization that revealed coronary artery
disease. Cardiac surgery was consulted and he underwent
preoperative workup. On ___ he was brought to the operating
room where he underwent a coronary artery bypass graft surgery.
Please see operative report for further details. Post
operatively he was taken to the intensive care unit for
management. That evening he was weaned from sedation, awoke at
baseline, and was extubated without complications. Post
operative day one he was started on betablockers and diuretics.
He continued to progress and was transitioned to the floor.
Chest tubes and epicardial wires were removed per protocol. He
worked with physical therapy on strength and mobility. He
continued to progress and was ready for discharge home on post
operative day four with services.
Medications on Admission:
Atorvastatin 80 mg daily
Aspirin 81 mg daily
Lisinopril 5 mg daily
Toprol XL 100 mg daily
Lorazepam 0.5 qhs prn sleep as per pcp records
Discharge ___:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Atorvastatin 80 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Metoprolol Tartrate 75 mg PO Q8H
RX *metoprolol tartrate 75 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*90 Tablet Refills:*1
5. Miconazole Powder 2% 1 Appl TP BID groin Duration: 7 Days
please clean with soap and water and dry thoroughly before
applying powder
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain:
moderate/severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY
hold for diarrhea
RX *polyethylene glycol 3350 [Miralax] 17 gram 17 powder(s) by
mouth once a day Disp #*3 Packet Refills:*0
8. Ranitidine 150 mg PO DAILY Duration: 1 Month
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
9. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary artery disease s/p coronary revascularization
Secondary diagnosis
Developmental delay
Anxiety
Herpes Zoster
Vein stripping left leg
Additional procedures to right leg for varicose veins
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Oxycodone and acetaminophen
Incisions:
Sternal - healing well, ___ erythema or drainage
Leg Right - healing well, ___ erythema or drainage.
Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, ___ baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please ___ 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
___ 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
___ lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
19866116-DS-18 | 19,866,116 | 23,725,879 | DS | 18 | 2150-03-26 00:00:00 | 2150-03-28 17:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea, palpitations, chest pressure, fatigue
Major Surgical or Invasive Procedure:
TEE, MITRAL VALVE ATTEMPTED REPAIR (30MM ___
ANNULOPLASTY BAND), REPLACEMENT WITH 29MM ___ ___
BIOPROSTHETIC VALVE ; BIATRIAL MAZE, CRYO THEREPY; LEFT ATRIAL
APPENDAGE LIGATION WITH ATRICLIP (35MM) ___
History of Present Illness:
Ms. ___ is a ___ female, without significant
cardiac history or risk factors, who presents with 3 days of
worsening shortness of breath.
She reported that about a week ago, she started feeling
fatigued.
She thought she was developing a cold, though denied cough,
fever, chills. Her fatigued persisted, though about three days
ago she developed acute SOB. Dyspnea persisted even when lying
down and she required pillows to prop her up. Though still had
poor sleep. She felt limited on ambulation due to dyspnea. Also,
endorsed new palpitations and that her heartbeat felt irregular.
On ___, she had "chest heaviness" and pressure that was not
changed with breathing, lasted several hours and seemed to
radiate to neck. The chest pressure improved, though SOB
remained limiting and so she presented to ___ on
___.
At ___, found to be in CHF with a new mitral egurgitation
murmur. BNP was elevated. CT showed evidence of bilateral
pleural effusions as well as possible infiltrates. Was given
Levaquin 750 mg, ASA 325 mg, enoxaparin 60 mg, metoprolol 12.5
mg, and was treated for nausea with Zofran and Phenergan.
Patient was transferred to ___ for cardiac evaluation.
In the ED initial vitals were T 98.8 HR 102 BP 97/61 RR 16 O2
sat 94% 3L NC. EKG showed sinus rhythm, normal axis and
intervals, STD in anterolateral leads. Labs/studies notable for
BNP>6000, bicarb 19, ALT/AST 127/56, INR 1.3, trop 0.02, and Hgb
10.8, lactate 1.4.
Patient denied headache, vision changes, sore throat, cough,
runny nose, fever, aches/pains, chest pain, abdominal pain,
bowel habit changes, or dysuria.
Patient was not given any medications prior to transfer to the
floor.
Past Medical History:
Endometrial cancer s/p resection ___ (no chemotherapy)
Mitral regurgitation
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: T 97.6 BP 100/64 HR 110 RR 16 O2 sat 96% 3l
___: Well developed, well nourished in NAD on nasal
cannula.
Oriented x3. Mood, affect appropriate.
HEENT: Atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva
were pink. No pallor or cyanosis of the oral mucosa.
NECK: JVP elevated to angle of jaw.
CARDIAC: Tachycardia, regular rhythm. Normal S1, S2. IV/VI
systolic murmur loudest at apex and radiates to back. No rubs,
or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Bibasilar crackles. No
wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM:
==========================
___: NAD [x]
Neurological: A/O x3 [x] non-focal [x]
HEENT: PEERL [x]
Cardiovascular: RRR [x] Irregular [] Murmur [] Rub []
Respiratory: Clear with decreased bases [x] No resp distress
[x]
GI/Abdomen: Bowel sounds present-normoactive [x] Soft [x] ND [x]
NT [x]
Extremities:
Right Upper extremity Warm [] Edema
Left Upper extremity Warm [] Edema
Right Lower extremity Warm [x] Edema tr
Left Lower extremity Warm [x] Edema tr
Pulses:
DP Right:1 Left:1
___ Right:1 Left:1
Radial Right:1 Left:1
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI [x] no erythema[x] no drainage [x]
Sternum stable [x]
Pertinent Results:
IMAGING/STUDIES:
==================
___ TTE
CONCLUSION:
The left atrial volume index is moderately increased. A
prominent Eustachian valve is seen in the right atrium (normal
variant). There is no evidence for an atrial septal defect by
2D/color Doppler. The estimated right atrial pressure is
>15mmHg. 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%. Due to severity of
mitral regurgitation, intrinsic left ventricular systolic
function is likely lower. Left ventricular cardiac index is low
normal (2.0-2.5 L/ min/m2). There is no resting left ventricular
outflow tract gradient. No ventricular septal defect is seen.
Normal right ventricular cavity size with normal free wall
motion. The aortic sinus diameter is normal
for gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal with a normal descending aorta
diameter. The aortic valve leaflets (3) appear structurally
normal. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets are mildly thickend and myxomatous with
partial posterior leaflet flail. Torn mitral valve chordae are
seen. There is an eccentric, interatrial septum directed jet of
SEVERE [4+] mitral regurgitation. Due to the Coanda effect, the
severity of mitral regurgitation could be UNDERestimated. The
pulmonic valve leaflets are normal. There is mild pulmonic
regurgitation. The tricuspid valve leaflets appear structurally
normal with systolic prolapse. There is moderate [2+] tricuspid
regurgitation. There is moderate to severe pulmonary artery
systolic hypertension. There is a trivial pericardial effusion.
A right pleural
effusion is present
IMPRESSION: Partial flail posterior mitral leaflet with mobile
echodensity that is most likely chordal tear given underlying
severe prolapse but a vegetation cannot be excluded on the basis
of this study alone (? are there positive blood cultures/fever
to support endocarditis). There is severe eccentric mitral
regurgitation. Hyperdynamic left ventricle (intrinsic function
reduced due to the MR). Tricuspid valve prolapse with moderate
tricuspid regurgitation. Moderate pulmonary hypertension. No
prior study is available for comparison.
FINDINGS:
LEFT ATRIUM ___ VEINS: Moderately increased ___ volume
index.
RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC):
Normal RA
size. Prominent Eustachian valve (normal variant). No atrial
septal defect by 2D/color Doppler. Dilated IVC with reduced
inspiratory collapse==>RA pressure >15 mmHg.
LEFT VENTRICLE (LV): Normal wall thicknesses. Normal cavity
size. Normal regional/global systolic function. The visually
estimated left ventricular ejection fraction is >=70%. Intrinsic
LVEF likely lower due to severity of mitral regurgitation. Low
normal cardiac index (2.0-2.5 L/min/m2). No
ventricular septal defect. No resting outflow tract gradient.
RIGHT VENTRICLE (RV): Normal cavity size. Normal free wall
motion.
AORTA: Normal sinus diameter for gender. Normal ascending
diameter for gender. Normal arch diameter. Normal descending
aorta. Focal calcifications in aortic sinus.
AORTIC VALVE (AV): Normal/thin (3) leaflets. No stenosis. No
regurgitation.
MITRAL VALVE (MV): Mildly thickened/myxomatous leaflets. Partial
posterior leaflet flail. Mild MAC. Torn chordae present. Severe
[4+] regurgitation. Interatrial septal directed regurgitant jet.
Regurgitation severity could be UNDERestimated due to Coanda
effect.
PULMONIC VALVE (PV): Normal leaflets. Mild regurgitation.
TRICUSPID VALVE (TV): Normal leaflets. Systolic prolapse
present. Moderate [2+] regurgitation. Moderate to severe
pulmonary artery systolic hypertension.
PERICARDIUM: Trivial effusion.
PLEURAL EFFUSION/ASCITES: Right pleural effusion.
EXAMINATION: UNILAT LOWER EXT VEINS LEFT ___
INDICATION: ___ year old woman with s/p MVR/MAZE// DVT-acute LLE
pain
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation
was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral
doppler of the left common femoral, femoral, and popliteal
veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and
peroneal veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
EXAMINATION: CHEST (PA AND LAT) ___
INDICATION: ___ year old woman s/p MVR eval for ptx interval
change
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Pulmonary edema has improved. Bilateral effusions are
unchanged.
Cardiomediastinal silhouette is stable. No pneumothorax is
seen.
