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19867608-DS-5
| 19,867,608 | 28,433,700 |
DS
| 5 |
2197-09-12 00:00:00
|
2197-09-12 20:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
Staples ___
History of Present Illness:
Ms. ___ is an ___ yo F who presented to the ED following a fall
while walking in the middle of the night after triping over a
chair. Pt sustained a laceration to her scalp and was bleeding
and brought in by ambulance to the ED. In the ED she was noted
to be intoxicated on alcohol with a blood alcohol in the 200s.
She was observed there but was unable to participate with ___ in
order to be cleared for home and is admitted to the floor to
ensure of this. In addition, while in the ED her initial HCT was
38 and dropped to 33 and then 31. She ahd no further evidence of
bleeding. Initial head CT was negative.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Patient is unsure of her medical history but knows she has:
hypothyroidism
may have an irregular heart beat or an extra heart beat
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.7, 115/61, 85, 20, 97RA
General - ___ elderly female in NAD, resting comfortably in bed
HEENT - abrasion to the left maxillary region without current
bleeding. Laceration approximated with staples in her scalp well
approximated and dried sanguinous dressing in place
Neck - no neck stiffness
CV - regular rate, intermittent irregular beats, no MRG
appreicate
Lungs -CTAB
Abdomen -Soft, nontender, nondistende, no palpable masses
GU -no foley
Ext - Left upper arm with ecchymosis in the medial bicep, no
lower extremity edema. Very thin extremities
Neuro - A+Ox3, FTN intact
Skin - abrasions as noted above, no other skin lesions present
Discharge Physical Exam:
VSS
General: thin appearing female in NAD, sitting up in bed eating
breakfast in NAD
HEENT: persistnet unchanged lesions on her face and lac on her
head well approximated
Cardiac: RRR, no MRG appreciated
GU, Ext, and Neuro exam unchanged.
Gait- patient was walked without assistance >100feet using her
own cane, narrow gait with good avoidance of obstacles. Normal
pivots and turns.
Pertinent Results:
Admission labs:
___ 12:00AM BLOOD WBC-11.3* RBC-3.88* Hgb-12.6 Hct-38.5
MCV-99* MCH-32.5* MCHC-32.8 RDW-13.2 Plt ___
___ 12:00AM BLOOD Neuts-76.5* ___ Monos-3.4 Eos-1.3
Baso-0.4
___ 12:00AM BLOOD Glucose-117* UreaN-15 Creat-0.6 Na-139
K-4.0 Cl-103 HCO3-22 AnGap-18
___ 12:00AM BLOOD ALT-24 AST-32 AlkPhos-35 TotBili-0.7
___ 12:00AM BLOOD Lipase-53
___ 12:00AM BLOOD cTropnT-<0.01
___ 12:00AM BLOOD Albumin-4.2
___ 08:20AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.8
___ 08:20AM BLOOD VitB12-326
___ 12:00AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge labs:
___ 08:20AM BLOOD WBC-6.2 RBC-3.31* Hgb-10.8* Hct-32.3*
MCV-98 MCH-32.7* MCHC-33.4 RDW-13.2 Plt ___
___ 08:20AM BLOOD Glucose-94 UreaN-11 Creat-0.7 Na-139
K-3.5 Cl-104 HCO3-25 AnGap-14
Imaging:
Trauma xray ___: Single AP view of the pelvis: Overlying
trauma board obscures fine detail. The patient is status post
right hip fixation with intramedullary rod and gamma nail.
There are stable severe degenerative changes of the left hip
with loss of joint space and subchondral sclerosis. No fracture
identified. No pubic symphysis or SI joint diastasis.
Degenerative changes of the lower lumbar spine.
CT Cspine ___: IMPRESSION:No evidence of acute fracture or
traumatic malalignment. NOTE ADDED AT ATTENDING REVIEW: There is
a 14 x 10 x 13 mm soft tissue mass immediately superior to the
hyoid bone in the midline. This is most likely a thyroglossal
duct cyst. This was not seen on the sagittal T1 images of the
___ brain MR, suggesting it has grown in that interval.
This finding was entered in the Radiology Department Critical
Reports system.
CT head ___: IMPRESSION: 1. No acute intracranial process.
2. Laceration and scalp hematoma overlying the left
frontoparietal bones
Brief Hospital Course:
Ms. ___ is an ___ yo F w/ PMH of hypothyroidism who presented
s/p fall while intoxicated on alcohol who is currently
hemodynamically stable and only sustained a laceration to her
scalp.
#Fall- appears to be secondary to mechanical fall worsened by
likely ataxia from alcohol intoxication. ___ describes tripping
over a chair. She was walked in the morning without difficulty.
Will need her staples out in 10 days -2 weeks.
#Anemia- pt had decrease in HCT from 38 on arrival to 31 today.
This was in the setting of a large scalp laceration with known
bleeding and no intracranial bleed. Hematocrit was stable on
recheck. She has no other lesions present to suggest ongoing
bleeding and no complaints of back or hip pain to suggest
bleeding in these areas. She likely had acute blood loss from
her scalp. This was trended and stable.
#Alcohol use- patient reports drinking when out to dinner and
that this is every other night. Now with a significnat fall and
head laceration that could have been more morbid this should
hopeully help to convince her that decreasing the quantity would
be beneficial.
#Hypothyroidism- patient does not know dose of her levothyroxine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral daily
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. zoledronic acid 4 mg/5 mL injection qyear
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral daily
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. zoledronic acid 4 mg/5 mL injection qyear
Discharge Disposition:
Home
Discharge Diagnosis:
Fall
Alcohol intoxication
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 here at ___. You were
admitted to the hospital after you had fallen at home. You
sustain a large cut to your head and had no internal head
bleeding. You were also found to be intoxicated with alcohol. We
recommend that you watch teh amount of alcohol you consume as
this can make you more unsteady on your feet and also as you get
older you have harder time breaking it down.
Followup Instructions:
___
|
19867608-DS-7
| 19,867,608 | 26,314,808 |
DS
| 7 |
2201-08-15 00:00:00
|
2201-08-15 15:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
aphasia, left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ woman with past medical history
significant for thyroid disease as well as A. fib not on
anticoagulation due to fall risk only on aspirin who presents as
an outside hospital transfer status post TPA.
Briefly, patient was in her usual state of health until 6:10 ___
on ___ when her daughter came to visit and noticed that she
had slurred speech and left facial droop and questionable left
arm weakness she was brought to an outside hospital where a code
stroke was activated. She had an ___ stroke scale of 4. CT head
scan without acute process, but did show extensive cerebellar
encephalomalacia. She was given TPA at 7:30 ___ and was
subsequently transferred to ___
for further management.
At ___ stroke scale is 1
for
mild left-sided facial weakness patient reports feeling back to
her baseline.
Exam notable for mild left-sided facial weakness intact mental
status intact sensation no dysmetria pupils equally round and
reactive extraocular eye movement intact she did have 5-
weakness
and triceps and IP which was pain related. At baseline
according to her.
Past Medical History:
PMH:
-Hypothyroidism
-Thyroglosal duct cyst
-Irregular hear beat
PSH:
-appendectomy
-?thyroidectomy
-repair of R hip fracture ___
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION EXAM:
Vitals: P: 74 R: 16 BP:129/78 SaO2:99RA
- General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. She had some difficulty
with
the hx. 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:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: milf left lower facial
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. mild resting and postural tremor in BUE.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 5 *5- ___ *5- 5 5 5 5 5 5
R 5 5 ___ ___ 5 5 5 5 5
* pain limited
-DTRs:
1+ thoughout, difficult to obtain cause she would complain of
pain.
-Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS.
-Coordination: No dysmetria on FNF bilaterally.
-Gait: Deferred
DISCHARGE EXAM:
General: lying in bed, in no acute distress
Lungs: breathing comfortably on room air.
CV: well-perfused
Abd: non-distended
Extremities: non-edematous
Neuro:
MS: Awake, alert, oriented to person, place, date. Attentive
with appropriate responses to questions. Speech fluent with
intact comprehension, no dysarthria, no paraphasias. Normal
prosody.
CN: Pupils round, minimally reactive, with R pupil slightly
smaller than left vs 3>2 bilaterally. Restricted upgaze. Visual
fields full to confrontation. R eye ptosis (patient reports some
ptosis at baseline). V: Facial sensation intact to light touch.
VII: face symmetric with subtle left lower facial droop. VIII:
Hearing intact to finger-rub bilaterally. IX, X: Palate elevates
symmetrically. XI: ___ strength in trapezii.
Motor: RUE and LUE ___ in biceps; Right triceps 5- compared to
Left. Bilateral FE ___. RLE ___ in quads, ham, ___, TA; L
IP 4+, L ham 4+ , L TA 5-.
Reflexes: deferred
Sensation: Intact to light touch and pinprick "sharp all over!"
Coordination: FNF intact bilaterally. Subtle intention tremor
bilaterally
Reflexes: 2+, 1+ patellar
Gait: Deferred
Pertinent Results:
___ 08:00AM BLOOD WBC-5.9 RBC-2.92* Hgb-10.1* Hct-29.6*
MCV-101* MCH-34.6* MCHC-34.1 RDW-13.9 RDWSD-51.5* Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD ___ PTT-25.0 ___
___ 08:00AM BLOOD Glucose-76 UreaN-15 Creat-0.7 Na-140
K-4.5 Cl-103 HCO3-24 AnGap-13
___ 10:15PM BLOOD Glucose-92 UreaN-19 Creat-0.8 Na-137
K-5.1 Cl-99 HCO3-22 AnGap-16
___ 08:00AM BLOOD ALT-12 AST-17 AlkPhos-57
___ 08:00AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.8 Cholest-181
___ 08:00AM BLOOD %HbA1c-4.7 eAG-88
___ 08:00AM BLOOD Triglyc-93 HDL-60 CHOL/HD-3.0 LDLcalc-102
IMAGING:
CTA HEAD AND CTA NECK ___ (Wet read):
Noncontrast CT: No acute large territorial infarct, intracranial
hemorrhage, edema or mass.
CTA: No evidence of dissection, occlusion, aneurysm >3mm, or
flow limiting stenosis.
Other: There is right apical pleural scarring and calcification.
MRI:
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with slurred speech and left
facial// stroke
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial
imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique
were then
obtained.
COMPARISON CT head without contrast ___.
FINDINGS:
A small area of slow diffusion with associated abnormal T2/FLAIR
signal
involves the right parietal cortex ___, 22) compatible with
a late acute
to early subacute infarct. There is no evidence of hemorrhage,
masses, mass
effect or midline shift. There are moderate subcortical, deep
and
periventricular T2/FLAIR white matter hyperintensities
compatible with chronic
small vessel ischemic disease given the patient's age. There is
T1/T2
hyperintensity at the left petrous apex with question of a
punctate area of
associated diffusion abnormality favored to represent a
cholesterol granuloma.
The major intracranial vascular flow voids are maintained.
There is relative
prominence of the ventricles relative to the cerebral sulci.
There is
evidence of a large retrocerebellar arachnoid cyst resulting in
mass effect
and significant atrophy of the cerebellar vermis and to a lesser
extent the
left and right cerebellar hemispheres.. The paranasal sinuses
and mastoid air
cells are normal. Status post right lens replacement.
IMPRESSION:
1. Small late acute to early subacute infarct of the right
parietal cortex.
2. Moderate white matter chronic small vessel ischemic disease.
3. Relative prominence of the ventricles compared to the
cerebral sulci can be seen in the setting of a communicating
type hydrocephalus.
4. Evidence of a large retrocerebellar arachnoid cyst resulting
in mass effect and significant atrophy of the cerebellar vermis
and to a lesser extent the left and right cerebellar
hemispheres.
5. T1/T2 hyperintensity at the left petrous apex with question
of a punctate area of associated diffusion abnormality favored
to represent a cholesterol granuloma. Additional differential
considerations include petrous apicitis. Findings are less
likely to be secondary to an underlying mass lesion given the
intact peripheral bony cortex.
Brief Hospital Course:
This is a ___ woman with past medical history
significant for thyroid disease as well as atrial fibrillation
not on anticoagulation who presented to OSH with dysarthria,
left facial droop and possible left arm weakness concerning for
stroke. She received tPA in OSH and was transferred to ___ for
further management. MRI demonstrated right parieto-occipital
infarct. Etiology thought to be cardio-embolic. Her clinical
exam improved s/p tPA with only mild residual left-sided
weakness confined predominantly to left lower extremity flexors.
Stroke risk factors: LDL 120, A1C 4.8%, TSH 0.36, atrial
fibrillation
We started atorvastatin 40 mg and ASA 81 mg until a decision was
made to start anticoagulation with apixaban.
After discussion with patient and with family, the decision was
made to start apixaban (CHADSVASC 6, HASBLED 4 presuming
starting heparin). On discharge, ASA 81 was discontinued and
apixaban was started at a 2.5 mg BID regimen (age>___, weight
<60kg). We also started her on atorvastatin 40 mg for LDL 120.
She was also found to have a urinary tract infection on
admission, which is being treated with macrobid. She was
discharged to rehab in stable condition.
Chronic Issues: Holding home diltiazem for SBP <140s, can resume
as tolerated/necessary
Transitional Issues:
# Right parieto-occipital infarct:
- continue apixaban 2.5 mg BID (age >___ regimen)
- continue atorvastatin 40 qhs
- ___ as tolerated
- SEVERE FALL PRECAUTIONS, HIGH BLEED RISK
# Urinary tract infection: E coli
- continue macrobid, last dose ___ for total of ___HA/ASA Core Measures for Ischemic Stroke and Transient
Ischemic Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed â () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes - () No
4. LDL documented? (x) Yes (LDL =120 ) - () 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 if LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (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 >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
35 minute were spent on discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Aspirin 81 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Calcium Carbonate 500 mg PO Frequency is Unknown
5. Cyanocobalamin 100 mcg PO DAILY
6. Diltiazem 30 mg PO TID
Discharge Medications:
1. Apixaban 2.5 mg PO BID
2. Atorvastatin 40 mg PO QPM
3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
4. Calcium Carbonate 500 mg PO DAILY
5. Cyanocobalamin 100 mcg PO DAILY
6. Diltiazem 30 mg PO TID
HOLD FOR SBP>150
7. FoLIC Acid 1 mg PO DAILY
8. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
___ were hospitalized due to symptoms of stroke resulting from
an ACUTE ISCHEMIC STROKE, a condition where a blood vessel
providing oxygen and nutrients to the brain is blocked by a
clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed ___ 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
- hypertension
- hyperlipidemia (LDL 120)
We are changing your medications as follows:
START: Apixaban as a blood thinner to reduce your risk of stroke
START: Atorvastatin 40 mg to reduce your risk of stroke
STOP: ASPIRIN 81 MG
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
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19867817-DS-16
| 19,867,817 | 29,298,626 |
DS
| 16 |
2204-05-03 00:00:00
|
2204-05-03 13:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
morphine / metformin / Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Left Foot infection
Major Surgical or Invasive Procedure:
___: Left foot debridement and bone biopsy
History of Present Illness:
___ with DM presents to the ED for infection to the LLE, likely
osteomyelitis with failure of oral abx s/p L first met head
resection x 3 months. Pt has a history of neuropathy secondary
to cancer/treatment approxiately ___ years ago. He had a
temperature of 101 on ___ and started Bactrim and Augmentin
from his PCP due to increased redness to prior operative site on
his left foot. He is finishing his course on ___ and ___
but has some worsening redness and swelling to his left foot.
He is seen by Dr. ___ on a regular basis in clinic which
is who referred him into the ED today for I&D and admission for
IV
abx. Pt admits to decreased apetite, lethargy but denies any
prior nausea or vomitting. However, after his I&D, patient
relates to having an "upset stomach". He admits to having daily
diarrhea for the last past month. He states his doctors have
tested his stool and have not found a cause. He is scheduled to
have a colonoscopy in the future.
Past Medical History:
Cancer ___ years ago, neuropathy secondary to chemotherapy,
OSA on CPAP,DM
Social History:
___
Family History:
Heart disease, cancer, arthritis
Physical Exam:
PE on admission
98.3 78 143/80 18 99% RA
General: NAD
CV: RRR
Resp: No respiratory distress
Abdomen: Soft, NT, Nondistended
Left Lower Extremity: Red and swollen medial aspect of pt's left
foot. Two pinhole ulcerations over prior surgical site with
serous and bloody discharge. Positive probe to bone. After
deep
probing, 2 ccs of purulence were expressed from the proximal
ulcer where there was the most amount of fluctuance.
PE at Discharge
VSS
General: NAD
CV: RRR
Resp: No respiratory distress
Abdomen: Soft, NT, Nondistended
Left Lower Extremity: Clean, dry, intact dressing to left foot.
Cap refill <3 seconds to digits.
Neuro: A&Ox3
Pertinent Results:
___ 01:25PM BLOOD WBC-7.9 RBC-4.02* Hgb-12.2* Hct-35.6*
MCV-89 MCH-30.3 MCHC-34.3 RDW-13.8 Plt ___
___ 01:25PM BLOOD Plt ___
___ 01:25PM BLOOD Glucose-94 UreaN-19 Creat-1.2 Na-135
K-3.8 Cl-98 HCO3-26 AnGap-15
___ 05:58AM BLOOD ALT-46* AST-24 LD(LDH)-175 AlkPhos-88
TotBili-0.1
___ 05:58AM BLOOD CRP-81.2*
___ 01:34PM BLOOD Lactate-1.9
___ 07:00AM BLOOD WBC-8.0 RBC-4.18* Hgb-12.6* Hct-37.6*
MCV-90 MCH-30.1 MCHC-33.4 RDW-13.7 Plt ___
___ 04:45AM BLOOD WBC-10.1 RBC-3.79* Hgb-11.6* Hct-33.1*
MCV-87 MCH-30.6 MCHC-35.1* RDW-13.9 Plt ___
___ 07:00AM BLOOD Glucose-142* UreaN-19 Creat-1.1 Na-138
K-4.8 Cl-98 HCO3-29 AnGap-16
___ 04:45AM BLOOD Glucose-184* UreaN-15 Creat-1.1 Na-135
K-4.1 Cl-97 HCO3-28 AnGap-14
___ 07:00AM BLOOD Calcium-10.1 Mg-1.9
___ 04:45AM BLOOD Calcium-9.2 Phos-4.6* Mg-1.8
___ 06:45PM BLOOD Vanco-11.8
X-ray Left foot ___:
Postoperative changes throughout the first through third rays.
Moderate soft tissue swelling; infection cannot be excluded. No
subcutaneous gas detected
URINE CULTURE (Final ___: NO GROWTH.
Left Foot Swab (___)
GRAM STAIN (Final ___ (<1 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES.NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___ STAPH AUREUS COAG +. SPARSE
GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
___ 1:07 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 4:04 pm TISSUE FIRST METARTASAL LEFT FOOT.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
GRAM POSITIVE COCCUS(COCCI). SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary):
___: Pathology left ___ metatarsal: pending
Brief Hospital Course:
Mr. ___ is a ___ year old male who presented to the ED on
___. The patient was found to have a left foot infection.
While in the ED, a bedside incision and drainage was preformed.
X-rays could not rule role osteomyelitis. He was admitted to
podiatry for IV antibiotics and further debridement. Given
findings, the patient was taken to the operating room on
___ for a left foot debridement and closre. There were no
adverse events in the operating room; please see the operative
note for details. Pt was extubated, taken to the PACU until
stable, then transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oral dilaudid prn which
he did not require while hospitalized.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially placed on a diabetic diet.
He was made NPO with IVF at midnight on ___ for OR
debridement. A diabetic diet was resumed following the
procedure, which was well tolerated. Patient's intake and output
were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. At the time of admission,
the patient was started on vancomycin and zosyn. The wound was
cultured on admission and grew coag+ staph aureus and
corynebacterium. Patient reported that he did have some diarrhea
at home. C.diff culture was negative.] Infectious disease was
consulted who recommended continuing vancomycin and zosyn until
bone biopsy could be obtained. The patient was taken to the OR
on ___ for further debridement and bone biopsy. Microbiology
from ___ metatarsal gram stain was negative for microoranisms
and culture grew GPCs sparse growth. Pathology is still
currently pending. Infectious disease recommended PICC line
placement, discharge with cefazolin for 6 weeks, and follow up
as an outpatient. The patient was discharge on ___ with PICC
line in place and a prescription for 6 weeks of antibiotics was
sent to home infusion company.
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.
Endo: Patient is a known diabetic. He was placed on an insulin
sliding scale and blood sugars were routinely monitored. His
blood sugars remained well controlled while hospitalized.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating with a walker, 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
Medications on Admission:
Lisinopril, lovastatin, gabapentin, glimepiride, ibuprofen,
insulin glargine, Glucosamine chondroitin Plus, Multivitamin,
Discharge Medications:
1. Gabapentin 200 mg PO QAM
2. Gabapentin 500 mg PO QHS
3. Glargine 80 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
4. Lisinopril 20 mg PO DAILY
5. Lovastatin 20 mg oral qhs
6. Multivitamins 1 TAB PO DAILY
7. CefazoLIN 2 g IV Q8H
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 g IV q 8 hrs
Disp #*42 Intravenous Bag Refills:*2
8. Acetaminophen 325-650 mg PO Q6H:PRN pain
9. walker miscellaneous daily
RX *walker Use walker to be non-weightbearing to left foot
daily Disp #*1 Each Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Left Foot Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Non-weightbearing left foot
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___. You
presented to the Emergency Room at ___ on ___ for a left
foot infection where you underwent a bedside incision and
drainage. You were then admitted for IV antibiotics and
underwent a left foot debridement in the OR on ___. You
are now ready to continue your recovery at home. Please follow
these discharge instructions:
These are the discharge instructions for post-operative
discharge instructions.
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, severe increase in pain to operative site or pain
unrelieved by your pain medication, nausea, vomiting, chills,
foul smelling or colorful drainage from your incisions/wounds,
redness or swelling around your incisions, or any other symptoms
which are concerning to you.
Diet: ___ regular diet
Medication Instructions:
Resume your home medications.
You will be starting some new medications:
1. You armay take tylenol or ibuprofen as needed for pain.
2. If you were prescribed antibiotics, it is critical for you
to take them as prescribed and for the full course of the
regimen.
Activity:
You should remain non-weightbearing to your left foot in a
surgical shoe.
Wound Care:
You may shower but please keep dressings clean, dry, and intact.
Do not submerge your foot/leg in water.
Please call the doctor or page the ___ pager, if you have
increased pain, swelling, redness, or drainage to the operative
sites.
Followup Instructions:
___
|
19867817-DS-17
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DS
| 17 |
2205-09-22 00:00:00
|
2205-09-22 20:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
morphine / metformin / Iodinated Contrast Media - IV Dye / ACE
Inhibitors
Attending: ___.
Chief Complaint:
Right foot infection
Major Surgical or Invasive Procedure:
___: Right Foot partial hallux amputation
History of Present Illness:
Mr. ___ is a ___ M with DM, neuropathy, OSA, who presented
to the ED with complaints of R great toe swelling and redness x
5 days, worsening over the lst few ___ prior to presentation. He
reported fevers and chills as well during this time. His R
hallux nail was removed over a year ago and has not grown back.
He states that his R hallux became erythematous and swollen and
then progressed to edema of the lower leg with erythema
extending from the toe to the foot. He had noted purulent
drainage coming from the wound on his toe for several days which
had been squeezing out of the toe. He was dressing the area with
dry dressings. Due to worsening condition of the weekend he
called Dr. ___ recommended coming in to the ED for
further evaluation. He was evaluated in the ED and Xrays were
obtained which were concerning for bony changes indicating
likely osteomyelitis. He was admitted for IV antibiotics and
hallux amputation.
Past Medical History:
Cancer ___ years ago
neuropathy secondary to chemotherapy
OSA on CPAP
DM
Social History:
___
Family History:
Heart disease, cancer, arthritis
Physical Exam:
On Admission:
Initial Vitals: T: 98.1 HR:62 BP:156/87 RR:18 O2:100% RA FSBG
200
General: NAD
CV: RRR
Resp: No respiratory distress
Abdomen: Soft, NT, Nondistended
Lower Extremity Focused Exam: DP/Pt pulses palpable b/l, cap
refill >3 sec to the digits. Edema noted to the Right leg and
foot. + venous stasis changes noted. . Erythema present to right
hallux extending to the proximal calf on the R leg . Light touch
sensation diminished to the feet b/l. Ulceration to the dorsal
aspect of the right hallux where his nail is no longer present.
The ulcer with a fibrous covering when debrided a deep
ulceration noted which probes to the distal phalanx. No
purulence noted to the area. Surrounding tissue is
hyperkeratotic. Superficial ulcerations noted to the anterior R
leg. He does not have pain in the right hallux but is
neuropathic. No pain with palpation of the Right calf and no
pain with R ankle plantar flexion.
On discharge:
Initial Vitals: T: 98.5 HR:65 BP:145/86 RR:18 O2:100% RA
General: NAD
CV: RRR
Resp: No respiratory distress
Abdomen: Soft, NT, Nondistended
Lower Extremity Focused Exam: DP/Pt pulses palpable b/l, cap
refill >3 sec to the digits. Edema noted to the Right leg and
foot. + venous stasis changes noted. Light touch sensation
diminished to the feet b/l. R hallux partial amputation surgical
site with well coapted incision with sutures intact. No
surrounding erythema.
Pertinent Results:
On Admission:
___ 11:21AM LACTATE-2.0
___ 11:00AM GLUCOSE-191* UREA N-14 CREAT-1.0 SODIUM-141
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15
___ 11:00AM estGFR-Using this
___ 11:00AM CALCIUM-9.9 PHOSPHATE-2.4*# MAGNESIUM-1.9
___ 11:00AM CRP-38.3*
___ 11:00AM WBC-4.9# RBC-4.01* HGB-12.7* HCT-36.8* MCV-92
MCH-31.7 MCHC-34.5 RDW-13.2 RDWSD-44.0
___ 11:00AM NEUTS-49.2 ___ MONOS-10.5 EOS-3.2
BASOS-1.2* IM ___ AbsNeut-2.42 AbsLymp-1.76 AbsMono-0.52
AbsEos-0.16 AbsBaso-0.06
___ 11:00AM PLT COUNT-319
Pathology: R hallux - pending
Micro:
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Brief Hospital Course:
The patient was admitted to the podiatric surgery service from
the emergency room on ___ for a R foot infection. On
admission, he was started on broad spectrum antibiotics. He was
taken to the operating room on ___ for a Right Hallux
partial amputation. Pt was evaluated by anesthesia and taken to
the operating room. There were no adverse events in the
operating room; please see the operative note for details.
Afterwards, pt was taken to the PACU in stable condition, then
transferred to the ward for observation.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled oral pain medication on a
PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. He was placed on oral
Clindamycin post operatively and discharged with 2 weeks of PO
Clindamycin. His intake and output were closely monitored and
noted to be adequtae. The patient received subcutaneous heparin
throughout admission; early and frequent ambulation were
strongly encouraged.
The patient was subsequently discharged to home on POD 1 with
intact dressing, PO antibiotics, and pain medication. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Multivitamins 1 TAB PO DAILY
2. Januvia (sitaGLIPtin) 25 mg oral Q24H
3. Gabapentin 200 mg PO QAM
4. Gabapentin 500 mg PO QPM
5. Hydroxychloroquine Sulfate 200 mg PO BID
6. Enalapril Maleate 10 mg PO DAILY
7. Glargine 80 Units Breakfast
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Glargine 80 Units Breakfast
3. Gabapentin 500 mg PO QPM
4. Hydroxychloroquine Sulfate 200 mg PO BID
5. Gabapentin 200 mg PO QAM
6. Januvia (sitaGLIPtin) 25 mg oral Q24H
7. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Already on medication. Please continue
8. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp
#*60 Tablet Refills:*0
9. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
10. DiphenhydrAMINE 25 mg PO QHS:PRN Insomnia
11. Clindamycin 300 mg PO Q6H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every 6 hours
Disp #*56 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right foot infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service on ___ for a Right foot
infection. You were brought to the operating room on ___ for
a partial amputation of your Right Big toe. You were given IV
antibiotics while here. You are being discharged home with the
following instructions:
ACTIVITY:
There are restrictions on activity. Please remain weight bearing
to the heel to your R foot until your follow up appointment. You
should keep this site elevated when ever possible (above the
level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking in a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
Followup Instructions:
___
|
19867817-DS-18
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DS
| 18 |
2207-01-26 00:00:00
|
2207-01-26 15:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
morphine / metformin / Iodinated Contrast Media - IV Dye / ACE
Inhibitors
Attending: ___.
Chief Complaint:
Right Foot abscess / cellulitis
Major Surgical or Invasive Procedure:
___: Right Foot I&D
History of Present Illness:
Mr. ___ is a ___ M with DM, neuropathy, OSA, who
presented initially to the ED on referral with complaints of R
foot cellulitis. He was seen for follow-up in ___ by Dr.
___ earlier in the day. He was sent to ___ for
admission for IV abx. He was recently admitted to ___
___ for an infection to the Right foot. He was admitted for
1 week and was discharged on IV zosyn with a PICC line. During
the admission he had a R foot Xray, MRI, and CT of the R foot.
He did not have any procedures or debridements done while at the
OSH. He was seen in the office today with ongoing erythema and
warmth to the dorsal right forefoot. He has a PICC line in
place. He denies any cough, HA, diarrhea, dysuria recently. He
denies current nausea or vomiting. Denies recent chills and
fevers. He states that his blood glucose levels have been under
control lately.
Past Medical History:
Cancer ___ years ago
neuropathy secondary to chemotherapy
OSA on CPAP
DM
Social History:
___
Family History:
Heart disease, cancer, arthritis
Physical Exam:
On Admission:
Initial Vitals: 98.2 74 126/85 16 96% RA
General: NAD
CV: RRR
Resp: No respiratory distress
Abdomen: Soft, NT, Nondistended
Lower Extremity Focused Exam: DP/Pt pulses palpable b/l, cap
refill >3 sec to the digits. Edema noted to the Right leg and
foot. + venous stasis changes noted. Erythema present to Right
Forefoot over the dorsal aspect of metatarsals ___. Small lesion
from recent aspiration of the foot. No ulcerations noted to the
right foot. No open leisons noted to the L foot. Light touch
sensation diminished to the feet b/l.
.
On Discharge:
Vitals: 98.1, 148/83, 86, 18, 96% on Ra
General: NAD
CV: RRR
Resp: No respiratory distress
Abdomen: Soft, NT, Nondistended
Lower Extremity Focused Exam: DP/Pt pulses palpable b/l, cap
refill >3 sec to the digits. Edema and erythema improved to the
Right forefoot. Incision noted to the dorsum of the right foot,
well coapted, sutures intact. No drainage noted. No purulence
expressed.
Pertinent Results:
On Admission:
___ 01:14PM BLOOD WBC-10.4*# RBC-4.04* Hgb-12.3* Hct-36.3*
MCV-90 MCH-30.4 MCHC-33.9 RDW-13.0 RDWSD-42.6 Plt ___
___ 01:14PM BLOOD Neuts-71.9* Lymphs-18.3* Monos-7.0
Eos-1.4 Baso-0.7 Im ___ AbsNeut-7.45*# AbsLymp-1.90
AbsMono-0.73 AbsEos-0.14 AbsBaso-0.07
___ 01:14PM BLOOD ___ PTT-29.3 ___
___ 01:14PM BLOOD Glucose-166* UreaN-17 Creat-1.3* Na-141
K-4.3 Cl-101 HCO3-25 AnGap-15
___ 01:29PM BLOOD Lactate-2.0
.
On Discharge:
___ 01:07AM BLOOD WBC-7.6 RBC-4.01* Hgb-12.3* Hct-36.5*
MCV-91 MCH-30.7 MCHC-33.7 RDW-12.8 RDWSD-42.7 Plt ___
___ 01:07AM BLOOD Glucose-196* UreaN-21* Creat-1.3* Na-140
K-4.2 Cl-99 HCO3-28 AnGap-13
___ 01:07AM BLOOD Calcium-9.8 Phos-3.7 Mg-1.6
___ 12:00AM BLOOD Vanco-15.0
.
IMAGING:
Right Foot Xray ___: No definite signs of osteomyelitis. No
gas seen.
U/S Right Foot ___: Soft tissue edema and a small fluid
pocket over the right foot measuring 1.2 x 0.7 x 1.1 cm, with
fluid seen tracking to the skin.
.
MICRO:
Right Foot wound culture:
___ 1:55 pm SWAB Site: FOOT RIGHT FOOT.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Brief Hospital Course:
The patient was admitted to the podiatric surgery service from
the ED on ___ for a Right foot infection. On admission, he
was started on broad spectrum antibiotics. He was taking to the
OR for Right Foot I&D with partial closure on ___. Pt was
evaluated by anesthesia and taken to the operating room. There
were no adverse events in the operating room; please see the
operative note for details.
Afterwards, pt was taken to the PACU in stable condition, then
transferred to the ward for observation.
.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled oral pain medication on a
PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. He was placed on
vancomycin, ciprofloxacin, and flagyl while hospitalized and
discharged with IV Vancomycin and oral ciprofloxacin for 1 week.
He had a prior PICC line placed at an OSH. The PICC line was
inspected and correct position confirmed on CXR.
.
His intake and output were closely monitored and noted to be
adequtae. The patient received subcutaneous heparin throughout
admission; early and frequent ambulation were strongly
encouraged.
.
The patient was subsequently discharged to home on POD2 with IV
abx course and ___. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. glimepiride 4 mg oral DAILY
4. Januvia (SITagliptin) 100 mg oral DAILY
5. Enalapril Maleate 10 mg PO DAILY
6. Gabapentin 600 mg PO BID
7. Hydroxychloroquine Sulfate 200 mg PO DAILY
8. Humalog 17 Units Dinner ___ 130 Units Breakfast Insulin SC
Sliding Scale using HUM InsulinMax Dose Override Reason: home
regimen
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*14 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. glimepiride 4 mg oral DAILY
5. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
6. Januvia (SITagliptin) 100 mg oral DAILY
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6H Disp #*20 Tablet
Refills:*0
8. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
9. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 1 gram 1000 mg IV every twelve (12) hours Disp
#*14 Vial Refills:*0
10. Enalapril Maleate 10 mg PO DAILY
11. Gabapentin 600 mg PO BID
12. Hydroxychloroquine Sulfate 200 mg PO DAILY
13. Humalog 17 Units Dinner
___ 130 Units Breakfast
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: home regimen
14. Multivitamins 1 TAB PO DAILY
15. Vitamin D ___ UNIT PO DAILY
16.Outpatient Lab Work
CBC w/ Diff, Cr, Vancomycin Trough on ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right Foot Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service for treatment of your Right
Foot infection. You were given IV antibiotics while here and
will be discharged with IV abx and a PICC line. You were taken
to the OR on ___ for a Right Foot Washout. You are being
discharged home with the following instructions:
ACTIVITY:
There are restrictions on activity. Please remain weight bearing
to the heel on your R foot until your follow up appointment. You
should keep this site elevated when ever possible (above the
level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking in a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
Followup Instructions:
___
|
19868102-DS-34
| 19,868,102 | 28,847,072 |
DS
| 34 |
2194-08-03 00:00:00
|
2194-08-04 22:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Tetracycline Analogues /
Erythromycin Base / Atenolol / Lidoderm / lisinopril / Combivent
Attending: ___.
Chief Complaint:
Dysuria/weakness/back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with NSCLC, PE on coumadin, recurrent SBOs, severe
arthritis and sciatica, and CAD, who was admitted with back pain
and a UTI.
Of note, Patient was recently hospitalized at ___
from ___ to ___. She was admitted there with 1 day
h/o diarrhea and abdominal pain. Her c.diff testing was
negative there, diarrhea thought secondary to viral enteritis.
She was noted to have melanotic stools which were guiaic
positive. Per discharge summary from ___, risks/benefits of
continuing coumadin in setting of GI bleed were discussed as
well as potential EGD and GI consultation. Decision was made by
daughter and patient to not undergo futher testing and to
continue warfarin. IN addition, patient had elevated troponin
at ___, diagnosed with NSTEMI, patient did not wish have
cardiac consultation or have further cardiac testing.
Physicians at ___ discussed hospice care with Ms. ___ and
___ daughter in setting of patient's continued failure to
thrive, although a final decision on hospice was not made. On
her day of discharge from ___, she developed dysuria and was
started on macrobid.
After patient was discharged to home she continued to have
dysuria and urinary frequency and also c/o back pain and
weakness. ___ was placed by ___ who subsequently
contacted patient's PCP, ___. Dr. ___
admission to ___ to clarify her anti-coagulation in setting of
GI bleed and h/o PEs and for palliative care consult.
On the floor, she is fatigued, reports feeling dehydrated and
continues to have lower abdominal pain, feels like she is having
occasional bladder spasms.
Past Medical History:
Coronary artery disease s/p MI in ___
Atrial fibrillation
s/p thoracoscopic left upper lobectomy ___ for two
distinct adenocarcinomas, S/P adjuvant chemotherapy ___ -
___ with carboplatin and pemetrexed
Postoperative right vocal cord paralysis.
Postoperative pulmonary embolism ___ and again ___, on long-standing Coumadin
Aortic stenosis
History of breast cancer and radiation.
History of melanoma, resected.
s/p Bilateral total knee replacements
Back pain
Squamous cell carcinoma
Small bowel obstruction s/p post-sigmoid colectomy
Hypertension
Osteoarthritis with significant sciatica
Subclinical carotid disease
Osteopenia
Emphysema
Hearing Loss
Hyperthyroidism
Macular Degeneration
s/p Bilateral cataract surgeries
Diverticulitis
Chronic renal insufficiency
Social History:
___
Family History:
No inflammatory bowel disease in family. Breast cancer (mother)
Physical Exam:
ADMISSION PHYSICAL EXAM:
==================
Vitals - T97.8 BP 168/65 HR 97 RR 18 98% on RA
Gen - Elderly female, cachectic, in NAD
HEENT - NC/AT, EOMI, sclera anicteric, oropharynx dry, no
tonsillar exudates
CV - RRR, ___ systolic murmur loudest at the apex, no rubs or
gallops
Lungs - Lungs CTAB, no wheezes or rhonchi
Abd - soft, diffusely tender, +BS, no rebound or guarding
Ext - 2+ radial and DP pulses, no c/c/e
Skin - no rashes or excoriations noted
Neuro - A+Ox3, moving all extremities, strength ___ at BLE on
leg ___ and ankle dorsiflexion/plantar flexion.
DISCHARGE PHYSICAL EXAM:
==================
Vitals - 98.0, 145/60, 80, 16, 97%RA
Gen - Elderly female, cachectic, dysphonic voice in NAD
HEENT - NC/AT, EOMI, sclera anicteric, oropharynx dry, no
tonsillar exudates
CV - RRR, ___ systolic murmur loudest at the apex, no rubs or
gallops
Lungs - Lungs CTAB, no wheezes or rhonchi
Abd - soft, diffusely tender, +BS, no rebound or guarding
Ext - 2+ radial and DP pulses, no c/c/e
BACK: mild spinal ttp along cervical and lumbar spine, full neck
ROM
Skin - no rashes or excoriations noted
Neuro - A+Ox3, moving all extremities, strength ___ at BLE on
leg ___ and ankle dorsiflexion/plantar flexion.
Pertinent Results:
ADMISSION AND TREND LABS:
====================
___ 07:45PM BLOOD WBC-10.4# RBC-4.45 Hgb-12.9 Hct-40.6
MCV-91 MCH-29.0 MCHC-31.8 RDW-13.1 Plt ___
___ 05:50AM BLOOD WBC-8.7 RBC-4.23 Hgb-12.5 Hct-38.6 MCV-91
MCH-29.5 MCHC-32.3 RDW-13.2 Plt ___
___ 07:45PM BLOOD Neuts-86.5* Lymphs-6.9* Monos-4.2 Eos-2.0
Baso-0.4
___ 07:45PM BLOOD ___ PTT-40.4* ___
___ 05:50AM BLOOD ___
___ 07:45PM BLOOD Glucose-85 UreaN-10 Creat-0.6 Na-132*
K-4.4 Cl-94* HCO3-26 AnGap-16
___ 05:50AM BLOOD Glucose-63* UreaN-14 Creat-0.5 Na-133
K-3.4 Cl-96 HCO3-23 AnGap-17
___ 07:45PM BLOOD ALT-16 AST-36 AlkPhos-63 TotBili-0.7
___ 07:45PM BLOOD Lipase-15
___ 07:45PM BLOOD cTropnT-0.05*
___ 07:45PM BLOOD Albumin-3.7 Calcium-8.8 Phos-4.0 Mg-1.7
___ 05:50AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.7
___ 07:52PM BLOOD Lactate-1.2
___ 08:45PM URINE Color-DkAmb Appear-Clear Sp ___
___ 08:45PM URINE Blood-MOD Nitrite-POS Protein-100
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 08:45PM URINE RBC-4* WBC-15* Bacteri-FEW Yeast-NONE
Epi-0 TransE-<1
___ 08:45PM URINE CastHy-1*
DISCHARGE LABS:
==============
___ 08:45AM BLOOD WBC-4.3 RBC-3.90* Hgb-11.3* Hct-36.5
MCV-94 MCH-28.9 MCHC-30.9* RDW-13.1 Plt ___
___ 08:45AM BLOOD ___ PTT-35.3 ___
___ 08:45AM BLOOD Glucose-112* UreaN-12 Creat-0.5 Na-135
K-3.9 Cl-98 HCO3-28 AnGap-13
MICRO:
======
___ 8:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 7:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
=======
CXR (___):
IMPRESSION: Better seen on the lateral view is slightly
increased opacity
in the retrocardiac region, potentially could be infectious, and
followup will
be necessary given patient's history.
CT HEAD (___):
IMPRESSION: No acute intracranial process.
Brief Hospital Course:
___ yo F with NSCLC, PE on coumadin, recurrent SBOs, severe
arthritis and sciatica, and CAD, who was admitted with back pain
and a UTI.
# Failure to thrive: Ongoing weight loss, worse over past year.
Has gone from 130 lbs in ___ to 100 lbs on admission here.
Likely related to her multiple medical co-morbidities and
multiple recent hospitalizations including 2 for SBOs over past
year (___ and ___ and one for pneumonia in ___. In
addition she has decreased appetite which is contributing. She
was seen by Dr. ___ GI in ___, who felt her
weight loss/FTT was related to ongoing narcotic regimen with
resultant decreased appetite. She recently saw her PCP (Dr.
___ in ___ and had discussion regarding goals of care.
Per Dr. ___, Ms. ___ has expressed wish to focus on
comfort and quality of life. Patient was started on ensure
supplementation per nutritionist recommendations. She was seen
by palliative care who recommended benecalorie and ensure diet
supplementation. Goals of care were discussed with patient,
she would not like hospice at this time, but home with continued
services. She was discharged to home with home ___ and skilled
nursing.
# Back pain: Patient has a significant history of arthritis and
sciatica which she has struggled with for many years and pain
control has been challenging. She was continued on her home
MSContin and oxycodone and was discharged on this regimen. No
increases in pain regimen were made given concerns for sedation
and fall risk.
# UTI: UA concerning for UTI. ___ culture grew < 5000
e.coli colonies with intermediate resistance pattern (sensitive
to tetracycline, ceftriaxone; resistant to ciprofloxacin and
Bactrim). Patient reported burning symptoms, and frequent
urination. She was started on IV ceftriaxone and switched to PO
cefpodoxime. She completed her antibiotic course while an
inpatient. Her UTI symptoms resolved. Of note, urine culture
and blood cultures drawn at ___ were negative.
# NSTEMI: patient diagnosed with NSTEMI at ___
earlier this week. Patient declined further cardiac workup
including cardiology consultation, catheterization and
echocardiogram per ___ records. Patient was started on
moderate dose statin at ___. On admission to ___ patient
was continued on statin and aspirin.