MEASUREMENTS:
LEFT ATRIUM ___ ATRIUM (RA)
___ Ejection
Velocity:
0.20m/
sec
(>0.55)
LEFT VENTRICLE (LV)
Pre-op TEE Visual Ejection
Fraction:
55-60% (nl
M:52-72;F:54-74)
AORTIC VALVE (AV)
LV Outflow Tract
(LVOT) Diam:
1.9cm
MITRAL VALVE (MV)
C-Septal Distance: 2.5cm
Anterior Leaflet Length: 2.7cm
EMR 2853-P-IP-OP (___) Name: ___ MRN: ___
Study Date: ___ 11:20:00 p. ___
THORACIC AORTA/PULMONARY ARTERY (PA)
Annulus: 2.0cm
Sinus: 3.0cm (nl M<4.1;F<3.7)
Sinus Index: 2.0cm/
m2
(nl M<2.2;F<2.3)
Sinotubular Junction: 2.2cm
Ascending: 3.2cm (nl M<3.9;F<3.6)
Ascending Index: 2.2cm/
m2
(nl M<2.0;F<2.3)
Arch: 2.4cm (nl<=3.0)
Descending: 2.2cm (nl<=2.5)
Posterior Leaflet
Length:
1.6cm
TRICUSPID VALVE (TV)
Annular Diameter: 4.0cm
FINDINGS:
ADDITIONAL FINDINGS: 3D Imaging rendering with interpretation
and reporting with image post
processing under concurrent supervision; requiring an
independent workstation. No TEE related
complications.
PRE-OPERATIVE STATE: Pre-bypass assessment. Sinus rhythm.
Left Atrium ___ Veins: No spontaneous echo contrast
or thrombus in the ___.
Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC):
Normal RA size. No atrial septal
defect by 2D/color flow Doppler. Negative bubble study for PFO
at rest (Valsalva not performed).
Left Ventricle (LV): Normal cavity size. Normal regional &
global systolic function. Intrinsic function may be
underestimated due to the severity of mitral regurgitation.
Right Ventricle (RV): Mild cavity dilation. Mild hypokinesis of
the mid free wall and apex; preserved basal contractility.
Aorta: Normal sinus diameter. Normal ascending diameter. Normal
arch diameter. Normal descending aorta diameter. No dissection.
Aortic Valve: Thin/mobile (3) leaflets. No stenosis. Trace
regurgitation.
Mitral Valve: Moderately thickened/myxomatous leaflets. Partial
posterior leaflet flail of P2 extending to P1 with visible torn
chords. Prolapse of the P1 segment. No stenosis. Mild posterior
annular calcification along P2. SEVERE [4+] regurgitation with
systolic flow reversal the pulmonary veins. Eccentric,
anteriorly directed jet.
Tricuspid Valve: Mildly thickened/myxomatous leaflets. Moderate
[2+] septally-directed regurgitation.
No systolic hepatic venous flow reversal.
Pericardium: Very small posterior effusion.
Miscellaneous: Left pleural effusion.
POST-OP STATE: The post-bypass TEE was performed at 15:15:00.
After initial separation from
cardiopulmonary bypass, there was severe mitral regurgitation
secondary to systolic anterior motion of
the repaired mitral valve. The patient was receiving milrinone,
vasopressin, and epinephrine 0.03 mcg/
kg/min at the time. Despite increasing preload and afterload,
discontinuing epinephrine, and slowing the
heart rate, significant ___ and MR remained, so the decision was
made to return to bypass for valve
replacement.
The findings after the second bypass run are as follows:
Rhythm: AV paced rhythm intially, transitioned to Atrial pacing.
Support: Vasopressor(s): epinephrine (weaned off over course of
exam), norepinephrine, milrinone, vasopressin
Left Ventricle: Preserved ejection fraction on noted support.
Abnormal septal motion consistent with
postoperative state (more prominent with AV pacing).
Right Ventricle: Right ventricular function is now low normal
(in the setting of inotropes).
Aortic Valve: No change in aortic valve morphology from
preoperative state. No change in aortic regurgitation.
Mitral Valve: Bioprosthesis. Well-seated prosthesis. Normal
leaflet motion. Post-bypass, mean mitral valve gradient = 3mmHg.
Normal gradient for prosthesis. Trace valvular regurgitation
(normal for
prosthesis). No paravalvular leak.
Tricuspid Valve: Intiially moderate after separation from
bypass, decreasing to mild [1+] valvular regurgitation at the
end of the case.
Pericardium: No effusion.
PA LAT: IMPRESSION: Pulmonary edema has improved. Bilateral
effusions are unchanged. Cardiomediastinal silhouette is stable.
No pneumothorax is seen.
___:56AM BLOOD WBC-9.6 RBC-3.00* Hgb-9.5* Hct-29.0*
MCV-97 MCH-31.7 MCHC-32.8 RDW-14.0 RDWSD-49.0* Plt ___
___ 05:00AM BLOOD ___
___ 04:56AM BLOOD Glucose-106* UreaN-14 Creat-0.6 Na-136
K-4.9 Cl-96 HCO3-28 AnGap-12
Brief Hospital Course:
The patient was transferred from ___ and was
admitted to the ___ service. She was started on diuretics and
blood cultures were sent. She underwent cardiac cath which
showed clean coronaries. She triggered for atrial fibrillation
at a rapid rate and was transferred to the CCU. She underwent
MVR(29mm ___ tissue ___ ligation on ___.
She tolerated the procedure well and was transferred to the
CVICU in stable condition.
On POD#1 she was extubated and the pressors were weaned off. Her
chest tubes and epicardial pacing wires were discontinued. She
had small bilateral pneumothoraces which resolved on follow up
chest xray. She had an accelerated junctional rhythm and was
evaluated by EP service. She will go home with ___ of hearts
monitor on Toprol 12.5 PO Daily per EP recommendations. Per Dr.
___ anticoagulation required as there was only a single
episode of AF pre-op.
The patient was neurologically intact and remained
hemodynamically stable. The patient was gently diuresed toward
the preoperative weight. The patient was transferred to the
telemetry floor for further recovery. She remained in the
hospital on POD 8 for orthostasis. Lasix was dc'd and
orthostasis resolved. The patient was evaluated by the Physical
Therapy service for assistance with strength and mobility. By
the time of discharge on POD 9 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home with ___ services
in good condition with appropriate follow up instructions
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin EC 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. 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 #*20 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 2 tablet(s) by mouth once a day
Disp #*60 Tablet Refills:*0
6. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth four times a day Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
mitral valve regurgitation with flail leaflet
atrial fibrillation
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
No Edema
Discharge Instructions:
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
19866174-DS-6 | 19,866,174 | 25,506,151 | DS | 6 | 2164-01-18 00:00:00 | 2164-01-18 21:23:00 |
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, right leg swelling
Major Surgical or Invasive Procedure:
Cardiac Catheterization:
Hemodynamics:
PA sys 50 dys 21 mean 31
PCW A wave 22 V wave 21 mean 18
RA A wave 15 V wave 13 mean 11
LMCA had no significant stenosis
LAD had mid 90% and distal 70% lesions
Circumflex had no significant stenosis
RCA had 90% proximal and 50% mid to distal stenosis
Impressions:
1. Severe 2 vessel CAD
2. Successful ___
3. Successful ___ x 2 lesions
Recommendations:
1. Aspirin 325 mg daily x 1 month and then 81 mg daily
2. Plavix 75 mg daily x minimul ___ year
History of Present Illness:
___ s/p aortic and mitral valve replacement at ___
___ in ___ (she had two vessel disease that was not
revascularized during surgery due to poor conduit) now with
severe bioprosthetic AI presents with painful RLE with swelling
and redness. This started 3 days ago, denies fevers.
Re her cardiac history she has had dyspnea on exertion for years
and over the past few weeks it has worsened. She has had repair
of the aortic and mitral valves about ___ yrs ago at ___ and
when she started having dyspnea she had an Echocardiogram on
___ which demonstrated preserved left ventricular function
and severe aortic regurgitation, aortic valve bioprosthesis peak
and mean gradients of 45mmHg and 27mmHg, respectively. The
mitral valve appeared well-seated. There was mild mitral and
tricuspid regurgitation. Nuclear stress test on ___ did not
demonstrate any evidence of myocardial ischemia or infarction.
On ___ given her recent dyspnea there was concern for
bioprosthetic aortic insufficiency so she was evaluated by Dr.
___ not to be a candidate for redo surgery given
risk and recommended TAVR.
Per cardiac surgery note Patient was seen by Dr. ___ on ___
this week though note not available at this time. She was found
to have leaking aortic valve and plan is replacement within 3
weeks.
Over the past few weeks her weight has increased from a dry wt
of 140 to 160 today. She denies orthopnea and reports chronic ___
edema unchanged compared to baseline. Review of systems is
negative for fevers, chills, chest pain, abdominal pain, nausea,
vomiting, diarrhea. She has had no dietary changes.
In the ED initial vitals were: 98.3 68 155/53 16 93% ra
- Physical exam in ED was notable for reddened painless RLE
above mallelolus 5cm, no JVD.
- Labs were significant for grossly positive u/a, INR 5.4, K5.3,
___ 38,964, wbc 8.6.
- ECG with RBBB unchanged from prior, no ishemia
- CXR showed cardiomegaly and small bilateral effusions with
mild pulmonary edema with left lung opacity potentially
atelectasis or fluid in the fissure although superimposed
infection is possible.
- Patient was given: IV Furosemide 80 mg Doxycycline Hyclate 100
mg Cephalexin 500 mg
Vitals prior to transfer were: Today 20:25 0 69 168/54 24 95% RA
On the floor she is in no distress
Review of Systems: (+) per HPI
Past Medical History:
Bioprosthetic Aortic Insufficiency
aortic and mitral valve replacement at ___ in
___. Of note, she had two vessel disease that was not
revascularized during surgery due to poor conduit
Depression
Amblyopia
Cataract
Deep Vein Thrombosis
Glaucoma
Gout
Hyperlipidemia
Hypertension
Onychomycosis
Pulmonary Hypertension
Past Surgical History:
Carpal Tunnel Release, bilateral
Hysterectomy
Pilonidal cyst
Past Cardiac Procedures:
Bioprosthetic aortic and mitral valve replacement ___
Social History:
___
Family History:
Father - unknown
Mother - heart problems
Siblings - heart problems
Physical Exam:
ADMISSION PHYSICAL:
=========================
Vitals: 73 kg 97.4 184/88 69 94% ra
GENERAL: NAD appears dyspneic
NECK:elev JVP at 12
CARDIAC: RRR, loud III/VI diastolic murmur with a stridorous
component
LUNG: crackles at bases
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 2+ ___ edema RLE with area of redness that is
weaping
DISCHARGE PHYSICAL:
=========================
Vitals: 97.6, 137/58 (116-140 SBP), 80s-100s, 18, 96 on RA
Weight on admission: 72.7 kg (standing)
DISCHARGE WEIGHT: 63.5 kg
General: well appearing (younger than stated age) female in NAD,
pleasant and interactive
Neck: JVP to mid-neck at 90 degrees
Lungs: clear to auscultation bilaterally, good air movement
CV: RRR, ___ systolic murmur, ___ diastolic murmur
Abdomen: +BS, soft, NT/ND
Ext: wwp, trace to 1+ edema bilaterally to upper calf
Pertinent Results:
ADMISSION LABS:
===============================
___ 05:45PM BLOOD WBC-8.6 RBC-4.42 Hgb-14.2 Hct-42.0 MCV-95
MCH-32.1* MCHC-33.8 RDW-14.1 Plt ___
___ 05:45PM BLOOD Neuts-70.8* ___ Monos-5.7 Eos-2.9
Baso-0.6
___ 06:13PM BLOOD ___ PTT-47.4* ___
___ 05:45PM BLOOD Glucose-181* UreaN-19 Creat-0.9 Na-133
K-6.3* Cl-96 HCO3-27 AnGap-16
___ 05:45PM BLOOD ___
___ 05:45PM BLOOD cTropnT-0.04*
___ 05:45PM BLOOD Calcium-10.3 Phos-3.0 Mg-1.9
DISCHARGE LABS:
===============================
___ 06:26AM BLOOD WBC-9.1 RBC-3.91* Hgb-12.7 Hct-37.2
MCV-95 MCH-32.5* MCHC-34.1 RDW-13.8 Plt ___
___ 06:26AM BLOOD ___ PTT-70.9* ___
___ 06:26AM BLOOD Glucose-105* UreaN-15 Creat-0.9 Na-139
K-4.7 Cl-104 HCO3-25 AnGap-15
___ 06:40AM BLOOD Mg-2.0
___ 01:00AM BLOOD CK-MB-3 cTropnT-0.22*
___ 06:26AM BLOOD CK-MB-3 cTropnT-0.20*
STUDIES:
===============================
CXR (___):
IMPRESSION:
Cardiomegaly and small bilateral effusions with mild pulmonary
edema. Left lung opacity potentially atelectasis or fluid in the
fissure although superimposed infection is possible.
ECHOCARDIOGRAM - TTE (___):
The left atrium is dilated. The estimated right atrial pressure
is at least 15 mmHg. The left ventricular cavity is moderately
dilated. There is severe global left ventricular hypokinesis
(LVEF = 25 %). The right ventricular free wall is hypertrophied.
The right ventricular cavity is moderately dilated with moderate
global free wall hypokinesis. There are focal calcifications in
the aortic arch. A bioprosthetic aortic valve prosthesis is
present. Moderate to severe (3+) aortic regurgitation is seen. A
bioprosthetic mitral valve prosthesis is present. The
transmitral gradient is normal for this prosthesis. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The tricuspid valve leaflets fail to fully
coapt. Severe [4+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. [In the setting
of at least moderate to severe tricuspid regurgitation, the
estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] The
pulmonic valve leaflets are thickened. Significant pulmonic
regurgitation is seen. There is no pericardial effusion.
ECHOCARDIOGRAM - TEE (___):
Mild spontaneous echo contrast is seen in the body of the left
atrium. No atrial septal defect is seen by 2D or color Doppler.
LV systolic function appears depressed. Right ventricle with
mild global free wall hypokinesis. There are simple atheroma in
the descending thoracic aorta. A bioprosthetic aortic valve
prosthesis is present. The prosthetic aortic valve leaflets
appear normal No masses or vegetations are seen on the aortic
valve. Trace aortic regurgitation is seen. A bioprosthetic
mitral valve prosthesis is present. The motion of the mitral
valve prosthetic leaflets appears normal. No mass or vegetation
is seen on the mitral valve. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: No intracardiac mass or valvular vegetations seen.
Well-seated aortic valve bioprosthesis with trace aortic
regurgitation. Well-seated mitral valve bioprosthesis with trace
mitral regurgitation. Moderate tricuspid regurgitation.
Brief Hospital Course:
Patient is a ___ s/p aortic and mitral valve replacement at
___ in ___ now with severe
bioprosthetic AI presents with cellulitis and signs of
decompensated heart failure. She was found to have Strep
viridans bacteremia and was kept in the hospital for diuresis
and TAVR evaluation.
# Acute on chronic systolic CHF: Pt has had chronic dyspnea for
the past year related to severe bioprosthetic AI and she feels
her dyspnea has worsened over the past ___ months. Admission
exam notable for volume overloaded state (elevated JVP,
crackles, ___ edema), ___ 38___, and CXR showed pulmonary
edema. Pt has gained weight (admission weight 72.7 kg up from
dry weight 63.6 kg). Etiology for progressive decompensation is
most likely severe AI.
-TTE showed EF 25%, moderate to severe AR, severe TR,
significant PR
-Diuresed with lasix 80 mg IV ___. Changed to torsemide 40
mg daily for discharge.
-Changed atenolol to carvedilol and increased losartan for
afterload reduction. Added spironolactone 25 mg daily
-Discharge weight: 63.5 kg
#CAD: As part of TAVR workup, patient recieved a cardiac cath
that showed disease in RCA ___ 1) and LAD ___ 2).
Post-procedurally, patient had bradycardia which resolved with
atropine x1. No further bradycardia outside of cath lab.
-Aspirin 325 mg daily x 1 month then 81 mg daily.
-Plavix 75 mg daily x minimum ___ year.
-Losartan and carvedilol as above. Increased atorvastatin to 80
mg daily.
# Bioprosthetic AI: Pt was evaluated by C-surgery on ___ and
given age, fraility it was felt she was not a surgical candidate
for redo and it was recommended she be referred to Dr ___
TAVR consideration. Patient received a cardiac cath (see above)
and a carotid ultrasound. She will see Dr. ___ in ___ for
discussion of TAVR.
# Patient presented with RLE cellulitis and BCx grew Strep
viridans in ___ bottles. Consulted ID, who felt it was not safe
to assume this was a contaminant, recommended a TEE ___,
negative for vegetations) and treatment with IV ceftriaxone x 2
weeks (last day ___. Repeat BCx were negative.
# ___ Records:
-___ TTE: mild ___, LVEF 60%, RVEF normal,
Bioprosthetic valve in aorta well positioned. Moderate AI.
Bioprosthetic valve well seated in mitral position. trace MR.
___ TR, PASP elevated at 47mm mercury
-___ cath: LMCA minimal disease, LAD with discrete eccentric
50-70% lesion, Circ minimal disease, RCA discrete complex ___
lesion
-___: LENIS: patient with PE following cardiac valve
replacement also with DVT of right soleal vein and DVT of left
peroneal and soleal veins.
# Anticoagulation: Pt appears to be on anticoagulation for prior
DVT/PE vs. bioprosthetic valves. After discussion with PCP,
there was not a clear reason for long-term anticoagulation,
especially given ASA and Plavix now. Warfarin was stopped.
TRANSITIONAL ISSUES:
[ ] Patient will need close titration of home diuretics.
Consider decreasing to torsemide 20 mg daily if she persistently
loses weight in the next few days.
[ ] Last dose Ceftriaxone ___
[ ] ASA 325 mg daily should be decreased to 81 mg daily after 1
month, ___
[ ] Please repeat chem 7 on ___ for potassium and creatinine
monitoring given addition of spironolactone and torsemide
[ ] Further evaluation for TAVR per Dr. ___
[ ] Emergency Contact: ___ (daughter - ___
and/or
___ (son - ___. Full Code.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
2. Lorazepam 0.5 mg PO QHS
3. Atenolol 100 mg PO DAILY
4. Atenolol 50 mg PO HS
5. Diltiazem Extended-Release 180 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Warfarin 5 mg PO DAILY16
8. Atorvastatin 10 mg PO QPM
9. Ferrous Sulfate 325 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. travoprost 0.004 % ophthalmic hs
12. Omeprazole 20 mg PO BID
13. Aspirin 81 mg PO DAILY
14. Venlafaxine XR 112.5 mg PO DAILY
15. Sertraline 150 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Diltiazem Extended-Release 180 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Lorazepam 0.5 mg PO QHS
RX *lorazepam 0.5 mg 1 tablet by mouth at bedtime Disp #*14
Tablet Refills:*0
7. Losartan Potassium 100 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO BID
10. Sertraline 150 mg PO DAILY
11. Venlafaxine XR 112.5 mg PO DAILY
12. Carvedilol 12.5 mg PO BID
13. CeftriaXONE 2 gm IV Q24H
Last day is ___. Clopidogrel 75 mg PO DAILY
15. Spironolactone 25 mg PO DAILY
16. Torsemide 40 mg PO DAILY
17. travoprost 0.004 % ophthalmic hs
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
acute systolic congestive heart failure
SECONDARY:
aortic insufficiency
bacteremia
coronary artery 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 admitted to the hospital for leg redness and swelling.
Your redness was because of a skin infection (cellulitis) while
the swelling in both of your legs was from fluid overload due to
heart failure. This means your heart was not pumping as
effectively as it had been and fluid went into your legs and
your lungs. We gave you a medicine (called a diuretic) to make
you urinate in order to remove the fluid. You will continue to
take a new medication, torsemide, as an outpatient to prevent
fluid build up. You should weigh yourself every day and call
your doctor if your weight goes up by more than 3 lbs.
Your heart failure is probably caused by a leaky valve (the
aortic valve) in your heart. There is a procedure where a new
valve can be placed over the leaky one called TAVR ("taver" or
transcutaneous aortic valve replacement). Our TAVR team wanted
to determine if you would be a good candidate for this procedure
so you also had an ultrasound of your heart and a
catheterization to take a picture of the coronary arteries
surrounding your heart. There were several areas in these
arteries that were narrow and at risk for causing a heart attack
so stents were placed in the arteries to keep them open and
allow good blood flow to your heart.
Unfortunately, when we checked your blood for an infection, it
grew a bacteria called Strep viridans. We are giving you an IV
antibiotic for this (called ceftriaxone) which you will take
through your ___ line until ___. Your rehab facility will
continue this medicine.