# NSCLC : Stable at this time, but likely one of many of her
semi-active comorbidities contributing to her overall functional
decline.
# Murmur: Significant murmur heard loudest at the apex,
concerning for mitral regurgitation. Asymptomatic at this time.
Patient reported she has been told she has murmur in the past.
Further workup was not pursued as this murmur is old, patient
declined cardiology consult, including echo, at ___ earlier
this week, and would not pursue any invasive procedure to
repair.
# PE: History of recurrent PEs on coumadin. Managed by ___
___ clinic. INR supra therapeutic on admission.
Warfarin initially held. Was resumed with normalization of INR.
She was discharged on her home dose of warfarin (5 mg daily).
# SBOs/?Chron's: followed by Dr. ___ with GI. ___ Dr. ___,
___ was question of Chron's on previous CT scan, was started
on mesalamine. Develops SBOs when stops mesalamine per webOMR
note from Dr. ___ ___. She was continued on her home
mesalamine.
TRANSITIONAL ISSUES:
================
# UTI: cultures at ___ grew e.coli (< 5000 colonies)
sensitive to IV ceftriaxone. Although low number of colonies,
given patient was initially symptomatic with dysuria, she was
treated with IV ceftriaxone, switched to PO cefpodoxime and
completed course on ___. She had no dysuria or urinary frequency
on discharge.
# Weight loss/Failure to thrive: has been ongoing for number of
months. Patient reports poor appetite which her GI physician
(Dr. ___ believes may be related to chronic opioid use per his
OMR note from ___. Failure to thrive also likely related to
multiple hospitalizations this past year. Seen by nutrition who
recommended Ensure supplementation. Recommend continued
monitoring of weight on discharge follow up.
# Goals of care: palliative care was consulted to assist in
goals of care discussion. Patient at this time does not seem
prepared for hospice care, was discharged to home with skilled
nursing and home physical therapy. Recommend continued
discussion regarding goals of care with patient on outpatient
follow up.
# Back pain: patient with ongoing chronic back pain. Patient was
continued on home MS ___ and oxycodone. No changes were made
in her analgesic regimen given concerns for sedation and fall
risk.
# Supratherapeutic INR: patient with supratherapeutic INR to 3.4
on ___. Warfarin held for one day, was restarted at home dose 5
mg daily. Patient is followed by ___ clinic. Recommend
next INR check on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH DAILY:PRN cough/wheezing
2. Aspirin 81 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Gabapentin 600 mg PO HS
6. Morphine SR (MS ___ 15 mg PO Q12H
7. Omeprazole 20 mg PO DAILY
8. Oxybutynin 5 mg PO DAILY
9. Warfarin 5 mg PO DAILY16
10. Zolpidem Tartrate 5 mg PO HS
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
12. Atorvastatin 40 mg PO DAILY
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. Multivitamins 1 TAB PO DAILY
15. Senna 8.6 mg PO BID:PRN constipation
16. Mesalamine 1000 mg PO BID
17. Nitrofurantoin (Macrodantin) 100 mg PO Q6H x 7 days
(starting ___
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH DAILY:PRN cough/wheezing
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Gabapentin 600 mg PO HS
7. Mesalamine 1000 mg PO BID
8. Morphine SR (MS ___ 15 mg PO Q12H
9. Omeprazole 20 mg PO DAILY
10. Oxybutynin 5 mg PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
12. Senna 8.6 mg PO BID:PRN constipation
13. Zolpidem Tartrate 5 mg PO HS
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Multivitamins 1 TAB PO DAILY
16. Warfarin 5 mg PO DAILY16
17. Outpatient Lab Work
Check ___ as directed
ICD-9-CM Diagnosis Code 415.1 Pulmonary embolism and infarction
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Urinary Tract Infection
- Failure to Thrive
- Chronic back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure caring for you during your admission to ___
___. You were admitted for
evaluation of ongoing frequent urination and weakness. You were
started on antibiotics for a urinary tract infection. You were
seen by the palliative care team for assistance in developing a
plan of care going forward with regards to your goals of care.
You have a follow up appointment scheduled in the palliative
care team clinic later this month. You improved clinically and
it was determined you could be discharged to home.
- Your ___ Team
Followup Instructions:
___
|
19868276-DS-11
| 19,868,276 | 25,054,736 |
DS
| 11 |
2163-08-04 00:00:00
|
2163-09-06 23:14:00
|
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:
CT guided bone biopsy of left humerus ___
History of Present Illness:
Patient is a ___ yo male with PMH of pathologic fracture, getting
ongoing malignancy work-up who presents with abdominal pain x2
days.
On ___, he he broke his arm while plunging a toilet. He was
then seen at ___ and sling was placed. He was referred
to ortho hand consult and he discovered he had a pathologic
fracture. He underwent MRI/ CT which showed liver mass and
thrombosis. Anticoagulation was not started at that time. Last
week, he had diarrhea for several days. His diarrhea then
resolved but he developed intermittent abdominal pain 2 days
ago. Pain was intermittent, crampy, rated as ___. Relieved by
rest, worsened with movement, eating. He did not take any
medications for the pain (though has oxycodone for shoulder
pain). He denies fevers. chills, vomiting, constipation,
dysuria. Last bowel movement was this morning. Denies bloody or
black stool.
In the ED, triage vitals were 97.4 73 140/57 16 99. Labs were
significant for AST 330, ALT 344, ALk Phos 384, T Bili 2.7. RUQ
US showed large mass in left hepatic lobe as well as portal vein
thrombosis. Exam showed guaic positive brown stool. He was given
morphine 5 mg iv and ondansetron 4 mg iv. He underwent head CT
which was negative for mass or bleed. VS prior to transfer were:
98.7, 117/64, 65, 15, 99% room air.
Past Medical History:
-pathologic L humeral fx
-HTN
-DMII
-depression
-CKD
-BPH
-Thrombocytopenia
-Obesity
-Colonic polyp
-Osteoarthritis
Social History:
___
Family History:
bladder cancer in father, no other hx of cancer in family.
mother died of heart disease
Physical Exam:
ADMISSION:
VS: Tc 98.2, Tm 98.4. Hr 61-70. BP 107-120/56-79. R16 98%RA.
I/O: 2875/250+
GENERAL: Well appearing male in NAD.
HEENT: Sclera anicteric. MMM.
CARDIAC: RRR with no m/r/g
LUNGS: CTA b/l with no w/r/r.
ABDOMEN: Soft, non-distended, non-tender to palpation. No HSM or
tenderness appreciated. no evidence of ascites
EXTREMITIES: no edema Warm and well perfused, no clubbing or
cyanosis. left shoulder very tender
NEUROLOGY: AAOx3 no asterixis
DISCHARGE:
GENERAL: Well appearing male in NAD.
HEENT: Sclera anicteric. MMM.
CARDIAC: RRR with no m/r/g
LUNGS: CTA b/l with no w/r/r.
ABDOMEN: Soft, non-distended, non-tender to palpation. No HSM or
tenderness appreciated. no evidence of ascites
EXTREMITIES: no edema Warm and well perfused, no clubbing or
cyanosis. left shoulder very tender
NEUROLOGY: AAOx3 no asterixis
Pertinent Results:
CBC:
___ 11:40AM BLOOD WBC-3.7* RBC-4.00* Hgb-11.9* Hct-36.3*
MCV-91 MCH-29.8 MCHC-32.8 RDW-16.1* Plt Ct-84*
___ 06:05AM BLOOD WBC-3.3* RBC-3.64* Hgb-10.8* Hct-33.0*
MCV-91 MCH-29.6 MCHC-32.6 RDW-16.0* Plt Ct-88*
___ 05:45AM BLOOD WBC-3.1* RBC-3.63* Hgb-10.9* Hct-34.3*
MCV-94 MCH-30.2 MCHC-31.9 RDW-16.1* Plt Ct-74*
___ 06:40AM BLOOD WBC-2.4* RBC-3.41* Hgb-10.3* Hct-31.8*
MCV-93 MCH-30.1 MCHC-32.2 RDW-16.3* Plt Ct-72*
___ 06:10AM BLOOD WBC-2.8* RBC-3.22* Hgb-9.3* Hct-29.8*
MCV-93 MCH-29.0 MCHC-31.3 RDW-16.3* Plt Ct-76*
___ 06:10AM BLOOD ___ PTT-30.7 ___
___ 06:10AM BLOOD Ret Aut-1.7
CHEM-7:
___ 11:40AM BLOOD Glucose-167* UreaN-32* Creat-1.2 Na-139
K-4.3 Cl-104 HCO3-24 AnGap-15
___ 06:05AM BLOOD Glucose-113* UreaN-35* Creat-1.9* Na-142
K-4.5 Cl-107 HCO3-27 AnGap-13
___ 02:45PM BLOOD UreaN-40* Creat-2.0* Na-139 K-4.5 Cl-103
HCO3-25 AnGap-16
___ 05:45AM BLOOD Glucose-171* UreaN-41* Creat-1.8* Na-139
K-4.7 Cl-105 HCO3-26 AnGap-13
___ 06:40AM BLOOD Glucose-120* UreaN-32* Creat-1.5* Na-140
K-4.7 Cl-109* HCO3-24 AnGap-12
___ 06:10AM BLOOD Glucose-102* UreaN-25* Creat-1.1 Na-140
K-4.0 Cl-110* HCO3-23 AnGap-11
LFTS:
___ 11:40AM BLOOD ALT-344* AST-330* AlkPhos-384*
TotBili-2.7*
___ 06:05AM BLOOD ALT-342* AST-251* AlkPhos-332*
TotBili-1.6*
___ 05:45AM BLOOD ALT-347* AST-263* AlkPhos-372*
TotBili-2.6*
___ 06:40AM BLOOD ALT-294* AST-183* LD(LDH)-185
AlkPhos-332* TotBili-1.8*
___ 06:10AM BLOOD ALT-216* AST-120* LD(LDH)-175
AlkPhos-272* TotBili-1.3
___ 11:40AM BLOOD Lipase-60
___ 05:45AM BLOOD TotProt-6.2* Albumin-3.5 Globuln-2.7
Calcium-9.0 Phos-3.9 Mg-2.3
___ 11:40AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE
CANCER SCREENING:
___ 11:40AM BLOOD CEA-4.9* AFP-689.7*
MRI Abdomen ___:
IMPRESSION:
1. Irregular heterogeneous mass lesion occupying the left
hepatic lobe with
signal characteristics most suggestive of HCC. Mass invades the
portal venous
system with tumor thrombus in the left portal vein extending
into the
bifurcation and the right portal vein.
2. Splenomegaly and mild quantity of ascites.
3. Simple cysts in the kidneys bilaterally.
4. Gallbladder sludge and stones.
Renal U/S ___:
IMPRESSION: Mildly elevated resistive indices bilaterally.
Otherwise, normal
renal duplex.
CT Guided biopsy of Left Humerus mass ___:
IMPRESSION:
1. Successful CT-guided biopsy of large left humerus mass, as
described. The
core biopsy specimens were sent to pathology.
2. Large left humerus mass and pathologic fracture, as above
Abdominal US ___
7.7 x 6.5 x 5.6 cm large heterogenous mass in left hepatic lobe
concernign for malignancy. Main portal and left portal vein not
definitively identified likely persistent thrombus (seen on OSH
CT). contracted gallbladder.
CT head ___
No acute intracranial process including hemorrhage or metastatic
disease however note that MRI is more sensitive for metastatic
disease
CT ___ at ___: "6 cm diameter, ill-defined focal mass
lesion in the left lobe of the liver...Thrombosis off the right
as well as the left branch of the main portal vein. The thrombus
is seen to extend into the distal portion of the main portal
vein. The thrombus in the left branch of the portal vein is seen
to extend into its smaller branches in the left lobe. The
superior mesenteric vein and the splenic veins unremarkable.
There are collateral vessels present at the porta hepatis."
Left hepatic mass lesion, consistent with neoplastic process.
Indeterminate small segment five hepatic lesion. This can be
further characterized on dedicated MRI of the liver.
Thrombosis of the right and left branches of the portal vein
with extension of the thrombus into the distalmost portion of
the main portal vein.
Brief Hospital Course:
___ yo male with recent pathologic fracture in ___, found to
have liver mass and portal vein thrombosis 10 days ago now
presenting with abdominal pain x 2 days.
Active Issues:
# ___: Patients Cr rose to high of 2.0 (from b/l 1.2) with
studies showing it to be prerenal. Cr came down to 1.1 on
discharge with administration of IV fluids. Losartan was held
while inpatient. Renal u/s with no acute changes.
# Liver mass/ transamininitis: likely malignancy (___ given
elevated AFP>600, but also consider testicular tumor).
transaminitis likely from liver mass.
- MRI to evaluate mass: Read not back upon discharge. Evaluate
portal vein thrombosis as well as to look at Liver Mass (HCC vs.
met). Per GI, AFP>600 dx of HCC. No need for colonoscopy.
Patient probably has cirrhosis (previously unknown) from
Steatohepatitis and that is the reason for the HCC. Will need an
EGD as an outpatient to evaluate for varices. Will follow bone
biopsy results to see if bone mass is a met. Will need hem onc
as outpatient. Hepatitis serologies: HCVAb -, HBSAg -, HBSAb
borderline (incomplete response to vaccination), HBcAb -. Tumor
markers: AFP: 689, CEA 4.9, ___.
# Pathologic shoulder fracture and fracture: Patient received CT
guided bone biopsy, will need to follow results to see
pathology.
# Portal vein thrombosis: recently diagnosed on CT at ___. Not
on anticoagulation because most likely a chronic issue. Also,
thrombocytopenic and guaiac positive stool. MRI to follow up for
cause of thrombosis. If large thromobosis may not be candidate
for TACE later due to reliance on Hepatic artery.
Chronic Issues:
# Pancytopenia: Unclear etiology, however, given likely HCC,
thrombocytopenia likely caused by cirrhosis. Patient denies ETOH
use recently and denies signs and symptoms of infections
currently.
#HTN: normotensive during admission
#DMII: diet controlled as outpatient. Patient put on minimal SSI
as inpatient.
Transition Issues:
#Follow up CT guided biopsy results for histology of humerus
tumor
#Follow up MRI abdomen to see if appears to be HCC vs.
metastasis
#Will need follow up with Hem Onc for multiple masses, likely
neoplasms
#Outpatient EGD to look for varices since likely cirrhosis
Medications on Admission:
1. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
2. Citalopram 10 mg PO DAILY
3. Amlodipine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Glucosamine *NF* (glucosamine sulfate) 500 mg Oral unknown
6. psyllium *NF* 3.4 gram/5.8 gram Oral daily
7. Ascorbic Acid Dose is Unknown PO DAILY
8. PreserVision *NF* (vit C-vit
E-copper-ZnOx-lutein;<br>vitamins A,C,E-zinc-copper) unknown
Oral daily
9. Vitamin D 1000 UNIT PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. garlic *NF* unknown Oral daily
12. Fish Oil (Omega 3) Dose is Unknown PO DAILY
13. Losartan Potassium 100 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Citalopram 10 mg PO DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp
#*40 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Glucosamine *NF* (glucosamine sulfate) 500 mg Oral unknown
6. psyllium *NF* 3.4 gram/5.8 gram Oral daily
7. Ascorbic Acid ___ mg PO DAILY
8. PreserVision *NF* (vit C-vit
E-copper-ZnOx-lutein;<br>vitamins A,C,E-zinc-copper) 1 tablet
ORAL DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. garlic *NF* 1 tablet ORAL DAILY
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. Losartan Potassium 100 mg PO DAILY
14. Senna 1 TAB PO BID constipation
Please give additional dose now
RX *senna 8.6 mg 1 tablet by mouth twice daily Disp #*60 Tablet
Refills:*0
15. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Liver and Bone mass, suspected Hepatocellular carcinoma
Secondary Diagnosis:
Pancytopenia
Portal Vein Thrombosis, thought to be tumor invasion (await
final MRI read prior to considering anticoagulation)
Pathologic fracture of left humerus
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you while you were in the
hospital. You came to the hospital for intermittent, crampy
abdominal pain that you had had for a few days prior to coming
to the hospital. In the hospital, tests indicated that you had
some injury to your liver. This was thought to be caused by the
liver mass and portal vein thrombosis (blockage of a vessel in
your liver) that you were recently diagnosed with. You had also
been recently diagnosed with a mass in your left upper arm which
caused you to break your arm. To determine the cause of this
mass, the radiolgist took a biopsy of it, which will also help
us tell if it is related to your liver mass. A CT scan of your
head showed no pathologic changes. While you were here your
kidney function temporarily worsened, but improved back to your
baseline with fluids. You are being discharged with close follow
up and your primary care physician at ___ should set up with
an appointment with ___ Hematology-Oncology as soon as your
biopsy results and the final report of your liver MRI return.
Followup Instructions:
___
|
19868580-DS-10
| 19,868,580 | 21,645,685 |
DS
| 10 |
2173-05-08 00:00:00
|
2173-05-09 06:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Bactrim / omeprazole
Attending: ___
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old woman with metastatic breast cancer,
known mets to liver and bone with recent klebsiella bacteremia
and PTBD placement, who is admitted with confusion.
She presents with altered mental status. The patient herself has
no complaints. Her husband notes that since yesterday morning,
she has been acting confused and waxing and waning pattern,
sometimes talking to people that are not there. She has been
complaining of right flank pain for possibly weeks.
Hx of liver mets with biliary drain. Recent presentation with
AMS found to have cholangitis grew pan-sensitive Klebsiella on
blood cultures. Left with biliary drain capped. Has been on abx
until 1 week ago (___).
In the ED, initial VS were pain 0, T 98.2, HR93, BP 152/82, RR
18, O2 100%RA. Patient was oriented to self, place, and day of
week but not month and had some epigastric tenderness. Initial
labs notable for WBC 5.2 (82%N), HCT 32.6, PLT 325, Nl chem7,
lactate 1.9, negative UA. CT head was unremarkable and CT a/p
showed concern for early colitis along with persistent
intrahepatic biliary duct dilation and hepatic and bony mets.
Patient was given IV vanc, cipro, and flagyl along with 1L NS
and 0.25mg IV dilaudid x2. VS prior to admission were pain 8, T
98.5, HR 97, BP 146/67. RR 20, O2 95%RA.
On arrival to the floor, patient reports continued pain. Says
that her family says she was talking about a person named ___
or ___ but they don't know anyone who goes by that name. She
continues to have severe Right sided abdominal pain not improved
after getting hydromorphone in the ED. She remembers me from
prior admission.
Of note, patient was recently admitted from ___ with
lethargy and confusion and was found to have cholangitis and
klebsiella bacteremia. She underwent PTBD placement and was
treated with a 2-week course of ceftriaxone/flagyl (ended ___
and plan for ___ follow up of PTBD. Lethargy and confusion
improved with treatment. Her HCTZ sand isosorbide were
discontinue during this admission because her blood pressures
were well contolled (ACEi continued).
Past Medical History:
PAST ONCOLOGIC HISTORY:
Oncology history:
___ She was diagnosed with a 3.0 cm ER negative, PR positive
and node positive left breast cancer with ___ positive axillary
LN. She was treated with mastectomy followed by chemotherapy
with
adriamycin (75 mg/m2 for 4 cycles) and then IV CMF for 6 months.
This was followed by postmastectomy chest wall irradiation.
___ right breast mammogram negative
___ she was seen for evaluation of a "crease" noted in
the
left breast reconstruction site and for anterior chest wall
discomfort.
___ breast MRI: no new suspicious enhancing masses but
sternum w/ abnormal T2 hyperintensity as well as in adjacent
anterior chest wall.
___ bone scan at the ___ showed uptake within the sternum
corresponding to a mixed sclerotic and lytic lesions seen on the
chest CT. This was new when compared to previous bone scan from
___.
chest CT what appeared to be a new right lung nodule upon review
by Thoracic surgery as well as a 5 mm nodule in the left lower
lobe and ground glass nodule to the right upper lobe. There was
a
mixed sclerotic and lytic lesion within the sternum with
pathologic fracture concerning for metastatic disease.
___ Dr ___ Thoracic ___ at the ___ did a VATS
biopsy of the RUL and a biopsy of the spiculated ectopic bone in
the left parasternal region in the area where the 2nd rib
inserted. The pathology of the RUL showed metastatic
adenocarcinoma 0.6 cm consistent with spread from a breast
primary. The chest wall biopsy showed metastatic adenocarcinoma
involving skeletal muscle and fibrous tissue consistent with
spread from a breast primary. The metastases were ER positive
(>95%), PR positive (50%) and HER 2/neu negative.
___ initiated letrozole
___ initiated zometa after clearance by her dentist.
___ bone scan showed persistent abnormal update in the
sternum consistent with metastatic disease without new areas of
abnormality. The chest/abd/pelvic CT showed sternal metastases,
resection of the RUL metastases without evidence of recurrence,
stable LLL nodule (over many years) and a new small sclerotic
lesion within the T10 vertebral body, new met vs zometa.
___ repeat staging bone scan and CT scan showed no
evidence of tumor progression
___ right sided power portocath placed without incident
at
the ___
___ CT scan and bone scan showed sclerotic bony lesions
presumed to be metastatic are stable. no new lesions
___nd bone scan showed that the
sternal metastasis was stable. no new lesions
___nd bone scan showed stable abnormal sternal
activity consistent with her known osseous metastases.
___ She has had repeat staging CT and bone scans which
showed no evidence of tumor progression.
___ The bone scan/CT showed Stable abnormal activity
sternum consistent with stable metastatic lesion.
___ chest CT/bone scan. no significant change. The bone
scan showed new areas of abnormally increased activity involving
approximately L1 and L5 and the left hip suspicious for
metastases. She had plain films obtained on ___. This showed
sclerosis at the right pedicle of L5 concerning for metastasis.
Additional area of uptake involving the posterior elements of S1
on the left could represent an additional metastasis.
___ She had an MRI of her lumbar spine. This showed that
there is diminished T1 and increased STIR signal within the L5
vertebral body at the inferior endplate on the right and within
the right pedicle of L1. Both of these areas abnormally enhance.
The findings correspond to the bone scan abnormalities and are
suspicious for metastatic foci.
___ started faslodex and palbociclib (125 mg po a day x
21
day)
___ She has had a head MRI which did not show parenchymal
metastatic disease. She reports having right sided low back and
buttock discomfort.
___ she had repeat bone scan which showed areas of
abnormal activity including the sternum, L5, L1 and left hip
most
consistent with metastases slightly more pronounced activity
compared to previous exam which is possibly secondary to
treatment response. New area of increased activity T11 vertebra
which could be new metastasis or a metastasis with developing
treatment response and healing. There was a subtle area of
mildly
increased activity right posterior approximately seventh rib
which is nonspecific .
___ The c/a/p CT scan showed that the bony metastases
have increased in size and density. discussed that the changes
could have been due to a treatment effect, given her increased
discomfort, we discussed that this is now felt to be more
consistent with progression.
___ seen by Dr ___ at the ___ Onc
department. She recommended RT to the lumbar spine. She had her
planning on ___ and started on ___. She received 10
fractions of RT.
___ took exemestane
___ She was admitted to the ___
under the care of Dr ___ with chest pain, which was felt
most likely to be non-cardiac in etiology. CT-A which was
negative for PE. However this revealed several liver lesions for
which additional imaging was recommended. She had an MRI of the
liver on ___ which demonstrated innumerable liver lesions
consistent with metastatic disease. She had a bone scan on
___ which showed uptake in the sternum, L5, left pubic
symphysis, left iliac bone and posterior 7th rib.
___ started capecitabine
___ she was seen by Dr ___ was advised RT to the
sternum and left hip. She was treated with 10 fractions from
___. Her chemotherapy was held during this time
period.
___ She was admitted to the ___
with increased abdominal pain. She had a CT scan which showed
her
liver lesions but had no acute findings.
Current treatment plan: started capecitabine on ___
She has had her most recent cycle given at 1000 mg bid x 14 days
(followed by 7 days off) on ___ and completed this on
___.
She will start her ___ cycle on ___ at the increased dose of
1000 mg in the AM and 1500 mg in the ___ x 14 days
zometa given 3 mg IV on ___ due to her prior renal
insufficiency, held on ___ as Cr was 1.6, held on ___ as
her Cr was 1.4, restarted, to be changed to every three months
as
of ___
B12 1000 micrograms IM monthly
PAST MEDICAL HISTORY: per ___ records
DM
Depression
HTN
Hypothyroid
CAD with a 50% LAD lesion on catherization. She was admitted to
a
hospital in ___ with an episode of chest pain. She ruled out
for
an MI and had a negative ETT.
She had a colonoscopy in ___ which showed colitis. C diff
was negative. She was treated with flagyl. She has had a
colonoscopy by Dr ___ at the ___ on ___. An adenomatous
polyp was removed.
She is followed by Dr ___ a history of fibromyalgia.
She is followed by the pain service. ___, RF, CCP ab and CPK all
of which were normal. Xrays of her hands and knees showed DJD.
Social History:
___
Family History:
Reviewed, not found to be relevant to this hospitalization and
illness
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS:
GENERAL: Middle age women, slowly conversant while lying in bed,
appears mildly uncomfortable
HEENT: NCAT, dry MM, PERRL, anicteric sclera
CARDIAC: RRR, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Tenderness to palpation over epigastrium and RLQ
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM:
=======================
VS: 98.1, 112-138/45-82, 70-82, ___, 96-99% RA
I/O: 8h 370/600, 24h 1723/2350
GENERAL: Laying in bed in NAD
HEENT: NCAT, dry MM, PERRL, anicteric sclera
CARDIAC: RRR, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Mildly tender over RUQ drain site. Soft, +BS
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS:
=============
___ 04:15PM BLOOD WBC-5.2 RBC-3.06* Hgb-9.9* Hct-32.6*
MCV-107*# MCH-32.4* MCHC-30.4* RDW-18.7* RDWSD-73.5* Plt ___
___ 04:15PM BLOOD Neuts-81.6* Lymphs-7.1* Monos-9.2 Eos-1.1
Baso-0.6 Im ___ AbsNeut-4.26 AbsLymp-0.37* AbsMono-0.48
AbsEos-0.06 AbsBaso-0.03
___ 04:15PM BLOOD Plt ___
___ 04:15PM BLOOD Glucose-201* UreaN-15 Creat-0.7 Na-136
K-4.5 Cl-100 HCO3-24 AnGap-17
___ 04:15PM BLOOD ALT-20 AST-57* AlkPhos-1014* TotBili-1.1
___ 04:15PM BLOOD Lipase-30
___ 04:15PM BLOOD Albumin-3.5
___ 05:20PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 05:20PM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE
Epi-1
___ 05:20PM URINE Mucous-RARE
DISCHARGE LABS:
=============
___ 05:52AM BLOOD WBC-5.2 RBC-3.19* Hgb-10.1* Hct-32.8*
MCV-103* MCH-31.7 MCHC-30.8* RDW-17.7* RDWSD-67.7* Plt ___
___ 05:52AM BLOOD ___ PTT-45.9* ___
___ 05:52AM BLOOD Glucose-146* UreaN-15 Creat-0.8 Na-138
K-4.2 Cl-105 HCO3-21* AnGap-16
___ 05:52AM BLOOD ALT-18 AST-49* LD(LDH)-211 AlkPhos-864*
TotBili-1.0
___ 05:52AM BLOOD Calcium-9.3 Phos-4.8* Mg-1.8
___ 05:45AM BLOOD GGT-378*
IMAGING:
=======
PORTABLE ABDOMEN ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
stool is seenin the descending colon.There is no free
intraperitoneal air.
Osseous structures are unremarkable.A at PTB the catheter is
seen in the right upper quadrant in correct position.Surgical
clips are noted along the left hemi abdomen.
IMPRESSION:
Nonobstructive bowel gas pattern.
CT abd/pelvis ___:
1. Persistent intrahepatic biliary duct dilatation likely due to
malignant obstruction given extensive hepatic metastatic disease
in a patient who is status post percutaneous biliary drainage
catheter.
2. Innumerable hepatic lesions concerning for metastatic
disease.
3. Sclerotic bony metastases in lower thoracic and lumbar spine
including L1 and L5 vertebral body.
4. Subtle fat stranding and wall edema of the ascending colon
and
cecum can be seen with early colitis. Given location typhlitis
is
on the differential.
5. Hypoattenuating lesion at the upper pole the right kidney new
since ___ from ___ but present on last month's exam. Given
persistence and lack of significant change, infection is less
likely. Malignant lesion is suspected. Followup on future exam
is suggested.
CT head: ___
No acute intracranial process.
Brief Hospital Course:
Ms. ___ is a ___ with breast cancer metastatic to liver and
bone, recent PTBD placement for obstructive transaminitis, now
admitted for RUQ pain.
# Abdominal pain, colitis vs biliary obstruction:
Her abdominal pain was concerning for right-sided colitis seen
on imaging vs biliary obstruction in the setting of recent PTBD
placement and rising AlkPhos (TBili stable). Patients imaging
scans are notable for colitis on CT scan, with concern for
several days of diarrhea, although currently having semi-formed
stools. In setting of recent abx and hospitalization, concern
also remained for CDiff infection. Patient has also had recent
cholangitis s/p PTBD placement, which was uncapped prior to
admission. On admission, patients TBili was down from recent
hospitalization, but ALP is acutely elevated with elevated GGT,
with concern for biliary obstruction. ___ was consulted on this
admission, and pt was assessed with initial plan to interrogate
current drain for possible drain vs placement of new drain for
further decompression. However in setting of isolated APhos rise
while patient improving with IV Abx and no drainage while
uncapped, as well as reassuring imaging showing improvement in
the R posterior aspect and L lobes ductal dilatation, ___ advised
capping drains and trending LFTs and watching for clinical
improvement. Pain improved on antibiotics (5 days of CTX/Flagyl)
and supportive care. C diff negative. At the time of discharge,
alk phos was stable in ___.
# Confusion
# Acute encephalopathy: patients symptoms were likely due to
likely toxic/metabolic/deliurum given patients setting of acute
illness and pain. Patient is also on multiple CNS agents
including Oxycontin, oxycodone, gabapentin, duloxetine, Topamax,
Ativan, buproprion but all are chronic meds. At the time of
admission, patient was at her baseline baseline, with head CT
unremarkable.
# Metastatic breast cancer: During this admission, patient was
most recently on capecitabine, with last cycle of 14 days on 7
days off on ___. Currently being held due to acute illness,
with plan to reevaluate patient once stabilized.
# Diabetes: patients home metformin was held during this
admission, and patient was maintained on insulin sliding scales.
# Depression: during this admission, patients home BuPROPion
(Sustained Release)200 mg PO QAM and Duloxetine 120 mg PO DAILY
# HTN: during this admission, pts home Enalapril Maleate 20mg
PO/NG DAILY and Atenolol 50 mg PO/NG DAILY was continued.
#Hypothyroidism: during this admission, patients home
levothyroxine 75 mcg PO/NG DAILY was continued.
# CAD during this admission, patients home Atorvastatin 40 po
QPM was continued.
#Pain: during this admission, patients home Gabapentin 300
daily, 900 QHS, OxyCODONE SR (OxyconTIN) 40 mg PO Q12H and home
Oxycodone 10mg Q4H was continued.
TRANSITIONAL ISSUES:
====================
- She will be discharged directly to oncology appointment with
Dr. ___ above).
- She with going home with a drain in her RUQ. She should follow
up with ___ at her scheduled appointment next week.
- For pain she will be sent home on her home dose of Gabapentin
300 daily, 900 QHS, OxyCODONE SR (OxyconTIN) 40 mg PO Q12H and
home Oxycodone 10mg Q4H.
- She last had a BM on ___ with the aid of a suppository. She
was sent home on a bowel regimen and instructed to call her
doctor if she has not had a BM in > a week.
- Pain improved on antibiotics, 5 days of CTX/Flagyl, last day
___, and supportive care. C diff negative.
- At the time of discharge, alk phos was stable in ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 200 mg PO QAM
2. DULoxetine 120 mg PO DAILY
3. Enalapril Maleate 20 mg PO DAILY
4. Famotidine 40 mg PO BID
5. Gabapentin 300 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. LORazepam 0.5-1 mg PO BID PRN anxiety, nausea
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
10. Vitamin D ___ UNIT PO DAILY
11. Aspirin 81 mg PO DAILY
12. Atenolol 50 mg PO DAILY
13. Atorvastatin 40 mg PO QPM
14. Gabapentin 900 mg PO QHS
15. MetFORMIN (Glucophage) 1000 mg PO BID
16. Topiramate (Topamax) 100 mg PO QHS
17. zoledronic acid 3 mg injection Other
18. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS
19. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
20. Senna 8.6 mg PO BID
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*20 Tablet
Refills:*0
2. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth
daily Disp #*30 Packet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. BuPROPion (Sustained Release) 200 mg PO QAM
7. DULoxetine 120 mg PO DAILY
8. Enalapril Maleate 20 mg PO DAILY
9. Famotidine 40 mg PO BID
10. Gabapentin 300 mg PO DAILY
11. Gabapentin 900 mg PO QHS
12. Levothyroxine Sodium 75 mcg PO DAILY
13. LORazepam 0.5-1 mg PO BID PRN anxiety, nausea
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS
16. Ondansetron 8 mg PO Q8H:PRN nausea
17. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
18. OxyCODONE SR (OxyconTIN) 40 mg PO Q12H
19. Senna 8.6 mg PO BID
20. Topiramate (Topamax) 100 mg PO QHS
21. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Metastatic breast cancer (ERPR+/HER2-)
SECONDARY DIAGNOSIS:
Colitis
Transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure being part of your care at ___. You were
admitted to the hospital due to right sided abdominal
discomfort. You were found to have colitis (irritation of the
colon) on a CT scan. You were treated for this with antibiotics.
You were also found to have elevation in your liver enzymes, and
your were evaluated by interventional radiology. No evidence of
an obstruction in your bile ducts was found, and your liver
enzymes stabilized.
After discharge, please continue to follow up with your
outpatient doctors as described below.
It was a pleasure being part of your care.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19868788-DS-9
| 19,868,788 | 21,272,923 |
DS
| 9 |
2146-09-05 00:00:00
|
2146-09-06 07:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
NECK PAIN
Major Surgical or Invasive Procedure:
Right sided PICC placed on ___
History of Present Illness:
___ with no medical history presents with progressive cervical
neck pain >1month and malaise and fevers x4 days.
The patient denies any trauma or manipulation to his neck. He
stated the pain is in the back of his neck and is without
radiation. It is exacerbated with flexion and extension of his
neck. He has also endorsed headache and occasional photophobia.
He also endorses decreased PO intake in the setting of his
malaise.
He visited OSH ED yesterday in ___, and reports his
temperature was measured at ___. He reports he had lab work
done and was ultimately given antibiotics and Tylenol before
being discharged home. Today, he presents to ___ ED because
his symptoms have not improved and his neck pain has worsened
slightly.
No nausea/vomiting/diarrhea or abdominal pain. No issues going
to the bathroom. No paresthesia or localized weakness. No
difficulty ambulating. No chest pain or dyspnea. +Cough x1 day.
Patient received ctx and vanc at ___ on ___
In the ED, initial vitals were:
98.5 88 127/90 18 99% RA
Exam notable for TTP to lower C spine and paraspinal muscles, no
meningitis, normal strength
Labs showed
___: 13.2 PTT: 31.8 INR: 1.2
CRP: 187.2
13.0
9.8>----<190
39.4
N:65.1 L:21.1 M:12.3 E:0.6 Bas:0.4 ___: 0.5 Absneut: 6.40
Abslymp: 2.08 Absmono: 1.21 Abseos: 0.06 Absbaso: 0.04
ALT: 23 AP: 78 Tbili: 0.5 Alb: 3.8
AST: 27 Lip: 30
131|97|16
----------<120
3.6|22|0.9
Lactate:1.0
CSF
Protein 19 Glucose 68
WBC 1 RBC 7 Poly 0 Lymph 86 Mono 14
Imaging showed
___ MRI CERVICAL, THORACIC,
IMPRESSION:
1. Motion degraded study, especially in the cervical and lumbar
spine
2. Edema with enhancement along the C5-C6 endplates, favored to
be
degenerative in etiology. However, infection is not completely
excluded. No epidural collection is seen.
3. Mild multilevel multifactorial degenerative disease of the
cervical spine without high-grade neural foramina or spinal
canal stenosis at any level.
4. Unremarkable MRI of the thoracic spine
5. Mild degenerative disc disease in the lumbar spine without
neural foramina or spinal canal stenosis at any level.
Received:
___ 01:06 IVF 1000 mL LR Started 150 mL/hr
___ 06:15 IM Ketorolac 30 mg
___ 06:15 IV DiphenhydrAMINE 25 mg
___ 06:20 PO Acetaminophen 1000 mg
___ 06:20 IVF 1000 mL NS 1000 mL
___ 09:16 IV Vancomycin 1000 mg
___ 14:50 IVF 1000 mL LR
___ 15:36 IV CefTRIAXone 2 gm
___ 15:36 PO Acetaminophen 1000 mg
Patient underwent lumbar puncture which was not concerning for
meningitis.
Ortho spine was consulted who recommended admission to medicine
for IV antibiotics.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports mild neck pain
exacerbated with movement.
Past Medical History:
NONE
Social History:
___
Family History:
DM2 and CAD in father
Physical ___:
ADMISSION
Vital Signs: 99.5 131/79 83 18 95 RA
GEN: NAD
HEENT: No cervical LAD. Pain with extension and flexion. OP
clear
___: RRR no MRG
RESP: No increased WOB. Crackles L base
ABD: NTND NABS
EXT: Warm, no edema
MSK: TTP on cervical and thoracic spinous processes. No
paraspinal tenderness.
NEURO: CN II-XII grossly intact. Strength ___ UE and ___ b/l
DISCHARGE
Vitals: Tm 98.1 Tc 97.9 114/70 80 18 99 ra
GEN: NAD
HEENT: No cervical ___: RRR no MRG
RESP: No increased WOB. Crackles L base
ABD: NTND NABS
EXT: Warm, no edema. R PICC in place
MSK: No TTP on cervical and thoracic spinous processes. No
paraspinal tenderness.
Pertinent Results:
ADMISSION
___ 11:35PM BLOOD WBC-9.8 RBC-4.29* Hgb-13.0* Hct-39.4*
MCV-92 MCH-30.3 MCHC-33.0 RDW-13.2 RDWSD-44.5 Plt ___
___ 11:35PM BLOOD Neuts-65.1 ___ Monos-12.3
Eos-0.6* Baso-0.4 Im ___ AbsNeut-6.40* AbsLymp-2.08
AbsMono-1.21* AbsEos-0.06 AbsBaso-0.04
___ 11:35PM BLOOD ___ PTT-31.8 ___
___ 11:35PM BLOOD Glucose-120* UreaN-16 Creat-0.9 Na-131*
K-3.6 Cl-97 HCO3-22 AnGap-16
___ 11:35PM BLOOD ALT-23 AST-27 AlkPhos-78 TotBili-0.5
___ 11:35PM BLOOD Lipase-30
___ 05:54AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.9
___ 11:35PM BLOOD CRP-187.2*
___ 11:45PM BLOOD Lactate-1.0
PERTINENT
___ 11:45PM BLOOD Lactate-1.0
___ 03:04PM BLOOD Vanco-7.9*
___ 01:40PM BLOOD HIV Ab-Negative
___ 11:35PM BLOOD CRP-187.2*
___ 05:54AM BLOOD CRP-245.6*
___ 06:00AM BLOOD CRP-222.6*
___ 07:05AM BLOOD CRP-74.5*
___ 05:32AM BLOOD CRP-19.5*
___ 05:33AM BLOOD CK(CPK)-45*
DISCHARGE
___ 05:32AM BLOOD WBC-10.1* RBC-4.74 Hgb-14.4 Hct-43.0
MCV-91 MCH-30.4 MCHC-33.5 RDW-12.9 RDWSD-42.3 Plt ___
___ 05:33AM BLOOD Glucose-107* UreaN-16 Creat-0.8 Na-138
K-4.5 Cl-102 HCO3-26 AnGap-15
___ 05:33AM BLOOD ALT-119* AST-76* CK(CPK)-45* AlkPhos-142*
TotBili-0.2
___ 05:33AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.1
MICROBIOLOGY
__________________________________________________________
___ 8:46 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 6:59 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 6:49 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 6:04 am CSF;SPINAL FLUID Source: LP #3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 11:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:35 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
___ Imaging MRI CERVICAL, THORACIC,
IMPRESSION:
1. Study is severely degraded by motion.
2. Edema with enhancement along the C5-C6 endplates. While
findings are
suggestive of degenerative changes, differential considerations
of infectious
or inflammatory etiology are not excluded on the basis
examination. If
clinically indicated, consider correlation with serum
inflammatory markers.
3. Within limits of study, no definite epidural collection is
seen.
4. Mild multilevel multifactorial degenerative disease of the
cervical spine
without high-grade neural foramina or spinal canal stenosis at
any level.
5. Unremarkable MRI of the thoracic spine
6. Multilevel degenerative changes described.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
There are no prior chest radiographs available for review.
Combination of atelectasis and consolidation is present at the
base of the
left lower lobe, consistent with pneumonia. Suggest follow-up
chest
radiograph in ___ weeks to document substantial resolution.
Lungs otherwise clear. Cardiomediastinal and hilar silhouettes
and pleural surfaces are normal
___ Imaging MR ___ W/O CONTR
IMPRESSION:
1. Stable edema with enhancement along the C5-C6 endplates.
This is favored to be degenerative in etiology. However, given
the presence of enhancement, infectious or inflammatory etiology
is not excluded though favored to be less likely.
2. Stable my multilevel multifactorial degenerative disease of
the cervical spine, without high-grade neural foramina or spinal
canal stenosis at any level.
Brief Hospital Course:
___ with no PMH presents with progressive neck pain x1 month in
the setting of fevers/chills and malaise. Found to have discitis
on MRI and elevated CRP, admitted to medicine for IV
antibiotics.
#Discitis: Pt c/o progressive neck pain x1 month. Recently
developed fevers/chills and malaise x4 days. Neurological
examination intact. MRI spine in ED showed edema with
enhancement along the C5-C6 endplates which may be c/w
degenerative changes, however given his elevated CRP to 187.2
there was concern for discitis. CSF not consistent with
meningitis. No history of IVDU or recent injection/manipulation
into joint space which makes pathogenesis for this patient's
discitis likely a hematogenous spread from an unknown source,
possibly PNA (see below, though timing not entirely consistent).
HIV Ab negative. Patient was seen in the ED by ortho spine who
recommended IV antibiotics and admission to medicine. Repeat MRI
on ___ to assess for progression showed discitis. Vanco trough
was sub-therapeutic at 7.9 and therefore required q8h dosing.
After being seen by ID they recommended daptomycin and
ceftriaxone. Dapto was chosen over vancomycin as patient was
sub-therapeutic and would have required q8H dosing for
vancomycin. Of note OSH blood cultures were negative x2.
Per ID patient will required Dapto/CTX (D1 ___ x>6wks and
weekly ESR/CRP, LFTs, CK and CBC w. diff. Patient was set up
with ___ to receive daily IV antibiotics.
#Community Aquired Pneumonia: Patient has been c/o
non-productive cough x1 day. No increased work of breathing or
hypoxia, however, pt has crackles on left base and CXR shows LLL
infiltrate. s/p 5 days of azithro and continued on ceftriaxone
as above.