Because you had stents placed, you will have to take a new
medicine called Plavix (or clopidogrel) to prevent the stents
from getting blood clots. We are also starting you on two water
pills (or diuretics) called torsemide and spironolactone to help
prevent fluid from building up in your body. We also stopped
your Coumadin because it is no longer needed. All of your
medication changes are listed in your discharge medication list.
We have scheduled follow up appointments with your primary care
doctor, ___, and our TAVR team (specialty
cardiologists) to discuss a valve replacement to make your fluid
overload and breathing better. The appointment details are
below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19866267-DS-20 | 19,866,267 | 23,331,401 | DS | 20 | 2116-05-20 00:00:00 | 2116-05-23 15:22:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left heel ulcer
Major Surgical or Invasive Procedure:
___: Left BKA
History of Present Illness:
___ with b/l fem-pop bypasses ___ years ago) who was
previously doing well until late ___ when she developed R ___
toe blister that gradually worsened. As a result of offloading
her right foot, she overused the left and developed a left heel
ulcer. She ultimately underwent an angiogram with Dr ___ on
___ that showed patent inflow and a stenosis of the R CFA at
the level of the anastomosis with the fem-pop graft; an
angioplasty was done here. On the left side she had patent
inflow
and graft with outflow into a diminutive anterior tibial artery,
an occluded personal and ___, with areas of the peroneal that
were
patent; there was minimal good flow to the ankle. On ___,
she
underwent a R fourth ray amputation and excisional debridement
of
the left heel. She saw Dr ___ in follow up on ___, at
which
time the left heel was further debrided and it was decided to
continue wound care and follow up in 2 months for wound care and
4 months with an arterial duplex. She preferred to continue her
wound care closer to home. Her Plavix was discontinued at that
time. She was on Coumadin for her peripheral vascular disease.
On
___, she hit her left heel hard and developed pain. She also
notes increasing left sided calf pain at rest. She also reports
that she sees another vascular surgeon and he recommended a left
BKA and so she went to her preoperative visit where she was told
that her labs were abnormal. Her mom was concerned about the
pain
so given all of this, she went to the ___ ED, where
she was evaluated apparently by vascular surgery and it was
decided to transfer her here for further care. Her Hct in the ED
was 20 so she received 1u prbcs.
Past Medical History:
VASCULAR HISTORY: Bilateral fem-pop, ?ileofemoral endarterectomy
on R
PAST MEDICAL HISTORY:
Type 1 diabetes since age ___, hypertension, tachycardia (?due to
anxiety), restless leg syndrome
PAST SURGICAL HISTORY:
Bilateral fem-pop, ?ileofemoral endarterectomy on R, b/l frozen
shoulder release, L carpal tunnel with multiple trigger finger
releases, appendectomy, cholecystectomy, c-section
Social History:
___
Family History:
F/H of AAA. Grandfather with AAA and cerebral aneurysm,
grandmother with diabetes, multiple family members with CAD
Physical Exam:
On admission
VS: 98.6, 96, 98/64, 18, 98% RA
Gen: NAD
CV: RRR
Pulm: breathing comfortably on room air
Abd: soft, nondistended, nontender, old scars
Ext: some left leg swelling; no sensation distally (only feels
some pressure, which is stable for her given her neuropathy),
able to move toes. toes slightly cool bilaterally. left heel has
black ulcer with small amount of surrounding erythema and white
unhealthy tissue. ulcer is slightly boggy. no crepitus,
fluctuance surrounding. right amputation site has small area of
dry gangrene.
___ Pulses: b/l p/d/d/d (___)
On discharge:
Gen: no acute distress, well appearing
CV: RRR
P: nonlabored breathing on room air
Abd: soft, nontender, nondistended
Ext: L amputation site well-healed with staples in place; no
surrounding erythema, fluctance, or signs of infection
Pertinent Results:
___ 04:36AM BLOOD WBC-14.0* RBC-2.58* Hgb-7.4* Hct-22.9*
MCV-89 MCH-28.7 MCHC-32.3 RDW-15.7* RDWSD-51.7* Plt ___
___ 12:22PM BLOOD WBC-11.1* RBC-2.45* Hgb-7.1* Hct-22.2*
MCV-91 MCH-29.0 MCHC-32.0 RDW-15.8* RDWSD-52.3* Plt ___
___ 06:30AM BLOOD WBC-12.0* RBC-2.81* Hgb-8.0* Hct-25.4*
MCV-90 MCH-28.5 MCHC-31.5* RDW-15.5 RDWSD-52.0* Plt ___
___ 07:10AM BLOOD WBC-14.2* RBC-2.78* Hgb-8.1* Hct-24.8*
MCV-89 MCH-29.1 MCHC-32.7 RDW-15.4 RDWSD-50.4* Plt ___
___ 08:10AM BLOOD WBC-19.6* RBC-3.45* Hgb-9.9* Hct-30.2*
MCV-88 MCH-28.7 MCHC-32.8 RDW-15.3 RDWSD-48.3* Plt ___
___ 06:23AM BLOOD WBC-13.9* RBC-2.86* Hgb-8.2* Hct-25.1*
MCV-88 MCH-28.7 MCHC-32.7 RDW-14.6 RDWSD-47.1* Plt ___
___ 11:45PM BLOOD WBC-14.5*# RBC-2.38*# Hgb-6.8*#
Hct-20.8*# MCV-87 MCH-28.6 MCHC-32.7 RDW-15.0 RDWSD-47.4* Plt
___
Brief Hospital Course:
___ is a patient that was admitted to the vascular surgery
service for a heel ulcer. In the ED the patient had an Xray that
showed a heel fracture. Initially ortho was consulted however
the patient requested a BKA. The patient was started on
Vancomycin ciprofloxacin and flagyl. The patient tolerated the
procedure well. Post operatively the patient was found to be
hyperkalemic and slightly hyponatremic. She was fluid restricted
to 1.5L which seem to improve the hyponatremia and she was given
Lasix to resolve the hyperkalemia. Her pain was controlled with
PO dilaudid. On the day of discharge, she was well appearing and
her pain was well controlled.
Medications on Admission:
atorvastatin 80', aspirin 81', docusate 100'', lisinopril 2.5',
metoprolol succinate 50', amitriptyline 25', warfarin 7.5',
senna 8.6', insulin (2 units Humalog before each meal and at
bedtime, 18U lantus before bed)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*50 Tablet Refills:*0
2. Amitriptyline 25 mg PO QHS
3. Aspirin EC 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth every 8 hours Disp
#*30 Capsule Refills:*0
7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*50 Tablet Refills:*0
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*60 Tablet Refills:*0
8. Glargine 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Lisinopril 2.5 mg PO DAILY
10. Metoprolol Tartrate 25 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Senna 8.6 mg PO BID:PRN constipation
13. Warfarin 7.5 mg PO DAILY16
14. Milk of Magnesia 30 mL PO Q6H:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ and
underwent a below the knee amputation. You have now recovered
from surgery and are ready to be discharged. Please follow the
instructions below to continue your recovery:
ACTIVITY:
On the side of your amputation you are non weight bearing for
___ weeks.
You should keep this amputation site elevated when ever
possible.
You may use the opposite foot for transfers and pivots.
No driving until cleared by your Surgeon.
No heavy lifting greater than 20 pounds for the next 3 weeks.
BATHING/SHOWERING:
You may shower when you get home
No tub baths or pools / do not soak your foot for 4 weeks from
your date of surgery
WOUND CARE:
Sutures / Staples may have been removed before discharge. If
they are not, an appointment will be made for you to return for
staple removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
CAUTIONS:
If you smoke, please make every attempt to quit. Your primary
care physician can help with this. Smoking causes narrowing of
your blood vessels which in turn decreases circulation.
DIET:
Low fat, low cholesterol / if you are diabetic follow your
dietary restrictions as before
CALL THE OFFICE FOR: ___
Bleeding, redness of, or drainage from your foot wound
New pain, numbness or discoloration of the skin on the
effected foot
Fever greater than 101 degrees, chills, increased redness, or
pus draining from the incision site.
Followup Instructions:
___
|
19866753-DS-8 | 19,866,753 | 26,342,776 | DS | 8 | 2195-09-05 00:00:00 | 2195-09-12 19:47:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Demerol
Attending: ___.
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a h/o multiple medical problems including PE x 2 (most
recently ___ on coumadin for life) and COPD on 2L home O2,
severe arthritis (PMR vs seronegative RA), and chronic LBP s/p
multiple decompressive surgeries now p/w hemoptysis since last
night with increased SOB. Over the past ___ days, the pt has
noted mild HA, diffuse body ache, dyspnea (increased home O2
from 2 -> 3L), and cough. Last night pt produced a coin-sized
clot of blood, and she continued to bring up small amounts of
blood with cough this morning. She came to the ED. Over the past
few days, the patient has also noted a "lump" sensation below
her mid-sternum. This sensation is constant, does not radiate,
does not change with activity, and is not relieved by her GERD
meds. No palpitations, sweating, dysphagia or odynophagia.
.
On arrival in the ED, the patient's VS were: 98.1 99 129/55 18
100% on 4L NC. A chest X-ray demonstrated a RLL consolidation.
Blood cx x 2 were sent, and the patient was started on
ceftriaxone and azithromycin. She was admitted.
.
On arrival to the floor, VS were: 99.2 110/70 93 22 95% 3L. The
patient was pleasant and in NAD. Accompanied by son and
daughter. Asking to eat dinner.
.
Review of systems:
(+) Per HPI. In addition, (+) fatigue, constipation
(longstanding).
(-) Denies fever, chills, night sweats, recent weight loss or
gain, sinus tenderness, rhinorrhea, congestion, palpitations,
nausea, vomiting, diarrhea, abdominal pain, recent change in
bowel or bladder habits, dysuria.
Past Medical History:
PAST MEDICAL HISTORY:
-Pulmonary Embolisms s/p thoracic lamenectomy in ___
-Peripheral Edema
-Congestive Heart Failure
-Spondylythis
-Hypertension
-Hypercholestrolemia
-Depression
-Obesity
-Peripheral Neuropathy
-Chronic Pain Syndrome
-Fatty liver
-Hypothyroidism
-Thoracic disk herniation
.