TRANSITIONAL ISSUES
OPAT Diagnosis: Presumed C5-6 discitis/osteomyelitis
OPAT Antimicrobial Regimen and Projected Duration:
Agent & Dose:
1.Daptomycin 500 mg IV daily
2.Ceftriaxone 2 gm IV daily
Start Date: ___
Projected End Date: ___
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
CEFTRIAXONE: WEEKLY: CBC with differential, BUN, Cr, AST, ALT,
TB, ALK PHOS, ESR, CRP
DAPTOMYCIN: WEEKLY: CBC with differential, BUN, Cr, CPK
ADDITIONAL ORDERS:
*PLEASE OBTAIN WEEKLY ESR/CRP for patients with bone/joint
infections and endocarditis or endovascular infections
All questions regarding outpatient parenteral antibiotics after
discharge should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV q24 Disp
#*42 Intravenous Bag Refills:*0
3. Daptomycin 500 mg IV Q24H
RX *daptomycin [Cubicin] 500 mg 1 bag iv q24h Disp #*42 Vial
Refills:*0
4. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
5. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
DISCITIS
COMMUNITY AQUIRED PNEUMONIA
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 having pain in your
neck. You were found to have an infection of a disk between your
vertebrae in your neck. You were also found to have a pneumonia.
You received antibiotics through an IV. You were seen by our
infectious disease doctors who ___ that you will require long
term antibiotics (for a total of 6 weeks) through a
semi-permanent IV called a PICC line. You will receive these
antibiotics every day at the pheresis center at ___
campus.
Your discharge medications and appointments are detailed below.
We wish you the best!
Your ___ care team.
Followup Instructions:
___
|
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| 15 |
2123-05-26 00:00:00
|
2123-05-26 17:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of CKD stage
3, NIDDM2, CVA without residual deficit ___, HTN, HLD, glaucoma
who presented to the ED as referral from ___ urgent care on
___
for headache but then found to have hyponatremia to 125.
She has not had a headache before. NO trauma. It started
gradually a week ago, usually in middle of the night and wakes
up
with it, lasts ___ minutes although this morning it's
constant,
pain is in the 'center' of her head, as a dull pressure ache,
nonradiating except sometimes to the front/forehead. She
yesterday (on ___ then developed nausea, vomited twice
nonbloody
amounts, and had complete loss of appetite and ate nothing. She
did tolerate fluids (drank ___ glasses of water). She denies any
photophobia, phonophobia, neck pain, fever, back pain, vision
change, weakness, sensory changes/numbness or tingling. No jaw
pain/fatigue. No cough or sick contacts.
She has tried Tylenol which helped a bit at home.
Last known sodium per Atrius record is ___ at 139. Patient
has
never been hyponatremic before. She has no new medications
recently. She has been on HCTZ for years.
Otherwise has no chest pain, SOB, edema, weight change recently.
Past Medical History:
CKD stage 3, NIDDM2, CVA without residual deficit ___, HTN,
HLD,
glaucoma
Social History:
___
Family History:
She doesn't recall any family history of kidney disease in
family
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.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities
PSYCH: pleasant, appropriate affect
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time.
CRANIAL NERVES:
Visual fields are full to confrontation in all quadrants
bilaterally.
Pupils are equally round and reactive to light.
Extraocular movements are intact, with no ptosis.
Sensation over the face is intact and equal bilaterally for
sharp, dull, and light touch stimuli.
During mastication there is midline location of the jaw and
equal
contraction and able to keep both eyes shut to resistance.
Hearing is grossly intact bilaterally.
The palate and uvula elevate symmetrically, with an intact gag
reflex bilaterally.
Shoulder shrug is strong and equal bilaterally.
Tongue protrudes midline and moves symmetrically with no
fasciculations.
SENSATION: Bilaterally intact and equal for light touch in
fingers, forearms, toes and thighs.
STRENGTH: Good muscle bulk and tone throughout all extremities.
There is no pronator drift of outstretched arms. Strength ___
bilaterally for deltoid, bicep, tricep, quadricep. Grip strength
___ bilaterally.
CEREBELLAR: Finger to nose intact bilaterally.
.
.
DISCHARGE EXAM:
================
VS: 98.5 121/75 87 18 98% on RA
Gen: appears well, in NAD
HEENT: PERRL, anicteric sclera, no resting nystagmus, EOMI on my
exam, MMM, tongue midline, normal vocal quality
Chest: CTAB, normal WOB
Cards: RR, no m/r/g, 2+ distal pulses, no peripheral edema
Abd: S, NT, ND, BS+
GU: no SP or CVA tenderness
MSK: grossly normal strength in arms/legs
Neuro: AAOx4, clear speech, no facial droop, good attention,
normal coordination, no tremor
Pertinent Results:
ADMISSION LABS
___ 01:18AM BLOOD WBC-7.2 RBC-3.95 Hgb-11.1* Hct-33.1*
MCV-84 MCH-28.1 MCHC-33.5 RDW-13.1 RDWSD-39.8 Plt ___
___ 01:18AM BLOOD Neuts-73.4* Lymphs-17.0* Monos-8.7
Eos-0.4* Baso-0.1 Im ___ AbsNeut-5.30 AbsLymp-1.23
AbsMono-0.63 AbsEos-0.03* AbsBaso-0.01
___ 01:18AM BLOOD Glucose-129* UreaN-33* Creat-1.5* Na-123*
K-3.7 Cl-80* HCO3-25 AnGap-18
___ 01:18AM BLOOD Mg-1.5*
___ 09:55PM BLOOD Albumin-3.3*
___ 10:35AM BLOOD Osmolal-262*
___ 10:35AM BLOOD Cortsol-19.8
CT Head ___. No acute intracranial process.
2. Please note MRI of the brain is more sensitive for the
detection of acute
infarct and pontine lesions.
3. Atrophy, probable chronic right thalamic lesion, probable
small vessel
ischemic changes, and atherosclerotic vascular disease as
described.
DISCHARGE LABS
___ 06:44AM BLOOD WBC-7.9 RBC-3.79* Hgb-10.7* Hct-33.5*
MCV-88 MCH-28.2 MCHC-31.9* RDW-13.4 RDWSD-43.4 Plt ___
___ 06:55AM BLOOD ___ PTT-35.1 ___
___ 06:44AM BLOOD Glucose-90 UreaN-45* Creat-1.7* Na-134*
K-4.3 Cl-91* HCO3-___ AnGap-21*
___ 06:44AM BLOOD Calcium-10.0 Phos-4.3 Mg-1.6
PENDIN LABS AT DISCHARGE:
___ 12:21PM BLOOD SED RATE-PND
Brief Hospital Course:
Ms. ___ is a ___ female with history of CKD stage 3,
NIDDM2 (diet controlled), CVA without residual deficit ___,
HTN, HLD, glaucoma who presented to the ED as referral from ___
urgent care on ___ for headache but then found to have
hyponatremia to 123.
PROBLEMS:
#Hyponatremia
Patient presented with sodium of 123. Her last baseline from ___
year ago was normal Seen by nephrology, feels that this is
hyponatremia from free water intake and tea and toast diet, also
was on HCTZ. Clinically euvolemic. Her HCTZ was stopped and
sodium improved. Sodium was 134 on discharge. HCTZ was not
resumed.
#Headache
#Nausea, vomiting
The patient had ongoing headache with nausea & vomiting. CT
head noncontrast without acute pathology noted. Neurology was
consulted and recommended MRI brain. Initial MRI had some
enhancement which was consistent with either inflammation or
artifact. This was repeated and felt to be artifact. The patent
was started on low dose nortryptiline to manage headache.
Despite these interventions, her headache persisted. Improved
with sumatriptan 25 mg x1 and transition from Zofran to reglan
on ___. On ___ she was feeling much improved, with only mild
left frontal headache and mild nausea, also with improving
appetite and no vomiting today. She felt ready for discharge to
home. She declined LP as advised by Neurology, but was fully
agreeable to close follow-up in Neurology clinic. Discharged on
Nortriptyline 10 mg PO QHS standing, plus PRN sumatriptan for
headache (goal of taking less than 4 tabs per MONTH), and PRN
metoclopramide for nausea. ESR was added-on on ___ labs per
request of Neuro (for consideration of GCA, though overall they
maintained low suspicion for this). Neuro team (Dr. ___
will f/u the ESR result.
*Of note, patient drinks significant amounts of coffee at
baseline, and says that when the nausea/vomiting started, she
stopped drinking coffee. This may have contributed, at least in
part, to her headache.
#Hematuria
The patient had one episode of gross hematuria followed by
microscopic hematuria. She had no UTI symptoms and no evidence
of kidney stones. She was referred to urology as an outpatient.
# Asymptomatic bacteriuria
Patient had + UA and initial UCx grew mixed bacterial flora.
Repeat UA on ___ was also positive (large leuk esterase, neg
nitrites, >182 WBCs) and UCx from that specimen grew 2
morphologies of E. Coli. This E. coli was resistant only to
TMP-SMX. Had extensive discussion with pt. prior to discharge,
in which she denied having had any urinary symptoms (dysuria,
burning with urination, urinary frequency, urinary hesitancy,
etc.) nor any infectious symptoms such as fevers, chills,
rigors, or sweats prior to the onset of her nausea, vomiting and
headache. Given the absence of any symptoms to suggest true
urinary tract infection, no abx were administered during this
hospitalization.
#HTN
Continued home lisinopril, held HCTZ while inpatient and on
discharge. Remains normotensive at time of discharge, but may
ultimately require addition of a new anti-hypertensive agent for
optimal BP control. Would avoid thiazide diuretics in her case
going forward.
#HLD
Continued home simvastatin
#CKD stage 3
Fairly stable stable, Cr 1.7 on discharge, which is near her
baseline of 1.5 from ___. Has Nephrology f/u appt. scheduled
for ___
#NIDDM2
Diet controlled no need for glu checks or SSI
#History of CVA without residual deficit
Continued home aspirin, statin
.
.
.
======================
Transitional Issues:
1) Hyponatremia improved, but not completely resolved by the
time of discharge (Na 134 on day of discharge). Has Nephrology
f/u scheduled for ___
2) Discharged off of HCTZ in light of hyponatremia. BP OK on day
of discharge, but she may ultimately need initiation of another
BP agent.
Please see discharge summary for additional details.
3) Discharged on new daily medication for headache
(Nortryptyline 10 mg PO QHS) and PRN medication for headache
(sumatriptan 25 mg PO PRN MR1). Also discharged on new
medication for nausea (reglan 10 mg PO q8h PRN). Will follow-up
with Dr. ___ in Neurology ___ (time/date TBD).
4) Had gross hematuria followed by microscopic hematuria noted
on UA. Will have ___ clinic f/u (time/date TBD).
5) ESR added-on on day of discharge per Neurology request. Dr.
___ will f/u the results.
.
.
.
=====================
Time in care:
[x] Greater than 30 minutes in discharge-related activities on
the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Simvastatin 40 mg PO QPM
5. Lisinopril 40 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID
Discharge Medications:
1. Metoclopramide 10 mg PO Q8H:PRN nausea
RX *metoclopramide HCl 10 mg 1 tab by mouth q8h:PRN Disp #*10
Tablet Refills:*0
2. Nortriptyline 10 mg PO QHS
RX *nortriptyline 10 mg 1 tab by mouth at bedtime Disp #*30
Capsule Refills:*3
3. Sumatriptan Succinate 25 mg PO ONCE MR1 migraine headache
Duration: 1 Dose
RX *sumatriptan succinate 25 mg 1 tablet(s) by mouth ONCE:PRN
Disp #*10 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
6. FoLIC Acid 1 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID
10. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Hyponatremia
Nausea with vomiting
Headache
Hematuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because your sodium level was
low. This is likely because you were vomiting and not taking in
enough solutes along with water. We treated you with fluids
containing electrolytes and you improved.
You also had a headache with nausea and vomiting. You were seen
by the neurologists who recommended an MRI which was normal. You
were treated with medications to help control these symptoms and
you will need to follow up with the Neurology team in clinic.
Please call the clinic at ___ to make an appointment
with Dr. ___ the next 2 weeks.
You were found to have blood in your urine, we are in the
process of making a ___ clinic appointment for you to have
this evaluated.
It was a pleasure caring for you while you were in the hospital,
and we wish you a full and speedy recovery.
Sincerely,
The ___ Medicine Team
Followup Instructions:
___
|
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| 16 |
2124-11-12 00:00:00
|
2124-11-12 15:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrochlorothiazide
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
___ year old woman with CKD stage ___ HTN and DM, prior TIA,
T2DM, HTN, HLD and prior episode of hyponatremia ascribed to
poor
solute intake and thiazide contribution presenting with
hyponatremia.
She was in her USOH until ___ morning when she woke up with
a pressure like sensation with numbness at the top of her head
which resolved spontaneously. ___ morning she awoke feeling
generally unwell and felt a bit flushed. She had two episodes of
diarrhea and felt nauseous but did not vomit until
arrival to the ED ___. She measures a daily BP and typically
has SBP
120s, but when she checked it ___, she noted a SBP of 183. At
this
point she called EMS and was brought to the ED for further
evaluation.
On arrival to the ICU, She reports that at home she typically
follows a low salt diet - only adding small amounts of salt to
foods that she is cooking - as recommended by her physicians for
hypertension and prior ___ edema. She denies
excessive fluid intake - drinking only 2 glasses of water
normally, more recently for the past 2 days with 4 glasses of
water intake. She does not report any recent medication changes
asides from stopping aspirin 4 days prior. She denies any
ongoing
fever/chills, headache, lightheadedness/dizziness, chest pain,
SOB, cough, abdominal pain. Since her episode of vomiting she no
longer has had any nausea. She has been having normal bowel
movements since her 2 episodes of diarrhea this morning. She
does
note bilateral thigh pain ongoing for past day. Also feeling
quite thirsty.
Her history is notable for hyponatremia requiring admission in
___ - thought to be secondary to HCTZ and poor solute
intake. On discontinuation of HCTZ, her Na improved. Last Na 140
in ___ per Atrius records.
Past Medical History:
CKD stage 3, NIDDM2, CVA without residual deficit ___, HTN,
HLD,
glaucoma
Social History:
___
Family History:
She doesn't recall any family history of kidney disease in
family
Physical Exam:
Admission
==========
VS: T98.3, HR 86, BP 96/22, 100% RA
GEN: well appearing older woman
HEENT: PERRLA, EOMI, MMM
NECK: no JVD
CV: RRR, nl S1S2, no m/r/g
RESP: CTAB
GI: soft, NTND
MSK: mild TTP in bilateral thighs
SKIN: WWP, cap refill <2s, mild LLE calf swelling, no pitting
edema
NEURO: A&Ox3, CN II-XII intact, moving all 4 extremities
spontaneously
PSYCH: pleasant, mood appropriate
Discharge
========
PHYSICAL EXAM:
___ 0354 Temp: 97.5 PO BP: 121/75 L Lying HR: 80 RR: 18 O2
sat: 98% O2 delivery: Ra
GENERAL: NAD well-appearing woman
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose. No TTP of upper thighs
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, 4+ strength at hip flexors bilaterally,
___ extensors.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Labs
=============
___ 06:50AM BLOOD WBC-6.4 RBC-3.43* Hgb-9.8* Hct-29.7*
MCV-87 MCH-28.6 MCHC-33.0 RDW-11.9 RDWSD-37.7 Plt ___
___ 06:50AM BLOOD Glucose-121* UreaN-37* Creat-1.6* Na-112*
K-5.0 Cl-83* HCO3-17* AnGap-12
___ 06:50AM BLOOD ALT-15 AST-15 AlkPhos-108* TotBili-0.2
___ 06:50AM BLOOD Lipase-380*
___ 04:55PM BLOOD Calcium-9.1 Phos-3.3 Mg-1.4*
___ 08:00PM BLOOD Osmolal-263*
___ 05:05PM BLOOD Na-115*
Discharge and Pertinent Labs
============================
___ 05:02AM BLOOD WBC-4.8 RBC-2.97* Hgb-8.5* Hct-27.1*
MCV-91 MCH-28.6 MCHC-31.4* RDW-12.2 RDWSD-41.0 Plt ___
___ 05:02AM BLOOD Glucose-97 UreaN-37* Creat-1.6* Na-136
K-4.8 Cl-102 HCO3-25 AnGap-9*
___ 05:02AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.3
___ 06:38AM BLOOD TSH-2.0
___ 06:38AM BLOOD Cortsol-13.9
Imaging
=======
___ CXR IMPRESSION:
No pneumonia or acute cardiopulmonary process.
___ CT head IMPRESSION:
No acute intracranial process.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with CKD, DMII, and poorly
controlled hypertension, presenting with malaise, and diarrhea
found to have severe hyponatremia.
# Hyponatremia
Patient was transferred from the ED to ICU for management of her
hyponatremia as it was 112 at presentation. Serum osm low at
263, consistent with hypotonic hyponatremia. Urine osm low as
well suggesting low solute intake +/- excessive free water
intake (though patient only reporting drinking ___ glasses
daily). Potentially hypovolemic as improved with 1L LR in ED and
patient with recent 2 episodes of diarrhea- however urine osm
very dilute which would be atypical for pure hypovolemia.
Component of low solute intake may also be contributing. On ___,
Uosm 236 creating more of an SIADH-like picture. Pain would be
the only obvious trigger(headaches, which we managed as below).
No other medication, pulmonary, or intracranial process to
explain SIADH and TSH/cortisol WNL. She was treated only with
fluid restriction. Renal consulted. She got DDAVP x1 for
over-rapid correction, which may contribute to SIADH picture in
___. Otherwise, her Na trended upwards appropriately. Counseled
on consuming a normal amount of sodium at home and restricting
her water intake. By time of dc, Na was 136.
#Thigh pain
# Elevated CK
Pt found to have CK elevated to just under ___. No history of
fall or extreme exertion. She c/o bilateral thigh pain but she
struggles to define how long, and no TTP and no obvious
weakness. Simvastatin was held, CK downtrended, so statin
myopathy a possibilty. Renal function was stable so low concern
for rhabdo. Will hold statin at discharge and encourage her to
follow up with PCP about cholesterol management.
#Headaches
Likely muscular spasm of neck leading to tension type headache,
treated with warm compress, cyclobenzaprine and lidocaine path
with good effect. Discharged with cyclobenzaprine and Tylenol
for 1 week until PCP ___.
# Non-anion gap metabolic acidosis: resolved
Started on sodium bicarb 650mg TID per renal. Stopped it at time
of discharge due to resolved electrolyte imbalance.
# CKD stage ___
Creatinine within recent baseline. Slight rise in BUN from 27 to
37 on day of discharge; encourage follow up with PCP.
# HTN
- continued amlodipine and lisinopril
# DM, non-insulin dependent diabetes
- HISS in house. Manages with diet at home.
# Chronic anemia
Likely secondary to renal disease. Hb did downtrend throughout
admission from 9.8->8.5, attributed to phlebotomy given q6 H
blood draws. Continued home iron supplementation.
Transitional Issues
====================
[] please check Chem-7 within 1 week of discharge to monitor
sodium level and renal function, Na 136 on discharge
[] Please check CBC to ensure stability of Hgb, Hgb 8.5 on
discharge (stable)
[] holding statin given elevated CK of unclear etiology, would
consider changing class of statin if needs to be resumed and
monitoring symptoms and CK level closely vs alternative
class/agent
[] close f/u with PCP and renal re; diet and sodium intake.
[] consider dietician referral for counseling on diet to best
improve her sodium/solute/protein intake
[] f/u headaches, likely tension from neck spasm. discharged
with 10 pills of cyclobenzaprine, instruction to use warm
compresses on her neck and OTC lidocaine patches for her
headaches
#CODE STATUS: Full
#EMERGENCY CONTACT: daughters: ___ ___ and ___
___
Greater than 30 minutes spent in care coordination and
counseling on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO QAM
2. Simvastatin 40 mg PO QHS
3. Lisinopril 40 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/HA
2. Cyclobenzaprine 5 mg PO BID:PRN neck pain
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
3. amLODIPine 5 mg PO QAM
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
5. Ferrous Sulfate 325 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Symptomatic Hyponatremia
Secondary: Headache, HTN, DM, CKD, HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You had a low sodium level
What did you receive in the hospital?
- We restricted how much fluid you should drink so that your
sodium would improve.
What should you do once you leave the hospital?
- Please restrict your water intake to about 1 liter per day and
eat a normal diet (do not restrict your sodium). We encourage
protein intake by incorporating meat, beans, yogurt in your
diet.
- Please take your medications as prescribed and go to your
future appointments which are listed below.
-Please stop taking your simvastatin
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
19869263-DS-11
| 19,869,263 | 22,718,441 |
DS
| 11 |
2130-07-03 00:00:00
|
2130-07-03 10:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L wrist pain
Major Surgical or Invasive Procedure:
ORIF of L distal radius
History of Present Illness:
___ sp mechanical fall from standing. Immediate left
wrist pain. OSH XR shows L distal radius with volar laceration.
Tx to ___.
Past Medical History:
HTN
Hypercholesterolemia
Social History:
___
Family History:
NC
Physical Exam:
Easy work of breathing
laceration over ulnar aspect of volar wrist, 1 cm in length with
draining fracture hematoma. Deformity.
SILT M/U/R/ax
Fires EPL/FPL/ DIO/
2+ radial pulse
Pertinent Results:
___ 09:00PM GLUCOSE-122* UREA N-26* CREAT-0.9 SODIUM-139
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
___ 09:00PM estGFR-Using this
___ 09:00PM WBC-10.0 RBC-3.38* HGB-10.9* HCT-33.6*
MCV-99* MCH-32.3* MCHC-32.5 RDW-12.4
___ 09:00PM NEUTS-80.9* LYMPHS-14.3* MONOS-4.3 EOS-0.1
BASOS-0.3
___ 09:00PM PLT COUNT-217
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L distal radius fx and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF of the L distal radius, 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 LUE.
After procedure, patient's weight-bearing status was
transitioned to NWB through the L wrist. Throughout the
hospitalization, patient worked with physical therapy who deemed
placement in rehab was the safest option for her.
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: The patient was not transfused blood for acute
blood loss anemia.
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: She was prescribed lovenox for DVT prophylaxis and
she was encouraged to get up and ambulate as early as possible.
At the time of discharge on ***, POD #***, 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 placed on chemical DVT
prophylaxis for a total of 2 weeks post operatively. All
questions were answered prior to discharge and the patient
expressed readiness for discharge.
Medications on Admission:
Pravastatin
Hydrocholorothiazide
Ca/VitD
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L distal radius fracture
Discharge Condition:
At the time of discharge, Ms. ___ was A&Ox3, ambulating,
tolerating PO's and pain controlled without nausea.
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.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- NWB LUE through the wrist. ROMAT through the elbow and
shoulder
Followup Instructions:
___
|
19869927-DS-16
| 19,869,927 | 25,639,610 |
DS
| 16 |
2124-01-08 00:00:00
|
2124-01-08 11:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
morphine
Attending: ___.
Chief Complaint:
right periprosthetic fracture of the femur/hip
Major Surgical or Invasive Procedure:
Conservative non-operative management and pain control
History of Present Illness:
___ female with severe ___ disease s/p R hip hemi
converted to THA converted to constrained THA and left hip hemi
___ and ___ with multiple R THA dislocations presents with
the
above fracture s/p mechanical fall in her bathroom overnight.
She
was taken to ___ where they got xrays and transferred her
here. She is slightly confused but thinks she was a little dizzy
when she fell but denies head strike, LOC or any other injuries.
Per documentation, she sustained a right hip fx in ___
and
had a hemiarthroplasty which was converted to a THA due to
recurrent dislocations which was subsequently converted to a
constrained THA. She has been treated by Dr. ___ at ___
and Dr. ___ at ___ however I currently don't have any notes
from there. At baseline, she reports that she is mainly
wheelchair bound but uses a walker to get around with
assistance.
She reports that she lives with her son. Used to work as a
___. Has a baseline right foot drop and peripheral
neuropathy. Reports some antecedent lateral right hip pain for
several weeks prior to the fall but no groin pain. Denies any
new
numbness/tingling.
Past Medical History:
___ DISEASE
NEUROPATHY
DEPRESSION
EXTRA-PULMONARY TUBERCULOSIS
Loss of kidney
PAST MEDICAL HISTORY: ___ disease, lung disease,
thyroid
disease, depression, anxiety, peripheral neuropathy.
PE
___ DISEASE
NEUROPATHY
DEPRESSION
EXTRA-PULMONARY TUBERCULOSIS
WRIST PAIN
PAST SURGICAL HISTORY: ___ right hip hemi s/p multiple
dislocations conversion to THA then conversion to constrained
THA. Left hip hemiarthroplasty
Social History:
___
Family History:
NC
Physical Exam:
On Admission:
General: Well-appearing elderly female in no acute distress.
Slightly confused at times.
Right lower extremity:
- Skin intact
- Soft, minimally tender thigh
- leg lengths equal
- has baseline foot drop, fires ___
- SPLT S/S/SP/DP/T distributions but with baseline neuropathy
- foot WWP with bcr
Upon Discharge:
Vitals: Temp: 98.5 PO BP: 128/73 L Lying HR: 66 RR:
16 O2 sat: 95% O2 delivery: Ra
General: sleeping this am
MSK:
Right lower extremity:
- Soft, minimally tender thigh
- leg lengths equal
- has baseline foot drop, fires ___
- SPLT S/S/SP/DP/T distributions but with baseline neuropathy
- foot WWP with bcr
Pertinent Results:
___ 05:40AM BLOOD WBC-9.1 RBC-3.52* Hgb-11.0* Hct-33.4*
MCV-95 MCH-31.3 MCHC-32.9 RDW-13.0 RDWSD-44.7 Plt ___
___ 05:40AM BLOOD Neuts-69.5 ___ Monos-7.5 Eos-1.4
Baso-0.4 Im ___ AbsNeut-6.30* AbsLymp-1.87 AbsMono-0.68
AbsEos-0.13 AbsBaso-0.04
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD ___ PTT-26.1 ___
___ 06:55AM BLOOD Glucose-89 UreaN-14 Creat-0.7 Na-142
K-3.9 Cl-104 HCO3-29 AnGap-9*
___ 05:40AM BLOOD Glucose-92 UreaN-16 Creat-0.6 Na-144
K-4.0 Cl-105 HCO3-26 AnGap-13
___ 05:50AM URINE Color-Yellow Appear-Cloudy* Sp ___
___ 05:50AM URINE Blood-MOD* Nitrite-POS* Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG*
___ 05:50AM URINE RBC-12* WBC->182* Bacteri-MANY*
Yeast-NONE Epi-0
___ 05:50AM URINE WBC Clm-FEW* Mucous-FEW*
**FINAL REPORT ___
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
___ 06:40AM BLOOD WBC-7.7 RBC-3.54* Hgb-10.9* Hct-33.0*
MCV-93 MCH-30.8 MCHC-33.0 RDW-12.8 RDWSD-43.8 Plt ___
___ 06:40AM BLOOD Glucose-97 UreaN-10 Creat-0.6 Na-138
K-4.1 Cl-99 HCO3-25 AnGap-14
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right periprosthetic femur fracture and was admitted to
the orthopedic surgery service. The patient was treated
non-operatively, with close pain management, which the patient
tolerated well. The patient was found to have PROTEUS MIRABILIS
UTI, and was started on a five day course of PO
___. She received inpatient anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to ___ was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touchdown weight bearing to the right lower extremity with
gentle passive range of motion of the right lower extremity and
right hip as tolerated. left lower extremity weight bearing as
tolerated. She will be discharged on lovenox 40mg daily for 4
weeks for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
Medications - Prescription
CARBIDOPA-LEVODOPA - carbidopa 25 mg-levodopa 100 mg tablet. 1.5
tablet(s) by mouth Four times a day - (Dose adjustment - no new
Rx)
CARBIDOPA-LEVODOPA [SINEMET CR] - Sinemet CR 50 mg-200 mg
tablet,extended release. 1 tablet(s) by mouth at bedtime -
(Dose
adjustment - no new Rx)
ENTACAPONE - entacapone 200 mg tablet. 1 tablet(s) by mouth five
times daily - (Dose adjustment - no new Rx)
LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth daily
as needed for anxiety - (Prescribed by Other Provider)
Medications - OTC
CALCIUM CITRATE-VITAMIN D3 [CALCIUM CITRATE + D] - Dosage
uncertain - (Prescribed by Other Provider: 1 QD)Entered by
MA/Other Staff
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Dosage uncertain -
(Prescribed by Other Provider: 1 QD)Entered by MA/Other Staff
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Cefpodoxime Proxetil 100 mg PO/NG Q12H Duration: 5 Days
RX *cefpodoxime 100 mg 1 tablet(s) by mouth twice daily Disp
#*10 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe
Refills:*0
5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 0.5 to 1 tablet(s) by mouth every four (4)
hours Disp #*38 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 8.6 mg PO BID
8. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
9. BuPROPion XL (Once Daily) 150 mg PO DAILY
10. Carbidopa-Levodopa (___) 1.5 TAB PO QID
11. Carbidopa-Levodopa CR (50-200) 1 TAB PO QHS
12. ENTAcapone 200 mg PO 5X/DAY
13. Gabapentin 400 mg PO DAILY
14. LORazepam 0.5 mg PO DAILY:PRN anxiety
15. Nortriptyline 50 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Right periprosthetic hip 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:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for evaluation by the orthopedic
surgery service. It is normal to feel tired or "washed out"
after being hospitalized, and this feeling should improve over
the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weight bearing to the right lower extremity with gentle
passive range of motion of the right lower extremity and right
hip 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 lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
Non-weight bearing to the right lower extremity with gentle
passive range of motion of the right lower extremity and right
hip as tolerated
Followup Instructions:
___
|
19869927-DS-17
| 19,869,927 | 29,822,629 |
DS
| 17 |
2124-03-14 00:00:00
|
2124-03-14 12:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
morphine
Attending: ___
Chief Complaint:
recurrent right THA dislocations
Major Surgical or Invasive Procedure:
___: revision right THA
History of Present Illness:
___ year old female with known right THA recurrent dislocations
and periprosthetic fracture, p/w R THA dislocation, now s/p
failed right THA closed reduction ___, ___. Transferred
to ___ for right THA revision with Dr. ___.
Past Medical History:
PAST MEDICAL HISTORY: ___ disease, extra-pulmonary
tuberculosis, thyroid disease, depression, anxiety, peripheral
neuropathy, PE
PAST SURGICAL HISTORY: ___ right hip hemi s/p multiple
dislocations conversion to THA then conversion to constrained
THA. Left hip hemiarthroplasty
Social History:
___
Family History:
Non-contributory
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with Aquacel dressing with scant
serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* RLE foot drop
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 09:50AM BLOOD WBC-8.6 RBC-2.71* Hgb-8.3* Hct-25.2*
MCV-93 MCH-30.6 MCHC-32.9 RDW-14.6 RDWSD-49.7* Plt ___
___ 05:18AM BLOOD WBC-8.4 RBC-2.95* Hgb-8.9* Hct-26.9*
MCV-91 MCH-30.2 MCHC-33.1 RDW-14.9 RDWSD-50.0* Plt ___
___ 03:49AM BLOOD WBC-11.5* RBC-3.64* Hgb-11.0* Hct-32.9*
MCV-90 MCH-30.2 MCHC-33.4 RDW-14.5 RDWSD-48.1* Plt ___
___ 06:47PM BLOOD WBC-7.5 RBC-2.89* Hgb-9.2* Hct-28.1*
MCV-97 MCH-31.8 MCHC-32.7 RDW-12.9 RDWSD-46.0 Plt ___
___ 06:47PM BLOOD Neuts-62.5 ___ Monos-11.5 Eos-1.2
Baso-0.4 Im ___ AbsNeut-4.68 AbsLymp-1.80 AbsMono-0.86*
AbsEos-0.09 AbsBaso-0.03
___ 03:49AM BLOOD Glucose-156* UreaN-14 Creat-0.6 Na-140
K-4.1 Cl-102 HCO3-26 AnGap-12
___ 06:47PM BLOOD Glucose-110* UreaN-17 Creat-0.6 Na-141
K-4.4 Cl-101 HCO3-25 AnGap-15
___ 05:18AM BLOOD Mg-2.0
___ 03:49AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.6
___ 11:51AM BLOOD CRP-78.1*
___ 06:47PM BLOOD LtGrnHD-HOLD
___ 06:47PM BLOOD GreenHd-HOLD
___ 09:09PM BLOOD ___ pH-7.30*
___ 09:09PM BLOOD Glucose-100 Lactate-1.7 Na-138 K-3.5
Cl-108 calHCO3-23
___ 09:09PM BLOOD Hgb-11.0* calcHCT-33
___ 09:09PM BLOOD freeCa-0.93*
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: patient received 500ml IV fluid bolus for hypotension
___ and low urine output. Patient triggered in the afternoon
for hypotension 82/40 with mild dizziness reported. Hematocrit
was 32.9. Patient was given another 500ml IV fluid bolus and BPs
improved to 110s/60. Foley was discontinued and patient was
voiding independently after with baseline incontinence and low
PVRs.
POD #2: Patient had complaint of right calf pain and ultrasound
was obtained to rule out DVT. Results showed bilateral lower
extremity deep venous thrombosis with some areas of occlusive
and other areas of nonocclusive thrombus. Patient was switched
from Lovenox to Xarelto treatment dose at this time.
POD #3. Aquacel dressing changed due to moderate staining.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient received Lovenox daily for DVT
prophylaxis starting on the morning of POD#1. Patient was
switched to Xarelto 15mg twice daily upon discovery of bilateral
DVTs on POD #2. The surgical dressing will remain on until
POD#7 after surgery. 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 touch down weight bearing
on the operative extremity with posterior precautions. Walker or
two crutches.
Ms. ___ is discharged to rehab in stable condition.
Medications on Admission:
1. Carbidopa-Levodopa CR (50-200) 1 TAB PO TID
2. Carbidopa-Levodopa (___) 1 TAB PO QHS
3. ENTAcapone 200 mg PO TID
4. Gabapentin 300 mg PO DAILY
5. Lactulose 15 mL PO BID
6. Escitalopram Oxalate 10 mg PO DAILY
7. LORazepam 0.5 mg PO Q8H:PRN anxiety, agitation
8. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
9. Nortriptyline 25 mg PO QHS
10. Senna 8.6 mg PO BID:PRN Constipation - First Line
11. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Rivaroxaban 15 mg PO BID
Take 15mg twice daily for 21 days, then 20mg daily for 3 months
3. Acetaminophen 1000 mg PO Q8H
4. Carbidopa-Levodopa (___) 1 TAB PO TID
5. Carbidopa-Levodopa CR (50-200) 1 TAB PO QHS
6. ENTAcapone 200 mg PO TID
7. Escitalopram Oxalate 10 mg PO DAILY
8. Gabapentin 300 mg PO DAILY
9. Lactulose 15 mL PO BID
10. LORazepam 0.5 mg PO Q8H:PRN anxiety, agitation
11. Nortriptyline 25 mg PO QHS
12. Senna 8.6 mg PO BID:PRN Constipation - First Line
13. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
recurrent right THA dislocations
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Please continue Xarelto 15mg twice daily for
21 days (start date: ___, then 20mg daily for 3 months for
treatment of DVT. Please contact your PCP for refills on
medication.
9. WOUND CARE: Please remove Aquacel dressing on POD#7 after
surgery. It is okay to shower after surgery after 5 days but no
tub baths, swimming, or submerging your incision until after
your four (4) week checkup. Please place a dry sterile dressing
on the wound after aqaucel is removed each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
10. ___ (once at home): Home ___, dressing changes as
instructed, and wound checks.
11. ACTIVITY: Touch down weight bearing with posterior
precautions. No strenuous exercise or heavy lifting until
follow up appointment. Mobilize frequently.
Physical Therapy:
Touch down weight bearing right lower extremity
Posterior hip precautions
Mobilize frequently
Multipodus boot on RLE when in bed only
Treatments Frequency:
remove aquacel POD#7 after surgery
apply dry sterile dressing daily if needed after aquacel
dressing is removed
wound checks daily after aquacel removed
staple removal and replace with steri-strips at follow up visit
in clinic
Followup Instructions:
___
|
19869932-DS-8
| 19,869,932 | 20,019,120 |
DS
| 8 |
2181-06-30 00:00:00
|
2181-07-04 11:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right UPJ obstructing calculus
Major Surgical or Invasive Procedure:
NAME OF OPERATION ___: ___, right retrograde
pyelogram,
right ureteral stent placement.
History of Present Illness:
___ year old female with a past medical history significant for
recent nephrolithiasis who presents with right flank pain.
Past Medical History:
Chlamydia
___ CYSTOSCOPY RETROGRADE PYELOGRAM RIGHT CYSTOSCOPY STENT
PLACEMENT RIGHT ___
___ cystoscopy right retrograde pyelogram, right
ureteroscopy basket removal of stones, right ureteral stent
exchange ___
___ right ureteral stent placement ___
Social History:
___
Family History:
N/A
Physical Exam:
WdWn female, NAD, AVSS
Interactive, cooperative
Abdomen soft, Nt/Nd
Flank pain improved
Lower extremities w/out edema or pitting and no report of calf
pain
Pertinent Results:
___ 07:15AM BLOOD WBC-11.3* RBC-3.01* Hgb-10.0* Hct-28.8*
MCV-96 MCH-33.2* MCHC-34.7 RDW-12.4 RDWSD-44.0 Plt ___
___ 05:04AM BLOOD WBC-17.3* RBC-3.24* Hgb-10.5* Hct-31.3*
MCV-97 MCH-32.4* MCHC-33.5 RDW-12.5 RDWSD-44.4 Plt ___
___ 09:18AM BLOOD WBC-18.7* RBC-3.95 Hgb-13.0 Hct-39.0
MCV-99* MCH-32.9* MCHC-33.3 RDW-12.4 RDWSD-44.7 Plt ___
___ 09:18AM BLOOD Neuts-83.4* Lymphs-8.2* Monos-7.5
Eos-0.0* Baso-0.3 Im ___ AbsNeut-15.56* AbsLymp-1.54
AbsMono-1.41* AbsEos-0.00* AbsBaso-0.05
___ 07:15AM BLOOD Glucose-99 UreaN-8 Creat-0.8 Na-138 K-3.5
Cl-104 HCO3-24 AnGap-10
___ 05:04AM BLOOD Glucose-89 UreaN-7 Creat-0.8 Na-137 K-3.8
Cl-103 HCO3-21* AnGap-13
___ 09:18AM BLOOD Glucose-85 UreaN-8 Creat-0.8 Na-138 K-3.9
Cl-102 HCO3-21* AnGap-15
___ 09:18AM BLOOD ALT-9 AST-13 AlkPhos-95 TotBili-0.5
___ 09:18AM BLOOD Albumin-4.6 Calcium-11.0* Phos-2.2*
Mg-1.8
___ 09:18AM BLOOD HIV Ab-NEG
___ 8:42 am URINE USE 68986D.
**FINAL REPORT ___
URINE CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP B. >100,000 CFU/mL.
Brief Hospital Course:
Ms. ___ was admitted to Dr. ___ for
nephrolithiasis management with a known obstructing stone and
marked right flank pain with fevers and leukocytosis concerning
for urinary tract infection. She underwent urgent cystoscopy,
right retrograde pyelogram, right ureteral stent placement. She
tolerated the procedure well and recovered in the PACU before
transfer to the general surgical floor. See the dictated
operative note for full details. Overnight, the patient was
hydrated with intravenous fluids and received appropriate
perioperative prophylactic antibiotics but spiked a fever to 103
and had the onset of an unrelenting headache not much improved
with IV dilaudid. She was given Fioricet, IV fluids,
anti-emetics and narcotic pain medications and monitored for
fever spikes. Her headache improved and she was kept for
observation and fever watch until POD2. On POD2, catheter was
removed and she voided without difficulty. At discharge on
POD2, Ms. ___ pain was controlled with oral pain
medications, she was tolerating regular diet, ambulating without
assistance, and voiding without difficulty. She was explicitly
advised to follow up as directed as the indwelling ureteral
stent must be removed and or exchanged and she is to complete
the course of antibiotics.
Medications on Admission:
NONE
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Pain -
Moderate
RX *butalbital-acetaminophen-caff [Fioricet] 50 mg-300 mg-40 mg
___ caps by mouth q8hrs Disp #*9 Capsule Refills:*0
2. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
3. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 7 Days
100mg PO BID x 7 days
followed by 100mg PO daily for 14 days.
RX *cefpodoxime 100 mg one tab by mouth AS directed Disp #*28
Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg one capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
5. Ibuprofen 400-600 mg PO Q8H:PRN Pain - Mild
available over the counter for pain/fever
6. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second
Line
7. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin [Flomax] 0.4 mg ONE cap by mouth Daily Disp #*30
Capsule Refills:*0
8.SCHOOL NOTE
Ms. ___ was under medical care from ___ through ___.
Discharge Disposition:
Home
Discharge Diagnosis:
NEPHROLITHIASIS: Obstructing right-sided UPJ calculus.
URINARY TRACT INFECTION (BETA STREPTOCOCCUS GROUP B)
HEADACHE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control.
-You should not take more than 4000mg (4g) of
Tylenol/Acetmainophen from ALL sources.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks; no vaginal
intercourse while ureteral stent remains in place
Followup Instructions:
___
|
19869932-DS-9
| 19,869,932 | 24,863,978 |
DS
| 9 |
2181-11-02 00:00:00
|
2181-11-03 07:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right flank pain
Major Surgical or Invasive Procedure:
Right ureteroscopy, laser lithotripsy, ureteral stent placement
History of Present Illness:
Patient is a ___ female with a history of nephrolithiasis
secondary to a parathyroid adenoma who presents with right flank
pain.
The pain started yesterday and was sharp and stabbing in nature.
It radiates to the right lower abdominal quadrant. This has been
more severe than her past episodes of ureteral obstruction. As
the pain has continued to grow worse, she decided to present to
the ED today. Endorses nausea and vomiting in addition to the
right flank pain. Denies fevers, hematuria, and dysuria at this
time.
Of note, the patient has had two separate obstructive events in
the past few years on the right side which both had required
ureteral stent placement with concern for active infection.
Past Medical History:
Chlamydia
___ CYSTOSCOPY RETROGRADE PYELOGRAM RIGHT CYSTOSCOPY STENT
PLACEMENT RIGHT ___
___ cystoscopy right retrograde pyelogram, right
ureteroscopy basket removal of stones, right ureteral stent
exchange ___
___ right ureteral stent placement ___
Social History:
___
Family History:
No family history of nephrolithiasis
N/A
Physical Exam:
Physical Exam on Date of Discharge:
WdWn, NAD, AVSS
Interactive, cooperative
Abdomen soft, Nt/Nd
Flank pain resolved
Lower extremities w/out edema or pitting and no report of calf
pain
Pertinent Results:
___ 12:08PM URINE RBC-2 WBC-15* BACTERIA-FEW* YEAST-NONE
EPI-2
___ 05:40AM BLOOD WBC-9.1 RBC-3.23* Hgb-10.1* Hct-31.6*
MCV-98 MCH-31.3 MCHC-32.0 RDW-13.6 RDWSD-49.0* Plt ___
___ 05:40AM BLOOD Glucose-78 UreaN-10 Creat-0.8 Na-140
K-4.3 Cl-108 HCO3-25 AnGap-7*
Brief Hospital Course:
___ was admitted to the urology service for
nephrolithiasis management. She underwent right ureteroscopy,
laser lithotripsy and stent placement.
She tolerated the procedure well and recovered in the PACU
before transfer to the general surgical floor. See the dictated
operative note for full details.
Intravenous fluids, Toradol and Flomax were given to help
facilitate passage of stones. At discharge, patients pain was
controlled with oral pain medications, tolerating regular diet,
ambulating without assistance, and voiding without difficulty.
Patient was explicitly advised to follow up as directed as the
indwelling ureteral stent must be removed and or exchanged.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Potassium Citrate 5 mEq PO TID W/MEALS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
PACU ONLY
3. Gabapentin 100 mg PO ONCE Duration: 1 Dose
PACU ONLY
4. Oxybutynin 5 mg PO TID
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times a
day Disp #*15 Tablet Refills:*0
5. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a
day Disp #*15 Tablet Refills:*0
6. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
7. Potassium Citrate 5 mEq PO TID W/MEALS
Hold for K >
Discharge Disposition:
Home
Discharge Diagnosis:
Right ureteral stones
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or,
if applicable to you, the indwelling ureteral stent. You may
also experience some pain associated with spasm of your ureter.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urinethis, as noted above, is expected and will gradually
improvecontinue to drink plenty of fluids to flush out your
urinary system
-Resume your pre-admission/home medications EXCEPT as noted.
-You should ALWAYS call to inform, review and discuss any
medication changes and your post-operative course with your
primary care doctor.
-IBUPROFEN (the active ingredient of Advil, Motrin, etc.) may be
taken even though you may also be taking ACETAMINOPHEN
(Tylenol). You may alternate these medications for pain control.
-For pain control, try TYLENOL FIRST, then the ibuprofen (unless
otherwise advised), and then take the narcotic pain medication
(if prescribed) as prescribed if additional pain relief is
needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that may
be health care spending account reimbursable.
-Docusate sodium (Colace) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks
Followup Instructions:
___
|
19871556-DS-12
| 19,871,556 | 21,313,675 |
DS
| 12 |
2173-08-07 00:00:00
|
2173-08-08 21:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
================
___ 03:10PM BLOOD WBC-14.7* RBC-5.67 Hgb-16.9 Hct-49.3
MCV-87 MCH-29.8 MCHC-34.3 RDW-13.5 RDWSD-43.4 Plt ___
___ 03:10PM BLOOD Neuts-72.2* Lymphs-18.1* Monos-9.0
Eos-0.1* Baso-0.2 Im ___ AbsNeut-10.61* AbsLymp-2.66
AbsMono-1.32* AbsEos-0.02* AbsBaso-0.03
___ 03:10PM BLOOD ___ PTT-28.8 ___
___ 03:10PM BLOOD Glucose-118* UreaN-10 Creat-1.2 Na-145
K-4.2 Cl-102 HCO3-26 AnGap-17
___ 03:10PM BLOOD ALT-23 AST-32 AlkPhos-73 TotBili-0.5
___ 03:10PM BLOOD Albumin-4.8 Calcium-9.7 Phos-4.2 Mg-1.9
___ 03:26PM BLOOD K-3.5
PERTINENT LABS:
================
___ 03:10PM BLOOD Lipase-98*
___ 03:10PM BLOOD ALT-23 AST-32 AlkPhos-73 TotBili-0.5
MICRO:
========
NONE
IMAGING:
==========
MR CERVICAL SPINE W/O CONTRAST ___
IMPRESSION:
1. The previously seen minimally displaced C6 anterior superior
corner
fracture demonstrates associated bone marrow edema, focal
disruption of the anterior longitudinal ligament, and mild
prevertebral edema extending along the cervical spine.
2. Interspinous ligament edema at C4-C5, and to a lesser extent
at C5-C6 and C2-C3, without clear evidence for ligamentum flavum
edema or disruption. Overlying edema in the midline posterior
paravertebral soft tissues along the cervical spine.
3. High signal on STIR images in the C3-C4 disc, without disc
disruption, and without extension to the anterior longitudinal
posterior longitudinal
ligament, most likely degenerative in etiology.
4. No evidence for epidural collection or spinal cord signal
abnormality.
5. Multilevel degenerative disease. Spinal canal narrowing is
mild-to-moderate at C4-C5 and mild at other levels. Advanced
neural foraminal narrowing at multiple levels, as detailed
above.
DISCHARGE LABS:
=================
___ 06:51AM BLOOD WBC-12.1* RBC-5.43 Hgb-16.2 Hct-47.9
MCV-88 MCH-29.8 MCHC-33.8 RDW-13.9 RDWSD-44.8 Plt ___
___ 06:51AM BLOOD Plt ___
___ 06:51AM BLOOD Glucose-89 UreaN-12 Creat-1.1 Na-143
K-3.9 Cl-102 HCO3-26 AnGap-15
___ 06:51AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.0
DISCHARGE PHYSICAL EXAM:
============================
VITALS:24 HR Data (last updated ___ @ 742)
Temp: 98.0 (Tm 98.5), BP: 156/108 (144-156/92-108), HR: 97
(97-100), RR: 18, O2 sat: 97% (95-97), O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress. Wearing
C-collar.
EYES: Laceration across crown of caput with 3 staples and dried
blood around site. PERRL, EOMI. Sclera anicteric and without
injection.
ENT: MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
MSK: No spinous process tenderness. No CVA tenderness. No
clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout, including
with thumb flexion/extension/abduction/adduction. Normal
sensation. AOx3.
PSYCH: appropriate mood and affect
Brief Hospital Course:
___ male presenting after MVC found to have C6 avulsion
fracture and a superficial scalp laceration that required 3
staples. In the ER his course was complicated by two episodes of
emesis after receiving IV pain medication and uncontrolled
hypertension (SBP in the 200s) in the setting of medication
non-adherence. He was evaluated by ortho-spine and placed in a
hard C-collar with instructions to wear it at all times and
___ in outpatient clinic in ___ weeks. For his
hypertension, he was re-started on his amlodipine 10 mg and his
lisinopril was uptitrated to 10 mg daily. He was lost to
___ with his PCP and did not have refills of his
medications which may account for his uncontrolled hypertension,
in addition to pain, n/v. He was observed for one night in the
hospital, did not have recurrence of coffee ground emesis and
remained asymptomatic from hypertension, and was then discharged
home after medications delivered to his bedside (lisinopril 10
mg, amlodipine 10 mg, and simvastatin 20 mg).
TRANSITIONAL ISSUES:
=======================
[] Patient presented s/p MVC with imaging c/w avulsion fracture
at C6. He was recommended to wear C-collar at all times until
___ follow up arranged on ___. Patient also advised
to avoid lifting, bending and twisting.
[] Patient has staples in place for head laceration. Should be
removed at PCP follow up in ___
[] BP control: patient started on lisinopril 10mg daily and
amlodipine 10mg daily. Please titrate BP medications as
necessary in outpatient setting.
[] Patient re-initiated on lisinopril 10mg daily during
admission. Please check electrolytes at PCP ___.
[] Please obtain a baseline EKG at patient's scheduled PCP
___.
[] Patient previously taking simvastatin 20mg qPM several
months. Restarted on admission. Consider rechecking cholesterol
panel and LFTs in outpatient setting and possibly uptitrate
statin dosing.
[] Patient previously taking vitamin D supplement daily. Please
recheck vitamin D level in outpatient setting and consider
restarting supplementation.
ACUTE ISSUES:
=============
#Hypertesnive urgency
SBPs in the 200s on admission and in the past he was prescribed
multiple medications, including amlodipine, chlorthalidone and
lisinopril. He stated that he has not been taking medications
for several months since his prescriptions ran out over a year
ago and he encountered problems scheduling a PCP ___ and
forgot to call back to make an appointment. During this
hospitalization, he was restarted on amlodipine 10mg daily as
well as captopril TID, which was converted and uptitrated to
lisinopril 10mg qd on day of discharge. His blood pressure
medications should be titrated in the outpatient setting as he
will likely require an increased dose of lisinopril. He was
counseled on lifestyle changes to improve his blood pressure as
well. Also, his electrolytes should be checked at his PCP
___ appointment in the setting of re-initiation of ACEI.
#C6 avulsion fracture s/p MVC
#Neck pain
#Multilevel degenerative changes of cervical spine
Patient presented s/p MVC. CT C-spine and CT head performed at
OSH significant for avulsion fracture at C6 and on exam he has
paresthesias bilaterally in his thumbs and forearms in a C6
dermatomal distribution. MR of the cervical spine was notable
for bone marrow edema, focal disruption of the anterior
longitudinal ligament, and mild prevertebral edema extending
along the cervical spine, as well as multiple other acute
findings which likely explain his thumb parasthesias. Also
chronic findings indicating degenerative disease. See report for
full details. Ortho spine was consulted and recommend patient
wear C-collar at all times until follow up in ___ weeks for
repeat imaging (can shower below the brace). Patient advised to
avoid all bending, lifting and twisting until outpatient spine
center follow up. Patient also with staples in place to head
laceration that were placed at OSH and should be removed ___
after placement (___), at PCP follow up.
#Emesis
2 episodes of emesis in ED after receiving IV pain medications,
initially reported as coffee-ground emesis. Once admitted,
patient tolerating PO intake without nausea/vomiting. Unclear
from pt history if it was hematemasis or just dark brown emesis.
Less likely to be a ___ tear with no prior history of
liver disease, NSAID/steroid use and Hgb stable. Trauma surgery
was consulted in the ER and thought hematemesis likely
non-traumatic in origin and recommended discharge home with
close PCP follow up pending need for GIB work up. CBC was
trended and was stable. PCP should consider GI referral in
outpatient setting if ongoing concern for UGIB.
CHRONIC ISSUES:
===============
#HLD
Patient previously taking simvastatin 20mg qPM several months.
Restarted on admission.
#Vitamin D deficiency
Patient previously taking vitamin D supplement daily, but no
longer.
#CODE: Full Code, presumed
#CONTACT: ___ number: ___
Medications on Admission:
NONE
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
#Hypertensive urgency
#Emesis
#C6 avulsion fracture s/p MVC
#HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were admitted to the hospital because you had a minor car
accident and after you had numbness in your hands
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You had a picture (MRI) of the spine that showed that you
fractured your C6 vertebrae and you were given a neck brace to
wear for your fracture.
- You had 3 staples placed on your scalp from a cut from the car
accident. These will need to be removed in ___ days.
- Your blood pressure was very high (200/100) and you were
started back on medications to treat your high blood pressure
(amlodipine and lisinopril)
- You had an episode of vomiting after receiving pain
medications but that resolved on its own
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
- Please wear your C-collar at all times until you are
re-evaluated at your follow up appointment with the spine
specialists on ___. Please avoid lifting, bending, and
twisting.
We wish you all the ___!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19871603-DS-26
| 19,871,603 | 20,376,534 |
DS
| 26 |
2175-04-27 00:00:00
|
2175-04-27 13:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Iodine-Iodine Containing / Aspirin
Attending: ___.
Chief Complaint:
Left ___ femur fracture
Major Surgical or Invasive Procedure:
___: Open reduction and internal fixation of Left
___ femur fracture with ___ plate
History of Present Illness:
___ F with a complex PMHx including dementia, L hip fx s/p
THR in ___ from nursing home with concern for recurrence of L
femur fx. Onset: 1d prior. No preceding witnessed trauma. Pt
is poor historian at baseline ___ dementia. Per medical
records,
nursing home appreciated painless swelling of L femur last
evening. No reports of ASx: f/c, n/v/d, pulselessness, pain,
CP/SOB, abd pain, dysuria or foul smelling urine.
Past Medical History:
- Recent GI bleed
- Coronary artery disease s/p MI (___)
- Congestive Heart Failure (EF45% in ___
- Moderate pulmonary artery systolic hypertension
- Mild-moderate tricuspid regurgiation
- Carotid stenosis
- Hypertension
- Hyperlipidemia
- Dementia (A&OX2 at baseline)
- Chronic renal insufficiency, stage III
- Iron deficiency anemia with h/o heme positive stools
- GERD
- Constipation
- Macular degeneration
- s/p fall in ___ with ICH
- h/o left hip fracture with replacement (___)
- h/p right hip fracture with repair ___
- h/o lower GI bleed
- h/o pneumonias including aspiration PNA (___)
- h/o UTIs, Staph Aureus
- Left breast lumpectomy
(obtained from ___, not patient)
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death.
(per OMR)
Physical Exam:
NAD, AOx1 only
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
R M U SITLT
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
BLE skin clean and intact
+ TTP over L femur, L hip is internally rotated and 3cm
shortened, no distal pulselessness, no erythema, no edema, no
induration or ecchymosis
Thighs and legs are soft
+oain with passive motion of L hip
1+ ___ and DP pulses
Contralateral extremity examined with good range of motion,
SILT,
motors intact and no pain or edema
Pertinent Results:
___ 05:30PM WBC-8.1 RBC-2.97* HGB-8.8* HCT-28.0* MCV-94
MCH-29.8 MCHC-31.6 RDW-13.5
___ 05:30PM NEUTS-69.4 ___ MONOS-4.5 EOS-2.2
BASOS-0.5
___ 05:30PM PLT COUNT-502*#
___ 05:30PM GLUCOSE-86 UREA N-25* CREAT-0.8 SODIUM-142
POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-24 ANION GAP-16
___ 05:30PM CALCIUM-8.3* PHOSPHATE-4.1 MAGNESIUM-2.2
___ 05:30PM ___ PTT-31.0 ___
___ 05:45PM URINE RBC-1 WBC-8* BACTERIA-FEW YEAST-NONE
EPI-<1
Brief Hospital Course:
Ms. ___ was admitted to the Orthopedic service on ___
for a left periprosthetic femur fracture after being evaluated
and treated with closed reduction in the emergency room. She
underwent open reduction internal fixation of the fracture
without complication on ___. Please see operative report for
full details. She was extubated without difficulty and
transferred to the recovery room in stable condition. In the
early post-operative course Ms. ___ did well and was
transferred to the floor in stable condition.
She was transfused 1 unit of packed red cells for post-operative
anemia with an appropriate hematocrit response. She was started
IV antibiotics for a UTI discovered on pre-operative laboratory
analysis. She was started initially on IV ciprofloxacin, but
switched to IV cefepime, when cultures results for a UTI during
a previous hospital admissions revealed UTIs with resistance to
ciprofloxacin and bactrim. She will be discharged on cefpodoxime
to complete a 7-day course of antibiotics.
She had adequate pain management and worked with physical
therapy while in the hospital. The remainder of her hospital
course was uneventful and Ms. ___ is being discharged to
rehab in stable condition.
Medications on Admission:
Torsemide 20 mg Tab 1 Tablet(s) by mouth once a day
Vitamin D-3 200 mg (500 mg)-400 unit Tab
Senna 8.6 mg Cap
Niferex ___ mg Cap
Tums 300 mg (750 mg) Chewable Tab (
Aspirin 81 mg Chewable Tab
Omega-3 Fatty Acids 1,000 mg Cap
Vasotec 2.5 mg Tab
Zocor 5 mg Tab
Prilosec 10 mg Cap
Isosorbide Mononitrate SR 30 mg 24 hr Tab 1 Tablet(s) by mouth
once a day
Nitroglycerin SR 2.5 mg Cap
Ambien 5 mg Tab Trazodone 50 mg Tab
Toprol XL 25 mg 24 hr Tab
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. morphine 5 mg/mL Solution Sig: ___ mg Injection Q3H (every 3
hours) as needed for pain.
3. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO every ___ hours as
needed for pain for 2 weeks: Hold if somnolent or RR<12.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
8. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day).
9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
10. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
11. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. enalapril maleate 5 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
13. simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
14. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
15. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
16. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Injection
Subcutaneous QPM (once a day (in the evening)) for 4 weeks.
17. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
18. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
19. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Injection Q8H (every 8 hours) as needed for
nausea/vomiting.
20. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
21. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 days.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left periprosthetic femur 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:
MEDICINE
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
ORTHHOPEDIC WOUND CARE:
- Keep Incision clean and dry.
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dresssing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Activity:
- Continue to be non-weight bearing on your left leg
- You should not lift anything greater than 5 pounds.
- Elevate left leg to reduce swelling and pain.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___ 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
Physical Therapy:
Activity: OOB to chair for meals
Right lower extremity: Full weight bearing
Left lower extremity: Non weight bearing
Keep Left heel elevated off bed.
Followup Instructions:
___
|
19871967-DS-12
| 19,871,967 | 23,090,698 |
DS
| 12 |
2170-09-09 00:00:00
|
2170-09-10 15:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Codeine / Percocet
Attending: ___.
Chief Complaint:
supratherapeutic INR, mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with history of RA, LV anuerysm on coumadin,
CVA and DVT ___ on anticoagulation, CAD with EF ___ admitted
with supratherapeutic INR after mechanical fall at home. Patient
fell at home on day of admission, missing chair when trying to
sit on it. No headstrike, LOC, snycopal symptoms or palpitations
prior to or after event. No pain, ambulatory after fall. After
event, patient was notified by ___ clinic that INR was
supratherapeutic and to go to ED. No report of bleeding except
for blood streaked toilet paper and 3 drops of blood in toilet
water today, attributed to hemmorrhoids. No report of abnormal
bruising.
In the ED, initial VS: 97.6 85 132/54 18 97% RA. Chest X-ray
with no acute process, CT Head with no acute process. INR 10.21,
HCT 30.5 Guaiac negative. Due to elevated INR, HCT drop from 36
patient is admitted to medicine. Recieved macrobid for possible
UTI.
On arrival to the medical floor, patient resting comfortably
with no complaints. Denies urinary symptoms such as dysuria,
hematuria - however endorses incontinence that is stable due to
inability to make it to the restroom after diuretics due to RA.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, melena, dysuria, hematuria.
Past Medical History:
- Rheumatoid Arthritis
- Previous IMI with aneurysm
- Systolic HF, EF ___
- CVA, ___, residual left sided weakness
- Coronary Artery Disease, s/p IMI ___, EF ___, stable
left ventricle aneurysm
- DVT, ___, left lower extremity, while on anticoagulation
- Peripheral edema
- Hyperlipidemia
- Hypertension
- Rhematoid Arthritis, on prednisone and MTX
- s/p cholecystectomy
Social History:
___
Family History:
No family history of clotting disorders.
Physical Exam:
Admission physical exam:
VS - Temp 98.5 F, BP 152/95 , HR 82 , R 18 , O2-sat 98% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, JVP appears just above clavicle at 30 degrees, no
carotid bruits
HEART - RRR, no m/r/g, no extra heart sounds
LUNGS - CTAB, no wheezes/rales/ronchi, good air movement, resp
unlabored, no accessory muscle use
ABDOMEN - +BS, NT/ND, no ascites
EXTREMITIES - 1+ edema in bilateral lower extremities to
mid-shin, WWP, no c/c, 2+ peripheral pulses palpable. marked
deformities of knee, wrist and PIP joints with swelling around
joints.
SKIN - no rashes or lesions noted
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, but limited by pain, sensation grossly intact
throughout.
.
Discharge physical exam:
VS - Temp 98.6 Tmax 98.6F, BP 128/63 (100-130'/40-70') , HR 74
(70-90') , R 13 , O2-sat 98% RA
GENERAL - Alert, interactive, in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, JVP appears just above clavicle at 30 degrees, no
carotid bruits
HEART - RRR, no m/r/g, no extra heart sounds
LUNGS - CTAB, no wheezes/rales/ronchi, good air movement, resp
unlabored, no accessory muscle use
ABDOMEN - +BS, NT/ND, no ascites
EXTREMITIES - trace edema in bilateral lower extremities to
mid-shin, WWP, no c/c, faint peripheral pulses palpable. marked
deformities of knee, wrist and PIP joints with swelling around
joints.
SKIN - no rashes
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, but limited by pain, sensation grossly intact
throughout.
Pertinent Results:
Admission labs:
===============
___ 06:55PM BLOOD WBC-9.3 RBC-3.52* Hgb-9.0* Hct-30.5*
MCV-87 MCH-25.6* MCHC-29.5* RDW-16.8* Plt ___
___ 06:55PM BLOOD ___ PTT-89.6* ___
___ 06:55PM BLOOD Glucose-96 UreaN-15 Creat-1.1 Na-142
K-4.4 Cl-105 HCO3-19* AnGap-22*
___ 06:25AM BLOOD ALT-8 AST-13 AlkPhos-87 TotBili-0.1
.
Discharge labs:
===============
___ 06:45AM BLOOD Iron-19*
___ 06:45AM BLOOD calTIBC-270 Ferritn-65 TRF-208
___ 06:45AM BLOOD TSH-0.89
___ 06:25AM BLOOD Ret Aut-1.7
___ 06:25AM BLOOD WBC-9.2 RBC-3.32* Hgb-8.4* Hct-28.8*
MCV-87 MCH-25.2* MCHC-29.0* RDW-16.7* Plt ___
___ 06:25AM BLOOD ___ PTT-42.9* ___
___ 06:25AM BLOOD Creat-1.3* Na-141 K-3.2* Cl-103 HCO3-27
AnGap-14
.
EKG:
====
___
Sinus rhythm with a single ventricular premature beat. Inferior
wall
myocardial infarction with early R wave progression. Consider
posterior
myocardial infarction of indeterminate age. Borderline
intraventricular
conduction delay. ST-T wave abnormalities. Since the previous
tracing
of ___ ST-T wave abnormalities are less prominent.
.
Urine:
======
___ 08:30PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
___ 08:30PM URINE RBC-3* WBC-61* Bacteri-FEW Yeast-NONE
Epi-<1 RenalEp-<1
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
.
Imaging:
========
CT head without contrast ___
There is no evidence of acute intracranial hemorrhage, edema,
mass, mass
effect, or large vascular territorial infarction. New tiny
hypodensities
within the thalami are old small lacunes, but new since ___.
The ventricles and sulci are moderately prominent, unchanged
since ___, reflecting diffuse cortical atrophy. The middle ear
cavities, mastoid air cells, and included views of the paranasal
sinuses are clear. There is no acute fracture.
IMPRESSION: No acute intracranial process.
Brief Hospital Course:
___ year old woman with complicated medical history (please see
past medical history) admitted with supratherapeutic INR,
mechanical fall and report of BRBPR with FOBT Negative in ED,
improving INR after vitamin K 5 mg PO, no bleeding, relatively
stable H/H, discharged home with INR of 2.4 and coumadin of 3 mg
taken at 4pm ___. She will go home with home services and
INR check. She preferred to go home over going to rehab.
# Supratherapeutic INR - INR 10.2 on arrival to ED and recieved
Vitamin K 5 mg PO x 1 prior to transfer to medical floor. No new
medication. No dietary change. No evidence of bleeding active
bleeding (negative CT, no pain, no hematomas on exam). No
visible blood in subsequent stools. Report of BRBPR on toilet
paper at home, no gross bleeding, guaiac negative on exam. H/H
relatively stable (Hct ___ though lower than her prior in
___ (36). She is on coumadin for prevoius LV aneurysm and
developed CVA and DVT while on coumadin. She has significant ASA
allergy (tongue swelling). INR on discharge was 2.4 and received
on her discharge day 3 mg at 4pm. Anti-coagulation clinci is
notifed. ___ she will have a blood draw for INR and the
anti-coagulation nurses will be notifed with the result.
# Anemia - known to be iron deficient on iron supplements. per
history, consistent with hemorrhoids. No hemodynamic
instability. Guaiac negative in ED. No visible blood in stool
per patient while in the hospital. Iron recheck while in house
shows Iron of 19 and ferritin low-normal (ferritin could be
lower than this but possibly higher since it's an acute phase
reactant). Also, TIBC normal which should be high if purely iron
deficient. Most likely there is a component of anemia of chronic
disease as well. H/H relatively stable though lower than her
prior in ___. Retics 1.7. Iron supplement was increased to
twice daily given her iron profile findings.
# Acute renal failure: Cr was up from 1.1 to 1.3. could be
pre-renal. FeUrea 31% (FeNa not calculated given she is on
lasix). Patient reports drinking less fluid in the hospital
comapred to home. She has EF ___ based on echo ___. No
suspicion for renal etiologies since no new medications were
taken. No concern for post-renal etiologies, patient is passing
good amount of urine. She is encouraged to go back to her
drinking pattern at home. She will have a blood draw ___
which will include chem 7.
# Stable chronic systolic HF: asymptomatic. continued atenolol
and lasix. holding lisinopril given Cr slightly increased.
Lisinopril can be restarted once Cr improves to her baseline.
# S/p Fall - no evidence of trauma, CT Head negative. Likely in
setting of overall weakness from chronic medical issues. ___
evaluated the patient and recommended rehab. However patient
favored going home since she has a daughter living with her and
another living on the ___ floor. The daughter was called after
taking patient's permission and explained the importance of 24
hour surveillance since the daughter living with her is there
MOST of the time and not all the time. The daughter understood
the instructions.
# ? UTI - recieved macrobid in ED, we held antibiotics given
culture was only mixed urine flora.
# Thrombocytosis - elevated, previously in 500's. Likely stress
response or iron defiency anemia. Acute phase reactant.
# RA: generalized joint pain, limiting ability to move. We
continued home prednisone. She takes methotrexate weekly. We
started calcium, vitamin D and omeprazole since she is on
steroids. Per daughter her overall level of functioning is worse
over the last 1 month. She is scheduled for Rheum. clinic follow
up.
# Hypertension - We continued atenolol, amlodipine. held
lisinopril for uptrending Cr. Can be restarted once Cr improves.
# Peripheral edema - continued lasix
.
.
========================
TRANSITIONAL ISSUES:
- Lisinopril can be restarted once Cr improves
- Rheum follow up for her RA. Might need changing/uptitrating
medications since per daughter her overall level of functioning
is worse over the last 1 month
- Please f/u Cr and H/H ___.
- Might need further f/u for Cr. Might need down-titratation of
lasix if needed since it seems pre-renal.
- INR will be checked ___ and result will be called to
___ clinic for further management
Medications on Admission:
- Amlodipine 5 mg daily
- Atenolol 100 mg BID
- Furosemide 80 mg BID
- Lisinopril 40 mg daily
- Lovastatin 80 mg daily
- Methotrexat 22.5 mg q week
- NTG prn
- Prednisone 5 mg daily
- Warfarin 4 mg MWF, 2 mg TThSaSu
- Tylenol ___ mg q8h prn pain
- Ferrous Sulfate 325 mg daily
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atenolol 100 mg Tablet Sig: One (1) Tablet PO twice a day.
3. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. lovastatin 40 mg Tablet Sig: Two (2) Tablet PO at bedtime.
5. methotrexate sodium 2.5 mg Tablet Sig: Nine (9) Tablet PO
once a week.
6. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 min: max 3 tablet. if does not help for chest
pain, please call ___.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
11. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
INR, CBC, chem 7 will be drawn ___. Please fax results to
___, Dr ___. Please call ___
with the INR value.
13. ferrous sulfate 325 mg (65 mg iron) Tablet, Delayed Release
(E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a
day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
14. Coumadin 1 mg Tablet Sig: Four (4) Tablet PO
___.
15. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO
___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Supratherapeutic INR
Acute renal failure
Secondary:
Rheumatoid arhtritis
History of DVT
History of Stroke
Chronic stable systolic heart failure
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 great pleasure taking care of you as your doctor. As
you know you were admitted after your coumadin level was found
to be 10 after you had a mechanical fall. We scanned your head
and there was no bleeding. You had a few droplets of blood
within your stool at home. No similar episode occured after your
admission. Your stool analsysis for blood in the emergency room
was negative. We monitored your blood level and it was stable
throughout your stay.
We held your coumadin and gave you vitamin K on admission which
resulted in bringing your INR down to the target of ___ and
re-initiation of coumadin at 3 mg given on your discharge day.
You will need to follow up with the ___ clinic for
further management of your coumadin.
You were evaluated by physical therapy who recommended rehab
however you preferred to be at home since you have your daughter
living with you in addition to other family members living in
the same building.
Your blood level remained stable however this was slightly lower
than your blood levels in ___. Your kidney function
has slightly worsened which seems most likely to drinking less
fluid while in the hospital. You will need to follow up on your
kidney function along with your blood level and coumadin level
when blood is drawn on ___. Please continue drinking fluids
at the same rate you were drinking at home prior to admission
with the same diuretic regimen. This might need to be changed
based on your blood test on ___.
We made the following changes in your medication list:
- Please HOLD lisinopril until you see Dr. ___
- ___ RESTART coumadin 4 mg ___, 2 mg ___ this will
be monitored by the anticoagulation nurses at Dr. ___
___
- ___ INCREASE iron tablets to 1 tablet twice daily
- Please START omeprazole daily
- Please START calcium tablet daily
- Please START vitamin D tablet daily
You are provided with a prescription to check your coumadin
level. In addition, your blood levels and kidney function will
be re-checked. Please do the tests tomorrow, ___, and have
the results faxed to Dr ___ office at ___.
Regarding your INR, please have the visiting nurse call
___ to provide the result to the anticoagulant nurses.
___ 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.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19871967-DS-13
| 19,871,967 | 20,520,290 |
DS
| 13 |
2170-09-15 00:00:00
|
2170-09-15 20:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Codeine / Percocet
Attending: ___.
Chief Complaint:
severe joint pains
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with history of RA, LV aneurysm on coumadin,
CVA ___ and DVT on anticoagulation, CAD with EF ___ recently
discharged from ___ ___ after admission for supratherapeutic
INR, re-admitted for severe joint pains. Patient was doing well
at home until she noted increased pain her bilateral wrist and
ankle joints. She had more difficulty than normal walking to the
bathroom with assistance. On the day of admission, the patient
noted increasing pain in her joints to the point that she was
yelling in pain, and her daughter called an ambulance.
.
In the ED, initial VS: 97.8 82 138/56 18 95%RA. Labs notable for
HCT 31.2 (stable), creatinine 1.3 (baseline ~1.1-1.3), troponin
<0.01 and UA WNL. Chest X-ray with no acute process. EKG
unchanged from prior, exam with quaiac positive brown stool. CT
A/P showed complete thrombus of the common iliac artery with
reconstitution of the common femoral and internal iliac branches
distally and CBD dilitation (s/p CCY) and mild descending
sigmoid, and rectal wall thickening. Vascular surgery was
consulted for thrombus and feel most likely chronic as
reconstitution present and distal pulses intact. Right EJ placed
for access and patient had new oxygen requirement after morphine
administration. Recieved Morphine 5 mg IV x2, Ceftriaxone and
Flagyl for possible colitis.
Of note, the patient has been followed by vascular surgery as an
outpatient for carotid stenosis.
Past Medical History:
- Rheumatoid Arthritis
- Previous IMI with aneurysm
- Systolic HF, EF ___
- CVA, ___, residual left sided weakness
- Coronary Artery Disease, s/p IMI ___, EF ___, stable
left ventricle aneurysm
- DVT, ___, left lower extremity, while on anticoagulation
- Peripheral edema
- Hyperlipidemia
- Hypertension
- Rhematoid Arthritis, on prednisone and MTX
- s/p cholecystectomy
Social History:
___
Family History:
No family history of clotting disorders.
Physical Exam:
Admission physical exam:
VS - 98 142/65 18 95%RA
GENERAL - Pleasant, NAD
HEART - RRR, no m/r/g, no excess sounds
LUNGS - CTAB, trace bibasilar crackle, no wheeze or rhonchi,
unlabored, no accessory muscle use
ABDOMEN - soft, non-tender
EXTREMITIES - 1+ edema in bilateral lower extremities to
mid-shin, WWP, no c/c, 2+ peripheral pulses palpable. marked
deformities of knee, wrist and PIP joints with swelling around
joints - most notable on right ___ and ___ knuckle.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, moves all 4
extremities against gravity, but limited by pain, sensation
grossly intact throughout.
Discharge physical exam:
VS - 98.4 Tmax 98.4 142/76 (120-150'/60-70') 73 (60-70') 18
93-100%RA
GENERAL - Pleasant, NAD
HEART - RRR, no m/r/g, no excess sounds
LUNGS - CTAB, trace bibasilar crackle, no wheeze or rhonchi,
unlabored, no accessory muscle use
ABDOMEN - soft, non-tender
EXTREMITIES - 1+ edema in bilateral lower extremities to
mid-shin, left > right at baseline per patient, WWP, no c/c, 2+
peripheral pulses palpable. marked deformities of knee, wrist
and PIP joints with swelling around joints - most notable on
right ___ and ___ knuckle. these are better than prior admission
exam.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, moves all 4
extremities against gravity, but limited by pain, sensation
grossly intact throughout.
Pertinent Results:
Admission labs:
===============
___ 03:00PM BLOOD WBC-9.9 RBC-3.32* Hgb-8.6* Hct-29.3*
MCV-88 MCH-25.8* MCHC-29.2* RDW-16.9* Plt ___
___ 03:00PM BLOOD Neuts-75* Bands-0 Lymphs-17* Monos-7
Eos-1 Baso-0 ___ Myelos-0
___ 03:35PM BLOOD ___ PTT-38.3* ___
___ 03:35PM BLOOD Glucose-108* UreaN-24* Creat-1.3* Na-143
K-3.9 Cl-105 HCO3-23 AnGap-19
___ 03:35PM BLOOD ALT-11 AST-16 CK(CPK)-67 AlkPhos-91
TotBili-0.1
___ 03:35PM BLOOD cTropnT-<0.01
___ 12:50AM BLOOD cTropnT-<0.01
___ 03:35PM BLOOD Lipase-29
___ 03:35PM BLOOD Albumin-3.4* Calcium-9.3 Phos-3.7 Mg-2.1
___ 06:20AM BLOOD CRP-171.0*
___ 06:20AM BLOOD ESR-135*
.
Discharge labs:
===============
___ 07:05AM BLOOD WBC-9.4 RBC-3.43* Hgb-8.8* Hct-30.4*
MCV-89 MCH-25.6* MCHC-28.9* RDW-17.5* Plt ___
___ 03:35PM BLOOD Neuts-81.0* Lymphs-12.4* Monos-5.0
Eos-1.3 Baso-0.2
___ 07:05AM BLOOD ___ PTT-43.1* ___
___ 07:05AM BLOOD Glucose-84 UreaN-23* Creat-1.2* Na-142
K-3.9 Cl-103 HCO3-27 AnGap-16
___ 07:05AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.0
.
Urine:
======
___ 08:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 08:30PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-0
.
Microbiology:
=============
Urine culture: no growth
Blood culture: pending
.
Imaging:
========
CT Abdomen/Pelvis with contrast:
IMPRESSION:
1. Complete occlusion of the right common iliac artery as well
as boith internal and external branches with distal
reconstitution of flow. Proximal left internal iliac occlusion
with reconstitution. Findings are new since ___, but likely
chronic.
2. Dilation of the common bile duct to 16 mm and is greater than
expected even after post-cholecystectomy. Correlate with LFTs.
3. Equivocal mild thickening of the sigmoid colon and rectal
wall indicate a mild colitis. Large mesenteric vessels are
patent.
.
Chest X-ray:
FINDINGS: Frontal AP and lateral views of the chest were
obtained. Low lung volumes result in bronchovascular crowding.
There is no focal consolidation, pleural effusion or
pneumothorax. Cardiac and mediastinal silhouettes and hilar
contours are stable with mild cardiomegaly. Loss of vertebral
body height at multiple levels in the thoracic spine is
unchanged. IMPRESSION: No acute intrathoracic process
.
Carotid US:
Right ICA 60-69% stenosis.
Left ICA 80-99% stenosis
Lower Ext Arterial doppler:
Findings indicate significant aorto-biiliac disease as well as
left SFA disease.
Lower extremity venous doppler:
IMPRESSION:
No evidence of DVT within the lower extremities bilaterally.
Brief Hospital Course:
Ms. ___ is an ___ year old pleasant woman with history of RA,
CVA ___ on anticoagulation, CAD with EF ___ recently
discharged from ___ ___ after admission for
supratherapeutic INR, re-admitted for severe joint pains. After
discussing with rheumatologist, she was placed on higher
prednisone regimen which resulted in improvement of her
symptoms. Given her FOBT positive stools in the setting of INR
of 4.7 on admission (which could be secondary to her chronic
hemorrhoids), CT abdomen pelvis was done which revealed
equivocal thickening of sigmoid and rectum which will require
outpatient follow up by colonoscopy. CT also showed common
femoral artery thrombus which seems chronic per vascular surgery
team, further studies showed significant aorto-biiliac disease
and left SFA disease. Discharged home in stable condition with
home physical therapy service. Coumadin held given INR 3.7 on
discharge.
.
# Joint Pain: Most likely secondary to flare of RA as this is
consistent with her previous pain and patient has elevated ESR.
Improved after 20 mg prednisone daily for 2 days with subsequent
continuation of prednisone at 15 mg daily dose. She will
continue on this regimen till she sees her rheumatologist as
scheduled. She is provided 30 tablet of morphine immediate
release 15 mg to be taken every 6 hour as needed for pain. Bowel
regimen is recommended as well to avoid constipation.
.
# Supratherapeutic INR: ongoing issue. Unclear why, suspect diet
non-compliance though patient does not report change in her diet
or medication. Reports compliance to home medications and
instructions. Coumadin was held during her stay and her INR
slowly down-trended from 4.7 to 3.7 on discharge. She is
instructed to hold coumadin till she sees her primary care
physician ___ 2 days of discharge.
.
# Common Iliac Artery Thrombus: Likely chronic. lower extremity
arterial studies suggest aorto-biiliac disease with left SFA
disease. Patient is not on aspirin given her aspirin allergy. On
coumadin. Vascular surgery was following with us during her stay
and recommended outpatient follow up for further discussion
regarding intervention.
.
# Sigmiod Wall Thickening on CT: No symptoms currently. H/H
stable throughout her stay. Report is equivocal for mild
thickening at the sigmoid and rectum. Would recommend outpatient
colonsocopy as follow up.
.
# Carotid stenosis: Outpatient issue. Carotid US was done on
this admission and shows bilateral disease, left > right (please
see results section for further details). allergic to aspirin.
INR 3.7 on day of discharge. Vascular surgery was following
during her stay and will be evaluated by them as outpatient.
.
# Acute renal failure: This was noted during her prior admission
when Cr increased from 1.1 to 1.3. After reviewing her recent Cr
levels, it seems her baseline is 1.1-1.3 and she remained within
this range during her hospital stay. We continued her home lasix
regimen of 80 mg twice daily along with restarting her home
lisinopril at half dose of 20 mg daily (was held at her prior
discharge given the rise in Cr from 1.1 to 1.3).
.
# Guaiac Positive Stool: Outpatient follow-up. H/H stable.
Asymptomatic. Colonoscopy recommended as above. Could be
secondary to her chronic hemorrhoids.
.
# Thrombocytosis: stable
.
# Hypertension: We continued atenolol, amlodipine and restarted
half dose home lisinopril as above.
.
# Peripheral edema: We continued home lasix.
===============================================================
# Transistional issues:
- Please schedule outpatient colonoscopy to further evaluate the
equivocal mild thickening at the sigmoid and rectum
- Please follow INR closely and change coumadin dose accordingly
- Common Iliac Artery Thrombus along with aorto-biiliac disease
and left SFA disease. Also, carotid artery stenosis. All will be
followed by vascular surgery as outpatient
Medications on Admission:
- Amlodipine 5 mg daily
- Atenolol 100 mg BID
- Furosemide 80 mg BID
- Lovastatin 80 mg qHS
- Methotrexate 22.5 mg q week
- NTG prn
- Prednisone 5 mg daily
- Warfarin 4 mg MWF, 2 mg TThSaSu
- Tylenol ___ mg q8h prn pain
- Ferrous Sulfate 325 mg twice daily
- Omeprazole 40 mg daily
- Calcium carbonate 1 tab daily
- Vitamin D3 1000 unit daily
- Lisinopril 40 mg daily (was on hold from prior admission
pending creatinine)
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atenolol 100 mg Tablet Sig: One (1) Tablet PO twice a day.
3. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. lovastatin 40 mg Tablet Sig: Two (2) Tablet PO at bedtime.
5. methotrexate sodium 2.5 mg Tablet Sig: Nine (9) Tablet PO
once a week.
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual once a day as needed for chest pain: 1 tab each 5
min, call ___ after ___ tab. .
7. prednisone 5 mg Tablet Sig: Three (3) Tablet PO at bedtime.
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO twice a day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Supratherapeutic INR
Rheumatoid arthritis
Right common iliac artery thrombosis
aorto-biiliac arterial disease
Diseased left superficial femoral artery
Carotid artery stenosis bilateral, left worse than right
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. You were admitted to ___
___ for increased pain in your
joints. We increased the dose of the prednisone which helped to
control the joint swelling and pain. You were evaluated by
physical therapy who feel that you are safe to return home.
.
Your coumadin level (INR) was 4.7 on admission. We held your
coumadin during your stay and monitored the INR. Your INR prior
to discharge was 3.7. Please continue to hold the coumadin until
you see Dr. ___ on ___.
.
You reported black stool, which was positive for blood. This ___
be secondary to your hemorrhoids, however you ___ need a
colonoscopy to better evaluate this in the future. Your blood
levels remained stable during your stay.
.
You had a cat scan of your belly which showed mild thickening at
the end of the colon. The cat scan also showed a clot in your
right pelvic artery which appears to be chronic. You were
evaluated by vascular surgery and will follow up with them as an
outpatient.
.
The ultrasound of your neck showed narrowing of the carotid
artery on both sides, left worse than right. This will be
evaluated by the vascular surgery team as an outpatient.
.
We made the following changes to your medications:
- Please INCREASE prednisone to 15 mg daily
- Please RESTART lisinopril but at 20 mg daily (NOT 40mg daily)
- Please START morphine 15 mg every 6 hours as needed for pain
- Please START colace and senna to prevent constipation while
you are taking the morphine
- Please HOLD the warfarin (coumadin) until you see Dr. ___
.
Please continue taking the rest of your home medications the way
you were taking them at home.
.
Please follow with your appointments as illustrated below
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19871967-DS-15
| 19,871,967 | 24,301,152 |
DS
| 15 |
2176-06-03 00:00:00
|
2176-06-03 17:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Codeine / Percocet / calcium carbonate / tramadol
Attending: ___.
Chief Complaint:
severe pain with swelling of the face and the
legs
and is unable to move the legs
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female with past medical history significant for
CVA,
rheumatoid arthritis, on warfarin presents with lateral hip
pain.
The patient reports that she has chronic pain throughout her
body, as well as her right hip. She states that she awoke this
morning and was unable to get out of bed due to the pain. She
reports that her pain is improved now that she has been resting.
She reports that over the past week, she has been having
increasing difficulty ambulating. She normally ambulates with a
walker.
She denies any fevers, chills, chest pain, abdominal pain.
She reports that she stopped Lasix before ___ per her
doctor's instructions, and she has severe swelling especially in
her feet. She said, she restarted the Lasix at half her normal
dose over the last week, but it hasn't really helped her.
She denies any falls. She denies any paresthesias. She reports
ongoing urinary incontinence, denies any new paresthesias, fecal
incontinence, urinary retention. She was scheduled to see her
rheumatologist today, however due to her severe pain and it
difficulty in bleeding, she was referred to the emergency
department.
She has known renal injury in ___ as per review of PCP
___.
Past Medical History:
- Cataracts s/p OS surgery in ___
- CVA ___, R frontal and R medial cerebellar embolic
infarcts, on warfarin
- L ventricular aneurysm
- CAD (chronic atypical chest pain w/ old inferior wall MI)
- Glucose intolerance
- HLD
- HTN
- Hypokalemia
- Peripheral edema, likely chronic venous insufficiency
- PVD (Common Iliac Artery Thrombus, aorto-biiliac disease, left
SFA disease, carotid artery stenosis)
- RA (on MTX, prednisone)
- osteoporosis
- s/p cholecystectomy
- DVT ___, on warfarin for chronic DVTs as well as
left ventricular aneurysm and poor ventricular function as per
review of the hematology notes in ___.
Social History:
___
Family History:
She has four healthy children.
Physical Exam:
ADMISSION Physical Exam:
==========================
VITALS: 97.5 124/66 86 18 96 ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes, poor
dentition. Oropharynx is clear.
NECK: Could not appreciate JVD.
CARDIAC: Regular rhythm, irregular rate (PVCs?). Audible S1 and
S2. +++Systolic murmur
LUNGS: Dependent lung field with inspiratory crackles. No
wheezes. No increased work of breathing.
BACK: No spinous process tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly. +Hernia
EXTREMITIES: ___ pitting edema to waist. Pulses DP/Radial 1+
bilaterally.