PAST SURGICAL HISTORY:
-Oral surgery ___
-Appendectomy
-Ovarian cyst removal
Social History:
___
Family History:
Mother ___ cancer at ___
Father "bone cancer"
No known bleeding disorders
Physical Exam:
Physical Exam:
Vitals:99.2 110/70 93 22 95% 3L
General: Alert, oriented, no acute distress. Speaking full
sentences.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Good air ___, some crackles at R base, very mild
expiratory wheezing
CV: RRR no murmurs
Abdomen: soft, non-tender, non-distended, (+) bowel sounds
Ext: Warm, well perfused. Trace edema bl at feet.
Neuro: AAOx3. Speech fluent, appropriate. (+) "house" backwards.
PERRL 3>2. EOMI. ___. TML. MAE ___ (but ___ about shoulder
___ joint pain). No drift. SILT grossly. No dysmetria on FNF.
Pertinent Results:
___ 02:50PM ___ PTT-37.0* ___
___ 02:50PM PLT COUNT-213
___ 02:50PM NEUTS-85.3* LYMPHS-10.3* MONOS-3.3 EOS-0.9
BASOS-0.2
___ 02:50PM WBC-8.1 RBC-4.16* HGB-12.0 HCT-36.8 MCV-89
MCH-28.8 MCHC-32.5 RDW-16.5*
___ 02:50PM estGFR-Using this
___ 02:50PM GLUCOSE-132* UREA N-17 CREAT-0.9 SODIUM-140
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-29 ANION GAP-13
CHEST CTA
FINDINGS:
Again demonstrated are grossly stable scattered centrilobular
emphysematous changes throughout the lungs. There is clustered
mild peribronchovascular nodularity in the right lower lobe
superior segment (___) and right lower lobe basilar
segments. Mild clustered peribronchovascular nodularity in the
periphery of the right upper lobe posteriorly (2:21) and
anteriorly (___) and also in the right middle lobe medially
(___:42). Right posterolateral pleural fat herniation (4:23).
Mild right posterior pleural thickening (2:27). The left lung is
grossly clear without focal consolidation. A small nodule is
seen in the right middle lobe (3:44, 603b:33) measuring
approximately 6 mm.
No pleural effusions or pneumothorax. The central airways are
patent.
Stable mildly prominent mediastinal lymph nodes measuring up to
8 mm in
greatest short axis (2:17). No significant axillary
lymphadenopathy.
Normal cardiac size with minimal anterior pericardial effusion.
Mild
calcifications at the aortic valve.
There is no main, lobar, or segmental pulmonary embolus. No
thoracic aortic dissection. Calcified atherosclerotic vascular
disease of the distal descending thoracoabdominal aorta and at
the aortic arch.
Limited images of the upper abdomen are grossly unremarkable.
Incompletely seen degenerative joint disease at the left
glenohumeral joint with anteromedial humeral head osteophyte
formation. Multilevel degenerative disc disease throughout the
thoracic spine with a stable T8 compression deformity and
osseous fusion at T7-T8. Old right-sided lateral fifth through
seventh rib fracture deformities. No acute fractures.
IMPRESSION:
1. Mild clustered nodularity in the right lower lobe, medial
right middle
lobe, and periphery of the right upper lobe detailed above,
which may
represent atypical pneumonia versus sequela of pulmonary
hemorrhage in the appropriate clinical setting. No lobar
consolidations or pulmonary masses.
2. No main, lobar, or segmental pulmonary emboli.
3. Stable scattered centrilobular emphysematous changes
throughout the lungs.
4. Stable T8 compression deformity and osseous fusion at T7-T8.
5. No thoracic aortic dissection.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
___ with a h/o multiple medical problems including PE x 2 (most
recently ___ on coumadin for life) and COPD on 2L home O2,
severe arthritis (PMR vs seronegative RA), and CHF now p/w
hemoptysis since last night with increased SOB.
.
ACTIVE ISSUES
.
# Hemoptysis - Likely ___ airway irritation from vigorous
coughing in the setting of pulmonary infx (viral vs bacterial
PNA, see below). The hemoptysis was low-volume and intermittent.
Other possible sources of hemorrhage include malignancy and PE,
though these are less likely given gradual-onset constitutional
sx (fatigue, body aches, etc), low volume of blood produced,
etc. On ___ the patient went a chest CTA for further w/u of her
hemoptysis. This did not demonstrate a PE, and her known
lymphadenopathy was stable. She produced a small amount of
blood-tinged sputum overnight on ___ and then steadily improved
until the time of discharge.
.
# RLL consolidation - Initially thought to be c/w CAP. The
patient is on some immunsuppr meds (low dose prednisone, MTX)
but pattern on CXR and her sx are less consistent with other
infx etiologies (e.g. fungal), and the pt does not have risk
factors for HCAP. On admission she was afebrile and without
leukocytosis. Her presentation seems less c/w COPD flare; pt has
not had notable flares previously and she has good air ___ and
minimal wheezing on exam. Could also be a viral PNA, but she was
treated empirically for CAP, receiging CTX 1g q24h + Azithro
500mg and then 250mg q24h with good response. Her home inhalers
were continued. Her oxygen requirement was stable at 3L. She
remained afebrile while in-house. Prior to discharge her CTX was
converted to oral cefpodoxime for outpatient therapy for a total
course of 7 days(ending ___ and 5 days of azithromycin (ending
___.
.
# Chest discomfort - Not concerning for angina/ACS given
history. Likely ___ underlying pulmonary process. Nothing
suspicious or concerning on CT chest. This discomfort improved
with treatment of her undlying pneumonia.
.
# h/o PE - Pt has h/o multiple PEs. INR was sub-therapeutic at
1.7 on admission. Weighing risk of catastrophic hemoptysis, her
anticoagulation was held initially. After her hemoptysis
improved and CTA did not demonstrate a malignancy or other
lesion a/w bleeding risk, the patient was started on a heparin
gtt to bridge her back. She started warfarin again but her INR
was sub-therapeutic by the day of discharge, so she was sent
home on lovenox. She will follow up shortly after discharge with
laboratory testing to determine the duration of lovenox that
will be needed.
.
INACTIVE ISSUES
# Chronic issues: HTN, hypothyroidism, ___ edema, ATH, GERD,
arthritis
-continued home meds
.
TRANSITIONAL ISSUES
-lovenox bridge, during which time she needs to have her INR
checked regularly
-Chest CTA revealed nodularity, as described in the included
radiology report
Medications on Admission:
- MTX 15 mg qweek
- Prednisone 3 mg daily
- Coumadin: 5 mg ___ 7.5 mg M-W-Th-Fr-Sa
- Fosamax 70 mg qWEEK
- Budesonide (pulmicort)- (180 mcg) 2 puffs BID
- Budesonide (symbicort)- (160 mcg-4.5 mcg) 2 puffs BID
- Formoterol fumarate (foradil) - 12 mcg Capsule, 1 puff BID
- Ipratropium (atrovent) - (17 mcg) 2 puffs TID
- Amitriptyline 75 mg QHS
- Lasix 40 mg daily
- Pravastatin 20 mg daily
- Folate 0.8 mg daily
- Vicodin 2 BID prn
- Levothyroxine 200 mcg daily,
- Lisinopril 10 mg daily
- MVI
- Ranitidine 150 mg daily
- Sertraline 100 mg daily
- Calcium carbonate - Vit D 1250mg-200U TID
Discharge Medications:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
___.
2. amitriptyline 50 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime).
3. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. hydrocodone-acetaminophen ___ mg Tablet Sig: Two (2) Tablet
PO BID PRN () as needed for joint pain.
6. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation TID (3 times a day).
7. ipratropium-albuterol ___ mcg/actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed for sob,
wheezing.
8. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
14. methotrexate sodium 2.5 mg Tablet Sig: Six (6) Tablet PO
QFRI (every ___.
15. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
16. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO every
twelve (12) hours for 4 days.
Disp:*16 Tablet(s)* Refills:*0*
17. warfarin 2.5 mg Tablet Sig: ___ Tablets PO once a day: Take
2 tablets on ___ and ___, and 3 tablets every other day.
18. enoxaparin 100 mg/mL Syringe Sig: One (1) mL Subcutaneous
every twelve (12) hours: You will need to take these injections
until your warfarin level is therapeutic. Please call Dr
___ your ___ clinic tomorrow, to discuss
having an INR check.
Disp:*10 mL* Refills:*2*
19. folic acid ___ mcg Tablet Sig: One (1) Tablet PO once a day.
20. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO twice a day.
21. Centrum Silver Oral
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
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 during your stay in the
hospital. You were admitted for a cough productive of blood, and
a chest x-ray revealed a pneumonia. You were started on
antibiotics, and a CAT scan of your chest excluded other
concerning causes for your cough. In particular, you did not
have a pulmonary embolism, which you have had in the past.
Fortunately, you improved with treatment of your pneumonia.
.
During your stay, the following changes were made to your
medications:
1. ADDED cefpodoxime 200 mg tabs, take two tabs every twelve
hours, which you should take for three more days (last doses on
___
2. ADDED azithromycin 250 mg tabs, take one tab once a day for
one more day (last dose on ___
3. ADDED enoxaparin (blood thinner) injections, which you will
take every twelve hours until your warfarin is at a therapeutic
level.
.
Please continue taking warfarin as per your prior prescription.
Followup Instructions:
___
|
19866759-DS-12 | 19,866,759 | 24,554,565 | DS | 12 | 2166-05-06 00:00:00 | 2166-05-06 21:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Oxycodone / Balmex / miconazole / Keflex / SilvaSorb / lidocaine
patch
Attending: ___.
Chief Complaint:
bilateral leg swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presents for bilateral knee pain after she played
tennis for ___ hours . Pt has some developmental delay and
participates in sports and recently flew to ___ for a tennis
tournament. She felt her both ankles were swollen after the long
plane ride. She also complains of cough which started last
___
for which she took a 8 day course of doxycycline which ended
yesterday.
She ___ shortness of breath, or chest pain or calf
tenderness.
Past Medical History:
PAST MEDICAL HISTORY:
- Peripheral nerve sheath tumor
- Borderline diabetes mellitus
- Hypothyroidism
- Bilateral knee osteoarthritis
- Developmental delay
PAST SURGICAL HISTORY:
- Tympanostomy tubes in ear at the age of ___
- Tonsillectomy at ___ years
- Wide tumor bed excision, right elbow area for intermediate
grade soft tissue sarcoma
Social History:
___
Family History:
Grandfather: colon cancer in grandfather
Father: DM2, CAD
Physical Exam:
General: NAD
VITAL SIGNS:98.2f PO 144 / 79 91 18 98 RA
HEENT: nc/at
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft,
LIMBS: very minimal non pitting edema. no erythema or rashes.