SKIN: Warm. Cap refill <2s. Skin abrasion/erythema near ankle.
+++Hyperpigmentation tender to palpation over right
buttocks/posterior hip.
NEUROLOGIC: CN2-12 intact. AOx3.
DISCHARGE PHYSICAL EXAM
==========================
24 HR Data (last updated ___ @ 1035)
Temp: 97.6 (Tm 99.5), BP: 156/53 (101-162/51-77), HR: 87
(76-88),
RR: 18, O2 sat: 97% (92-97), O2 delivery: Ra
Fluid Balance (last updated ___ @904)
Last 24 hours Total cumulative +240
IN: Total 1540 ml, PO Amt 1540 ml
OUT: Total 1300 ml, Urine Amt 1300 ml
GENERAL: Alert and interactive. In no acute distress.
HEENT: Normocephalic, atraumatic. Sclera anicteric. Moist mucous
membranes
NECK: JVD +8 cm
CARDIAC: Regular rate and rhythm. +II/VI systolic murmur at
right
sternal border and throughout precordium
LUNGS: CTAB
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: 2+ non-pitting edema to thigh. Ulnar deviation of
hands with swelling at ___ MCP joint, no notable erythema, some
warmth
NEUROLOGIC: AOx3.
Pertinent Results:
ADMISSION LABS
==================
___ 01:05PM BLOOD WBC-7.7 RBC-3.05* Hgb-6.2* Hct-22.9*
MCV-75*# MCH-20.3*# MCHC-27.1* RDW-22.5* RDWSD-60.1* Plt ___
___ 01:05PM BLOOD Neuts-68.2 Lymphs-18.3* Monos-11.4
Eos-1.2 Baso-0.4 NRBC-0.5* Im ___ AbsNeut-5.24 AbsLymp-1.41
AbsMono-0.88* AbsEos-0.09 AbsBaso-0.03
___ 01:05PM BLOOD ___ PTT-32.2 ___
___ 01:05PM BLOOD Plt ___
___ 01:05PM BLOOD Glucose-71 UreaN-28* Creat-1.7* Na-145
K-3.9 Cl-112* HCO3-16* AnGap-17
___ 01:05PM BLOOD Iron-19*
___ 01:05PM BLOOD calTIBC-309 Ferritn-21 TRF-238
DISCHARGE LABS
================
___ 09:05AM BLOOD WBC-16.1* RBC-4.02 Hgb-9.1* Hct-32.3*
MCV-80* MCH-22.6* MCHC-28.2* RDW-29.7* RDWSD-82.7* Plt ___
___ 01:05PM BLOOD Neuts-68.2 Lymphs-18.3* Monos-11.4
Eos-1.2 Baso-0.4 NRBC-0.5* Im ___ AbsNeut-5.24 AbsLymp-1.41
AbsMono-0.88* AbsEos-0.09 AbsBaso-0.03
___ 09:05AM BLOOD Plt ___
___ 09:05AM BLOOD ___ PTT-31.2 ___
___ 09:05AM BLOOD Glucose-154* UreaN-59* Creat-1.7* Na-143
K-3.9 Cl-97 HCO3-30 AnGap-16
___ 09:05AM BLOOD Calcium-8.9 Phos-2.1* Mg-2.3
___ 05:10AM BLOOD WBC-16.0* RBC-3.60* Hgb-8.2* Hct-28.9*
MCV-80* MCH-22.8* MCHC-28.4* RDW-30.2* RDWSD-85.3* Plt ___
___ 05:10AM BLOOD Plt ___
___ 05:10AM BLOOD Glucose-138* UreaN-66* Creat-1.6* Na-142
K-4.0 Cl-96 HCO3-34* AnGap-12
IMAGING
================
___ MRI HIP
IMPRESSION:
Images are degraded by motion artifact.
1. No evidence of avascular necrosis of the right hip.
2. Small nonspecific right hip effusion.
3. Mild-to-moderate degenerative changes of bilateral hips is
likely
degeneration and tearing of the anterior superior right labrum.
4. Diffuse subcutaneous, muscle, and presacral edema of the
pelvis may
represent anasarca.
5. There may be trace amount of fluid within the right sub
gluteus medius
bursal.
___ ECHO
IMPRESSION:Severe aortic valve stenosis.Normal left ventricular
cavity size with inferior aneurysm/akinesis c/w CAD. Severe
pulmonary artery systolic hypertension. Mild-moderate mitral
regurgitation.
Compared with the prior study (images reviewed) of ___,
severe aortic valve stenosis and severe PA systolic hypertension
are now present.
CLINICAL IMPLICATIONS:
The patient has severe aortic valve stenosis. Based on ___
ACC/AHA Valvular Heart Disease Guidelines, if the patient is
asymptomatic, it is reasonable to consider an exercise stress
test to confirm symptom status. In addition, a follow-up study
is suggested in ___ months. If they are symptomatic (angina,
syncope, CHF) and a surgical or TAVR candidate, a mechanical
intervention is recommended.
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or ___.
___ CT ABD
IMPRESSION:
1. No evidence of retroperitoneal bleed or other acute process
in the abdomen or pelvis.
2. Small right and trace left nonhemorrhagic pleural effusions,
diffuse
anasarca, and nonspecific nonhemorrhagic presacral edema.
3. Hypoattenuation of the blood pool relative the myocardium,
suggestive of anemia.
4. Diverticulosis, with no evidence of acute diverticulitis.
___ HIP XRAY
FINDINGS:
There is no fracture. Mild degenerative changes seen at the
hips bilaterally.
Degenerative changes noted at the pubic symphysis. SI joints
are grossly
unremarkable. Proximal femurs are within normal limits. There
is no
dislocation. Vascular calcifications are noted.
IMPRESSION:
No fracture.
___ CXR
IMPRESSION:
Probable small bilateral pleural effusions and right basilar
consolidation
suspicious for pneumonia.
MICROBIOLOGY
==================
___ BLOOD CULTURE- NGTD
Brief Hospital Course:
PATIENT SUMMARY STATEMENT FOR ADMISSION
==========================================
___ female with past medical history significant for
CVA, rheumatoid arthritis, on warfarin presents with lateral hip
pain w/overlying skin hyperpigmentation, anasarca, bilateral
pleural effusions on CXR, inspiratory crackles, and microcytic
anemia. Her clinical picture was consistent with a RA flare. She
was activity diuresis and was seen by rheumatology who increased
her prednisone, restarted MTX and plans to initiate a biologic.
She was also found to have interval worsening in her aortic
stenosis from moderate to severe, but denied any symptoms. She
was discharge to a rehab facility for further strengthening.
ACUTE MEDICAL/SURGICAL ISSUES ADDRESSED
==========================================
#Lateral Hip pain with difficulty moving legs
#Migratory joint pain in hands, rights, and arms
The patient has been experiencing chronic hip pain for over a
year, but presented with an acute increase in R hip pain that
prevented her from walking. Her pain is likely multifactorial in
origin. Xray showed chronic degenerative changes, likely due to
osteoarthritis. Patient also has a history of rheumatoid
arthritis, which may be contributing, and she was found to be
having an RA flare. She had point tenderness on exam, which may
also be indicative of trochanteric bursitis. Additionally,
patient has significant volume overload on exam in the setting
of holding Lasix. This extra weight on her legs was likely also
contributing to her pain. Patient was diuresed with IV Lasix
120mg IV BID to reduce volume overload and leg swelling.
Rheumatology was consulted to assess for an RA flare in the
setting of shooting pains in the hands and legs and recommended
increasing prednisone to 20 mg daily. Steroid injection for
trochanteric bursitis was also considered, but may be performed
in the outpatient setting if symptoms persist after further RA
treatment. Geriatrics was also consulted and provided
recommendations about ways to improve mobility and day to day
function at home. For symptomatic pain relief, the patient
received lidocaine patches and ointment, as well as Dilaudid 0.5
mg q8h PO PRN. Rheumatology recommended outpatient follow-up
with possibility of starting another medication, such as
rituximab, to optimize her RA control. She was discharged home
with methotrexate 12.5mg daily ___ and plan to follow-up
with rheumatology as an outpatient
#Acute on Chronic HFrEF
Decompensated heart failure with volume overload in the setting
of holding diuretics. Her BNP on admission was ___. Her last
echo in ___ showed EF of ___ and repeat echo during this
admission showed stable EF with progression to severe aortic
stenosis. To reduce volume overload she received 4 days of 120mg
IV Lasix BID. Over the hospitalization, her cumulative net fluid
balance was -4782 mL. Her home Atenolol 25 mg PO BID was
switched to Metoprolol Succinate XL 50 mg PO QHS. At discharge,
her leg swelling had markedly decreased and she was still
slightly volume up on discharge. She was started on torsemide
60mg to take daily at home and had scheduled follow-up with
cardiology.
#Microcytic anemia
Hemoglobin was 6.2 on admission without gross signs of bleeding.
She received 1 unit PRBC with an appropriate increase in her
hematocrit. Patient has a history of iron deficiency and anemia
of chronic inflammation, she's been on methotrexate, and history
of CKD may also be contributing. GI bleeding was also
considered, and stool guiac was positive. Additionally, given
patient's aortic stenosis, she may have ___ syndrome and GI
AVMs. At discharge, her hemoglobin was 9.1 and concern for brisk
GI bleed remained low.
#Seropositive RA
Patient had wide-spread joint pain during her stay, most notably
in her right hand, hip, shoulder and hands. Appeared to be
having an RA flare with increased pain. Rheumatology increased
prednisone to 20 mg initially, the 35mg daily. Because she did
not have further relief at the higher dose, she was again
deescalated to 20mg for discharge. She was also started on
omeprazole for ulcer prophylaxis with this. Based on geriatrics
recommendations, she received 0.5 mg q6h PRN PO Dilaudid for
pain. She was restarted on methotrexate 25mg (12.5mg BID on
___. Plan for rheumatology follow-up with possibility of
starting another medication or biologic on discharge.
#Hyperpigmentation on lateral thigh, may be early stage of
pressure ulcer. Monitored and did not progress.
#CXR with possible underlying PNA
Patient remained does not have cough, fever, and is satting 95%
on RA, making pneumonia unlikely. She did not require
antibiotics during this hospitalization.
CHRONIC ISSUES PERTINENT TO ADMISSION
======================================
#DVTs on warfarin, therapeutic INR
Continued 2mg daily warfarin.
#Bone Health
Continued high dose D, Fosamax.
TRANSITIONAL ISSUES
===================
# Patient has severe aortic stenosis but does not have symptoms
of dyspnea on exertion, angina, or syncope/pre-syncope. She
needs to be followed closely by cardiology and TTE should be
repeated in ___ months.
#Patient's RA is still not adequately managed. Her outpatient
rheumatologist is planning on starting her on a biologic for her
refractory symptoms as an outpatient. This should be arranged in
the coming days weeks, possibly while she is in rehab.
# Should there be any question of insurance coverage of her
medication for rheumatoid arthritis, please contact ___
___ (clinical pharmacist) for further information and
help with obtaining insurance coverage.
# Patients prednisone increased to 20 mg daily. Should it be
continued at this high a dose or higher for 30 days, she will
need to start PCP ___.
# Started on 0.5 mg PO Dilaudid q8h PRN for severe pain. Would
stop this if she has better symptomatic control of RA.
# Ensure daily bowel movement with narcotics
#Patient discharged on Torsemide 40 mg daily. At rehab, standing
weights should be obtained daily, if her weight is increasing by
3 pounds or more, torsemide should be increased to BID until
back to her original weight.
#Patient continues to have low H/H. CBCs should be obtained in
rehab and if signs of bleeding persist, would speak to patient
and family about goals of care with regard to pursuing
colonoscopy.
#Warfarin was increased to 2.5mg daily on ___ due to
subtherapeutic INR. Check INR on ___ to monitor for response.
#Restarting methotrexate on ___ and will need Chemistry,
BUN/Cr, LFTs, CRP/ESR in 2 weeks (___) and have these sent
to outpatient rheumatologist (fax ___
# Patient is currently full code, should her mobility and
functional status not improve, overall goals of care including
CPR and intubation in event of arrest should be further
discussed. These were broached, but ultimately it was decided
that patient make effort to improve quality of life with
aggressive medical treatment, should this not go well, plan was
to readdress goals and focus more exclusively on comfort and
remaining at home as long as possible.
NEW MEDICATIONS
================
DILAUDID 0.5MG QHS AND Q8H PRN SEVERE PAIN
OMEPRAZOLE 40MG DAILY
CHANGED MEDICATIONS
===================
TORSEMIDE 40MG DAILY
PREDNISONE 20MG
Warfarin 2.5 daily
HELD MEDICATIONS
=================
NONE
Code Status: Full confirmed
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H
2. Alendronate Sodium 70 mg PO QFRI
3. Atorvastatin 40 mg PO QPM
4. Vitamin D ___ UNIT PO 1X/WEEK (FR)
___ MD to order daily dose PO DAILY16
6. PredniSONE 5 mg PO DAILY
7. Atenolol 25 mg PO BID
8. Potassium Chloride 40 mEq PO DAILY
9. Lisinopril 20 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. Methotrexate 25 mg PO 1X/WEEK (FR)
Discharge Medications:
1. HYDROmorphone (Dilaudid) 0.5 mg PO Q6H:PRN Pain - Severe
RX *hydromorphone 2 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*10 Tablet Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. Metoprolol Succinate XL 50 mg PO QHS
5. Omeprazole 40 mg PO DAILY
6. Torsemide 40 mg PO DAILY
7. Acetaminophen 1000 mg PO TID
8. Methotrexate 12.5 mg PO QFRI
9. PredniSONE 20 mg PO DAILY
10. Warfarin 2.5 mg PO DAILY16
11. Alendronate Sodium 70 mg PO QFRI
12. Atorvastatin 40 mg PO QPM
13. Lisinopril 20 mg PO DAILY
14. Vitamin D ___ UNIT PO 1X/WEEK (FR)
15.Outpatient Lab Work
Please check CBC/diff, chem 10, LFTs, CRP/ESR on ___ and fax
results to Dr. ___ attention at ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
RA flare
Right hip pain
SECONDARY DIAGNOSIS
====================
Acute on Chronic Heart failure with reduced ejection fraction
Severe aortic stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Am,bulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You came to the hospital because you had pain in your hip. You
were also found to have extra fluid in your legs and body
because of your heart failure.
WHAT HAPPENED IN THE HOSPITAL?
- You were given medications to reduce swelling in your hip and
hands and to help with your pain. You were also given
medications to help remove extra fluid from your body and help
reduce your leg swelling. You received an MRI to look at your
hip and an echocardiogram to look at your heart.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
- Your dry weight is 129 pounds (this is a bed weight). Weigh
yourself every morning, call your doctor if your weight goes up
more than 3 lbs.
- You should take all of your other medications as prescribed.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19872263-DS-10
| 19,872,263 | 28,164,009 |
DS
| 10 |
2195-06-08 00:00:00
|
2195-06-08 10:11:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PSYCHIATRY
Allergies:
___
Attending: ___.
Chief Complaint:
"I've been depressed"
Major Surgical or Invasive Procedure:
10 ECT treatments
History of Present Illness:
From Dr. ___ ED ___ ___:
Pt is a ___ y.o. man with a hx of ___ with multiple psychiatric
hospitalizations (last 1 month ago) who self-presents with c/o
worsening depression and increasing suicidality. Please see Dr.
___ from ___ for additional details.
Patient reports that he was stable on lithium for ___ years,
but that lithium was discontinued in ___ due to kidney injury,
at which time he was swithced to lamotrigine. This was followed
by a manic episode, resulting in two psychiatric
hospitalizations, a restraining order against his brother, and a
request from the chiropractic board that his license be
suspended. Since ___, he has been increasingly depressed
with depressive sx including low mood, decreased energy,
decreased concentration, decreased appetite,
hopelessness/helplessness, anhedonia, cognitive slowing, and
decreased self-care. He reports that over the course of the
last week, he has been increasingly suicidal, with thoughts of
driving his car into traffic, jumping off of his girlfriend's
balcony, or overdosing on his medications. He denies any recent
suicidal
gestures but reports that as he was driving this morning, he
became acutely worried that he would act on the suicidal
ideations. He remains acutely hopeless, believes that even if
he is treated with ECT his life circumstances would warrant such
treatment pointless. He endorses feeling restless and pacing
throughout the day.
On psychiatric review of symptoms, he denies current sx of
mania; denies AVH, thought insertion/broadcasting/withdrawal,
and IOR; denies recent panic attacks. He reports that he has
been
adherent with his medication in the last ___ weeks and has not
been using substances over that time period either.
With the patient's permission, I spoke to his outpatient
psychiatrist, ___ (___) who confirmed the
history as above. Patient was treated with both risperidone and
olanzapine over the course of recent hospitalizations. He has
been concerned about the patient's safety though noted that he
has not been acutely suicidal prior to today. We discussed
inpatient hospitalization, with which he agreed, specifying the
advantages of hospitalization at a facility that could do ECT.
Past Medical History:
Past psychiatric history:
Per Dr. ___.
Hospitalizations: multiple, most recently ___ approximately
one month ago
Current treaters and treatment: Dr. ___
___ pt also sees an individual therapist
Medication and ECT trials: as per HPI, two recent tx with ECT
(one session each)
Self-injury: denies
Harm to others: denies
Access to weapons: denies
Past medical history:
- Afib/aflutter
- stage III CKD (lithium-induced), right total hip replacement,
osteoarthritis, left Achilles tendinitis, shin splints, bipolar
disorder, depression, retinal tearSUBSTANCE ABUSE HISTORY:
- denies EtOH, tobacco, other illicits
- per OMR, patient had been smoking marijuana daily for some
period of time prior to ___
Substance use history:
Denies ETOH/cocaine/heroin. MJ in the past.
Social History:
___
Family History:
- mother with ___, received ECT twice with benefit
- denies hx of attempted/completed suicides
Physical Exam:
From Dr. ___ Note, ___
Vital signs: HR 80, BP 159/98, O2 98% on RA, Temp 97.4, RR 16
General- In hospital gown, nad
Skin- no rashes
HEENT- MMM
Neck and Back- full rom
Lungs- CTAB
CV- NMRG S1 s2
Extremities- wwp, no edema
Neuro-
Cranial Nerves- II-XII intact
Motor: strength full throughout, nl tone, no cogwheeling
*Deep tendon Reflexes: 1+ symmetric uppers/lowers
Sensation: grossly intact
Coordination:
Finger-nose-finger : no dysmmetria
Gait/Romberg: nl / negative
Neuropsychiatric Examination:
*Appearance: In hospital gown, nad, well groomed
Behavior: answers questions
*Mood and Affect: "Depressed" extremely flat, restricted range
*Thought process: linear
*Thought Content: SI this am denies currentlty. Negative for
HI.
*Judgment and Insight: Poor/poor
Cognition:
*Attention, *orientation, and executive function: AOX3
___ reg ___ Prompt ___ m/c
*Fund of knowledge: presidents to ___
Calculations: 9 q = 2.25
Abstraction: intact
*Speech: nl rate, flat tone
*Language: fluent w/o paraphasic errors.
Pertinent Results:
___ 01:55PM BLOOD Plt ___
___ 12:00PM BLOOD Plt ___
___ 11:00AM BLOOD Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:40AM BLOOD Plt ___
___ 03:45AM BLOOD Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:25AM BLOOD Plt ___
___ 01:55PM BLOOD WBC-5.8 RBC-4.37* Hgb-14.1 Hct-39.5*
MCV-90# MCH-32.3* MCHC-35.8* RDW-13.0 Plt ___
___ 11:00AM BLOOD WBC-9.0# RBC-4.55* Hgb-14.5 Hct-41.0
MCV-90 MCH-31.9 MCHC-35.4* RDW-12.9 Plt ___
___ 07:20AM BLOOD WBC-10.0 RBC-4.17* Hgb-13.3* Hct-37.2*
MCV-89 MCH-31.9 MCHC-35.7* RDW-12.8 Plt ___
___ 07:40AM BLOOD WBC-7.5 RBC-4.12* Hgb-13.5* Hct-36.6*
MCV-89 MCH-32.7* MCHC-36.9* RDW-12.6 Plt ___
___ 03:45AM BLOOD WBC-5.3 RBC-3.99* Hgb-12.6* Hct-35.3*
MCV-89 MCH-31.5 MCHC-35.6* RDW-12.7 Plt ___
___ 01:55PM BLOOD Glucose-124* UreaN-22* Creat-1.7* Na-139
K-3.9 Cl-104 HCO3-29 AnGap-10
___ 06:00AM BLOOD Glucose-91 Creat-1.7* Na-140 K-3.9 Cl-104
HCO3-30 AnGap-10
___ 06:02AM BLOOD Glucose-90 UreaN-14 Creat-1.5* Na-143
K-4.1 Cl-108 HCO3-28 AnGap-11
___ 12:00PM BLOOD Glucose-144* UreaN-20 Creat-1.5* Na-143
K-3.9 Cl-105 HCO3-27 AnGap-15
___ 11:00AM BLOOD Glucose-131* UreaN-20 Creat-1.5* Na-140
K-4.2 Cl-101 HCO3-27 AnGap-16
___ 06:02AM BLOOD ALT-41* AST-24 LD(LDH)-186 AlkPhos-73
TotBili-0.9
___ 11:00AM BLOOD ALT-12 AST-16 AlkPhos-98 TotBili-1.8*
___ 07:20AM BLOOD ALT-13 AST-15 AlkPhos-87 TotBili-1.3
DirBili-0.3 IndBili-1.0
___ 04:22PM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.4
___ 06:02AM BLOOD Albumin-3.8 UricAcd-5.6
___ 04:49AM BLOOD Albumin-3.9
___ 12:00PM BLOOD Calcium-9.7 Phos-3.5 Mg-2.0
___ 11:00AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.0
___ 07:20AM BLOOD Ammonia-6*
___ 01:55PM BLOOD TSH-0.28
___ 07:20AM BLOOD TSH-0.50
___ 06:02AM BLOOD PTH-65
___ 12:00PM BLOOD PTH-47
___ 07:20AM BLOOD T4-8.0
___ 04:49AM BLOOD Cortsol-12.0 Testost-398 SHBG-36
calcFT-80 25VitD-23*
___ 12:00PM BLOOD 25VitD-28*
___ 01:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Legal: ___
Psychiatric: Patient noted to be significantly depressed with
prominent paranoid/psychotic symptoms on admission. Patient was
notably catastrophizing and feeling hopeless. His safety was
originally concerning within unit and he was placed on 5 min
checks for 2 days when he was seen frequently pacing,
ruminative, psychotic, and agitated. After, his degree of
agitation improved and patient stated that he did not feel safe
out of the unit but noted he felt safe inside of the unit and
was changed to 15 minute checks. He remained cooperative and
safe on the unit for the duration of his hospitalization.
Given cardiac concerns, constipation, and possible underlying
mixed episode, nortryptiline was discontinued soon after
admission. Patient was placed on Zyprexa which was titrated to
15mg for psychotic symptoms. Anesthesia and medicine cleared
patient for ECT. He missed his first trial because patient
claimed to have drank "sips" of water prior to ECT. On interview
of staff in unit, there was no evidence this occurred but ECT
had to be cancelled per protocol. This was felt to be as a form
of self-sabotage given patient's hopelessness. Patient was
placed on CO 12 hours prior to ECT and had first treatment on
___. The patient subsequently had 2 treatments prior to
being noted to have severe constipation with ileus believed to
be secondary to Zyprexa. Because of air-fluid levels in the
small intestine noted on a KUB, ECT was postponed for just over
1 week while the patients bowel regimen was increased with the
addition of suppositories twice daily, GI was consulted for
assistance, and Zyprexa was held. With these interventions, the
patient's constipation resolved and the patient was able to
resume ECT as of ___.
The patient had 4 additional ECT treatments with minimal
improvement in his depressive symptoms. On ___ he was
started on Risperdal 1mg BID as he started his ___ overall ECT
treatment but the first that was bilateral. His Risperdal dose
was increased to 3mg qhs and with additional bilateral ECT
treatments he showed worsening psychomotor retardation and
severe speech latency. Given his resistance to treatment so far
he was started on Venlafaxine 75mg on ___ which was increased
to 150mg the following day. However on ___ he displayed poor
short term memory such as the inability to recall his
girlfriends name and ECT was cancelled prior to his ___ overall
treatment. He was changed from Venlafaxine to Cymbalta 60mg
daily for maximal noradrenergic dosing and was uptitrated to
90mg daily. To protect against mania Depakote 1500mg daily was
added to his regimen and Risperdal was decreased to 2mg nightly.
The patient continued to display cognitive and physical slowing
so on ___ his Risperdal was tapered to 1mg and then
discontinued on ___ to evaluate for whether or not EPS was a
contributor to his degree of cognitive slowing and flattness.
Abilify was started to protect against mania with hope it would
have less of a sedating effect on the patient. His initial dose
was 5mg which was slowly increased to 20mg with good
tolerability. On ___ the patient displayed lethargy and poor
sleep, unsteady gait, worsening nausea and a workup revealed
steadily decreasing platelet count. His Depakote was held and
his platelets were trended which rebounded back to within normal
limits. He was also started on Ativan 1mg qhs for sleep. After
depakote was discontinued due to concern for intolerability, and
he was continued on cymbalta, Abilify and Ativan, the patient
began to show an increase in his energy level, mood, and social
interactions with other patients and staff as well as decrease
in his latency and PMR. He continued to report interrupted sleep
though. On ___ the patient continued to show improvement
except for poor sleep secondary to vivid nightmares. His
Cymbalta was decreased to 60mg. He was also changed from Ativan
to Klonopin and this was increased to 1.5mg QHS. On this
regimen the patient had improved sleep and was functioning at a
level near his baseline. At time of discharge he did not
demonstrate any signs of psychosis or mania. He was able to
reflect on his past depression and suicidal thoughts and it
remained clear that his suicidality had resolved and he was
easily future oriented and free of suicidal thinking. He was
able to develop a safety plan and was motivated to continue in a
partial hospital program after discharge.
Medical:
Constipation: During the course of the hospitalization, the
patient also noted several weeks of constipation, which he
reported having struggled with in the past. An extensive bowel
regimen was introduced including MOM, senna, docusate, Magnesium
citate and fleet enema, which was initially unsuccessful in
resolving constipation. A supine and erect abdominal X-ray was
done which revealed a large amount of fecal loading in the
descending colon, sigmoid and rectum, likely resulting in
functional obstruction as evidenced by air-fluid levels in the
cecum, ascending colon, and small bowel. The situation was
discussed with anesthesia who recommended holding ECT
temporarily due to risk of aspiration. A GI consult was
performed and recommended Moviprep 1L with dulcolax every other
day until a bowel movement occurs, Senna QHS, and Miralax
BID-TID until bowl movements are regular, then daily thereafter.
The patient's Zyprexa was held, as this was felt to be likely
secondary to ileus as a result of Zyprexa. With this
intervention, the patient had improvement in his constipation
and was able to resume ECT. Although the patient's constipation
improved, he noted it was not "normal" as he required
suppositories every other day in order to have bowel movements
in addition to his oral meds. An outpatient appointment was
scheduled with GI for defecography, anorectal manometry, and
consideration of anorectal ___.
Atrial Fibrillation/Flutter: Prior to beginning ECT, the
patient was cleared by anesthesia and medicine. He was evaluated
for baseline atrial fibrillation. Medicine recommended
continuing outpatient treatment (ASA 162mg daily). On ___
after his ECT treatment the patient went into Afib/flutter, was
asymptomatic and hemodynamically stable with HR in the ___ and
BP in the 120-130/70s. A cardiology consult was called and by
the time he was evaluated that afternoon he had spontaneously
converted back to sinus rhythm. They recommended EKGs after
each ECT treatment as well as starting Rivaroxaban 20mg daily
for stroke prevention. Additionally, If the patient continued
to remain in sinus rhythm after ECT had stopped he could be
taken off Rivaroxaban. On ___ and EKG revealed normal sinus
rhythm and the patient was without chest pain and palpitations
and his anti-coagulant was stopped. He was continued on aspirin
at his home dose
Thrombocytopenia: On ___ the patients platelet count was 144
which was decreased from multiple readings of 161 which were
prior to his starting Depakote. His Depakote dose was held and
over the next two days his level dropped to 129 and then to 120.
On ___ it began to rise and over the next 3 days was back
within normal limits at 156. At no time did the patient endorse
or show any abnormal bruising or bleeding. Hematology/oncology
and medicine were consulted and thought no further work up was
required and the thrombocytopenia was attributed to the
depakote, which he is no longer taking at this time
Chronic Kidney Disease: On ___ a renal consult was called to
explore re-starting the patient on Lithium as he had decades of
success on the medication and was showing minimal improvement at
this point during his hospitalization. They felt he could
safely re-start Lithium at lower doses and with close outpatient
monitoring would be with p[reserved kidney function for many
years. The patient thought about this over the course of a week
and ultimately decided against it as he fears dialysis in the
future.
Family/Collateral: Team was in contact with patient's outpatient
psychiatrist, Dr. ___, ___ therapist, ___, on
a weekly basis. Team was also in contact with patient's
girlfriend, ___, every several ___ was a big support
to the patient over the course of his hospitalization. Assisting
him in his move from his old office and taking care of his
affairs outside of the hospital. She agreed with the discharge
plan and will be staying with him the evening after discharge
and taking him to the day program the next day to assist with
the transition from the hospital.
Groups/Milieu: Patient was originally not partaking in groups or
interacting with other patients, though he was increasingly able
to attend and engage in group activities as the hospital course
progressed. Early in the admission, he was notably pacing
hallways during day, though this also improved over the course
of his admission. By the time of discharge, the patient was
participating well in groups, was brigther, and appropriately
social.
Risk Assessment: Patient is at a chronically elevated suicide
safety risk given his age, gender, race, treatment-refractory
bipolar depression with prominent psychotic symptoms in the
setting of hopelessness and major narcissistic injuries
(particularly, the loss of his ___ practice and
license). However, at time of discharge patient is no longer at
an acutely elevated risk from baseline as he has improved mood,
sleep, energy and is without any latency, psychomotor agitation,
psychotic symptoms, SI and HI. He has organized, future
orientated thinking and has expressed both short term and long
term goals. He has a support structure around him including his
girlfriend and outpatient providers with whom he has good
relationship. He has good insight to early warning signs of
mania and depression and knows who to reach for help. He is
medication compliant and n longer requires an inpatient level of
care. At this time the patient is fit for discharge home with a
partial program in place and ongoing mental health care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nortriptyline 25 mg PO BID
2. OLANZapine 10 mg PO HS
Discharge Medications:
1. Aripiprazole 20 mg PO DAILY
RX *aripiprazole [Abilify] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1
2. Duloxetine 60 mg PO QAM
RX *duloxetine [Cymbalta] 60 mg 1 capsule,delayed
___ by mouth daily Disp #*30 Capsule Refills:*1
3. ClonazePAM 1.5 mg PO QHS
RX *clonazepam 0.5 mg 3 tablet(s) by mouth at bedtime Disp #*60
Tablet Refills:*1
4. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*1
5. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 pakcet by mouth
twice a day Disp #*60 Packet Refills:*1
6. Bisacodyl ___ID:PRN constipation
RX *bisacodyl 10 mg 1 Suppository(s) rectally daily Disp #*30
Suppository Refills:*1
7. Aspirin 325 mg PO DAILY
8. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
I - Bipolar Disorder - depressive epsiode
II- Deferred
III - Constipation, Afib/aflutter, CKD
IV - Family conflict, unemployment, lack of social supports
V - 50
Discharge Condition:
*Appearance: Tall, Caucasian male wearing pants and sweater,
good grooming, freshly shaved
Behavior: Cooperative, appropriate, moderate PMR but improved,
mild latency that is improving daily, smiling at times
*Mood and Affect: 'Good,' Euthymic
*Thought process: Linear, goal oriented, no LOA
*Thought Content: no current SI/HI/AH/VH, focused on discharge
and transition home and to partial
*Judgment and Insight: Fair/Good
Cognition:
*Attention, *orientation, and executive function: attentive
to conversation
*Memory: Long term memory intact, short term memory intact
*Fund of knowledge: Appropriate
*Speech: Monotone, normal rate, normal volume
*Language: Fluent, no dysarthria
Ambulatory status: No limitations
Discharge Instructions:
-Please follow up with all outpatient appointments as listed -
take this discharge paperwork to your appointments.
-Please continue all medications as directed.
-Please avoid abusing alcohol and any drugs--whether
prescription drugs or illegal drugs--as this can further worsen
your medical and psychiatric illnesses.
-Please contact your outpatient psychiatrist or other providers
if you have any concerns.
-Please call ___ or go to your nearest emergency room if you
feel unsafe in any way and are unable to immediately reach your
health care providers.
-It was a pleasure to have worked with you, and we wish you the
best of health.
Followup Instructions:
___
|
19872265-DS-22
| 19,872,265 | 27,756,047 |
DS
| 22 |
2127-06-27 00:00:00
|
2127-06-30 12:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope, hypotension
Major Surgical or Invasive Procedure:
___ EGD
History of Present Illness:
Mr. ___ is a ___ male with history of CAD and recent
STEMI (s/p DES to OM ___, new iCMY/HFrEF (LVEF 30%)
presenting for rapid heart rate.
Patient reports that he has a visiting nurse coming to see him
at home by a few weeks ago. Patient denies any symptoms. Nursing
noted that his heart rate was around 100 but increased to 110s
upon moving or standing up. Called his cardiologist who
recommended he come into the ED for evaluation. Patient denying
any shortness of breath, chest pain, fevers, chills, cough.
In the ED:
VS: Tmax 99.1, P ___, BP 130/80, RR 16, 98% on RA
PE: Guaiac negative brown stool.
Labs: Hgb 9.5 (12.5 in ___), lactate 2.8, Cr 1.9
Imaging: CT A/P without e/v bleeding
Impression: Patient presenting with tachycardia, hypotension and
new anemia. Guaiac negative stool. Admit for further evaluation
Interventions: 1L NS, given home Ticagrelol
Consults: none
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
#Recent STEMI w ___
#HFrEF (iCMY LVEF ___
#Arthritis
#L eye blindness (traumatic, remote)
Social History:
___
Family History:
Brother with MI at age ___, other brother with CAD and stents x2
age ___
Physical Exam:
ADMISSION PHYSICAL:
========================
VITALS: Temp: 98.5 PO BP: 114/61 HR: 102 RR: 20 O2 sat: 96% O2
delivery: Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
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
DISCHARGE PHYSICAL:
========================
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, no conjunctival injection, left eye corneal
opacity
CV: Heart regular, no murmur, no S3, no S4.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-tender in all quadrants, non-distended.
No
rebound or guarding.
EXT: Warm and well perfused. No ___ edema.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, 4+/5 bilateral hip flexion, ___
bilateral ankle flexion, ___ upper
extremity
strength, no pronator drift, able to do finger to nose with eyes
closed. Bilateral foot drop. Sensation intact in lower
extremities.
PSYCH: pleasant, appropriate mood and affect
Pertinent Results:
ADMISSION LABS:
===================
___ 10:40AM BLOOD WBC-10.3* RBC-3.23* Hgb-9.9* Hct-28.7*
MCV-89 MCH-30.7 MCHC-34.5 RDW-17.2* RDWSD-54.9* Plt ___
___ 10:40AM BLOOD Neuts-75.5* Lymphs-9.8* Monos-8.6 Eos-3.7
Baso-0.8 Im ___ AbsNeut-7.78* AbsLymp-1.01* AbsMono-0.89*
AbsEos-0.38 AbsBaso-0.08
___ 04:02PM BLOOD Hypochr-NORMAL Anisocy-1+* Poiklo-NORMAL
Macrocy-1+* Microcy-NORMAL Polychr-NORMAL
___ 10:40AM BLOOD ___ PTT-29.6 ___
___ 04:02PM BLOOD Ret Aut-5.1* Abs Ret-0.16*
___ 10:40AM BLOOD Glucose-179* UreaN-34* Creat-1.8* Na-136
K-5.3* Cl-96 HCO3-21* AnGap-19*
___ 10:40AM BLOOD ALT-81* AST-140* LD(LDH)-825*
CK(CPK)-825* AlkPhos-272* TotBili-2.1*
___ 10:40AM BLOOD Lipase-147*
___ 10:40AM BLOOD cTropnT-0.28*
___ 05:30PM BLOOD CK-MB-7 cTropnT-0.24*
___ 12:08AM BLOOD proBNP-3314*
___ 10:40AM BLOOD Albumin-3.5 Iron-120
___ 10:40AM BLOOD calTIBC-257* Hapto-23* Ferritn-5213*
TRF-198*
MICROBIOLOGY:
===================
STUDIES:
===================
___ CT ABD/PELVIS W/O CONTRAST
IMPRESSION:
1. No acute intra-abdominal process. No evidence of
retroperitoneal hematoma.
___ RUQ U/S
IMPRESSION:
1. No biliary dilatation. Normal gallbladder.
2. Mild splenomegaly.
___ CXR
IMPRESSION:
Low lung volumes with minimal patchy retrocardiac opacity,
likely atelectasis. Please note that early infection, however,
is not excluded in the correct clinical setting.
___ EGD
Findings:
Esophagus:Normal esophagus.
Stomach:Normal stomach.
Duodenum:Normal duodenum.
Recommendations:
No evidence of bleeding
Consider other sources of anemia
Needs outpatient screening colonoscopy
DISCHARGE LABS:
===================
___ 05:57AM BLOOD WBC-8.8 RBC-2.87* Hgb-8.8* Hct-26.0*
MCV-91 MCH-30.7 MCHC-33.8 RDW-17.7* RDWSD-58.7* Plt ___
___ 05:43AM BLOOD Glucose-156* UreaN-23* Na-140 K-4.4
Cl-101 HCO3-24 AnGap-15
___ 05:57AM BLOOD ALT-57* AST-49* LD(LDH)-321* CK(CPK)-244
AlkPhos-233* TotBili-1.4
___ 05:43AM BLOOD TotProt-5.4*
___ 05:43AM BLOOD ___ CRP-43.1*
Brief Hospital Course:
Mr. ___ is a ___ male with history of CAD and recent
STEMI (s/p DES to OM ___, new iCMY/HFrEF (LVEF
30%)presenting with tachycardia and found to have profound
bilateral lower extremity weakness, lab abnormalities, and
hemolytic anemia with Hgb 9.4 down from 12.5.
ACUTE/ACTIVE PROBLEMS:
#Warm Auto-immune Hemolytic anemia
Low haptoglobin. Coombs positive (IgG+). Spherocytes on
peripheral smear. Unclear whether there is a precipitating
cause,
though it is suspicious that it is occurring in the setting of
so
many other lab abnormalities (as below). Now stablizlied around
hemoglobin of 9. Hematology initially considered prednisone but
deferred ultimately given stabilization. Hematology will reach
out to patient to setup outpatient follow-up appointment.
Torsemide was held on admission which has a sulfa-moiety. There
is a small possibility this was the precipitating factor in his
hemolytic anemia therefore if patient requires diuresis upon
discharge would either use ethacrynic acid or monitor counts
with resumption of Torsemide.
-Discharge Weight 85kg (dry weight).
-Either resume diuresis with ethaycrynic acid or monitor for
recurrent hemolytic anemia if using sulfa-based loop diuretic
-Will need cardiology f/u
-Hematology f/u (they will call patient)
#Bilateral Lower Leg Weakness
#Polyradiculopathy
#Falls/unsteady gait
#Concern for Myelopathy/myositis
Neurology and neurosurgery both consulted per neurology
assessment
Neurological examination revealed diffuse, distally-predominant
lower extremity weakness, decreased reflexes except at the left
patella, and pan-modal sensory deficits in the distal lower
extremities. MRI of the spine demonstrated multi-level
degenerative disc disease associated with severe canal and
foraminal stenosis in the lumbar spine. Serum studies have been
notable for hematological abnormalities, elevated inflammatory
markers, and elevated CK and LFTs that are tending toward
normal.
The degenerative changes in the lumbosacral spine could
certainly
be playing a prominent role in the lower extremity weakness. The
quickly and spontaneously normalizing CKs (even while on a
statin) seem to point away from a primary muscle process (e.g.
inclusion body myositis).
NEUROLOGY RECOMMENDATIONS:
- follow clinically
- nerve conduction studies/electromyography could be helpful,
and
may be done on an outpatient basis (will be arranged by
neurology)
- obtain bilateral ankle-foot orthotics
- fall precautions
- rehab
- Neurosurgery consulted recommended lumbar decompression
previously recommended at ___, is quite certain he does
not want surgical intervention at this time. Surgical planning
further complicated by DAPT post DES recently.
#LFT elevation
#Concern for Myelopathy
#Elevated CK- Improving without intervention save for change
from Atorvastatin to rousavstatin. ___ be secondary to
hemolysis.Perhaps acute viral illness or resolving rhabdo vs.
resolving myositis. CK and LFTs were normalizing on discharge.
-Patient offered lumbar decompression but he does not feel
surgery is within his goals of care at this time
- Send labs for polyradiculopathy w/u: B12, Lyme serologye
(negative), ___ (pending)
TSH, SPEP/UPEP (negative), RPR (negative), HIV (negative), A1c
(6.4), Hepatitis serologies (negative or immune)
- EMG/NCS - neurology will arrange outpatient study
#Elevated Transaminases
Unclear etiology. Improving. No obvious abnormalities on RUQUS
or
CT abd/pelvis. Possibly statin-induced. Of note, hemolysis
falsely elevates AST, ALT, CK. Improving today.
-Trend LFTs
-Switch atorvastatin 80 mg to rosuvastatin 20 mg
-F/U hepatitis serologies
-obtain CK-MB fraction (add on)
#Acute kidney failure
Improved with IVF in the ED, so likely a pre-renal component.
True baseline is not clear at this point. Improved.
-Trend Cr
-Held torsemide 30mg daily on discharge (discharge Cre 1.4)
-Encourage good PO intake with gentle IVF boluses as needed
#Concern for GI bleed
Anemia likely entirely explained by hemolysis. EGD without
evidence of bleeding. Patient needs outpatient colonoscopy
(never
had colonoscopy before), which has been scheduled for ___ at
1pm per GI team.
CHRONIC/STABLE PROBLEMS:
#CAD s/p recent STEMI with PCI
#sCHF (EF 26%)
Troponin and BNP both less than previous baselines. No concern
for active ischemia or decompensated heart failure at this time.
-Resume metoprolol XL on discharge
-Continue ASA, ticagrelor
-Rosuvastatin as above
-Hold Torsemide patient euvolemic on discharge but as risk for
volume overload (prior dose was Torsemide 30mg daily)
-Will need cardiology f/u
-Discharge dry weight is 85kg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Lisinopril 2.5 mg PO DAILY
4. Metoprolol Succinate XL 200 mg PO BID
5. TiCAGRELOR 90 mg PO BID
6. Torsemide 40 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Rosuvastatin Calcium 20 mg PO QPM
3. Aspirin 81 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
5. Metoprolol Succinate XL 200 mg PO BID
6. TiCAGRELOR 90 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Warm Auto immune hemolytic anemia
-Polyradiulopathy
-Lumbar and cervical degenerative disk disease
-HFrEF
-s/p STEMI
-CAD
Discharge Condition:
Fair
Alert and Oriented x 3
Amubulatory with walker
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with weakness, low blood
counts, and falls. We found you to have an auto-immune anemia
that recovered on its own. It is possible that your torsemide
played a role in causing the reaction but it is unclear. I have
stopped your torsemide on discharge. We also had neurology and
neurosurgery evaluate your leg weakness. They felt this is
likely from known lumbar degenerative disease but there are
other rarer possibilities still on the table. They would like to
see you in neurology clinic. When you leave the hospital you
should see neurology, cardiology, primary care, and neurosurgery
should you want to reconsider surgery on your spine to
potentially help with mobility.