SKIN: No rashes or skin breakdown
Brief Hospital Course:
___ is a ___ y F with Malignant peripheral nerve sheath
tumor,
metastatic to the lung despite Pazopanib treatment.
Pt has developmental disability , obesity and T2DM. She
recently had a flight to ___ and despite being active found
herself having leg swelling bilaterally.
US ___ showed R posterior tibial clot. Since it was
symptomatic for pt, decision was made to start pt on Lovenox
1mg\kg bid. Pt tolerated this without complicatinos and was
discharged in a stable condition
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO TID
2. Gabapentin 600 mg PO TID
3. Levothyroxine Sodium 75 mcg PO DAILY
4. PAZOPanib 600 mg oral DAILY
5. Clindamycin 450 mg PO Q8H
Discharge Medications:
1. Enoxaparin Sodium 100 mg SC Q12H Duration: 3 Months
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 100 mg/mL 100 mg SC twice daily Disp #*60 Syringe
Refills:*2
2. Benzonatate 100 mg PO TID
3. Gabapentin 600 mg PO TID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. HELD- PAZOPanib 600 mg oral DAILY This medication was held.
Do not restart PAZOPanib until you discuss with your oncologist.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right posterior Tibial Vein clot
Community acquired pneumonia
Discharge Condition:
Stable
Alert and communicative
Independent
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you. You were admitted here
because you had a blood clot in right leg. You were treated with
subcutaneous lovenox injections for the blood clot. You need to
continue this treatment for three months at least.
Please follow up with your other appointments as outpatient.
Sincerely,
___ MD
Followup Instructions:
___
|
19866759-DS-9 | 19,866,759 | 22,653,893 | DS | 9 | 2163-11-18 00:00:00 | 2163-11-18 15:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Oxycodone / Balmex / miconazole
Attending: ___.
Chief Complaint:
Elbow swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of a right elbow sarcoma (malignant nerve sheath tumor)
with mets to lung s/p 6 cycles doxorubin and 7 cycles liposomal
doxorubicin and Cyberknife in ___ p/w R elbow swelling. Pt
reports worsening pain ___, redness and swelling x 2 days. No
associated sxs otherwise. She denies f/c. Pt seen at ___
___ today. Records are limited but per report, pt was given
vancomycin and developed diffuse erythema and itchiness. Vanc
was stopped and pt given clinday 900mg iv and transferred to ___.
Initial vitals at the ___ ED were 98.2 70 130/83 14 99%. WBC
6.9. Lactate 1.8. CRP 23.1 and ESR 30. BCx were drawn from her
Port-a-Cath. Ortho onc consulted and recommended ongoing iv abx
and involving rad onc. MR elbow showed: "Interval increase in
intramuscular and soft tissue edema. Findings may reflect
ongoing evolution of post radiation change, but infection can
have a
similar appearance. No focal fluid collection or specific
evidence of osteomyelitis." Pt given dilaudid 1 mg iv x 2.
Past Medical History:
PAST MEDICAL HISTORY:
- intermediate grade soft tissue sarcoma of R elbow s/p wide
excision ___
- developmental delay
PAST SURGICAL HISTORY:
- Tympanostomy tubes in ear at the age of ___ years
- Tonsillectomy at ___ years
- Wide tumor bed excision, right elbow area for intermediate
grade soft tissue sarcoma
Social History:
___
Family History:
Grandfather: colon cancer in grandfather
Father: DM2, CAD
Physical Exam:
ADMISSION PHYSICAL EXAM:
T98.1 90 117/65 16 100% ra
NAD
eomi, perrl
neck supple
no ___
chest clear
rrr
abd benign
ext: RUE erythematous patch over medial aspect of R, with
ulceration
skin: rash as above
neuro: non-focal
psych: calm
DISCHARGE PHYSICAL EXAM:
T97.9 BP 124/64 HR 85 RR18 98%RA
GEN: NAD. appears comfortable resting in bed.
HEENT: PERRL.
CV: RRR. No murmurs.
Lungs: CBTA. No crackles/wheezes
Extremities: RUE erythematous and indurated patch over medial
aspect of R, with 5 mm x 5 mm ulceration tender to palpation.
Area of erythema outlined from admission appears unchanged.
Covered by wound dressing.
Skin: rash as above
Pertinent Results:
ADMISSION LABS:
___ 03:00AM BLOOD WBC-6.9 RBC-4.36 Hgb-14.2 Hct-40.9 MCV-94
MCH-32.7* MCHC-34.9 RDW-12.0 Plt ___
___ 03:00AM BLOOD Neuts-70.7* ___ Monos-6.3 Eos-1.1
Baso-1.0
___ 03:00AM BLOOD ___ PTT-34.6 ___
___ 03:00AM BLOOD ESR-30*
___ 03:00AM BLOOD Glucose-109* UreaN-10 Creat-0.7 Na-139
K-3.9 Cl-103 HCO3-22 AnGap-18
___ 05:24AM BLOOD ALT-9 AST-17 AlkPhos-91 TotBili-0.5
___ 05:24AM BLOOD Albumin-3.6 Calcium-9.1 Phos-4.3 Mg-1.8
___ 03:00AM BLOOD CRP-23.1*
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-5.8 RBC-4.18* Hgb-13.8 Hct-38.7
MCV-93 MCH-33.1* MCHC-35.7* RDW-12.2 Plt ___
___ 05:24AM BLOOD Neuts-60.1 ___ Monos-7.1 Eos-3.6
Baso-0.1
___ 06:00AM BLOOD Glucose-107* UreaN-13 Creat-1.1 Na-137
K-4.0 Cl-100 HCO3-27 AnGap-14
___ 06:00AM BLOOD Calcium-9.4 Phos-4.3 Mg-1.9
___ 06:10AM BLOOD Vanco-25.8*
___ 03:14AM BLOOD Lactate-1.8
Imagining:
___ Elbow MRI:
1. Interval increase in intramuscular and soft tissue edema.
Findings may reflect ongoing evolution of post radiation change,
but infection can have a similar appearance. No focal fluid
collection or specific evidence of osteomyelitis.
2. Heterogeneously enhancing mass at the right elbow has an
overall stable size compared to ___ but has undergone
interval increased necrosis.
3. Evaluation of known additional small enhancing lesions along
the ulna is limited due to differences in technique compared to
the prior exam.
___ Elbow MRI: IMPRESSION: The heterogenous mass at the
elbow is stable or possibly slightly increased in size when
compared to the prior study, the extent of necrosis appears
similar when compared to the prior study. Additional deposits
of tumor appear to have increased slightly in size along the
posterior aspect of
the ulna. The study and the report were reviewed by the staff
radiologist.
Brief Hospital Course:
___ hx of a right elbow MPNST metastatic to the lungs ___ now
s/p 6 cycles doxorubicin and 7 cycles liposomal doxorubicin in
___ and Cyberknife in ___ p/w R elbow swelling.
# ELBOW SWELLING: Cellulitis vs. radiation change. Initally
treated with one dose linezolid on ___ which was promptly
switched to Vanco+Keflex ___. She was transitioned to
bactrium/keflex ___ to be continued until ___. She was
evaluated by ortho for debridement of the wound but felt that
given there was evidence of tumor deep to wound resection would
be difficult and likely result in poor wound healing. Her pain
was controlled with PO dilaudid ___ mg every q3-4 hours. For
adjunctive therapy she was treated with standing tyneol and
standing ibuprofen. In addition, lidocaine jelly was applied to
the wound. Wound nursing provided recommendations regarding
wound cares which will be preformed by a ___ at home.
# Hypothyroidism: Continued home Levothyroxine
# Borderline DM: Monitored sugars in house which did not require
SSI.
Transitional issues:
--------------------
[ ] Taper dilaudid as outpatient
[ ] f/u wound for continued improvement
[ ] Ortho to continue to follow as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HYDROcodone-acetaminophen 5mg-500 mg mg oral q 6hr pain
2. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Acetaminophen 1000 mg PO Q12H
3. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp
#*22 Capsule Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q3-4H PRN pain
Please take with a stool softner. Do not drink alcohol. Do not
drive.
RX *hydromorphone 2 mg ___ tablet(s) by mouth every ___ hours
Disp #*30 Tablet Refills:*0
5. Ibuprofen 400 mg PO Q8H
Please take scheduled Ibuprofen 800 mg three times/day for 7
days
6. Lidocaine 5% Ointment 1 Appl TP DAILY PRN dressing changes
RX *lidocaine 5 % 1 application daily Refills:*0
7. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*11 Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID
9. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cellulitis
Malignant sheath tumor
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ for
cellulitis of your right arm. You also have a small area of
ulceration for which you were seen by wound. You will continue
to have a nurse come to your home to help you with your dressing
changes. At this time there is no role for surgical intervention
but should your wound worsen this can be considered at a later
date. You will have follow-up with the orthopedic surgeons in 2
weeks.
For your pain control, you should take Ibuprofen 800 mg three
times a day scheduled. Do not take more than 1800 mg in 24 hrs.
You should also take 1000 mg of acetaminophen (Tylenol) twice a
day- do not exceed 4 grams in 24 hours. In addition, we have
prescribed narcotic pain medication (Dilaudid) for you. You can
take ___ mg as needed up to every 2 hrs. This can cause
constipation so please take with a stool softner (Colace, 100 mg
twice a day and Senna 8.6 mg twice a day); available over the
counter.
Followup Instructions:
___
|
19867030-DS-12 | 19,867,030 | 29,161,145 | DS | 12 | 2184-03-20 00:00:00 | 2184-03-21 13:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / aspirin /
Celebrex
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic Appendectomy
History of Present Illness:
Mr. ___ is a ___ man with a PMH of hemophilia A presents
with abd pain from OSH. Pt reported ___ days of vague abdominal
pain. He presented to ___ after a fall yesterday because he was
concerned about bleeding. Imaging there was negative for
bleeding but his CT scan was consistent with appendicitis. He
was transferred to ___ on ___ given his history of
hemophilia.
He reports right lower quadrant pain and anorexia. He denies
fevers, chills, nausea or vomiting. He reports passing flatus,
having bowel movements and last ate at 7 pm prior to admission.
Pt is on factor VIII every other day and takes significant
amounts of pain medication at baseline.
Past Medical History:
hemophelia A
degenerative joint disease
Chronic pain with longstanding opiod use
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Exam: ___
vitals: 98.8 80 133/71 14 100% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, TTP in RLQ, no rebound, + guarding,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Discharge PE: ___
Vitals: 98.7, 62, 114/50, 18, 100% on RA
Gen: comfortable appearing young man
Lungs: CTAB
CV: S1, S2, RRR
Abd: soft, appropriately tender, nondistended, laparoscopic
sites OTA with steri strips without erythema
Ext: warm, well perfused
Neuro: Alert and oriented X3, MAE
Pertinent Results:
___ 01:19AM WBC-13.9* RBC-4.94 HGB-14.1 HCT-42.8 MCV-87
MCH-28.5 MCHC-32.9 RDW-12.7
___ 01:19AM PLT COUNT-348
___ 01:19AM GLUCOSE-92 UREA N-11 CREAT-1.1 SODIUM-138
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-24 ANION GAP-18
___ 03:04AM VIII-57
___ 01:28AM LACTATE-1.5
___ 03:04AM ___ PTT-42.0* ___
___ 05:45AM BLOOD WBC-6.7 RBC-4.06* Hgb-11.7* Hct-36.2*
MCV-89 MCH-28.9 MCHC-32.4 RDW-13.0 Plt ___
___ 07:50AM BLOOD FacVIII-67
___ 05:25AM BLOOD FacVIII-99
___ 05:45AM BLOOD FacVIII-74
___ 05:45AM BLOOD Glucose-91 UreaN-11 Creat-1.0 Na-140
K-4.0 Cl-103 HCO3-27 AnGap-14
___ 05:45AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.1
___: CT ABD/Pelvis: Acute appendicitis with an
appendicolith at the base of the appendix.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a PMH significant for
Hemophelia A and chronic pain with high dose opiod use who
presented to an outside hospital on ___ with 3 days of
abdominal pain. Per report, patient fell at home and was
concerned he was bleeding. Abdominal CT showed no hemmorhage but
was consistent with appendicitis. He was transferred to ___
on ___ and went to the OR with Dr. ___ a
laparoscopic appendectomy after Factor XIII replacement on that
same day. His operative course was uneventful with minimal blood
loss. Please see Operative report for details. The patient
recovered in the PACU and was transferred to the floor
hemodynamically stable.
He remained alert oriented, afebrile, and hemodynamically
stable. The chronic pain service was consulted. The patient was
controlled with his home dose of MS ___, an increased dose of
Oxycodone, and Lyrica was added. Hematology was consulted on
admission and the patient was started on Factor XIII infusions
that were titrated down to 1500 units BID. Factor XIII level was
74 on the day of discharge. His CBC was stable throughout the
entire hospital stay. Pt. was tolerating a regular diet without
nausea or vomitting and had a bowel movement prior to discharge.
His abdomen was soft, nondistended. He was ambulating
independently. At the time of discharge the patient stated good
understanding of Factor XIII replacement taper and expressed
independce at home since age ___. He will follow up with
hematology on ___ at ___. He was
dishcarged with a short prescription of oxycodone 20 mg Q3H and
Lyrica. He has an appointment with his Chronic pain Clinic on
___. They were made aware of the discharge pain regimen.
He will follow up with the Acute Care Clinic on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. factor XIII ___ unit injection QD
2. Morphine SR (MS ___ 30 mg PO Q12H PRN PAIN
3. OxycoDONE (Immediate Release) 20 mg PO 5X/DAY Pain
Discharge Medications:
1. Morphine SR (MS ___ 30 mg PO Q12H PRN PAIN
2. Acetaminophen 1000 mg PO Q8H
3. Docusate Sodium 100 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY Constipation
5. Pregabalin 50 mg PO TID
RX *pregabalin [Lyrica] 50 mg 1 capsule(s) by mouth three times
a day Disp #*21 Capsule Refills:*0
6. OxycoDONE (Immediate Release) 20 mg PO Q3H:PRN pain
RX *oxycodone 20 mg 1 tablet(s) by mouth Q3H Disp #*50 Tablet
Refills:*0
7. factor XIII 1500 Units injection BID Duration: 3 Days
Ends on ___
8. factor XIII 1500 Units injection Daily Duration: 7 Days
Starts ___
Discharge Disposition:
Home
Discharge Diagnosis:
appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ with appendycitis and you had your
appendix removed. The hematologists and the surgery team
followed your closely and you are now ready to recover at home.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Hematology will follow up with you as listed below:
You dosing taper schedule will be
Factor XIII 1500 units twice a day dosing for next 3 days, which
is through ___
On ___ Take 1500 units daily dosing for 7 days
Dr. ___ decide further outpatient management after you
see him on ___
Please take
Followup Instructions:
___
|
19867135-DS-13 | 19,867,135 | 21,097,459 | DS | 13 | 2192-07-21 00:00:00 | 2192-07-22 16:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
latex / coband
Attending: ___.
Chief Complaint:
neck soreness and headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief, the patient states that he was lifting heavy boxes on
___ when he noticed a sudden soreness of his neck and
posterior
head. On ___, he developed a significant headache. On ___,
he
had several bouts of emesis which led him to present for
evaluation. While at the OSH, he was noted to be hypertensive
with a SBP>200 and with an INR of 3.4. He received 2400 units of
K-centra for reversal and was transferred to ___ for further
evaluation. He last took aspirin yesterday.
Currently, he reports moderate nausea, mild neck pain, and a
___
headache. He notes that the nausea is more severe while flat.
His
most recent INR is 1.2.
Past Medical History:
PMHx:
- mechanical aortic valve
- HTN
- DM2
- BKA
Social History:
___
Family Hx:
Is there a family history of Aneurysms?
[X]No
[ ]Yes
Family History:
Mother with CAD
Father with ___
Physical Exam:
On discharge:
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Pronator Drift: [ ]Yes [x]No
Speech Fluent: [x]Yes [ ]No
Comprehension intact: [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
___
IPQuadHamATEHLGast
Right555***
Left55___
*Patient has below the knee amputation on right side
[x]Sensation intact to light touch
Pertinent Results:
Please see OMR
Brief Hospital Course:
___ was admitted to the hospital from the emergency
room after signs and symptoms and imaging were consistent with
an intraventricular hemorrhage. He was observed in the hospital
with frequent neuro checks as well as repeat imaging to assess
for worsening symptoms of which there were none. His headache
was improving, he was ambulating on his own, and remained stable
clinically throughout his hospitalization.
___ was consulted while he was inpatient and titrated and
adjusted his diabetes medications accordingly and made
recommendations for his home regimen.
___ was consulted and saw him on ___. They recommended home
upon discharge after ___ more visits.
He was discharged on ___. At the time of discharge he was
ambulating with assistance, voiding independently, tolerating PO
diet and pain meds, and his vital signs were stable.
He will restart his Aspirin on ___ and will restart his
coumadin on ___.
He should follow up with his PCP regarding diabetes and otitis
media. Patient will follow up with Dr. ___ on ___.
Medications on Admission:
atorvastatin 40 mg/day, isosorbide mononitrate ER 45 mg,
metformin 500 mg (HOLDING), Tamsulosin 0.4 mg, insulin 15 u/day,
metoprolol succinate ER 25 mg, gemfibrozil 600 mg BID, warfarin
1 mg
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
4. Docusate Sodium 100 mg PO BID
5. Senna 17.2 mg PO HS
6. Atorvastatin 40 mg PO QPM
7. Gemfibrozil 600 mg PO BID
8. Isosorbide Mononitrate (Extended Release) 45 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Metoprolol Succinate XL 25 mg PO BID
11. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
intraventricular hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Brain Hemorrhage without Surgery
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
- You may restart your Aspirin on ___ and may restart your
Coumadin on ___.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
19867291-DS-10 | 19,867,291 | 29,758,875 | DS | 10 | 2129-01-14 00:00:00 | 2129-01-19 21:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sevoflurane
Attending: ___
Chief Complaint:
Vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a PMHx of stage 4 metastatic breast
cancer (recurrent, with metastases to hip/acetabulum/TL
spine/lymphs), essential thrombocythemia, h/o PE, stage III CKD,
HTN, HLD, h/o pericardial effusion, and recent hypercalcemia.
She
is admitted from ED w/ new onset vertigo.
states that since ___ has had 3 episodes of dizziness in which
room is spinning. Generally occurs with movement. Tends to
resolve within ___ minutes. Patient also reports lightheadedness
with lie-sit to stand. This has been ongoing issue for patient
over past month.
Patient was seen by home ___ this AM and reported the new
symptoms
of vertigo. Patient also orthostatic with ___. Pts primary onc
Dr.
___ in ED to r/o CNS involvement of her disease.
In ED head CT was unremarkable. she was ___ by neurology w/o
evidence of neuro deficits, no nystagmus or dysmetria. It was
felt more likely vertigo ___ peripheral cause than central
although she did have abnormal gait and Romberg. lightheadedness
and unsteady gait felt likely multifactorial, related to her
peripheral neuropathy, likely autonomic dysfunction leading to
orthostasis, ___, hypnatremia, and anemia. However it was felt
further ___ should be performed and she was admitted for brain
MRI and ongoing neuro ___.
Patient denies fevers, chills, N/V, dysuria, change in bowel
habits (having regular BMs). No decreased urination. No
abdominal
pain. Is currently on oral chemo (Xeloda). Has weekly
paracentesis for ascites related to underlying disease. Most
recent ___. Reports normal PO intake. Still drinking fluids as
per usual.
Initial VS in ED 10:56 0 98 91 91/57 18 100%
REmained borderline hypotensive and sl tachy thru the day in ED,
improved w/ NS bolus prior to transfer to floor
REVIEW OF SYSTEMS:
10 point ROS reviewed and neg except for what is mentioned above
in HPI
Past Medical History:
PAST ONCOLOGIC HISTORY
- ___: L breast ca; ER+PR+HER 2/neu-; ___ LN. FEC
chemotherapy and bl masdtectomy (cb post-op PE, sp ___
Warfarin).