It was a pleasure taking care of you,
___
Followup Instructions:
___
|
19872420-DS-14
| 19,872,420 | 28,072,410 |
DS
| 14 |
2138-04-12 00:00:00
|
2138-04-12 14:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zyrtec / Bactrim / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ gentleman with ___ notable for prior
SBO ___ inflammatory (?NSAID-related) jejunal-ileal stricture,
depression, and gout, presenting with abdominal pain.
As previously documented, the patient has a had a long history
of SBO ___ jejunal-ileal stricture (as detailed below in ___).
His most recent admission was in ___ for SBO and has been
doing well since then. Over the past 3 weeks or so, he started a
dieting program with weight watchers with consultation from his
GI provider. On day of presentation, he woke up around 2am with
sudden onset abdominal discomfort. He describes it as episodic,
pressure-like pains throughout his abdomen occurring for a few
minutes every 5 minutes or so. He felt fine in between episodes
and attempted to wait to see if it would pass. This was similar
to pain during prior episodes of SBO. He was able to have a
small amount of water and ice but has not really had much more
PO intake. He has intermittent nausea without any emesis and
really has not had much emesis throughout his past episodes of
SBO.
Over the next few hours, he began to feel a "rolling" sensation
over his abdomen consistent with worsening of SBO during prior
episodes and called his outpatient GI doctor, who recommended
presentation to the ED for further management.
Of note, the patient has had increased intake of fiber in the
form of whole wheat pasta as part of his weight watcher's diet.
He otherwise denies any recent fever, although does have chills
and diaphoresis during episodes of his abdominal discomfort. He
is still passing gas and was able to make a BM on morning of
presentation. He denies any chest pain/pressure, SOB, dysuria,
urinary frequency, increased ___ swelling, melena, hematochezia,
or other complaints. He states that he has been off of any
NSAIDs, apart from 1 pill he accidentally took, since his SBO
issues began.
In the ED, initial VS were:
-97.4 84 143/91 16 100% RA
Exam notable for:
-Abd: Soft. Nondistended. Nontender to palpation. Normoactive
bowel sounds.
Labs showed:
- Normal CBC
- Normal Chem10
- Normal LFTs
- U/A notable just for trace protein and blood with 5 RBCs and 1
WBC; 0 epis
- Urine culture drawn, pending
Imaging showed:
-CT Abd/Pelvis with contrast showing: "Small-bowel obstruction
with transition point in the proximal ileum in the right lower
quadrant, similar to the prior exam. There is an approximately
25 cm long segment of small bowel wall proximal to the
transition point as well an approximately 10 cm segment of small
bowel distal to the transition point that demonstrates bowel
wall and mesenteric edema with mucosal hyperemia and adjacent
stranding suggestive of inflammation. However, bowel ischemia
cannot be excluded. Surgical consultation is advised."
Consults:
-Surgery was consulted, recommending no surgical intervention,
with highest suspicion for SBO related to known inflammatory
strictures and admission to medicine with GI consultation.
Patient received:
-Morphine 2mg IV x5
-NS x1L
-D51/NS @100cc/hr
Decision was made not to place NGT as patient was passing gas,
without significant nausea or emesis and has historically not
required NGT for prior episodes of SBO.
On arrival to the floor, patient reports worsening nausea and
desire to have NGT placed. He denies any active abdominal pain
and states that the morphine has been helping. He does feel
thirsty and would like some water. Endorses the above history.
Past Medical History:
-Recurrent SBO's ___ inflammatory stricture (felt to be ___
NSAID use; s/p diagnostic ex-lap ___ without remarkable
findings; capsule endoscopy in ___ showing gastric and
duodenal erosions; circumferential ulceration in mid-jejunum
with luminal narrowing with inability to capsule to pass
strictured area; anterograde and retrograde small bowel
enteroscopy in ___, followed by GI at ___
-Pre-exposure prophylaxis use (for HIV)
-Depression
-Gout
-s/p left ureteroscopy with lithotrypsy
Social History:
___
Family History:
No history of cancer and positive history of IBD in 2 nieces
(thinks IBD runs through their father/his brother-in-law's
family).
Physical Exam:
==============================
ADMISSION PHYSICAL EXAMINATION
==============================
VS: 119/69 77 18 98 RA
GENERAL: NAD, sitting up in bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, symmetric
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, crackles, rhonchi, breathing
comfortably without use of accessory muscles
ABDOMEN: soft, ND, NTTP, no r/g, BS+
EXTREMITIES: WWP, no pitting edema in b/l ___
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, strength ___ in b/l shoulder shrug, UE; able to
lift both legs up against downward pressure; sensation to light
touch grossly intact and symmetric along bilateral UE, torso,
and ___ symmetric smile, eyebrow raise and midline tongue on
protrusion
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
==============================
DISCHARGE PHYSICAL EXAMINATION
==============================
T:98.4 BP:131/85 HR:66 RR:18 SaO2:99 Ra
GENERAL: Well appearing man sitting on the side of my bed,
speaking to me in no apparent distress
HEENT: Pupils equal, no scleral icterus or injection. Moist
mucous membranes.
HEART: S1/S2 regular with no murmurs, rubs or S3/S4
LUNGS: Clear to auscultation bilaterally. No use of accessory
muscles or evidence of respiratory distress.
ABDOMEN: Abdomen is soft and non-distended. Non-tender even to
deep palpation. Normoactive bowel sounds.
EXTREMITIES: Warm extremities with no lower extremity edema.
NEURO: A&Ox3, grossly normal, walking the floor
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 12:02PM WBC-8.2 RBC-5.75 HGB-16.2 HCT-48.2 MCV-84
MCH-28.2 MCHC-33.6 RDW-12.9 RDWSD-39.2
___ 12:02PM ALBUMIN-4.7
___ 12:02PM LIPASE-32
___ 12:02PM ALT(SGPT)-15 AST(SGOT)-20 ALK PHOS-61 TOT
BILI-0.4
___ 12:02PM GLUCOSE-93 UREA N-14 CREAT-0.8 SODIUM-139
POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-26 ANION GAP-12
___ 12:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
==========================================
DISCHARGE AND PERTINENT LABORATORY STUDIES
==========================================
___ 06:14AM BLOOD WBC-3.4* RBC-4.90 Hgb-13.9 Hct-41.2
MCV-84 MCH-28.4 MCHC-33.7 RDW-12.7 RDWSD-38.6 Plt ___
___ 06:14AM BLOOD Glucose-89 UreaN-8 Creat-0.8 Na-144 K-4.2
Cl-105 HCO3-28 AnGap-11
___ 06:14AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1
===========================
REPORTS AND IMAGING STUDIES
===========================
___ CT ABDOMEN AND PELVIS WITH CONTRAST
IMPRESSION:
Small-bowel obstruction with transition point in the proximal
ileum in the right lower quadrant, similar to the prior exam.
There is an approximately 25 cm long segment of small bowel wall
proximal to the transition point as well an approximately 10 cm
segment of small bowel distal to the transition point that
demonstrates bowel wall and mesenteric edema with mucosal
hyperemia and adjacent stranding suggestive of inflammation.
However, bowel ischemia cannot be excluded. Surgical
consultation is advised.
------------
___ CXR
------------
Lungs are well expanded with subsegmental atelectasis in the
right lung base. Heart size is normal. The NG tube projects
over the stomach. There is no pleural effusion. No
pneumothorax
is seen
============
MICROBIOLOGY
============
___ Urine Culture = Negative
Brief Hospital Course:
=================
SUMMARY STATEMENT
=================
Mr. ___ is a ___ year old man with a mast medical history
significant for recurrent small bowel obstruction thought to be
secondary to inflammatory or NSAID-related strictures who was
admitted for a recurrent small bowel obstruction and
conservatively managed without surgical or procedural
intervention.
====================
ACUTE MEDICAL ISSUES
====================
#Small bowel obstruction:
The patient presents with symptomatology consistent with prior
SBO's without any acute nausea, vomiting, or surgical needs
given abdominal exam and passage of gas. The patient recently
had a change in diet due to initiation of a weight watcher's
regimen that included a meal of whole wheat pasta, ___ hours
after which his symptoms began. He described a rolling abdominal
pain classic for his prior small bowel obstructions. He did not
have any infectious, mingestion-related, or procedure-related
exposures.
Surgery was consulted and did not feel there was any indication
for surgical intervention. GI consulted, and no indication for
advanced endoscopic procedure at this time. At some point, he
may be a candidate for a repeat advanced endoscopy with repeat
biopsy (for possible Crohn's) and repeat balloon dilation. A
future MR enterography can also sometimes be diagnostic of
Crohn's disease and could be considered in the future. However,
definitive therapy will likely be surgical removal of his
stricture. Repeat surgery would be aided by the fact that his
stricture was tattooed during his last endoscopy. However, any
intervention would ideally be delayed for months after any acute
inflammation. Therefore, the patient was conservatively managed.
He had a NG tube placed to low-intermittent wall suction. And
after approximately 24-hours the patient was advanced slowly
from clear liquids and continued to pass gas and eventually had
two bowel movements prior to discharge. At the time of
discharge, he was tolerating a full low fiber diet.
======================
CHRONIC MEDICAL ISSUES
======================
#Depression: Patient reports allergy of twitches to generic
forms of wellbutrin. He brought a home supply that is expired
and declined to try the generic formulation. Therefore
wellbutrin was held during the hospitalization.
#Gout: Continued home allopurinol once able to take PO
#PREP use: Continued PREP per patient's request in hospital.
#Hypoandrogenism: Continued home testosterone
===================
TRANSITIONAL ISSUES
===================
- New Meds: None
- Stopped/Held Meds: As above, wellbutrin was held given patient
reported allergy to generic formulation of medication.
- Changed Meds: None
- Post-Discharge Follow-up Labs Needed: None
- Incidental Findings: None
[ ] Consider referral to colorectal surgery for resection of
bowel stricture given recurrent SBO's.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Testosterone Gel 1% 50 mg TP DAILY
2. BuPROPion (Sustained Release) 300 mg PO QAM
3. BuPROPion (Sustained Release) 150 mg PO QPM
4. Allopurinol ___ mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Loratadine 10 mg PO DAILY
7. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. BuPROPion (Sustained Release) 300 mg PO QAM
3. BuPROPion (Sustained Release) 150 mg PO QPM
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
5. Loratadine 10 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Testosterone Gel 1% 50 mg TP DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
=================
PRIMARY DIAGNOSIS
=================
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you while you were admitted to ___
___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
abdominal pain and we found out that you had a blockage in your
intestines (small bowel obstruction).
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We consulted both the gastroenterology team and the surgery
team, and neither team felt there was need for a surgical or
procedural intervention.
- We put a tube from your nose to your stomach to help resolve
your pain.
- Your pain resolved and we slowly introduced food back into
your diet.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- Remember to eat a low fiber diet, eat small meals and chew
your bites completely.
Sincerely,
___ Medicine Team
Followup Instructions:
___
|
19873349-DS-19
| 19,873,349 | 22,001,531 |
DS
| 19 |
2120-08-31 00:00:00
|
2120-08-31 11:55:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fatigue, SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with a PMH notable for
hemochromatosis who presents with dyspnea and hemoptysis.
Per ___ records, the patient went to his PCP's office on
___ for evaluation of myalgias, fever, and chill. At the
time, he reported no nasal congestion, sore throat, or cough,
but
he did mention having hemoptysis. He had crackles in the left
lung base, and was diagnose with a possible pneumonia. He was
given a prescription for doxycycline 200 mg on day 1, then 100
mg
daily for 9 days.
He reports to me that his symptoms started acutely the evening
of
___ with fevers, chills, and diffuse whole body pain.
Notably, he didn't have any cough or congestion. The symptoms
continued until ___, when he started having small amounts
of
scant, bright red hemoptysis. After he was seen in the office,
he
started taking doxycycline with some mild improvement. However,
he still felt extremely fatigued, and therefore, came into the
ED
for further evaluation. He denies having chest pain, nausea,
abdominal pain, diarrhea, or rashes.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
HEMOCHROMATOSIS
have not seen a doc for a year; moved back from ___ last
treatment ? in ___ in ___ has seen GI ___ for
the ___ mutation for hemochromatosis. He had a liver biopsy on
___ noting minimal portal mononuclear cell inflammation,
minimal lobular mononuclear cell inflammation with a rare
apoptotic hepatocyte; no steatosis or hyaline identified,
minimal
increase in portal fibrosis seen on trichrome stain and moderate
iron deposition, predominantly involving periportal and
mid-zonal
hepatocytes identified on iron stain.
DEPRESSION
seeing psych Dr. ___ at ___ hx of hospitalization
in ___ due to alcoholism and depression
ANXIETY
not controlled has had panic attacks while drinking but also,
since sober seeing psych for that
ALCOHOL USE
sober since ___
EYE SURGERY
OS ,lazy eye in childhood
SKIN MOLES
has seen derm
LOW BACK PAIN
ANKLE SPRAIN
b/l ; has pain off-on
HERPES ZOSTER
R side of trunk in the 90 th
Social History:
___
Family History:
FAMILY HISTORY:
Mother and two siblings have depression. Father had CAD and
hemochromatosis.
Physical Exam:
VITALS: ___ ___ Temp: 98.2 PO BP: 102/65 HR: 63 RR: 16 O2
sat: 97% O2 delivery: RA Dyspnea: 4 RASS: 0 Pain Score: ___
GENERAL: Fatigued appearing, in mild distress.
EYES: Anicteric, normal conjunctivae. 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 peripheral edema.
RESP: Lungs with decreased air movement throughout the entire
lung fields, no breath sounds in the left lower base. Breathing
is mildly labored.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. Live edge felt 2 cm below rib margin. No
splenomegaly.
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs.
SKIN: No rashes or ulcerations noted.
NEURO: Face symmetric, gaze conjugate with EOMI, speech fluent.
Sensation to light touch grossly intact throughout.
PSYCH: Good insight and judgment. Alert and oriented. Normal
memory. Pleasant affect.
Discharge exam:
VITALS:VSS and reviewed in eflow sheet.
98.0
PO 119 / 74
R Lying 64 16 97 RA
GENERAL: comfortable, breathing at normal rate, speaking in full
sentences.
EYES: Anicteric, normal conjunctivae. 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 peripheral edema.
RESP: b/l ae no w/c/r, decreased bs L.base.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs.
SKIN: No rashes or ulcerations noted.
NEURO: Face symmetric, gaze conjugate with EOMI, speech fluent.
Sensation to light touch grossly intact throughout.
PSYCH: Good insight and judgment. Alert and oriented. Normal
memory. Pleasant affect.
Pertinent Results:
___ 08:01AM BLOOD WBC-5.9 RBC-3.77* Hgb-12.1* Hct-35.2*
MCV-93 MCH-32.1* MCHC-34.4 RDW-13.6 RDWSD-46.4* Plt ___
___ 02:50PM BLOOD WBC-6.6 RBC-3.91* Hgb-12.6* Hct-36.5*
MCV-93 MCH-32.2* MCHC-34.5 RDW-13.5 RDWSD-46.0 Plt ___
___ 12:30AM BLOOD WBC-6.7 RBC-3.68* Hgb-11.9* Hct-33.9*
MCV-92 MCH-32.3* MCHC-35.1 RDW-13.3 RDWSD-45.3 Plt ___
___ 08:01AM BLOOD Glucose-92 UreaN-17 Creat-0.5 Na-141
K-3.5 Cl-103 HCO3-25 AnGap-13
___ 12:30AM BLOOD Glucose-107* UreaN-22* Creat-0.9 Na-132*
K-3.7 Cl-95* HCO3-20* AnGap-17
___ 12:30AM BLOOD ALT-16 AST-26 AlkPhos-57 TotBili-0.3
___ 12:30AM BLOOD Lipase-13
___ 08:01AM BLOOD Phos-2.8 Mg-2.0
___ 02:50PM BLOOD Phos-3.2 Mg-2.3
___ 12:30AM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.7 Mg-2.0
CTA chest:
IMPRESSION:
No evidence of pulmonary embolism or acute aortic abnormality.
Large, dense focal consolidation with air bronchograms in the
left lower lobe suggestive of acute lobar pneumonia with an
associated small left parapneumonic pleural effusion. Multiple
ground-glass opacities within the lingula and right upper/middle
lobes may represent additional foci of inflammation/infection.
CXR
IMPRESSION:
Large, left lower lobe pneumonia.
___ 08:30AM BLOOD WBC-6.1 RBC-3.78* Hgb-12.2* Hct-35.3*
MCV-93 MCH-32.3* MCHC-34.6 RDW-13.3 RDWSD-45.8 Plt ___
___ 08:30AM BLOOD K-3.8
___ 08:01AM BLOOD Glucose-92 UreaN-17 Creat-0.5 Na-141
K-3.5 Cl-103 HCO3-25 AnGap-13
___ 6:31 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
Reported to and read back by ___ @ 0010 ON
___ -
___.
PRESUMPTIVE POSITIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
Clinical correlation and additional testing suggested
including
culture and detection of serum antibody.
bcx NGTD
ucx: negative
Brief Hospital Course:
Mr. ___ is a ___ male with hemochromatosis who
presents with dyspnea and hemoptysis, found to have a large left
lower lobe pneumonia.
ACUTE/ACTIVE PROBLEMS:
# Acute Hypoxemic Respiratory Failure
# Legionella PNA with hemoptysis
Desaturated to ___ on RA in ED, and required 4L 02. On CT and
CXR he was found to have a large consolidation and clinically he
had associated hemoptysis. He was prescribed doxycycline as an
outpt and failed this regimen. Ulegionella was POSITIVE. Pt was
initially treated with IV ctx/azith and converted to PO
levofloxacin when legionella returned. He was rapidly weaned to
room air and did not have any ambulatory desaturations.
Hemoptysis improved and HCT stable. He was prescribed
levofloxacin for a 7 day course.
# Hyponatremia
Mild and asymptomatic. Related to pneumonia. Resolved.
# Anemia
New since ___, most likely related to acute infection. Not
enough blood loss suggested by history of hemoptysis. Stable.
Outpt f/u.
# Nicotine Dependence-nicotine patch 14 mg daily, prescribed at
discharged. Discussed with pt the need to limit/stop smoking
cigarettes and marijuana especially with his current pneumonia
and respiratory issues.
CHRONIC/STABLE PROBLEMS:
# Depression-held home citalopram in the setting of taking
levoflox to
avoid QTc prolongation
Time spent on dc related activities >30 min
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 30 mg PO DAILY
2. Doxycycline Hyclate 100 mg PO DAILY
3. Sildenafil 50 mg PO ASDIR
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
2. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour 1 patch daily Disp #*30 Patch
Refills:*0
3. Sildenafil 50 mg PO ASDIR
4. HELD- Citalopram 30 mg PO DAILY This medication was held. Do
not restart Citalopram until you finish your levofloxacin in
case of a potential drug interaction. Please call your doctor if
you experience any signs of withdrawal or depression during this
time.
Discharge Disposition:
Home
Discharge Diagnosis:
legionella pneumonia
hemoptysis
tobacco use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted or evaluation of fatigue and coughing up
blood. You had a CT and CXR that revealed a large left sided
pneumonia. You also had testing that was positive for
legionella. Therefore, you were treated with antibiotics for
legionella pneumonia. You will need a few more days of
antibiotics after discharge. You will need a repeat CXR or CT
scan after you are treated for your pneumonia to ensure it has
resolved.
Please try to stop smoking cigarettes and marijuana as this is
not good for your lungs, especially with a pneumonia. You were
prescribed a nicotine patch in case you would like this to
assist with stopping smoking.
Followup Instructions:
___
|
19873553-DS-15
| 19,873,553 | 23,523,042 |
DS
| 15 |
2187-07-24 00:00:00
|
2187-07-22 12:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weakness and tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo m with multiple myeloma s/p ___ velcade treatment on
___, presenting from his PCP office for weakness and
tachycardia. He states that he has been feeling fatigued and
weak since his second velcade treatment. Today, he was at his
PCP office and was found to have heart rate of 170 in office
today with BP 96/60 and was sent to ED for further evaluation.
He has had a low grade fever of 100 at home, nausea, and left
sided nonradiating chest pain. He has a history of hemorrhoids
and notes that he occasionally has bright red blood on the
toilet paper. He denies vomiting, diarrhea, and urinary
symptoms. He states that he has been having bilateral leg
swelling since velcade treatment and has gained 10lbs over the
course of treatment.
In the ED, initial VS were 100.0 77 118/74 18 95% RA.
Labs notable for WBC of 15.4, H/H of 13.4/39.9, Plt 72. BMP with
BUN/Cr of ___. ALT/AST 87/45. Troponin elevated to .10, with
repeat troponin 0.07.
He had a very prolonged ED course. Due to tachycardia and small
amounts of blood on tissue paper, GI was consulted. Given his
constellation of symptoms, they felt sepsis was more likely the
etiology of the patient's presentation, without concern for
acute GI bleed.
He initially received IV ceftriaxone, aspirin, pantoprazole,
ezetimibe 10 mg, acetaminophen, IV fluids. Influenza was sent
and was negative.
Initial CXR was negative. Due to a T max of 101.3, repeat CXR
showed blossoming right perihilar opacity.
In discussion with the ED resident, due to sepsis in this
patient undergoing chemotherapy with a blossoming chest
infiltrate, he was initiated on vancomycin and cefepime.
Upon arrival to the floor, the patient tells the story as
follows. He reports he feels significantly improved from when he
first came to the hospital. He reports that ever since his
second round of chemotherapy last week, he has felt extremely
weak. He reports that he has had "barely fevers" at home,
"chills," + cough productive of phlegm which has increased in
nature and is now bothering his wife. He denies shortness of
breath. He
endorses some chest discomfort, which is difficult to describe,
but is currently not present. It is not clearly inspiratory
pain.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- HLD
- Psoriasis
- Myositis
- Erectile Dysfunction
- Prostate Cancer s/p prostatectomy
- CKD
- HTN
- Multiple myeloma
- Migraines
- Contracture of joint of left hand
- s/p lumbar fusion
- Urinary incontinence
- L shoulder replacement
- L knee replacement
- 1st degree AV block
Social History:
___
Family History:
No FH of myeloma. Father with an MI
Physical Exam:
ADMISSION EXAM
VITALS: 99.4 PO 182 / 81 67 22 88 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
Mucous membranes dry
Neck supple and ranges in all directions
CV: Heart regular, no murmur
RESP: Lungs with rhonchi bilaterally, symmetric breath sounds,
frequent coughing fits with deep inspiration
Back: no CVA tenderness
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
EXT: + pitting edema bilaterally L>R, no calf pain
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM
Vital Signs: 97.7 173/90 ___ RA
glucose:
.
GEN: NAD, well-appearing
EYES: PERRL, EOMI, conjunctiva clear, anicteric
ENT: moist mucous membranes, no exudates
NECK: supple
CV: RRR s1s2 nl, no m/r/g
PULM: CTA with good air movement bilaterally. Breathing is
non-labored. Scattered crackles on the L>R
GI: normal BS, NT/ND, no HSM
EXT: warm, no c/c/e
SKIN: no rashes
NEURO: alert, oriented x 3, answers ? appropriately, follows
commands, non focal
PSYCH: appropriate
ACCESS: PIV
FOLEY: absent
Pertinent Results:
ADMISSION LABS
==============
___ 08:01PM BLOOD WBC-15.4* RBC-4.32* Hgb-13.4* Hct-39.9*
MCV-92 MCH-31.0 MCHC-33.6 RDW-17.0* RDWSD-55.8* Plt Ct-72*
___ 08:01PM BLOOD Neuts-94.6* Lymphs-2.5* Monos-1.9*
Eos-0.1* Baso-0.1 Im ___ AbsNeut-14.58* AbsLymp-0.38*
AbsMono-0.29 AbsEos-0.01* AbsBaso-0.02
___ 06:20AM BLOOD ___ PTT-23.8* ___
___ 08:01PM BLOOD Glucose-92 UreaN-30* Creat-0.9 Na-142
K-4.0 Cl-99 HCO3-29 AnGap-14
___ 11:34AM BLOOD ALT-87* AST-45* CK(CPK)-96 AlkPhos-46
TotBili-0.6
___ 08:01PM BLOOD cTropnT-0.10*
___ 03:48AM BLOOD cTropnT-0.07*
___ 06:20AM BLOOD proBNP-___*
___ 06:20AM BLOOD Calcium-7.4* Phos-2.1* Mg-1.9
___ 11:34AM BLOOD Albumin-2.9*
IMAGING/OTHER DIAGNOSTICS
=========================
CTA ___
No evidence of pulmonary embolism or aortic abnormality given
the
motion artifact limitations. Bilateral ground-glass opacity
and peribronchovascular consolidations predominantly in the
right upper lobe are concerning for multifocal pneumonia.
# ___ (___): PRELIM: 1. No evidence of intra hepatic
biliary ductal dilatation. 2. The common bile duct measures 0.6
cm, within normal limits for the patient's age. 3. The
gallbladder is decompressed without evidence of cholelithiasis.
.
Brief Hospital Course:
___ yo m with multiple myeloma on his ___ cycle of velcade/dex
(started treatment ___, presenting from his PCP office for
weakness and tachycardia, found to have sepsis secondary to
pneumonia. Given recent steroid exposure we are also ruling out
PJP.
# Sepsis due to pneumonia
# Acute hypoxic respiratory failure
# Immunosuppression due to recent high dose velcade/dex
# Erroneous dexamethasone dosing at home
Mr. ___ presented with fever, leukocytosis, and tachycardia,
with localizing symptoms of chest pain, cough, and weakness.
Initial CXR negative for infection, however, repeat showed
developing pulmonary infiltrate with pneumonia. Chest CTA
showed no evidence for PE, but evidence bilateral ground glass
opacitis c/w multifocal pneumonia. Given recent chemotherapy
and fever almost 24 hours after receiving CTX, abx broadened to
vancomycin/cefepime/azithro.
Given his improving symptoms fever curve, and white count on
abx, and the presence of some consolidation on CT, PJP seemed
overall less likely. However given elevated LDH, high doses of
steroids for past 6 weeks (patient had misunderstood
instructions and was taking 20 mg dex 5 days/wk for most of the
past 6 weeks instead of 20 mg 2 days/wk), hypoxia, and bilateral
ground glass on CT, there were initial attempts to r/o PJP. He
was unable to complete several attempts at getting induced
sputum for PJP. Beta-glucan was sent and presently pending (on
day of discharge).
Over time, while on abx, his respiration steadily improved and
he was weaned off oxygen. His cough/SOB also improved. He was
transitioned to PO cefpodox and vanco was stopped. Continued on
azithro. He continued to show steady improvement on this oral
regimen and thus discharged to complete the course at home.
# Thrombocytopenia:
Admission platelets of 68, worsened from prior known
thrombocytopenia, possibly as a side effect of velcade. No signs
or symptoms of active bleeding. Aspirin was temporarily
stopped.
#Transaminase elevation
New transaminase elevation since ___, worsened on hospital day
2. Could be due to acute illness or medications. Held statin -
which can be resumed once outpt LFTs show downtrending and OK
from outpatient doctors. ___ here showed no abnormalities.
#Asymptomatic Bacteruria (GNRs)
No symptoms and he is on broad antimicrobial coverage anyways
# Multiple myeloma:
Per Atrius records, patient was found to have monoclonal IgG
kappa protein by immunofixation (without detectable M-spike) and
elevated free kappa light chain during workup for gait
imbalance. His hemogram was completely normal, his renal
function was normal and he had no hypercalcemia. The skeletal
survey only showed possible lytic lesions of the skull, none
elsewhere. The bone marrow biopsy confirmed kappa light chain
restricted plasma cells about 30%.of total nucleated cells. He
is followed and undergoing treatment with velcade and decadron
(see note about dosing error above), with normalization of his
free kappa light chains after the first cycle.
# CKD;
Patient with a history of CKD with reported baseline Cr of
1.1-1.2, with recent improvement in creatinine to 1.0.
Creatinine nadired at 0.7 during admission after fluids.
# Primary prevention of cardiac illnesses:
- Held Aspirin 325 mg PO EVERY OTHER DAY in the setting of
thrombocytopenia for indication of primary prevention. This was
resumed.
# HTN:
Patient reported continuing to take nifidipine and
lizinopril-HCTZ, although there was some documentation
indicating they had been stopped. He was hypertensive up to 170s
despite his septic picture and so started initially on on
lisinopril/HCTZ. He was restarted on nifedipine on discharge
(as outpt records indicate that he was still prescribed on it).
>30 minutes spent in patient care and coordination of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. atorvastatin 20 mg oral DAILY
2. Ezetimibe 10 mg PO DAILY
3. Aspirin 325 mg PO EVERY OTHER DAY
4. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
5. coenzyme Q10 10 mg oral DAILY
6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. lisinopril-hydrochlorothiazide ___ mg oral DAILY
10. NIFEdipine (Extended Release) 60 mg PO DAILY
Discharge Medications:
1. Azithromycin 500 mg PO DAILY Duration: 5 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
2. Benzonatate 100 mg PO TID
RX *benzonatate [Tessalon Perles] 100 mg 1 capsule(s) by mouth
three times a day Disp #*30 Capsule Refills:*0
3. Cefpodoxime Proxetil 400 mg PO BID
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*16 Tablet Refills:*0
4. GuaiFENesin-Dextromethorphan 5 mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin [Robafen DM Cough] 100 mg-10
mg/5 mL 5 mL by mouth four times a day Refills:*0
5. Aspirin 325 mg PO EVERY OTHER DAY
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
7. coenzyme Q10 10 mg oral DAILY
8. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
9. Ezetimibe 10 mg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. lisinopril-hydrochlorothiazide ___ mg oral DAILY
12. NIFEdipine (Extended Release) 60 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
14. HELD- atorvastatin 20 mg oral DAILY This medication was
held. Do not restart atorvastatin until you follow up with your
primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Multifocal pneumonia
Transaminitis
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 looking after you. As you know, you were
admitted for multifocal pneumonia - which occurred in the
setting of getting steroids and recent Velcade. You received
intravenous antibiotics and then later, oral antibiotics with
significant improvement. Please complete the remaining doses
of antibiotics as prescribed. We anticipate you will make
steady improvements.
Of note, during your hospitalization, your liver tests were
noted to be elevated. A liver/gallbladder ultrasound was done -
which revealed no structural abnormality. Please do not take
the lipitor (as this can cause a liver test abnormality) until
otherwise instructed by your primary care doctor or oncologist.
Your other medications otherwise remain unchanged. We wish
you well and quick recovery.
Your ___ Team
Followup Instructions:
___
|
19873891-DS-8
| 19,873,891 | 23,955,728 |
DS
| 8 |
2128-04-25 00:00:00
|
2128-04-25 21:59:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Erythromycin
Base / Dilaudid / dairy products / adhesive tape
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
___ Upper endoscopy
___ Diagnostic paracentesis with removal of 2.4L
___ Diagnostic paracentesis with removal of 3L
History of Present Illness:
Ms. ___ is a ___ w/ pancreatic neuroendocrine tumor (stage
IV, diagnosed ___, w/ liver mets, s/p sphincterotomy and metal
biliary stent, s/p CK therapy, now stable on octreotide infusion
last received ___ c/b new cirrhosis ___ liver mets c/b
presumed SBP, varices, PVT on Apixaban, large ascites) admitted
with AMS like ___ decompensated liver disease (large ascites and
lower extremity edema, ?hepatic encephalopathy, possible SBP).
On review of the chart, pt was increasingly confused at home
with associated mild abdominal discomfort. In the ED, she was
noted to asterixis and A&Ox2. RUQ U/S showed no definite flow
w/in main portal vein, and cirrhosis with large ascites. CT
head w/out acute intracranial process. CXR with tiny right
pleural effusion, question of mild ileus. Paracentesis was
deferred due to anticoagulation, and her apixaban was held
overnight. She was treated empirically with ceftriaxone.
This morning, patient reports that her abdominal pain resolved
but she feels confused and fatigued. She also reports worsening
lower leg swelling. She denies any fevers, chills, nausea,
vomiting, headache, chest pain or shortness of breath. No
bloody BMs. ROS otherwise negative.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
Neuroendocrine tumor stage IV
- ___ Admitted to ___ with hematemesis
x 2. Denied any excessive NSAID or ETOH use, H/H 7.6/22.1 on
admission, transfused 2 units PRBC. LFTs also found to be to
elevated (AST 158, ALT 230, AP 311, TB 1.9). Viral hepatatis,
autoimmune hepatitis, and PBC serologies negative. EGD was
performed which revealed Barrett's esophagitis and probable
portal gastropathy without active bleeding. U/S that day
demonstrated ascites of unclear etiology, borderline fatty
liver,
and extrahepatic biliary dilatation. Course complicated by
Streptococcus bacteremia from presumed SBP and was started on
Levaquin and Vanco, TTE negative for endocarditis.
- ___ CT abdomen showed liver disease with ascites,
mesenteric varices, recanalization of the umbilical vein,
prominence of the spleen, cavernous transformation of the main
PV. There is intrahepatic biliary ductal dilatation. The CBD is
not seen well in the region of the expected location of the main
PV and therefore narrowing cannot be excluded.
- ___ MRI showed a 5 cm hypoenhancing mass in the region of
the pancreatic neck and proximal body as well as a 2.4 cm
hepatic
mass. Evidence of portal vein involvement by the mass, with
associated obstruction and resultant upper abdominal varices.
Narrowing of the distal intrapancreatic common duct by the
pancreatic lesion and intra- and extra-hepatic biliary ductal
dilatation. Small amount of ascites.
- ___ Chest CT showed no metastatic disease. Possibility
of
left parathyroid adenoma versus mild lymphadenopathy.
- ___ EUS here at ___ showed a 5.5 cm X 4 cm ill-defined
mass in the neck of the pancreas with irregular and poorly
defined borders. The mass was hypoechoic and heterogenous in
echotexture. There was an irregular plane between the mass and
normal appearing pancreatic parenchyma with normal size PD. It
was not clear if the mass was originating from the pancreas or
abutting adjacent pancreatic tissue. FNA was performed. A
___ lymph node was noted, measuring 5 mm in diameter
with well-defined borders. There was a caliber change of the PV
which was encased by the pancreatic mass. A 3 cm X 2 cm
well-defined mass was noted in the right hepatic lobe with
regular and well-defined borders. FNA was performed of the
masses in the pancreas and liver. Both the liver and pancreatic
lesions were POSITIVE FOR MALIGNANT CELLS, consistent with
pancreatic endocrine tumor. Tumor cells are positive for
cytokeratin cocktail, chromogranin and synaptophysin, but
negative for beta-catenin. Mib-1 stains only rare cells. No
mitoses are seen. The findings suggest a low-grade tumor.
- ___ Octreotide scan showed multiple liver mets and an
avid
pancreatic head mass
- ___ Start CK therapy
- ___ Completed 3 session of CK with 24 Gy to the
pancreatic
mass and 3 liver mets
- ___ CT torso showed a large heterogeneous mass at the
root
of the mesentery, with extension into the lesser sac, overall
unchanged in size but with increased encasement/obliteration of
the celiac axis as it courses through the ___ the mass.
Increased hypodensity adjacent to the fiducial seeds could
represent tumor necrosis/response to therapy.
- ___ CT torso showed multiple arterially-hyperenhancing
hepatic lesions throughout the right and left hepatic lobes
measuring up to 2.7 cm, consistent with neuroendocrine
metastases, are new to increased in size in the interval.
Interval stability of heterogeneous, predominantly
arterially-hyperenhancing 5.5 x 4.1 x 4.4 cm known
neuroendocrine
tumor. Unchanged obliteration of the celiac trunk. Patent
distal
hepatic arteries likely due to reconstitution from collateral
vessels. Interval development of occlusion of the main portal
vein extending to the origins of the intrahepatic portal
branches
with occlusion of the proximal left portal vein but distal
reconstitution of both right and left intrahepatic portal
branches. Occlusion of the splenic vein, with new splenomegaly.
- ___ MR liver showed a dominant mass centered in the
pancreatic head representing the primary neuroendocrine tumor
invading the portal confluence, with resultant thrombosis of the
main portal vein, and complete invasion of the celiac axis.
Overall, the mass is marginally smaller compared to baseline CT
examination from ___ but similar compared to basedline MRI
from ___. Multiple arterially enhancing metastases
within the liver, involving both lobes. Overall, this has
progressed compared to ___.
- ___ Start octreotide 20 mg LAR Q28 days
- ___ CT abdomen for abdominal pain showed peripancreatic
and mesenteric fat stranding and mild wall thickening of the
third and fourth portions of the duodenum are most likely
indicative of edema related to persistent portal vein
thrombosis.
Otherwise stable disease.
- ___ Octreotide scan showed intense radiotracer uptake
within the pancreatic head, unchanged from prior examinations.
Subtle focus of radiotracer uptake within segment 5 of the
liver,
but overall decreased radiotracer uptake within the liver in
comparison to the prior examination.
- ___ MR abdomen showed neuroendocrine tumor in the
pancreas and metastatic lesions in the liver are grossly stable.
PAST MEDICAL HISTORY:
- GERD
- Streptococcus bacteremia from presumed ___ (___)
___
- hematemesis
- atrial fibrillation post ERCP, responded well to metoprolol
5mg IV
Social History:
___
Family History:
Father alive, with hypertension. Mother died in ___ of MI. No
history of pancreatic cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: 98.8F 102/70 100% RA 93
General: NAD, frail and chronically ill appearing female,
Resting in bed comfortably wide awake
HEENT: MMM, sclera anicteric, no nystagmus
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, 2+ ___, +++ asterixis
SKIN: No rashes on the extremities
NEURO: Oriented to person, "___ and
___ Demonstrates some insight as to
reason for admission, but dates are off and unable to express
much more contextual information but able to provide more
distant
history.
DISCHARGE PHYSICAL EXAM:
VITAL SIGNS: Tm 98.2 BP 104/68 HR 98(100s) RR 18 99% RA
24hr I/O: 1220/1100 +1BM
8h I/O: ___
Wt: No weight today or ___ 133 lbs on ___ (dry weight 110
per patient)
General: NAD, frail, chronically ill appearing female laying in
bed
HEENT: MMM, sclera anicteric, no nystagmus, OP clear
CV: RRR, NL S1S2 no S3S4 No MRG.
PULM: CTAB, no wheezes or rales, dimished at bases.
ABD: BS+, soft, distended w/ fluid wave, no palpable masses or
HSM,caput medusa present.
LIMBS: WWP, 2+ ___ to hips, improved from yesterday.
SKIN: No rashes on the extremities
NEURO: A&Ox3, no asterixis, CNII-XII grossly intact.
Pertinent Results:
LABORATORY STUDIES ON ADMISSION
=======================================
___ 06:00PM BLOOD WBC-17.3*# RBC-3.21* Hgb-9.3* Hct-29.0*
MCV-90 MCH-29.0 MCHC-32.1 RDW-17.6* RDWSD-56.8* Plt ___
___ 06:00PM BLOOD Neuts-86.6* Lymphs-7.2* Monos-5.2
Eos-0.1* Baso-0.2 Im ___ AbsNeut-14.95*# AbsLymp-1.25
AbsMono-0.90* AbsEos-0.01* AbsBaso-0.03
___ 06:00PM BLOOD ___ PTT-23.7* ___
___ 06:00PM BLOOD Glucose-89 UreaN-11 Creat-0.8 Na-134
K-4.3 Cl-101 HCO3-21* AnGap-16
___ 06:00PM BLOOD ALT-59* AST-78* AlkPhos-562* TotBili-2.2*
___ 06:00PM BLOOD Lipase-7
___ 06:00PM BLOOD Albumin-2.3*
___ 05:50PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:50PM URINE Blood-NEG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-MOD
___ 05:50PM URINE RBC-2 WBC-60* Bacteri-FEW Yeast-NONE
Epi-9
___ 05:50PM URINE CastHy-3*
OTHER PERTINENT LABORATORY STUDIES
=======================================
___ 08:55AM BLOOD Ret Aut-3.0* Abs Ret-0.07
___ 06:25AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 06:45PM BLOOD Smooth-NEGATIVE
___ 06:25AM BLOOD AMA-NEGATIVE
___ 07:00PM BLOOD ___
___ 07:00PM BLOOD PEP-NO SPECIFI IgG-1241 IgA-255 IgM-233*
___ 06:45PM BLOOD HIV Ab-Negative
___ 07:00PM BLOOD HCV Ab-NEGATIVE
___ 03:40PM ASCITES WBC-795* RBC-495* Polys-78* Lymphs-1*
___ Macroph-21*
___ 03:40PM ASCITES TotPro-0.6 Glucose-125 LD(LDH)-35
TotBili-0.2 Albumin-LESS THAN
___ 03:15PM ASCITES WBC-135* RBC-435* Polys-2* Lymphs-29*
___ Mesothe-1* Macroph-68*
___ 03:15PM ASCITES TotPro-1.2 Glucose-178
LABORATORY STUDIES ON DISCHARGE
=======================================
___ 07:05AM BLOOD WBC-5.5 RBC-2.91* Hgb-8.7* Hct-26.8*
MCV-92 MCH-29.9 MCHC-32.5 RDW-17.3* RDWSD-57.6* Plt ___
___ 07:05AM BLOOD Glucose-102* UreaN-6 Creat-0.5 Na-133
K-4.0 Cl-99 HCO3-28 AnGap-10
___ 07:20AM BLOOD ALT-19 AST-29 AlkPhos-209* TotBili-1.4
MICROBIOLOGY
=======================================
___ Blood culture: pending
___ 5:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 3:40 pm PERITONEAL FLUID
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
IMAGING
=======================================
EGD ___
- Abnormal mucosa was noted in the gastroesophageal junction.
These findings are compatible with Barrettes esophagitis.
- 4 cords of grade III varices were seen starting at 31 cm from
the incisors in the gastroesophageal junction. There were
stigmata of recent bleeding.
Diagnostic Paracentesis ___
Technically successful ultrasound-guided diagnostic and
therapeutic
paracentesis yielding 2.4 L of clear yellow fluid from the right
lower quadrant. Samples were sent to the lab as requested.
CT Head ___: No acute intracranial process. CT with
contrast or MRI would be more sensitive for assessment of
intracranial mass lesions.
CXR ___: AP upright and lateral views of the chest
provided. There is a small left pleural effusion with
compressive atelectasis in the left lower lung. A tiny right
pleural effusion is also noted. The right lung is clear.
Cardiomediastinal silhouette is normal. Bony structures are
intact. A CBD metallic stent projects over the right upper
quadrant. Clips are noted in the upper abdominal midline. No
free air below the right hemidiaphragm. Gas-filled loops of
small bowel in the upper abdomen noted, question mild ileus.
Abd US ___:
1. Cirrhosis, with sequelae of portal hypertension, including
large ascites.
2. No definite flow is seen within the main portal vein.
Brief Hospital Course:
Ms. ___ is a ___ w/ pancreatic neuroendocrine tumor (stage
IV, diagnosed ___, w/ liver mets, s/p sphincterotomy and metal
biliary stent, s/p CK therapy, now stable on octreotide infusion
last received ___ c/b new cirrhosis ___ liver mets/XRT/PVT),
admitted with liver disease decompensated by SBP (CTX ___,
large ascites (s/p para ___/ 2L ___, 3L ___, restarted on oral
diuretics), hepatic encephalopathy (clearing w/
lactulose/rifaximin), PVT (previously on Apixaban holding AC in
setting of GIB), and GIB (s/p EGD w/ grade III GEJ varices, w/
stigmata of bleeding, not banded, H/H slightly downtrending but
hemodynamically stable).
#Variceal bleed
Baseline Hgb ___. Patient remained hemodynamically stable but
had a downtrending H/H (8.2 >6.2) with guaiac positive stool (no
BRBPR or melena). Received intermittent transfusions during
admission. Underwent EGD that showed grade III GEJ varices, w/
stigmata of bleeding.