- ___: ___ anastrozole
- ___: anemia
- ___: bone scan with L4, R iliac bone and L acetabulum, T4,
mets
L axillary LN; pericardia effusion
- ___: L axillary LN bx metastatic ca ER+(60% of nuclei), PR
Neg(0%) and HER-2/neu: 2+/Indeterminate-FISH negative for
amplification.
- ___: TTE w EF 55-60%; Grade I diastolic dysfunction; small
concentric pericardial effusion
- ___: Letrozole
- ___: L axillary mass minimally smaller. Mod pericardial
effusion; increased ascites and abd carcinomatosis (with mild
soft
tissue thickening on the dome of the bladder); mild L
hydronephrosis; new large L2 lytic lesion.
- ___: Bone scan w new L2 vertebral body and right iliac
bone adjacent lesions;
- ___: L axillary mass minimally smaller. Mod pericardial
effusion
- ___: Start Taxol
- ___: C5D1 Zometa/Taxol
___ received treatment with taxol
- ___: ___ admission ___ for anemia sp 3U PRBC.
Likely lymphangitis lung involvement. RUL lesion.
- ___: Started capecitabine
- ___: Bone scan w stable uptake in L2, L4, bl pelvis. No
new lesions.
PAST MEDICAL HISTORY:
# Pulmonary embolism (post op in ___, sp ___ warfarin)
# HTN (prior)
# Hypercalcemia
# HLD (prior)
# Pericardial effusion
# Essential thrombocythemia (previously on hydrea, per pt)
# ___ melanoma of L post thigh
# BCC L shoulder ___
# Herpes progenitalis
# Hearing loss
# Duodenitis
# Osteopenia
# Cerebral aneurysm
- L MCA; 16 mm x 10 mm. Followed by Dr. ___
# Ovarian cyst
# Major depressive disorder, recurrent episode
# Chronic kidney disease (CKD), stage III (moderate)
# Anxiety
# Internal hemorrhoids
# Hematuria
Social History:
___
Family History:
Mother had cancer and heart disorder
Family history of CAD
Physical Exam:
PHYSICAL EXAM:
General: NAD, Resting in bed comfortably
VITAL SIGNS: BP 82/50 94 78 95% ra ___ 136.7 lbs
HEENT: MMM, no OP lesions, no cervical or supraclavicular
adenopathy
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory disgress
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: Grossly normal, CNIII-XII intact, strength ___ b/l lower
and upper ext, no dysdiadochokinesia, no dysmetria
DISCHARGE PHYSICAL EXAM:
VS: afebrile, BP 90-100/50-70, HR 80-90s, RR ___, 96-100% on
RA
Gen: thin, cachectic elderly lady in NAD, resting comfortably in
bed
HEENT: MMM, no OP lesions, no cervical or supraclavicular
adenopathy
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: Grossly normal, CNIII-XII intact, strength ___ b/l lower
and upper ext, no dysdiadochokinesia, no dysmetria
Pertinent Results:
ADMISSION LABS:
___ 12:25PM BLOOD WBC-10.6 RBC-2.66* Hgb-9.0* Hct-25.9*
MCV-97 MCH-33.7*# MCHC-34.6 RDW-26.0* Plt ___
___ 12:25PM BLOOD Neuts-64.0 ___ Monos-5.5 Eos-7.3*
Baso-0.6
___ 12:25PM BLOOD ___ PTT-42.4* ___
___ 12:25PM BLOOD Plt ___
___ 12:25PM BLOOD Glucose-116* UreaN-34* Creat-1.2* Na-128*
K-5.0 Cl-101 HCO3-16* AnGap-16
___ 12:25PM BLOOD Calcium-8.5 Phos-3.1 Mg-2.2
___ 12:35PM BLOOD Lactate-1.6
DISCHARGE LABS:
___ 05:24AM BLOOD WBC-11.0 RBC-2.67* Hgb-8.9* Hct-25.6*
MCV-96 MCH-33.3* MCHC-34.7 RDW-26.6* Plt ___
___ 05:24AM BLOOD Plt ___
___ 05:24AM BLOOD Glucose-92 UreaN-23* Creat-0.8 Na-131*
K-4.5 Cl-107 HCO3-20* AnGap-9
___ 05:24AM BLOOD Calcium-7.5* Phos-1.6* Mg-2.0
PERTINENT IMAGING/STUDIES:
___ CT HEAD W/O CONTRAST
FINDINGS:
There is no evidence of acute major vascular territorial
infarction,
hemorrhage, edema, or large mass. The ventricles and sulci are
normal in size and configuration. No osseous abnormalities seen.
The paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
___: CT chest w/o contrast
IMPRESSION:
# Interval resolution of previous right upper lobe ground-glass
opacity, which was likely infectious or inflammatory in
etiology.
# New small left layering nonhemorrhagic pleural effusion with
minimal
associated partial passive atelectasis.
# Decreased small pericardial effusion.
# Stable T3 vertebral body metastasis.
___ CT abd/pelvis
IMPRESSION:
1. Increasing large amount of intra-abdominal ascites without
definite
evidence of peritoneal metastatic disease. .
2. Multiple osseous metastatic lesions, unchanged from the prior
study.
3. Please see the dedicated chest CT report for further details
regarding
intra thoracic findings
BONE SCAN ___ IMPRESSION:
1. New linear tracer uptake within the right tenth and eleventh
ribs, highly concerning for metastatic disease.
2. New focal areas of tracer uptake in several bilateral
anterior rib ends, compatible with fractures, as seen on the
recent CT from ___.
3. Stable areas of tracer uptake in the pelvis.
4. Decreased tracer uptake in the L2 and L4 vertebral bodies. 5.
Ascites.
Brief Hospital Course:
Ms ___ is a ___ with a PMHx of stage 4 metastatic breast
cancer (recurrent, with metastases to hip/acetabulum/TL
spine/lymphs), essential thrombocythemia, h/o PE, stage III CKD,
HTN, HLD, h/o pericardial effusion, and recent hypercalcemia.
She
is admitted from ED w/ new onset vertigo.
# Vertigo: patient presented with 3 episodes of vertigo
associated with turning of her head. Denied any diplopia,
ataxia, or other cerebellar signs. MRI was done to r/o posterior
circulation stroke given patient's extensive cancer history. The
MRI was negative for any sign of infarct. Patient was treated
with supportive care: zofran prn for nausea, and vestibular ___
for alleviating her symptoms of vertigo. In addition, patient
reported a few episodes of pre-syncope. She had these symptoms
most prominently after her paracentesis sessions. This was
likely due to volume depletion post paracentesis. Patient had 1
session of paracentesis during admission and was given albumin
post procedure. Throughout admission, she no longer had any
further episodes of vertigo or presyncope.
# Breast Cancer: Pt w/ hx of stage 4 metastatic breast cancer.
She underwent re-staging during her admission with the head MRI,
CT chest, CT abdomen/pelvis, and Bone Scan. All relevant imaging
can be found in OMR. Her imaging showed possible progression of
her disease on bone scan but without a CT correlate. Patient was
continued on her chemotherapy regimen of Xoloda at time of
discharge.
# Cerebral Aneurysm: while obtaining the MRI brain to rule out
posterior circulation stroke, an aneurysm of the left ICA was
found to have increased in size from previous examination. We
had the neurosurgery team consulted and they recommended
outpatient follow up at this time.
#NAGMA: patient presented with chronic low bicarb lower on
admit. Lactate was within normal limits, patient did not have
diarrhea or clear GI losses. Her condition was closely monitored
and was stable throughout admission.
#Hx ascites: mult recent paracentesis. No signs of infection on
fluid samples with negative culture. Negative for malignant
cells. Had 1x therapeutic paracentesis while admitted with
albumin repletion post procedure.
#Chronic anemia: Patient also with anemia, likely
___ chronic disease. EGD/colonscopy in ___ were not revealing.
Capsule endoscopy was recommended. S/p appropriate elevation in
H/H with 2U pRBCs on ___.
# TRANSITIONAL ISSUES:
- Outpatient physical therapy for optimization of balance and
gait
- Follow up with neurosurgery for evaluation of aneurysm
- Pt started on phosphorus repletion given persistently low Phos
values; should have electrolytes checked at next appointment
- Continue xoloda per primary oncology team
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 10 mg PO DAILY
2. Lorazepam 0.5 mg PO Q6H:PRN nausea/anxiety
3. letrozole 2.5 mg oral qd
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. capecitabine 1000 mg PO QAM
6. Capecitabine 1500 mg PO QPM
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Citalopram 10 mg PO DAILY
3. Lorazepam 0.5 mg PO Q6H:PRN nausea/anxiety
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. capecitabine 1000 mg PO QAM
6. Capecitabine 1500 mg PO QPM
7. letrozole 2.5 mg oral qd
8. Neutra-Phos 2 PKT PO DAILY
RX *potassium & sodium phosphates [Phos-NaK] 280 mg-160 mg-250
mg 2 powder(s) by mouth TWICE DAILY Disp #*60 Packet Refills:*0
9. Outpatient Physical Therapy
ICD-9 Code ___.4 Dizziness
Physical therapy for balance and gait training
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: benign positional vertigo
Secondary diagnosis: stage IV metastatic breast cancer, left ICA
aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were seen at the ___ due to
symptoms of dizziness (vertigo). We were concerned that the
dizziness was caused by a stroke. We performed an MRI during
your stay which did not show any sign of stroke; however, it
showed an enlargement of your known left carotid artery
aneurysm. During your admission, we also performed a CT scan and
bone scan to check for progression of the cancer. At this time,
there is no clear evidence that the cancer is spreading when
comparing the bone scan to the CT.
We had the neurosurgery team speak with ___ about the aneurysm.
They suggested that ___ follow up with Dr. ___ in clinic
after ___ get out of the hospital. Please refer to the
instructions on this sheet for setting up that appointment.
We determined that the cause of your dizziness is likely benign
positional vertigo (BPV) and had physical therapists work with
___ on how to alleviate these symptoms. We are sending ___ home
with a prescription to receive outpatient ___ sessions if needed.
We wish ___ the best!
Your ___ care team
Followup Instructions:
___
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Subsets and Splits