#Spontaneous bacterial peritonitis
Patient found to have SBP with ascites fluid showing 620 PMNs.
She received a 5-day course of Ceftriaxone IV ___ - ___.
Given albumin 1.5g/kg on D1 and 1g/kg on D3. She was
transitioned to ciprofloxacin for SBP prophylaxis.
#UTI
Patient found to have a UTI with urine culture showing >100k
cipro-resistant e.coli. She was treated with antibiotics (as
above). She denies any urinary symptoms.
#Hepatic encephalopathy
Pt admitted w/ AMS likely ___ acute hepatic encephalopathy in
setting of decompensated liver disease. NCHCT without acute
intracranial process. Likely precipitated by PVT and SBP.
Cleared w/ lactulose and rifaximin.
#Ascites
Pt found to have large ascites on RUQ U/S. Likely secondary to
portal hypertension (SAAG >1.1). Her home diuretics (Lasix 20mg
daily) and aldactone 50mg daily) were initially held in setting
of SBP and variceal bleed). She underwent paracentesis with
removal of 2L and 3L of peritoneal fluid on ___ and ___,
respectively. Prior to discharge, patient started on 40mg PO
lasix and 100 mg aldactone with no significant electrolyte
derangements. Goal to keep slightly net negative daily until
hepatology follow up given she was 20 lbs above dry weight.
#Portal vein thrombus
Pt w/ h/o PVT on Apixaban at home. RUQUS showed no definite flow
seen w/in the main portal vein. Anticoagulation was held in
setting of variceal bleed given unfavorable risk to benefit.
#Cirrhosis
Pt w/ newly diagnosed cirrhosis ___ liver mets/XRT/PVT. During
admission, liver disease decompensated by SBP (CTX ___,
large ascites (s/p para w/ 2L ___, 3L ___, hepatic
encephalopathy (clearing w/ lactulose/rifaximin), PVT
(previously on Apixaban holding AC in setting of GIB), and GIB
(s/p EGD w/ grade III GEJ varices, w/ stigmata of bleeding, not
banded, H/H now stable). Evidence of synthetic dysfunction with
elevated INR to 2.4 (improved s/p po vitamin K for 3 days).
Also with albumin 2.7. Liver serologies were unremarkable.
# Pancreatic neuroendocrine tumor
Pt w/ a h/o pancreatic neuroendocrine tumor, stage IV, diagnosed
___, w/ liver mets, s/p sphincterotomy and metal biliary
stent, s/p CK therapy, now stable on octreotide infusion (last
received ___.
#Coagulopathy
INR elevated to 2.4 on admission, likely secondary to cirrhosis.
She received a 3-day course of PO vitamin K with improvement in
INR to 1.5 at time of discharge.
#Protein malnutrition
Albumin 2.7, likely ___ malignancy, poor intake, and liver
disease. Nutrition consulted during admission recommended
supplemental ensures three times a day.
TRANSITIONAL ISSUES
=================================================
1. Pt was discharged on ciprofloxacin for SBP prophylaxis, which
she will need to continue indefinitely. If she has recurrent
SBP, could consider transitioning to cefpodoxime, as she had
ciprofloxacin-resistant UTI during admission.
2. Pt had suspected variceal bleed during admission. First EGD
showed 4 codes of grade III varices with stigmata of recent
bleeding. The pt had no further bleeding while inpatient. Repeat
EGD 5 days later only showed 1 cord of grade II varices so she
did not have any banding done
3. Pt was discharge on home Lasix and increased spironolactone.
She reports being 20lb up from dry weight on discharge. She
needs close monitoring of her volume status and diuretic
adjustments accordingly. ___ also need therapeutic paracentesis
4. Please get electrolytes in follow up 1 week from discharge
(Did not require repletions while inpatient)
5. Pt needs to continue rifaximin and lactulose (titrate to ___
BMs/day) to prevent recurrence of hepatic encephalopathy.
6. Patient's Apixaban was discontinued in setting of variceal
bleed, and was not restarted on discharge due to risk of
bleeding. Consider restarting a reversible anticoagulant if
appropriate in follow up
7. Nadolol was discontinued because it can increase mortality in
patients with cirrhosis with a history of SBP.
8. Patient declined home ___. She would benefit from daily
monitoring of weight and volume status. Also for medication
adherence and monitoring for hepatic encephalopathy. Please
readdress as outpatient
9. Discharge weight: 132lb (significantly volume overloaded with
2+ pitting edema to waist)
EMERGENCY CONTACT HCP: ___ (Aunt/HCP) ___
CODE: Full (confirmed)
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Nadolol 20 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
4. Apixaban 5 mg PO BID
5. Furosemide 40 mg PO DAILY
6. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO/NG Q24H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Lactulose 30 mL PO TID
Please take three times daily as needed to have 3 bowel
movements daily
RX *lactulose 20 gram/30 mL 30 mL by mouth three times a day
Refills:*0
3. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6hr prn: pain Disp #*14
Tablet Refills:*0
5. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Omeprazole 20 mg PO DAILY
7. Furosemide 40 mg PO DAILY
RX *furosemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
8. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8hr prn: nausea Disp
#*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Variceal GI bleed
Spontaneous bacterial peritonitis
Urinary tract infection
Portal vein thrombus
Hepatic encephalopathy
Ascites
Cirrhosis
Pancreatic neuroendocrine tumor
Coagulopathy
Protein malnutrition
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted to
___ because of your confusion. You were found to have hepatic
encephalopathy, which is when toxins build up in your body
because your liver is not functioning well. You were treated
medications to help you have bowel movements, which clear out
the toxins from your body. It is very important for you to
continue taking these medications (lactulose and rifaximin).
You should take lactulose so that you have 3 to 4 bowel
movements per day.
You were also found to have an infection in the abdominal fluid
in your belly. You were treated with IV antibiotics for this
infection (and also for your urinary tract infection). It is
very important for you to continue taking ciprofloxacin (which
is an oral antibiotic). You have to continue ciprofloxacin to
prevent future episodes of infection of your abdominal fluid.
You were also found to have fluid in your abdomen and your legs.
You underwent a procedure called a paracentesis to remove the
fluid from your abdomen. You were also restarted on increased
doses of diuretics (water pills) to remove the fluid from your
body. You should continue taking the water pills (Lasix and
aldactone) as prescribed. You should watch your weight closely
and call your doctor if your weight increases by 3 pounds or if
you become dizzy/lightheaded.
You were also found to have low blood counts (anemia) from
bleeding in your GI tract. This is from dilated blood vessels
(similar to varicose veins) that bleed in your esophagus and
stomach. You underwent a procedure called an endoscopy to look
at these blood vessels.
You were previously on a blood thinner called Eliquis for the
blood clot in your liver. This medication was stopped because
of your anemia and bleeding.
Please see the below "recommended follow-up" section for your
upcoming appointments.
Sincerely,
Your ___ team
Please call one of your physicians listed below if you have any
confusion, dizziness/lightheadedness, vomiting blood, bloody
bowel movements, worsening abdominal swelling, worsening leg
swelling, palpitations, fever, chills, or any other concerning
symptom
Oncologist: Dr. ___ ___
New PCP: Dr. ___ ___
New Hepatologist: Dr. ___ ___
Followup Instructions:
___
|
19874138-DS-13
| 19,874,138 | 28,761,606 |
DS
| 13 |
2189-10-09 00:00:00
|
2189-10-17 20:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Middle finger Pain & Alcohol Withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo M with a h/o IDDM, pancreatic
insufficiency,
and ETOH dependence, with hx of DKA, presents with right middle
finger pain and is being admitted for alcohol withdrawal. Per
report from ___ ED, patient was seen
yesterday night, had called EMS stating he been nauseated and
vomiting for one month, and had high blood glucoses. There his
fingerstick was 128, and patient had no complaints and only
wanted to sleep and be left alone. Unclear if he was intoxicated
at that time. Patient does endorse that he drinks etoh, though
he states his last drink was days ago. Currently, he denies that
he has had any nausea or vomiting, or diarrhea. He denies that
he has any chest pain, abdominal pain, fevers, chills, cough,
changes in bowel or bladder habits.
In the ED, initial vs were 97.0 118 ___ 100% RA. Patient
was tachycardic. EKG: ST @ 114. LAD NI <1mm STE ant/septal c/w
prior ECG. Admission labs: neg urine tox, UA with ketones, Na
130, K 5.4, BG 114, ALT 77. He received 3 L of normal saline,
Diazepam 5 mg x2, folic acid 1 mg and IV & PO thiamine. Pt also
noted to be somnlolent and scoring 9 on CIWA.
Transfer VS 97.0 115 132/85 16 97% RA.
On arrival to the floor, patient is sleeping and refuses to wake
up. He states he is here because his blood sugar is high and has
no other complaints. He demands to be left alone to sleep.
REVIEW OF SYSTEMS:
+polydipsia, +weight loss
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.
All other 10-system review negative in detail.
Past Medical History:
IDDM
Pancreatitis x 2 in ___ and ___
HBV surface ag positivity
Abnormal hemoglobin electropheresis in ___
H. pylori on EGD biopsy
Malaria as a child
Social History:
___
Family History:
No FH of DM
No MI, strokes
Mother died of dementia at ___, father died of unknown reasons at
___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS:98.3 137/91 107 20 99%RA BG:96
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, EOMI, PERRL, dry MM, oropharynx clear
no exudates, lesions or thrush
Neck: supple, JVP not elevated, no LAD
CV: Tachycardiac, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
diminished sensation to level of bilateral ankles, gait
deferred, finger-to-nose intact
VSS
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, EOMI, PERRL, dry MM, oropharynx clear
no exudates, lesions or thrush
Neck: supple, JVP not elevated, no LAD
CV: Tachycardiac, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
diminished sensation to level of bilateral ankles, gait
deferred, finger-to-nose intact
Pertinent Results:
Admission Labs:
___ 12:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 12:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 10:20AM GLUCOSE-116* UREA N-26* CREAT-0.4*
SODIUM-130* POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-21* ANION GAP-17
___ 08:40AM GLUCOSE-114* UREA N-32* CREAT-0.6 SODIUM-130*
POTASSIUM-5.4* CHLORIDE-91* TOTAL CO2-22 ANION GAP-22*
___ 08:40AM estGFR-Using this
___ 08:40AM ALT(SGPT)-77* AST(SGOT)-39 TOT BILI-0.4
___ 08:40AM LIPASE-10
___ 08:40AM ETHANOL-NEG
___ 08:40AM WBC-11.7*# RBC-5.47 HGB-13.2* HCT-42.7
MCV-78* MCH-24.1* MCHC-30.8* RDW-16.5*
___ 08:40AM NEUTS-81.0* LYMPHS-12.7* MONOS-4.4 EOS-1.7
BASOS-0.2
___ 08:40AM PLT COUNT-362
CT Head: here is no evidence of hemorrhage, edema, mass effect
or
infarction. Basal cisterns are patent. There is no shift of
normally midline structures. Gray-white matter differentiation
is preserved. The globes and orbits are unremarkable. No
osseous abnormality is identified. Secretions are seen within
the posterior and left nasal cavities with mucosal thickening in
the left maxillary sinus and ethmoid air cells. The middle ear
cavities are clear.
X-ray R hand: There is no acute fracture, dislocation, or
degenerative change. No suspicious lytic or sclerotic lesions
are identified. There is no soft tissue calcification or
radiopaque foreign body.
ECG: Sinus tachycardia. Left atrial abnormality. Left anterior
fascicular block. Delayed precordial R wave transition. Compared
to the previous tracing of ___ no diagnostic interim change.
Discharge Labs:
___ 07:50AM BLOOD WBC-6.1 RBC-4.42* Hgb-10.6* Hct-34.8*
MCV-79* MCH-24.1* MCHC-30.6* RDW-16.3* Plt ___
___ 07:50AM BLOOD Glucose-132* UreaN-8 Creat-0.3* Na-137
K-4.2 Cl-102 HCO3-25 AnGap-14
___ 07:50AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ yo M with a h/o IDDM, pancreatic
insufficiency,
and EtOH dependence, with hx of DKA, presents with right middle
finger pain and is being admitted for alcohol withdrawal.
Active Issues:
#Alcohol Withdrawal/EtOH dependence: Patient with known EtOH
dependence, but no h/o withdrawl seizures or LOC; he claims not
to drink more than 2 beers at a time. Pt was discharged to
___ on last admission on ___ to receive
further counseling. We put him on thiamine, folate, &
multivitamin. Monitored him on ___ protocol Q4H, diazepam 5mg
Q6H for CIWA>12.
#Right ___ finger pain: Pt reported right middle finger pain
without history of trauma. X-ray of finger shows no acute
fracture. Pt did not require pain medication. Unclear if patient
really had injury to finger or was malingering.
#IDDM: Poorly controlled with high insulin resistance. Pt is
followed by ___ last seen on ___ with a HbA1C of
11.4%. Per his recent discharge med list he is on Glargine 60
Units Breakfast and Glargine 30 Units Bedtime and is covered
with humalog sliding scale. However when he was seen at ___
he reported taking 25 units qhs and 50 units in AM and humalog
correction starting at 13 units and going up by 5 units for
every 40 plus bedtime correction. We continued lantus 25 units
QHS and 50 units QAM, & humalog sliding scale. His blood sugars
were within acceptable range on discharge.
Chronic Issues:
# Pancreatic Insufficiency: Patient with known h/o pancreatic
insufficiency in the setting of poorly controlled diabetes and
has had chronically loose stools. On last admission creon was
uptitrated to 4 caps per meal, and his stool remains formed. We
continue Creon 4 caps per meal and QHS.
#Tachycardia: Patient with known h/o sinus tachycardia on
previous admission ___, as well as in the ED on ___, with
persistent asymptomatic tachycardia to 100s at rest and
120s-140s on ambulation. Multiple EKGs demonstrated sinus
tachycardia with incomplete RBB and L anterior hemiblock, but
TTE on previous hospitalization (___) was essentially negative
for underlying pathology. His postural tachycardia is likely ___
diabetic autonomic neuropathy. We considered starting beta
blocker treatment if tachycardia persisted but his HR came down
into the 100-110's.
Transitional Issues: None
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Amitriptyline 100 mg PO HS
2. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
3. Creon 12 4 CAP PO QIDWMHS
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 600 mg PO TID
6. Glargine 60 Units Breakfast
Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Loperamide 2 mg PO QID:PRN diarrhea
8. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
2. Amitriptyline 100 mg PO HS
3. Creon 12 4 CAP PO QIDWMHS
4. Ferrous Sulfate 325 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Gabapentin 600 mg PO TID
7. Glargine 60 Units Breakfast
Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Loperamide 2 mg PO QID:PRN diarrhea
Discharge Disposition:
Home
Discharge Diagnosis:
Right ___ finger pain of unknown etiology
alcohol intocixation
IDDM
pancreatic Insufficiency
Tachycardia
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 on your recent hospitalization
to ___. You were hospitalized because you had right finger
pain, were intoxicated, and we were concerned that you may go
into withdrawal from alcohol. We obtained x-rays of your finger
which did not show any fracures, dislocations, foreign body, or
swelling. You also had images taken of your brain which did not
show any new changes although you do have brain atrophy
(shrinking of your brain size). We monitored you overnight for
signs of alcohol withdrawal. We gave you IV fluids and vitamins.
You currently do not have signs or symptoms of alcohol
withdrawal. We made no changes to your medications.
Followup Instructions:
___
|
19874288-DS-12
| 19,874,288 | 23,162,562 |
DS
| 12 |
2147-06-19 00:00:00
|
2147-06-19 17:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zoloft / Keppra / Lamictal / Trileptal / topiramate
Attending: ___.
Chief Complaint:
bil leg weakness, numbness, urinary retention, worsening back
pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/L2-3 laminectomy (2 months ago) and L4-___ presenting with bilateral leg weakness, numbness and
urinary retention. Reports progressive bilateral leg weakness
and numbness over the last ___s increasing chronic
back pain. Yesterday she was unable to walk her dog anymore and
so she presented to the emergency department. Denies bowel
incontinence or retention. Denies urinary incontinence. Reports
decreased urination over the last 24hrs but did not have a sense
of incomplete empyting of the bladder. No fever or chills.
In ED foley placed with >500cc out. Pt seen by neurosurg. Found
Right leg ___ strength. Left leg ___ strength. Sensation intact
bilaterally though reports decreased sensation in the saddle
region. Normal rectal tone. No perianal anesthesia. MRI
with/without contrast reviewed and discussed with ___ and
Attending, Dr. ___. MRI showing no signs of cord compression.
Symptoms are not explained by imaging. Neurosurg recommend that
urology or Uro-gynecology be consulted to evaluate these urinary
issues (overflow vs retention) prior to return home. Pt given
macrobid, gabapentin and IV morphine.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
# Seizures
# SVT s/p ablation
# Narrow angle glaucoma
# Depression
# cLBP
- s/p L4-L5 lumbar fusion
- s/p L3 full, partial L4 laminectomy (___)
# OA
# s/p R THR, L THR, L shoulder replacement
# s/p appy
# s/p TAH
# s/p CCY
Social History:
___
Family History:
no neurologic disease
Physical Exam:
Vitals: T:98.2 BP:155/69 P:67 R:18 O2:95%ra
PAIN: 7
General: nad
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, mildly tender suprapubic
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands, RLE strength ___ LLE ___
Pertinent Results:
___ 02:10PM GLUCOSE-91 UREA N-15 CREAT-0.8 SODIUM-142
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-28 ANION GAP-14
___ 02:10PM WBC-11.3* RBC-4.96 HGB-13.4 HCT-42.0 MCV-85
MCH-27.0 MCHC-31.9* RDW-13.8 RDWSD-42.6
___ 02:10PM NEUTS-71.6* ___ MONOS-5.7 EOS-1.6
BASOS-0.4 IM ___ AbsNeut-8.11* AbsLymp-2.30 AbsMono-0.64
AbsEos-0.18 AbsBaso-0.04
___ 02:10PM PLT COUNT-187
___ 02:10PM ___ PTT-33.1 ___
___ 06:23PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:23PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG
___ 06:23PM URINE RBC-6* WBC-30* BACTERIA-NONE YEAST-NONE
EPI-0
# MRI L Spine (___): The patient is status post posterior
laminectomy of the L3 and L4 with posterior fusion of L4-L5.
Alignment is unchanged from prior CT from ___, and
no significant canal stenosis is seen.
Postsurgical changes are noted in the paraspinal soft tissues
including granulation tissue, and there is a thin fluid
collection overlying the L3-L4 laminectomy site measuring 3.3 x
1.1 x 0.9 cm. There is subtle peripheral enhancement of this
fluid collection, and infection cannot be excluded.
# L-spine x-ray (Flex/ext) (___): In comparison with the study
of ___, there is little change in the appearance of
the posterior fusion at L4-L5 with laminectomy with no evidence
of hardware-related complication. Mild anterolisthesis at L4-L5
is again seen. The remainder of the vertebra and intervertebral
disc spaces are within normal limits, though there is apparent
osteopenia. Bilateral total hip prostheses are in place.
Brief Hospital Course:
ASSESSMENT & PLAN: ___ yoF h/o Seizures, SVT s/p ablation,
Depression, cLBP s/p L4-L5 lumbar fusion (___), L3 full/partial
L4 laminectomy (___) admitted with bil leg weakness,
numbness, urinary retention, worsening back pain,
# Neuro: Ms. ___ has a long history of back pains - s/p L4-5
lumbar fusion, L3-4 laminectomies ___. She presented with
lower extremity weakness and urinary overlow/retention. She was
evaluated by the neurosurgery team within the ED, and exam
revealed ___ motor strength throughout, L anterior thigh
numbness, no ___ clonus, and normal sphincter control. A L-spine
MRI obtained in the ED showed postoperative changes but no
anatomical findings to account for her symptoms - notably, there
was no focal spinal compression. The findings were unchanged
compared to past CT scan of the lumbar spine.
She was continued with her home regimen of acetaminophen and
oxycodone with good effect. To ensure that there was no dynamic
instability of the spine, L-spine x-ray under ext/flexion
conditions were obtained. This showed no signs of instability.
She was evaluated by ___ and deemed safe for discharge. She can
f/u with Dr. ___ as previously scheduled
# Urinary retention: When Ms. ___ was admitted, she clearly
had evidence of urinary retention. She had a foley placed and
>400 cc of urine was removed with the foley in place. Urology
was contacted and the decision was to have her discharged home
with a foley catheter and to follow up with urology (per her
preference - at the ___ Urological Associates) to perform
urodynamic studies. Other than the oxycodone (which she does
not take frequently), there was no identifiable medication to
cause urinary retention. Given her past vaginal deliveries, she
may have structural etiologies for her retention.
She was found during this hospitalization to have a dirty
U/A: ___ large, Nit neg, RBC 6 WBC 30. Urine culture grew
>100,000 ampicillin enterococcus. She was initially treated
with ceftriaxone - and then switched to ampicillin IV and later
PO augmenin (once the enterococcus was identified). She will
complete a 7 day course for complicated UTI. Foley care
training was provided to the patient.
# OTHER ISSUES AS OUTLINED.
#FEN: [] IVF [X] Oral [] NPO [] Tube Feeds []
Parenteral
#DVT PROPHYLAXIS: [X]heparin sc []SCDs
#LINES/DRAINS: [X] Peripheral [] PICC [] CVL [] Foley
#PRECAUTIONS: None
#COMMUNICATION: pt and daughter (HCP, ___ ___
#CONSULTS: ___ (contacted urology)
#CODE STATUS: [X]full code []DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Duloxetine 60 mg PO DAILY
2. Gabapentin 900 mg PO QHS
3. Gabapentin 600 mg PO QAM
4. Gabapentin 300 mg PO Q AFTERNOON
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
6. TraZODone 100 mg PO QHS
Discharge Medications:
1. Duloxetine 60 mg PO DAILY
2. Gabapentin 900 mg PO QHS
3. Gabapentin 600 mg PO QAM
4. Gabapentin 300 mg PO Q AFTERNOON
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
6. TraZODone 100 mg PO QHS
7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth every twelve (12) hours Disp #*12 Tablet
Refills:*0
8. Ibuprofen 600 mg PO Q8H:PRN headache/pain
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary retention
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure looking after you, Ms. ___. As you know,
you were admitted with lower extremity weakness, back pain, and
urinary retention. You had extensive workup for your symptoms -
including MRI L-spine and Lumbar x-ray in extension/flexion
positions. These results did not show any anatomical or
distinct cause for your symptoms. There was no impingement of
the spinal cord. As a result, the neurosurgery team (Dr.
___ did not recommend a surgical intervention.
You were noted to have a distended bladder from a urinary
retention. A foley catheter was placed with significant output
of urine. You will be discharged with the foley, and we
recommend that you follow with the urologist at ___ to do a
urodynamic testing to assess the cause of the urinary retention.
You also had a urinary tract infection (Enterococcus). For
this, you were placed on ampicillin (IV) and then subsequently
an oral antibiotic - Augmentin. This should be completed for an
additional 6 days.
Followup Instructions:
___
|
19874582-DS-11
| 19,874,582 | 25,101,421 |
DS
| 11 |
2120-06-05 00:00:00
|
2120-06-05 21:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / morphine / benzoil peroxide
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ laparoscopic appendectomy
History of Present Illness:
___ y/o M c/o abd pain since last night. initially
perimbulical, now RLQ. +anorexia, no n/v/d
He has had abd pain in the past, colonoscopies that just showed
inflammation, He underwent a cat scan upon admission which
showed acute uncomplicated appendicitis.
on truvada for PEP only
Past Medical History:
none
Social History:
___
Family History:
unknown
Physical Exam:
PHYSICAL EXAMINATION: ___
Temp: 99.0 HR: 116 BP: 130/74 Resp: 18 O(2)Sat: 99 Normal
Constitutional: Constitutional: comfortable
Head
/ Eyes: NC/AT
ENT: OP WNL
Resp: CTAB
Cards: RRR. s1,s2. no MRG.
Abd: S/+RLQ tenderness/ND
Flank: no CVAT
Skin: no rash
Ext: No c/c/e
Neuro: speech fluent
Psych: normal mood
Physical examination upon discharge: ___
General: NAD
CV: ns1, s2 ,-s3, -s4
LUNGS: clear
ABDOMEN: soft, tender, derma-bond on port sites, white covering
in umbilical port with derma-bond dressing
EXT: no pedal edema bil., no calf tenderness bil
NEURO: Alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 04:50PM BLOOD WBC-13.6* RBC-4.81 Hgb-15.5 Hct-46.7
MCV-97 MCH-32.2* MCHC-33.2 RDW-12.3 RDWSD-43.8 Plt ___
___ 04:50PM BLOOD Neuts-79.2* Lymphs-11.0* Monos-8.4
Eos-0.4* Baso-0.6 Im ___ AbsNeut-10.76* AbsLymp-1.50
AbsMono-1.14* AbsEos-0.05 AbsBaso-0.08
___ 04:50PM BLOOD Plt ___
___ 04:50PM BLOOD ___ PTT-34.7 ___
___ 04:50PM BLOOD Glucose-96 UreaN-13 Creat-0.9 Na-142
K-4.7 Cl-100 HCO3-32 AnGap-15
___ 04:50PM BLOOD Albumin-5.0
___: cat scan of abdomen and pelvis:
Acute uncomplicated appendicitis.
Brief Hospital Course:
___ year old male admitted to the hospital with abdominal pain.
He underwent a cat scan of the abdomen which showed a dilated
appendix with thickened walls, findings suggestive of acute
appendicitis. The patient was taken to the operating room where
he underwent a laparoscopic appendectomy.
The patient's operative course was stable with minimal blood
loss. He was extubated after the procedure and monitored in the
recovery room. After recovery from anesthesia, he resumed clear
liquids and advanced to a regular diet. His vital signs were
stable and he was afebrile. His pain was controlled with oral
analgesia and he was voiding without difficulty.
He was discharged home on the operative day in stable condition.
Post-operative instructions were reviewed prior to discharge.
A follow-up appointment was made in the acute care clinic.
Medications on Admission:
truvada PRN (prophylaxis)
Discharge Medications:
1. 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
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
may cause drowsines, do not drive while on this medicaiton
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
3. Senna 8.6 mg PO BID
4. Acetaminophen 650 mg PO Q6H
x 3 days then take every 6 hours as needed
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You
underwent a cat scan and you were found to appendicitis. You
were taken to the operating room to have your appendix removed.
You have done well since her surgery and you are preparing for
discharge home with the following instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
19875127-DS-21
| 19,875,127 | 27,651,507 |
DS
| 21 |
2123-04-18 00:00:00
|
2123-04-18 14:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F h/o squamous cell lung CA admitted with weakness and
dyspnea. The patient reports that she feels the same as she has
felt for many months with her baseline dyspnea and dry cough
with associated R-sided pleuritic CP, ___ intermittently.
However, per report, her family notes that she has been weaker
at home with increased needs in regards to her ADLs.
.
In the ED: 97.7 70 119/46 18 95%. initial Na 124. Pt given 1LNS
and repeat Na 128. cr 1.2 (up from baseline 0.9). CTA showed
known mass but no PE or PNA. Admitted to OMED.
.
ROS: as above; o/w complete ROS negative
Past Medical History:
# HTN
# sev COPD
# Lung CA
- torso CT: 5.7 cm spiculated mass in L apex abutting adjacent
vertebral bodies, ribs and adjacent to inf aspect of L
subclavian artery.
- CT-guided biopsy ___ differentiated squamous cell
carcinoma. TTF-1 +, ER/PR mammaglobin -, GCDFP -, Napsin -
- carboplatin/taxol 5 cycles,
- XRT
# Breast CA (infiltrating ductal carcinoma) ___
- T1c, N0, M0 grade III, ER/PR negative, HER-2/neu negative
stage I breastcancer. Nine axillary nodes negative.
- XRT L breast
# chronic small vessel infarction (brain MRI)
# mechanical fall s/p R pubic rami fx
# GERD
Social History:
___
Family History:
denies FH of malignancy
Physical Exam:
t98 124/78 70 20 95% ra
NAD
eomi, perrl
neck supple
no ___
chest clear
rrr
abd benign
ext w/wp
neuro non-focal
no rash
Pertinent Results:
___ 02:14PM NA+-128* K+-4.9
___ 01:55PM OSMOLAL-276
___ 12:13PM D-DIMER-1361*
___ 12:13PM WBC-1.5* RBC-2.80* HGB-9.0* HCT-26.7* MCV-95
MCH-32.0 MCHC-33.6 RDW-16.9*
___ 12:13PM NEUTS-72* BANDS-0 ___ MONOS-7 EOS-1
BASOS-0 ___ MYELOS-0
___ 10:00AM UREA N-20 CREAT-0.9 SODIUM-126*
POTASSIUM-5.3* CHLORIDE-90* TOTAL CO2-30 ANION GAP-11
___ 10:00AM CORTISOL-32.9*
___ 10:00AM NEUTS-80.3* LYMPHS-12.3* MONOS-7.0 EOS-0.3
BASOS-0.2
___ 10:00AM PLT COUNT-128*
.
CTA CHEST:
TECHNIQUE: Axial helical MDCT images were obtained from the
suprasternal
notch to the upper abdomen following the administration of 100
cc of
Omnipaque. Multiplanar reformatted images in coronal and
sagittal axes were
generated. Oblique MIPS were prepared in an independent work
station.
COMPARISON: Comparison is made to PET-CT dated ___,
and CT torso
dated ___.
FINDINGS:
CT THORAX:
Lung windows demonstrate a 5.7 x 4.5 cm left apical lung mass,
unchanged
compared to the prior examination. A few scattered small
nodules and nodular
densities also appear unchanged.
Severe, bilateral, panlobular emphysematous changes are noted.
No pleural effusion or pneumothorax is present. The airways are
patent to the
subsegmental level. Aerosolized secretions are seen within the
right mainstem
bronchus.
There is no mediastinal, hilar, or axillary lymph node
enlargement by CT size
criteria. Heart, pericardium, and great vessels are within
normal limits. No
hiatal hernia. The esophagus is mildly thickened, which may be
due to
radiation.
CTA THORAX: The aorta and main thoracic vessels are well
opacified. The
aorta demonstrates normal caliber throughout the thorax without
intramural
hematoma or dissection. The pulmonary arteries are opacified to
the segmental
level. The right and left pulmonary arteries are mildly
enlarged. There is no
filling defect to suggest pulmonary embolism.
BONES: Vertebral compression deformities of the T10 and T11
vertebral bodies
are noted, not identified on the prior CT Torso. No focal
osseous lesions
concerning for malignancy are seen.
Although this study is not designed for assessment of
intra-abdominal
structures, the visualized solid organs and stomach are
unremarkable.
Bilateral renal hypodensities are incompletely characterized but
likely
represent cysts.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Stable 5.7 x 4.5 cm left apical lung mass; small scattered
nodules and
nodular densities also appear unchanged.
3. Severe, bilateral, panlobular emphysematous changes.
4. Aerosolized secretions are seen within the right mainstem
bronchus.
5. New mild superior endplate compression fractures of T10 and
T11, new since
the earlier torso CT and probably new or increased since the
more recent
PET-CT study.
Brief Hospital Course:
___ yo F h/o squamous cell lung CA admitted with weakness
.
#WEAKNESS:
#CHEMOTHERAPY INDUCED ANEMIA:
Ms. ___ was admitted with physical weakness - notably after
the ___ cycle of chemotherapy and recent radiation therapy.
This weakness was attributed to the chemotherapy, anemia, with a
possible component of hyponatremia and depression. There was no
evidence of infection - CTA chest, U/A, blood cx, TSH were all
wnl. She was afebrile and had no focal infection. He was
found to have a hematocrit of 24 and nadir of 21.9. There was
no evidence of active bleeding. She underwent a 2u pRBC blood
transfusion and tolerated without problems.
She lives with her elderly husband and required more
assistance than can be provided at home. She was evaluated by ___
- who determined that she would benefit from rehab and was too
weak to go home.
.
#Hyponatremia: She was found to have a sodium of 120. Serum osm
were low end of normal with high urine sodium and osmolarity
most c/w SIADH in setting of known pulmonary malignancy. She was
fluid restricted to 1.5L/day. Her sodium improved to 131-132.
This should continue to be monitored - and salt tablets may be
considered if there is any worsening. .
.
#Lung CA: She recently completed her ___ cycle of
taxol/carboplatin as well as radiation therapy. Radiation
treatment was continued during this hospitalization and
reportedly has an additional 5 treatments. She has been magic
mouthwash PRN, compazine PRN. She was temporarily neutropenic
but with ANC 700 and increasing WBC, no longer needs to be
neutropenic. She was on magic mouthwash PRN, compazine PRN
.
#HTN: home lisinopril has been held
# GERD: ppi
# COPD:
- on salmeterol, tiotropium
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Omeprazole 20 mg PO DAILY
2. Tiotropium Bromide 1 CAP IH DAILY
3. Prochlorperazine 10 mg PO Q6H:PRN n/v
4. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Prochlorperazine 10 mg PO Q6H:PRN n/v
4. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
5. Tiotropium Bromide 1 CAP IH DAILY
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob
8. Maalox/Diphenhydramine/Lidocaine ___ mL PO TID:PRN before
meals
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Weakness
Anemia
Hyponatremia
Lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure to participate in your care. You were admitted
with weakness. You were found to have a low blood count (anemia)
due to the chemotherapy.
You were also found to have a low sodium level (hyponatremia).
This is likely due to the lung cancer. We recommend that you
limit the oral intake of fluids (1.5L/day) to avoid the sodium
getting too low. This can be followed at the rehab.
Please continue with the radiation therapy.
Followup Instructions:
___
|
19875364-DS-17
| 19,875,364 | 21,806,591 |
DS
| 17 |
2174-11-20 00:00:00
|
2174-11-20 09:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
thimerosal
Attending: ___.
Chief Complaint:
Code Stroke
Major Surgical or Invasive Procedure:
Brain biopsy
History of Present Illness:
HPI: The patient is a ___ year old right-handed man with a
history of recent fall with subsequent finding of SAH and brain
lesion with leptomeningeal enhancement and CSF pleocytosis. He
is referred to the ED from Neurology Clinic for confusion.
Neurology is consulted as part of a code stroke. History is
obtained from the patient's wife and the discharge summary from
___.
The patient was apparently well until approximately ___ when he
slipped on ice while walking his dog. There was a head strike
and minimal (seconds), if any, loss of consciousness.
Afterwards he took aspirin for headaches and ultimately
presented to ___ on ___ with headaches, nausea and
word-finding difficulty. Initial exam documented as afebrile
with SBP to 150s, awake ox3, "intermittent word finding
difficulties" but intact naming and repetition. CN, sensory,
cerebellar, and motor exams were documented as normal. He was
found to have left frontal lobe SAH on ___ and further imaging
with MRI showed multiple left hemispheric lesions and
leptomeningeal enhancement diffusely. CSF showed WBC 32,
protein 199, glucose 81. Cytology was negative. There may have
also been some viral studies which were negative. He was
initiated on Keppra for seizure ppx although no clinical
seizures were seen. Routine EEG showed left hemispheric slowing
but no epileptiform discharges. He was described as having
"cognitive slowing" that improved when keppra was decreased to
750mg BID. At the time of hospital discharge on ___, he is
reported as "AOx4, word finding difficulty present in
general conversation. Not able to follow complex commands.
Strength sensation coordination grossly intact."
His wife notes that the patient's language started to be
abnormal during his hospitalization and at the time of discharge
on ___ he was not fully conversational. Over the weekend, he
was answering only in yes and no answers but was still able to
go for walks with her and move arms and legs appropriately. He
was eating without difficulty.
Last night, Mr. ___ was much more agitated than usual and
was making frequent trips to the bathroom but wife did not think
he had diarrhea or was vomiting. He may have been trying to
urinate each time; wife was not sure.
Today, he appeared especially tired. She brought her husband to
see Dr. ___ neurologist) at ___ for a second
opinion. In the office, Mr. ___ slumped forward with eyes
closed and was not answering their questions for an unclear
amount of time. Per her report, vitals were stable. He was
referred to the ED.
In the ED, he was awake but lethargic and was saying yes, no,
and I don't know unreliably to questioning. A code stroke was
called at 11:56am. As described above, it was difficult to
understand time last known well, but per wife's estimation this
may have been 530am. Mr. ___ himself could not offer any
additional history. He was dry heaving and nauseated in the ED
and given
Zofran with good effect. NCHCT and CTA H&N were obtained as
described below.
ROS cannot be obtained from patient given aphasia. Positive
urinary frequency overnight. Per wife, no recent weight loss,
fevers/chills or nightsweats. No recent illnesses.
Past Medical History:
PMH/PSH:
- HLD on statin
- Recent fall (? mechanical) with resultant left frontal SAH and
finding of multiple left hemispheric lesions and leptomeningeal
enhancement and CSF pleocytosis without clear etiology
Social History:
___
Family History:
FAMILY HISTORY: No family history of stroke, seizure or
neurological conditions to his wife's knowledge.
Physical Exam:
============================================================
ADMISSION PHYSICAL EXAMINATION
============================================================
Vitals: 97.7 72 132/101 16 100% RA
General: Thin appearing man, appears unwell, eyes closed lying
in bed
HEENT: Posterior scalp with abrasion, no oropharyngeal lesions,
neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental Status - At time of intial code stroke he was lethargic
but arousable to loud voice, later on he was alert and awake.
He
was mildly inattentive. Not oriented to person place or time.
Comprehension was severely impaired and he would say only "yes,
no, I don't know" in a unreliable fashion when asked questions.
He did open mouth and smile on command, but not all one step
commands were followed reliably. No dysarthria. He did not
seem
to be bothered by his lack of understanding. Did not attempt to
communicate his needs through verbal gestures. Not technically
fluent because longest phrase 3 words and actually was a catch
phrase. He responded somewhat to visual cuing, for example
participated in confrontational strength exam. No evidence of
neglect.
- Cranial Nerves - Pupils round, right 2->1.5, left 2.5 -> 1.5
Hard to assess visual fields because does understand formal
testing and does not blink to threat reliably. EOMI on rough
assessment. R NLFF, but good activation. Hearing intact to
clap
bilaterally. Palate elevation symmetric. Tongue midline.
- Motor - Normal bulk and tone. No drift. Fine postural tremor.
No asterixis
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - He grimaces to noxious stimulus to all extremities.
Does not participate in DSS testing.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2+ 3 3 4
R 3 2+ 3 4 4
Crossed adductor on right. Bilateral pec jerk present.
Right knee with 2 beats of clonus, Right ankle with 4 beats
clonus. Left ankle with ___ beats clonus. No clonus at left
knee. Withdrawal vs toes down bilaterally.
- Coordination - assessment limited by comprehension deficit
- Gait - deferred
============================================================
DISCHARGE PHYSICAL EXAMINATION
============================================================
MS: speech fluent, able to say 5 word sentences, able to repeat
short phrases accurately, repeats long phrases with a few word
substitutions at the end, able to follow commands, moves all
extremities spontaneously
Pertinent Results:
============================================================
PERTINENT LAB RESULTS
============================================================
___ 06:00AM BLOOD WBC-7.4 RBC-4.34* Hgb-14.0 Hct-40.1
MCV-92 MCH-32.3* MCHC-34.9 RDW-11.9 RDWSD-40.6 Plt ___
___ 11:45AM BLOOD WBC-16.3*# RBC-4.81 Hgb-15.6 Hct-44.3
MCV-92 MCH-32.4* MCHC-35.2 RDW-11.9 RDWSD-40.2 Plt ___
___ 06:05AM BLOOD Neuts-58.8 ___ Monos-10.9 Eos-1.4
Baso-0.9 Im ___ AbsNeut-6.40* AbsLymp-3.00 AbsMono-1.19*
AbsEos-0.15 AbsBaso-0.10*
___ 06:00AM BLOOD Plt ___
___ 11:45AM BLOOD ___ PTT-26.9 ___
___ 05:55PM BLOOD Lupus-NEG
___ 06:00AM BLOOD Glucose-166* UreaN-25* Creat-0.7 Na-137
K-3.8 Cl-102 HCO3-27 AnGap-12
___ 11:45AM BLOOD UreaN-22*
___ 06:05AM BLOOD Glucose-104* UreaN-19 Creat-0.9 Na-138
K-4.3 Cl-101 HCO3-27 AnGap-14
___ 06:05AM BLOOD ALT-18 AST-18 LD(LDH)-196 AlkPhos-47
TotBili-0.7
___ 06:00AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.4
___ 06:05AM BLOOD Albumin-4.0 Calcium-9.5 Phos-4.8* Mg-2.4
Cholest-169
___ 05:55PM BLOOD Cryoglb-NO CRYOGLO
___ 06:50AM BLOOD %HbA1c-5.6 eAG-114
___ 06:05AM BLOOD Triglyc-53 HDL-85 CHOL/HD-2.0 LDLcalc-73
___ 06:05AM BLOOD TSH-1.1
___ 05:55PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE
___ 05:55PM BLOOD ANCA-NEGATIVE B
___ 05:55PM BLOOD dsDNA-NEGATIVE
___ 05:55PM BLOOD CRP-6.2*
___ 06:05AM BLOOD ___
___ 06:05AM BLOOD CRP-8.4*
___ 05:55PM BLOOD PEP-NO SPECIFI IgG-636* IgA-96 IgM-60
IFE-NO MONOCLO
___ 06:00AM BLOOD C3-106 C4-31
___ 03:30PM BLOOD HIV Ab-Negative
___ 05:55PM BLOOD HCV Ab-NEGATIVE
___ 11:53AM BLOOD ___ pO2-34* pCO2-39 pH-7.44
calTCO2-27 Base XS-1 Comment-STROKE
___ 11:53AM BLOOD Glucose-178* Na-136 K-3.9 Cl-98
calHCO3-26
___ 06:00AM BLOOD RO & ___
___ 06:00AM BLOOD RNP ANTIBODY-NEGATIVE
___ 11:05AM BLOOD MULTIPLE SCLEROSIS (MS) PROFILE-NEGATIVE
___ 05:55PM BLOOD CARDIOLIPIN ANTIBODIES (IGG,
IGM)-NEGATIVE
___ 05:55PM BLOOD SM ANTIBODY-NEGATIVE
___ 05:55PM BLOOD RNP ANTIBODY-NEGATIVE
___ 05:55PM BLOOD HEPATITIS Be ANTIGEN-NEGATIVE
___ 05:55PM BLOOD BARTONELLA (ROCHALIMEA) HENSELAE
ANTIBODIES, IGG AND IGM-NEGATIVE
___ 05:55PM BLOOD ASPERGILLUS ANTIBODY-NEGATIVE
___ 05:55PM BLOOD ANGIOTENSIN 1 - CONVERTING ___
___ 12:59PM BLOOD QUANTIFERON-TB GOLD-NEGATIVE
___ 06:05AM BLOOD SED RATE-2
============================================================
IMAGING
============================================================
CTA H/N ___
1. Large hypodensity in the left parietal, posterior temporal,
and occipital lobes has progressed since ___, with
mild mass effect on the left lateral ventricle and with relative
paucity of superficial blood vessels along the left parietal and
occipital lobes. Small hypodensity in the posterior inferior
right frontal lobe is new compared to ___. At the
time of final interpretation, biopsy has been performed, and
correlation with biopsy results is recommended.
2. No evidence for flow-limiting stenosis involving the major
cervical or
intracranial arteries.
3. No evidence for intracranial aneurysm or arteriovenous
malformation.
Painted major dural venous sinuses.
CT head ___
Stable hypodensity involving the left parietal, temporal, and
occipital cortex and white matter compared to ___,
with stable mass effect left lateral ventricle and stable mild
rightward shift of midline structures. No acute hemorrhage.
Please correlate with biopsy results.
CT abdomen/pelvis ___
No evidence of metastatic disease within the abdomen or pelvis.
CT chest ___
No lymphadenopathy. No suspicious lung nodules or masses. No
pleural
abnormalities.
CXR ___
Heart size and mediastinum are stable. Lungs are essentially
clear. No
pleural effusion or pneumothorax.
CXR ___
Right costophrenic angle not fully included on the image. Given
this, no
acute cardiopulmonary process seen.
MRI ___
1. Multiple supra and infratentorial subacute infarctions, with
associated
petechial hemorrhage, left greater than right, involving both
the gray and
white matter, which may be secondary to an embolic etiology from
a cardiac
source. Recommend correlation with echocardiogram. Associated
edema
resulting in sulcal effacement, predominantly along the left
parietal,
occipital and temporal lobes which may be a sequelae of the
evolving infarcts. Alternatively, this could represent amyloid
associated angiography with superimposed infarctions.
2. Multi focal abnormal leptomeningeal signal with associated
contrast
enhancement, which may represent subarachnoid hemorrhage from
the infarctions, or infection, although infection is less likely
given patient's clinical condition. Leptomeningeal
carcinomatosis were inflammation are also less likely given
negative results of prior CSF sample from the lumbar puncture.
Infection could give rise to infarction and hemorrhage.
Carcinomatosis or inflammation would be difficult to at
reconciled with the evidence of infarction and hemorrhage.
MRI ___
Marked interval progression of extensive leptomeningeal
enhancement with
areas of nodular thickening and enhancement, left greater than
right with some mass effect and effacement of left lateral
ventricle compared to the prior MRI from ___.
Given the rapid interval progression, infectious or inflammatory
etiologies, especially fungal are favored to be most likely.
The other possible etiology is leptomeningeal carcinomatosis
though favored to be less likely given the absence of any
primary malignancy identified so far. Sarcoidosis is unlikely
given the rapid progression.
Abd KUB ___
Normal bowel gas pattern. No evidence of bowel obstruction.
============================================================
OTHER DIAGNOSTIC TESTS
============================================================
EKG ___
Sinus rhythm. Baseline artifact. Tracing is within normal
limits.
Compared to the previous tracing of ___ the heart rate is
faster but
other findings are similar.
EKG ___
Limb lead reversal. Sinus bradycardia. Prominent R waves in
leads V1-V3
consistent with possible prior inferoposterior myocardial
infarction. Clinical correlation is suggested. Non-specific ST
segment changes. Compared to the previous tracing of ___
limb lead reversal is now appreciated and prominent R waves are
now seen in leads V1-V3.
EKG ___
Artifact is present. Sinus rhythm. Atrial ectopy. Non-specific
ST-T wave
changes. Compared to the previous tracing of ___ atrial
ectopy is new.
Early transition is no longer present and ST-T wave changes are
new.
LP cytology
Neg for malig cells
LP flow cytometry ___
RESULTS: 10-color analysis with linear side scatter vs. CD45
gating was used to evaluate lymphocytes, blasts, plasma cells. B
cells comprise 2% of lymphoid-gated events, are polyclonal. T
cells comprise 89% of lymphoid gated events. T cells have an
elevated helper-cytotoxic ratio of 10.
INTERPRETATION: Nonspecific T cell dominant lymphoid profile in
this limited panel; diagnostic immunophenotypic features of
involvement by lymphoma are not seen in specimen. Note is an
elevated ratio of CD4:CD8 (10). Correlation with clinical
findings and morphology (see separate pathology report
___-___) is recommended. Flow cytometry immunophenotyping may
not detect all abnormal populations due to topography, sampling
or artifacts of sample preparation.
Brief Hospital Course:
SUMMARY:
Mr. ___ is a ___ year-old right-handed man with a history of
fatigue x 6 months, mild cognitive problems x ___ months with an
acute worsening over the preceding 2 weeks, a fall with
posterior head trauma on ___, recent OSH admission ___ for
confusion / aphasia (SAH and enhancement on MRI, 32 WBC in CSF,
EEG neg) now admitted here ___ for worsening confusion /
aphasia. Neurology was initially consulted as part of a code
stroke for concern of acute change in mental status the morning
of admission. On exam, the patient had a fluent aphasia with
severely impaired comprehension, hyperreflexia throughout, and
slight right nasolabial fold flattening without other motor
weakness. He was admitted to the general neurology service for
further workup. MRi was notable for multifocal subacute
infarctions, L parietal / occipital edema, petechial and
subarachnoid hemorrhage, and L occipital / parietal
leptomeningeal enhancement. CTA shows small L MCA but neck
vessels clear. TTE from ___ was normal. The initial
differential considered for multi-focal infarcts with associated
SAH, edema, and enhancement was broad and included cardioembolic
stroke with hemorrhagic conversion and secondary inflammation,
inflammatory cerebral amyloid angiopathy, SAH with vasospasm,
vasculitis, CNS infection, and strokes secondary to
intravascular lymphoma. He underwent testing including
inflammatory vasculitis markers, LP cytology and flow cytometry,
infectious workup, MS panel, and serum immunoglobulin, all of
which was negative. The patient also underwent a brain biopsy
with the initial read consistent with inflammatory CAA, which
was felt to be the most likely diagnosis, and he was initiated
on a course of steroids with significant improvement in his
aphasia and cognitive function. The final pathology read and
additional microbiology stains were pending at the time of
discharge.
ACUTE:
#Cognitive decline / aphasia:
Given the patient's MRI findings concerning for a possible
inflammatory or infectious process, rheumatology and infectious
disease were consulted during the initial workup. Patient
underwent extensive testing for potential causes of his
cognitive decline and MRI findings, including inflammatory
markers (CRP, ESR), markers for autoimmune and connective tissue
disease (C3/C4, anti-RNP, ___, cardiolipin, ANCA, dsDNA,
ACE), infectious workup (HIV, Hep B, Hep C, Bartonella,
Aspergillus, Lyme disease), lymphoma workup (LP cytology and
flow cytometry, immunoglobulins), tox screen, as well as testing
for MS, multiple myeloma, ACE. Additional workup for other
vascular causes was negative including a head and neck CTA and
TTE. He also underwent a CT chest and CT abdomen/pelvis which
revealed no malignancy or lymphadenopathy. When the preliminary
read of the brain biopsy pathology was found to be consistent
with inflammatory CAA, the patient was initiated on a 5 day
course of methylprednisolone. He was then started on 60 mg
prednisone BID with plans to begin to taper the dose after 1
month. Patient was also initially placed on Keppra for seizure
prophylaxis, which was discontinued on hospital day 7. Given the
high dose steroid course, the patient was given Ca, Vit D,
Bactrim for PCP prophylaxis, and an insulin sliding scale with
regular finger sticks. During the hospitalization, patient
demonstrated marked improvement of his aphasia and by the time
of his discharge, he was able to... ######## ... He will
continue to be followed on an outpatient basis by both
rheumatology and neurology, and rheumatology will manage his
steroid taper and initiation of cyclophosphamide if the final
pathology results confirm inflammatory CAA and rule out
infection.
#Urinary retention:
During the course of his hospitalization, patient began to
complain of difficulty urinating without dysuria. Bladder scans
revealed post-void residuals of 400-600 and patient underwent
periodic straight catheterizations until he refused them. Per
report from patient's wife, he has a history of urinary
frequency and had been on oxybutynin at home, which was not
administered during the hospitalization. Although patient has a
history of prostate cancer he is s/p radiation and
prostatectomy. On exam, his abdomen was soft, non-tender, and
non-distended. His medications were reviewed, UA and urine
culture were negative for infection, and the cause of his acute
urinary retention was unclear. Patient continued to refuse Foley
placement or straight caths. Flomax was initiated and patient's
urinary output appeared to improve.
CHRONIC:
#Hypertension: Patient was continued on his home metoprolol and
his blood pressures were maintained SBP < 170. His home aspirin
was restarted during his hospitalization.
#Hyperlipidemia: Patient was continued on home atorvastatin
#Prostate cancer s/p radiation and prostatectomy: no further
management
#Transitional issues:
- Final pathology from the brain biopsy was pending at the time
of discharge
- Ro and ___ were pending at the time of discharge
- Patient will continue prednisone 60mg for 1 month (end date
___, rheumatology will prescribe the prednisone taper at his
appointment in 1 week) and will have outpatient follow-up with
rheumatology who will manage his prednisone taper and initiation
of cyclophosphamide if the final pathology confirms inflammatory
CAA and rules out infection
- Patient has completed baseline labwork required before
initiation of cyclophosphamide (CBC w diff, serum Cr, UA, LFTs,
Hep B and C, latent TB)
- Patient should remain on Ca, Vit D, bactrim SS qd while on
high-dose prednisone
- Patient will require outpatient bone density scan given
steroid course
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxybutynin 5 mg PO DAILY
2. zaleplon 10 mg oral DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Multivitamins 1 TAB PO DAILY
6. LeVETiracetam 750 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Fish Oil (Omega 3) Dose is Unknown PO DAILY
9. sildenafil 100 mg oral ONCE:PRN
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Oxybutynin 5 mg PO DAILY
7. sildenafil 100 mg oral ONCE:PRN
8. zaleplon 10 mg oral DAILY
9. Calcium Carbonate 500 mg PO DAILY
10. PredniSONE 60 mg PO DAILY Duration: 30 Doses
11. Sulfameth/Trimethoprim DS 1 TAB PO BID
12. Tamsulosin 0.4 mg PO QHS
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
Cerebral amyloid angiopathy, inflammatory subtype
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance.
Neuro: alert, able to repeat short sentences correctly but has
some word substitutions with long sentences, speech is better
with 5 word sentences, follows commands
Discharge Instructions:
Dear Mr. ___,
You were admitted with an episode of unresponsiveness and
difficulty speaking to the neurology service. Your imaging
revealed a large area of inflammation on the left side of your
brain, enhancement (lighting up) of the lining of your brain on
the left, small areas of bleeding, and new strokes. Your brain
biopsy revealed the inflammatory subtype of cerebral amyloid
angiopathy. You were treated with 5 days of IV steroids. The
infectious disease and rheumatology consultant agreed on this
plan. The remainder of your work-up (including blood work, urine
studies, spinal fluid) was unrevealing.
You will go home on 60mg of prednisone (steroid) daily for one
month. After that, the rheumatology team will decide how to
taper your steroids and whether you need cyclophosphamide. Some
pathology stains are still pending. You will get a phone call to
schedule a bone density scan. You will be treated with calcium,
vitamin D, famotidine, and bactrim while on steroids.
It was a pleasure meeting you!
Your ___ Team
Followup Instructions:
___
|
19875364-DS-18
| 19,875,364 | 23,970,540 |
DS
| 18 |
2174-12-04 00:00:00
|
2174-12-04 17:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
thimerosal
Attending: ___.
Chief Complaint:
Altered mental status, recent discharge from
neurology service.
Major Surgical or Invasive Procedure:
Cytoxan ___
History of Present Illness:
Mr. ___ is a ___ year-old right-handed man with a recent
diagnosis of CAA based on brain bx in the setting of neurologic
decline s/p recent discharge who presents for recurrent
neurologic cogntive decline.
For complete history of recent hospitalization, please review
discharge summary in our system. In Brief, he was admitted on
___ in the setting of progressive language decline, altered
mental status and an episode of possible LoC in an outpatient
clinic following a recent admission for ___ at ___. On the neurology service, he was found to have a
fluent aphasia, impaired comprehension and diffuse
hyper-reflexia. He underwent extensive evaluation including
"MRI
was notable for multifocal subacute
infarctions, L parietal / occipital edema, petechial and
subarachnoid hemorrhage, and L occipital / parietal
leptomeningeal enhancement", LP (found to have pleocytosis) with
normal flow and cytometry, infectious evaluation, MS panel and
serum ___ evaluation, which was unrevealing.
Eventually, on ___ he underwent brain biopsy, which was felt to
be consistent with inflammatory CAA. He was started on
corticosteroids- a 5 day pulse of methylprednisone 1g x5 days
and
then Prednisone 60mg PO QD- with significant improvement in his
mental status. He was discharged on oral prednisone.
Following discharge, he was initially was getting better and was
rehabbing at ___. Though still altered from baseline he
was ambulatory and conversant. Starting roughly ___
(roughly 3 days PTA) he began to have a cognitive decline.
Exact
details are unclear, but according to his wife who is at bedside
his "though process" has become fuzzy again and he could not
recall names or birthdays well. One night he called his wife at
2am, saying "I don't feel good and they are not treating me for
it". He once again became more confused. There was also
concern
for ambulatory difficulties and he had an episode of "knee
buckling today"
Of note however, at ___ I am told he had a disruptive
roommate and has not been sleeping well.
RoS unable to be gathered from the patient. The patient states
he otherwise feels well.
Past Medical History:
- HLD
- Recent fall (? mechanical) with resultant left frontal SAH and
finding of multiple left hemispheric lesions and leptomeningeal
enhancement and CSF pleocytosis without clear etiology
- Inflammatory cerebral amyloid angiopathy
Social History:
___
Family History:
No family history of stroke, seizure or neurological conditions
to his wife's knowledge.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals:
97.8 65 121/72 18 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT. Well healing biopsy site.
Neck: Supple,. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR
Abdomen: soft, mildly tender.
Extremities: WWP.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person. States he is at
___. Is unsure of date, month or year. He is
unable
to provide his own history and when asked begins to discuss a
convoluted story about his neighbor's dog. He is moderately
attentive to examiner, but cannot do attentive tasks. His
language in fluent, but with frequent neologisms. He can repeat
simple ___ word phrases, but not more complex phrases. Low and
high frequency naming is impaired (cannot name glove, hand,
finger, nail). Speech was not dysarthric. He is able to follow
some cammonds and relies on visual cues for others. He
demonstrated apraxia in both hands (brush your teeth, comb your
hair). No evidence of neglect. Recall is ___ at 2 min
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI grossly intact
without nystagmus. Visual fields appears grossly full to finger
wiggle.
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. Both arms drift upward
with
assessment of pronator drift (right>left).
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 throughout. No extinction
to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 3
R 3+ 3 3+ 3 3
Plantar response was flexor bilaterally.
+ Snout reflex. B/l Positive Palmomental reflexes
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
==============================================================
DISCHARGE PHYSICAL EXAM:
MS: Alert and oriented to self, not place or date. Difficulty
naming low frequency objects. Unable to follow complex commands.
Able to follow simple commands. + Nonsensenical speech. Minimal
spontaneous verbal output. +Perseveration.
CN: Eyes move in all directions. V1-V3 intact. No facial
asymmetry. Tongue midline.
Motor: No drift.
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
Gait: deferred
Pertinent Results:
ADMISSION LABS:
___ 12:31AM BLOOD WBC-19.2*# RBC-4.33* Hgb-13.9 Hct-40.7
MCV-94 MCH-32.1* MCHC-34.2 RDW-12.5 RDWSD-43.4 Plt ___
___ 12:31AM BLOOD Neuts-81.3* Lymphs-11.1* Monos-6.4
Eos-0.6* Baso-0.1 Im ___ AbsNeut-15.59*# AbsLymp-2.13
AbsMono-1.23* AbsEos-0.12 AbsBaso-0.02
___ 12:31AM BLOOD ___ PTT-26.9 ___
___ 12:31AM BLOOD Glucose-94 UreaN-21* Creat-1.1 Na-132*
K-4.4 Cl-98 HCO3-25 AnGap-13
___ 12:31AM BLOOD ALT-28 AST-17 AlkPhos-56 TotBili-0.4
___ 12:31AM BLOOD cTropnT-<0.01
___ 12:31AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.5
___ 12:31AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
CT HEAD ___:
1. Postsurgical change related to patient's left parietal
craniotomy and brain biopsy.
2. Grossly stable left parietal, occipital and temporal white
matter probable edema compared to ___ pre-biopsy
examination.
3. No evidence of acute hemorrhage.
4. Please note MRI of the brain is more sensitive for the
detection of acute infarct.
CXR ___:
No acute cardiopulmonary process.
CT ABD/PELVIS ___:
1. No evidence of diverticulitis or colitis.
2. Significant colonic fecal loading, particularly in the right
colon and
rectum.
MRI HEAD ___:
1. Scattered foci of slow diffusion probably involving the left
parietal
cortex with associated linear gradient echo hypointensity and T1
hyperintensity consistent with petechial hemorrhage and/or
laminar necrosis.
Additional foci of slow diffusion involving the bilateral
cerebellar
hemispheres and cerebrum. Overall the extent of slow diffusion
as a decreased in comparison to prior study consistent with
evolving ischemic change, however there several new foci of slow
diffusion involving the right cerebellar hemisphere, anterior
right temporal cortex, and left anterior centrum semi ovale.
2. Leptomeningeal enhancement involving the bilateral cerebral
hemispheres and cerebellar folia which have mildly increased in
comparison to prior study.
Overall, findings are suspicious for inflammatory cerebral
amyloid angiopathy with differential including embolic infarcts,
vasculitis, or
meningoencephalitis.
CXR ___:
In comparison a ___ chest radiograph, the lungs remain
clear, with no areas of consolidation to suggest the presence of
pneumonia.
RENAL ULTRASOUND ___:
1. No hydronephrosis. Simple left renal cyst incidentally
noted.
2. Markedly distended urinary bladder with approximately 1000
cc. The patient was unable to void.
DISCHARGE LABS:
___ 10:18AM BLOOD WBC-1.7*# RBC-3.98* Hgb-12.6* Hct-37.0*
MCV-93 MCH-31.7 MCHC-34.1 RDW-12.1 RDWSD-41.1 Plt ___
___ 10:18AM BLOOD Glucose-146* UreaN-15 Creat-0.6 Na-131*
K-3.8 Cl-99 HCO3-25 AnGap-11
___ 10:18AM BLOOD Calcium-7.6* Phos-1.9* Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ right-handed man with a recent
diagnosis of inflammatory CAA based on brain bx in the setting
of neurologic decline s/p recent discharge who presents for
recurrent language deficits.
History is concerning for recurrent neurologic decline in
language, mental status and possible ambulation. Exam reveals
disorientation, inattention, a global aphasia with more
involvement of expression than reception with return of
primitive reflexes and diffuse hyper-reflexia.
Given his history of inflammatory CAA, there was a concern for
failure of his current immunosuppresion regimen to control his
symptoms. This was confirmed by repeat MRI, which shows new
inflammatory lesions and worsened leptomeningeal enhancement.
During his last hospitalization, he was pulsed with
Methylprednisolone 1g and subsequently transitioned to PO
prednisone. However, since his symptoms improved on
Methylprednisolone, this was restarted on admission. He is s/p 5
sessions with stability of symptoms. Rheumatology was consulted
who recommended Cyclophosphamide treatment, which was done ___.
He will receive Cyclophosphamide q monthly and follow-up with
rheumatology and neurology as an outpatient.
However, on ___, patient was found to be c. diff positive and
was started on Vancomycin 125mg po, with plan for 14 day course.
He clinically appeared well but was monitored for clinical
deterioration for three days prior to discharge. He remained
afebrile and clinically stable. He was deemed well enough to
return to rehab.
Of note, patient has a history of chronic urinary retention and
required intermittent bladder scans and straight
catheterizations. He was discharged with a Foley, which should
be removed at rehab.
TRANSITIONAL ISSUES:
-f/u rheum: 2 week post-Cytoxan for nadir labs
-continue on aspirin
-continue Vancomycin until ___
-Prednisone taper to be finalized at f/u rheum appointment
-continue on insulin sliding scale, Famotidine, Ca/Vit D while
on steroids
-continue Bactrim while on steroids
-Foley in place since ___, please consider discontinuation
after arrival to rehab
-Note patient has chronic urinary retention, was getting bladder
scanned q8h and prn straight cath for >450 cc
-daily cbc with diff to follow for neutropenia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Oxybutynin 5 mg PO DAILY
6. sildenafil 100 mg oral ONCE:PRN
7. zaleplon 10 mg oral DAILY
8. Calcium Carbonate 500 mg PO DAILY
9. PredniSONE 60 mg PO DAILY
10. Sulfameth/Trimethoprim DS 1 TAB PO BID
11. Tamsulosin 0.4 mg PO QHS
12. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Calcium Carbonate 500 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Tamsulosin 0.4 mg PO QHS
7. Vitamin D 1000 UNIT PO DAILY
8. Famotidine 20 mg PO BID
9. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
10. LeVETiracetam 500 mg PO BID
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
12. PredniSONE 60 mg PO DAILY
13. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 14 Days
14. Oxybutynin 5 mg PO DAILY
15. zaleplon 10 mg oral DAILY
16. Phosphorus 500 mg PO TID Duration: 3 Doses
Discharge Disposition:
Extended Care
Facility:
___
Rehabilitation and ___)
Discharge Diagnosis:
Inflammatory cerebral amyloid angiopathy
Clostridium dificile
Urinary retention
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with worsening language. You had an
MRI which showed progression of your inflammatory cerebral
amyloid angiopathy. You were given steroids and chemotherapy and
will need to continue this as an outpatient every month.
You were also found to have an infection of your colon called
"c. difficile" and will need to complete a 14 day course of
antibiotics.
Please continue taking all medications as prescribed.
Please follow-up with your PCP in the next ___ weeks. Follow-up
with stroke neurology and rheumatology at the appointments
scheduled below.
It was a pleasure taking care of you,
Your ___ Neurologists
Followup Instructions:
___
|
19875364-DS-19
| 19,875,364 | 23,358,906 |
DS
| 19 |
2174-12-22 00:00:00
|
2174-12-23 15:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
thimerosal
Attending: ___.
Chief Complaint:
neutropenic fever, encephalopathy
Major Surgical or Invasive Procedure:
Lumbar Puncture ___
History of Present Illness:
___ year old male with history of inflammatory CAA diagnosed on
brain biopsy, recently admitted and received pulse dose steroids
and cyclophosphamide ___, and recently diagnosed with C.
diff colitis at rehab presenting from rehab with encephalopathy
and neutropenic fevers.
Per report, since discharge to rehab ___ pt's mental status has
not changed substantially, however he was noted by his wife to
be slower. In addition, he had a foley placed at rehab for
possible urinary retention. Today at rehab he developed a fever
to 102.7 rectally in the setting of neutropenia, so he was
referred to the ___ ED for further management.
In the ED, initial vital signs were: 99.8 109 122/70 20 98% RA
- Exam was notable for: Poor mental status with possible lower
extremity weakness , lower abdominal tenderness
- Labs were notable for: WBC 0.9 with ANC 216, H/H 11.7/33.4,
plts 194, Na 126, K 3.7, BUN/Cr ___, ALT 212, AST 110, total
bili 0.4, lactate 1.8
- UA with 1 WBC, few bacteria, neg leuks and nitrites
- Imaging: CT head demonstrated no significant interval change
in the confluent left parietal, occipital, and temporal white
matter hypodensities that could reflect edema related to the
biopsy; CXR did not demonstrate an acute process; MRI ___,
___, and L-spine demonstrated normal cord signal with
possible evidence of vertebral body hemangiomas
- The patient was given:
___ 14:44 PO Acetaminophen 1000 mg
___ 14:44 IVF 1000 mL NS 1000 mL
___ 15:09 IV CefePIME 2 g
___ 15:09 IVF 1000 mL NS 1000 mL
___ 15:45 IV MetRONIDAZOLE (FLagyl) 500 mg
___ 16:22 IV Vancomycin 1000 mg
___ 19:59 IV Acyclovir 600 mg
___ 19:59 PO Ibuprofen 600 mg
___ 22:14 IV Lorazepam .5 mg
___ 23:22 IV MethylPREDNISolone Sodium Succ 40 mg
- Consults: Neurology, Rheumatology, and Hem/Onc were consulted
in the ED.
Neurology recommended NCHCT and subsequent LP, as well as MRI
spine to assess for myelopathy or polyradiculopathy
Rheumatology recommended hemo/onc consult for question of
utility of neupogen, and recommended changing steroids to
methylprednisolone 40mg IV daily given encephalopathy
Hem/onc recommended against neupogen unless unstable or septic
Vitals prior to transfer were: 100.0 91 109/62 16 98% RA
Upon arrival to the floor, pt is unable to report complaints.
REVIEW OF SYSTEMS: Unable to obtain
Past Medical History:
- HLD
- Recent fall (? mechanical) with resultant left frontal SAH and
finding of multiple left hemispheric lesions and leptomeningeal
enhancement and CSF pleocytosis without clear etiology
- Inflammatory cerebral amyloid angiopathy
Social History:
___
Family History:
No family history of stroke, seizure or neurological conditions
to his wife's knowledge.
Physical Exam:
ADMISSION EXAM
==============
VITALS: 98.0 ___ 18 98% on RA, Wt 66kg
GENERAL: Somnolent, minimally arousable.
HEENT: normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, pupils pinpoint bilaterally.
NECK: Supple, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-distended, no
organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: Arousable to sternal rub, follows commands in UE.
DISCHARGE EXAM
==============
VITALS: 97.8, 131/94, 105, 16, 98% RA
GENERAL: no acute distress
HEENT: no conjunctival pallor or scleral icterus
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally anteriorly, without
wheezes or rhonchi.
ABDOMEN: NABS, soft, non-distended, non-tender
EXTREMITIES: WWP, no edema
SKIN: no rash
NEUROLOGIC: opens eyes to voice, looks at examiner, does not
vocalize response to questions, squeezes left hand when hands
are touched
Pertinent Results:
ADMISSION LABS
==============
___ 01:06PM BLOOD WBC-0.9* RBC-3.74* Hgb-11.7* Hct-33.4*
MCV-89 MCH-31.3 MCHC-35.0 RDW-11.9 RDWSD-38.7 Plt ___
___ 01:06PM BLOOD Neuts-24* Bands-0 ___ Monos-45*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.22*
AbsLymp-0.28* AbsMono-0.41 AbsEos-0.00* AbsBaso-0.00*
___ 01:06PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Burr-OCCASIONAL Fragmen-OCCASIONAL
___ 01:06PM BLOOD ___ PTT-26.1 ___
___ 01:06PM BLOOD Glucose-172* UreaN-13 Creat-0.5 Na-126*
K-3.7 Cl-94* HCO3-24 AnGap-12
___ 01:06PM BLOOD ALT-212* AST-110* AlkPhos-74 TotBili-0.4
___ 06:48AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.1
___ 06:48AM BLOOD Osmolal-270*
___ 06:48AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative IgM HAV-Negative
___ 01:32PM BLOOD Lactate-1.8
___ 07:27AM BLOOD Lactate-1.3
___ 06:00PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:00PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 06:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:56AM URINE Hours-RANDOM UreaN-159 Creat-16 Na-24
K-10 Cl-29
___ 05:56AM URINE Osmolal-156
PERTINENT LABS
==============
___ 06:42AM BLOOD Albumin-2.4* Calcium-8.2* Phos-2.6*
Mg-2.1
DISCHARGE LABS
==============
___ 11:30AM BLOOD WBC-20.7* RBC-3.96* Hgb-12.6* Hct-37.8*
MCV-96 MCH-31.8 MCHC-33.3 RDW-14.2 RDWSD-47.8* Plt ___
IMAGING
=======
CXR ___
IMPRESSION:
No acute cardiopulmonary abnormality.
CT Head ___
IMPRESSION:
1. No significant interval change in the confluent left
parietal, occipital, and temporal white matter hypodensity that
could reflect sequela of patient's inflammatory amyloid
angiopathy.
2. No evidence of acute hemorrhage.
3. No mass effect.
MR ___, L-spine ___ (prelim)
Normal cord signal. Scattered T1 and T2 hyperintense vertebral
body lesions, likely representing vertebral body hemangioma.
Otherwise normal bone marrow signal. No epidural collection. No
abnormal focus of post gadolinium enhancement. No areas of
critical canal or neural foraminal stenosis.
MRI head w/ and w/o contrast ___. Interval development of new infarcts of the right and left
temporal lobe,left frontal lobe and left cerebellar hemisphere
from examination of ___. The dominant lesion is in
the right temporal lobe measuring
approximately 6 mm.
2. Confluent FLAIR hyperintense signal of the left parietal and
temporal lobes are re-identified, increased in extent along the
anterior inferior left temporal lobe, corresponding to regions
of new infarct.
3. Additional regions of previously described infarcts and left
parietal
cortical laminar necrosis and/or petechial hemorrhage are
re-identified.
Expected evolution of prior infarcts, including new enhancement
of a right
anterior temporal lobe infarct is identified.
4. Leptomeningeal enhancement and FLAIR hyperintense signal of
the bilateral cerebral and cerebellar hemispheres is similar
appearance to prior examination.
5. The constellation of findings are suspicious for cerebral
amyloid angitis with differential considerations including
vasculitis, embolic infarcts and meningoencephalitis.
CXR ___
No focal consolidation concerning for aspiration and/or
pneumonia.
NCHCT ___:
1. No evidence of hemorrhage or midline shift.
2. Multiple evolving infarcts and chronic white matter changes
are overall similar in distribution to the most recent MR
examination.
MICROBIOLOGY
============
BCx ___ x 2: NGTD
Urine culture ___ 6:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
CSF gram stain, fluid culture ___: No microorganisms, negative
culture
CSF fungal culture ___: NGTD
CSF HIV viral load: NEGATIVE
Central line catheter tip culture ___: NEGATIVE
Fecal culture, campylobacter culture, Ova and parasites,
yersinia culture, E.coli 0157:H7 culture ___: NEGATIVE
Brief Hospital Course:
___ year old male with history of inflammatory CAA diagnosed on
brain biopsy, recently admitted and received pulse dose steroids
and cyclophosphamide ___, recently diagnosed C. diff colitis
presenting from rehab with encephalopathy and neutropenic
fevers, found to have ___ weakness and UTI. Patient was found to
have new strokes on MRI suggestive of progression of his
underlying CAA. He was trialed on a 5 day pulse of steroids with
improvement in alertness but otherwise limited mental status and
residual deficits due to multiple strokes. Given what his wife
described as his preferences for quality of life and alertness,
the patient was transitioned to comfort care and discharged home
on hospice.
# Cerebral Amyloid Angiopathy, CVA: The patient had been
recently diagnosed with inflammatory CAA on brain biopsy during
prior admission. The patient presented with worsening mental
status associated with some focal neurologic deficits. The
patient was evaluated with MRI which showed new lesions in the
temporal area new infarcts of the right and left temporal lobe,
left frontal lobe and left cerebellar hemisphere. This was
thought to represent progression of his underlying angiopathy.
Work up for other etiology of stroke - including TEE, blood
cultures and monitoring on telemetry did not show evidence of
endocarditis, blood clot or arrhythmia. The patient was
initially treated with increased dose of prednisone,
transitioned to a course of high dose methylpred for 5 days as a
pulse. This resulted in some improvement in alertness, but
significant change in his mental staus. The patient was
continued on his prophylactic regimen of PPI and bactrim while
receiving this treatment. The patient was not treated with ASA
or any other anticoagulation/antiplatelet agent as these are
controversial and contraindication in CAA. The patient was
evaluated with EEG which showed some evidence of epileptiform
discharge and his keppra was increased to 750mg PO BID. The
patient's goals of care, in the setting of severe neurologic
deficit and progression of disease, were managed as below.
# Goals of Care: The patient was found to have new strokes,
thought to be related to progression of his underlying cerebral
amyloid angiopathy. The patient experienced many complications
and side effects from the steroid and immunosuppressant
treatment he was receiving, with limited improvement in his
mental status or functional capacity. The patient's wife and
healthcare proxy emphasized the patient's values - namely,
quality of life, alertness, time with family. She described him
as a previously high functioning individual, who would not want
to pursue further treatment while he was limited in this way.
Palliative care was consulted and in discussion between family,
medicine team, palliative team, rheumatology and neurology, the
decision was made to transition to comfort care and the patient
was discharged on hospice. The patient was continued on keppra,
nystatin for prevention of seizure and palliation of thrush. The
patient was started on methylphenidate PRN in order to bolster
mental status and energy in the hope of providing more quality
time with his wife and family.
# Neutropenic fevers: The patient initially presented with fever
in the setting of neutropenia (ANC 216) and receiving
cyclophosphamide. Pt's fevers in combination with encephalopathy
were concerning for CNS infection, however also with active C.
diff infection as possible source. The patient was evaluated
with LP with ___, which showed improved WBC and protein from
prior LP, although results were possibly misleading in the
setting of having receive steroids per the neurology consult
service. Microbiology studies including gram stain, viral
studies and cultures were negative. The patient was initially
started on broad spectrum antibiotic coverage with vancomycin,
cefepime, ampicillin and acyclovir and his cyclophosphamide was
held. Antibiotics were narrowed to cefepime and then
ciprofloxacin when infectious work-up revealed urinary tract
infection with sensitive pseudomonas. The patient was continued
on antibiotics to complete a ___nd his neutropenia
resolved.
# C. diff colitis: Pt recently diagnosed with C. diff at rehab
facility. His PO vanco 125mg q6h was continued, alternating with
IV metronidazole when he was unable to take PO. The patient's
course was completed on ___, but he was continued on his
antibiotic regimen through his pulse dose of steroids
prophylactically. These were discontinued upon discharge per
GOC.
# Melena/Hematochezia: The patient was noted to have bloody
stool, both dark with some red blood. This was thought to be
related to GI irritation in the setting of high dose steroids
(though he was maintained on PPI prophylaxis) vs. related to a
complication of his ongoing C diff infection. The patient's
blood counts were monitored and remained stable. The patient's
family was offered KUB for further evaluation, to rule out toxic
megacolon, but they declined given goals of care. The patient
was treated with 48hrs of IV PPI, transitioned to PO PPI, which
was ultimately stopped upon discharge given goals of care.
# ___ weakness: Patient with apparent ___ weakness in the ED, MRI
C/T/L performed which showed no evidence of spinal cord
compression. The patient was evaluated with LP and MRI as above
which showed new strokes.
# Transaminitis: Patient noted to have a transaminitis on
admission, which improved during his course. This was thought to
represent mild hypoperfusion vs. toxic insult. The patient's
statin was held and his transaminitis improved.
# Complicated UTI: The patient was found to have a UCx positive
for pan sensitive pseudomonas. Though small number of organisms
noted in the sample, he was treated with a 10 day course of
ciprofloxacin given his prior neutropenia
# Hyponatremia: The patient was noted to be hyponatremic to 126.
Urine lytes were suggestive of pre-renal etiology, The patient's
Na improved with IVF.
# Thrush: the patient was noted to have oral lesions concerning
for thrush. He was treated with nystatin which he should
continue after discharge for symptomatic relief.
# Type 2 DM: provided insulin sliding scale, held at discharge
given GOC.
# Hyperlipidemia: Held home statin in the setting of
transaminitis. Discontinued upon discharge given GOC.
# BPH/Spasmodic bladder: Initially held home tamsulosin in the
setting of transaminitis and AMS, but restarted given urinary
retention. The patient had a foley placed while hospitalized due
to persistent urinary retention. This was continued after
discharge for symptomatic management.
# Hypertension: Held home metoprolol given difficulty taking PO,
transitioned to IV. This was stopped upon discharge given GOC.
# SVT: The patient was found to have an episode of narrow
complex tachycardia, associated with hypotension. The patient
was treated with carotid massage with resolution of arrhythmia
and stabilization of blood pressure. The patient was treated
with IVF. He was evaluated with CXR which showed no evidence of
aspiration. SVT was thought to be secondary to underlying
medical illness vs. beta blocker withdrawal in the setting of
difficulty taking PO. The patient was restarted on IV metoprolol
and monitored on telemetry with stabilization of HR and no
further episodes of SVT.
TRANSITIONAL ISSUES
===================
- Patient's wife requested autopsy after the patient's death,
pathology department at ___ was notified, please ensure that
this is arranged at the time of the patient's passing.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Calcium Carbonate 500 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Tamsulosin 0.4 mg PO QHS
7. Vitamin D 1000 UNIT PO DAILY
8. Famotidine 20 mg PO BID
9. LeVETiracetam 500 mg PO BID
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. PredniSONE 60 mg PO DAILY
12. Vancomycin Oral Liquid ___ mg PO Q6H
13. Oxybutynin 5 mg PO DAILY
14. zaleplon 10 mg oral DAILY
15. Phosphorus 500 mg PO TID
16. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. MethylPHENIDATE (Ritalin) 10 mg PO TID
RX *methylphenidate 10 mg 1 tablet(s) by mouth twice daily Disp
#*30 Tablet Refills:*0
2. Nystatin Oral Suspension 5 mL PO QID thrush
RX *nystatin 100,000 unit/mL 5 mL by mouth three to four times
daily Refills:*0
3. LevETIRAcetam 750 mg PO BID
RX *levetiracetam 100 mg/mL 7.5 mL by mouth twice daily
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Cerebral Amyloid Angiopathy, Cerebrovascular Accident,
Neutropenic Fever, Complicated Urinary Tract Infection,
Supraventricular Tachycardia
Secondary: Clostridium Difficile Colitis, Benign Prostatic
Hypertrophy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital with low blood counts and
fevers. We believe this was caused by the medication that you
were taking for your Cerebral Amyloid Angiopathy. You were found
to have an infection in your urinary tract and we treated you
with antibiotics.
While in the hospital, you were found to have worsened mental
status and some changes in your neurologic exam. You were
evaluated by our neurology team. You were found on MRI of your
head to have some new strokes. We believe these were related to
your Cerebral Amyloid Angiopathy. We evaluated you for other
causes of stroke, but these were unrevealing. We treated you
with a high dose of steroids to see if this would help your
mental status. This improved your alertness but you still had
some residual difficulty moving around and speaking. Your wife
explained to us that you value quality of life and ability to
think and interact, so we stopped treatment and decided to make
you more comfortable so that you could spend time at home with
your family.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19875442-DS-17
| 19,875,442 | 20,035,597 |
DS
| 17 |
2119-07-31 00:00:00
|
2119-07-31 10:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___ year old gentleman transferred from OSH s/p pedestrian struck
by car.
Major Surgical or Invasive Procedure:
___
1. Open reduction, internal C-wire fixation right ___
carpometacarpal joint.
2. Application short-arm cast.
3. Wrist block by surgeon.
History of Present Illness:
This patient is a ___ year old male who was transferred from an
outside hospital after he was hit by a car while walking on
sidewalk. He suffered an injury to his right lower extremity.
The patient had a knee dislocation. Patient was reduced at
outside hospital. Pulses were intact. Patient also probably has
a fracture of the fifth metacarpal on the left hand area. He
reported no loss of consciousness or neck pain. Patient denied
any numbness or weakness.
Past Medical History:
PMHx: None.
MSHx: Appendectomy, cholecystectomy
Social History:
___
Family History:
Non-contributory.
Physical Exam:
On admission:
HR: 89 BP: 100/59 Resp: 18 O(2)Sat: 98
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
Extr/Back: Right knee swelling, left fifth metacarpal
swelling
Skin: No rash, Warm and dry
Neuro: Speech fluent
On discharge:
VS T 99.1 PO, HR 94, BP 120/60, RR 18, sat 97% on room air.
General: AAO x 3. In no acute distress.
Card: S1, S2 regular, ___ systolic murmur heard best at apex.
No edema.
Pulm: Clear bilaterally. Diminished in bases bilaterally.
GI: Positive BS throughout. Soft, non-tender, non-distended.
GU: Voiding clear urine.
Extrem: Pulses 2+ in all extremities. Right FA in short cast.
No sensory or motor deficits. Right leg in ___ brace.
No sensory or motor deficits noted.
Pertinent Results:
___ 07:40PM BLOOD WBC-14.8* RBC-3.88* Hgb-12.0* Hct-35.4*
MCV-91 MCH-30.8 MCHC-33.8 RDW-12.9 Plt ___
___ 07:40PM BLOOD Neuts-83.1* Lymphs-12.0* Monos-4.6
Eos-0.1 Baso-0.2
___ 07:40PM BLOOD Plt ___
___ 07:40PM BLOOD Glucose-214* UreaN-16 Creat-0.7 Na-139
K-4.1 Cl-108 HCO3-20* AnGap-15
___ 07:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:30PM BLOOD WBC-8.4 RBC-2.85* Hgb-8.8* Hct-26.0*
MCV-92 MCH-31.0 MCHC-33.9 RDW-14.4 Plt ___
___ 01:30PM BLOOD Plt ___
___ 01:30PM BLOOD Glucose-255* UreaN-14 Creat-0.5 Na-135
K-3.8 Cl-100 HCO3-27 AnGap-12
___ 01:30PM BLOOD Calcium-8.5 Phos-3.3 Mg-2.2
___ CTA of lower extremities w/ and w/o constrast:
1. Filling defect within the right superficial femoral artery
is likely a
small intimal flap.
2. Active extravasation into a mid-thigh intramuscular hematoma
from a branch of the superficial femoral artery.
3. Multiple fracture fragments of the medial condyle of the
distal right
femur.
4. Atherosclerotic disease of the right posterior tibial artery
with chronic occlusion beyond the mid portion.
5. Scattered atherosclerotic disease with moderate to severe
narrowing in the left distal anterior tibial artery and dorsalis
pedis artery.
6. Large left inguinal hernia containing segments of large
bowel without
evidence of obstruction.
7. Diverticulosis without evidence of diverticulitis.
___ Hand radiograph (AP, lat, oblique)
Irregularity and subtle lucency involving the lateral aspect of
the base of
the fifth metacarpal suspicious for a small nondisplaced
fracture. There is also widening between the base of the fourth
and fifth metacarpals suggestiveof ligamentous injury. Please
correlate with pain at this location.
___ Right ankle radiograph
Likely subtle non-displaced distal right fibular fracture.
___ CT of right upper extremity
Comminuted fracture at the base of the fifth metacarpal,
extending to the
carpometacarpal joint.
Brief Hospital Course:
Mr. ___ is a ___ speaking ___ year old gentleman who
was struck by a car while walking on a sidewalk. He was
immediately brought to an outside hospital in ___
where imaging showed fractures of the right ___ metacarpal,
right femur, and left tibia. He was then transferred to ___
for further evaluation. In the trauma bay he was hypotensive to
the 70's but remained fluid responsive.
As the patient does not speak any ___, a ___
interpreter was frequently utilized to facilitate assessments,
discuss treatment options and plan of care.
Multiple imaging studies were completed during his inpatient
stay. The following are Mr. ___ injuries and the
subsequent course for each:
1. Fracture of the right ___ metacarpal
Imaging showed irregularity and widening of the base between ___
and ___ metacarpals, and lucenecy at the base of the ___
metacarpal suspicious for small
nondisplaced fracture. The Plastics/Hand service was consulted
for further management. An ulnar gutter splint was initially
placed. Upon further evaluation, Mr. ___ was taken to the
OR where he underwent an open reduction, internal C-wire
fixation to his right ___ carpometacarpal joint. A short-arm
cast was applied thereafter.
The patient has not experienced any sensory or motor deficits
post procedure. Physical and occupational therapy has seen the
patient for evaluation and initial rehabilitation.
2. Right distal medial femur fracture, right knee dislocation
Mr. ___ knee dislocation was discovered at the outside
hospital initially, and the fracture was reduced at that time.
Upon further imaging, there was a small fracture to the distal
medial femur found as well. Orthopedics was consulted at ___
and recommendations were made for the patient to wear a long leg
brace locked in extension at all times. Vascular checks were
conducted every four hours. He was instructed to not bear
weight on the extremity. Otherwise, he needed no further
surgical intervention. The patient has been working closely
with physical therapy. Ambulation has been difficult as the
patient requires crutches to ambulate and likely a wheelchair to
travel (via airport) back to ___.
Because there was a subtle non-displaced distal right fibular
fracture noted on imaging, the patient was instructed to wear an
air cast at all times. It required no surgical intervention.
5. Posterior right thigh hematoma
Given his lower extremity injuries, a CTA with runoff was
obtained on admission to ___, which revealed active
extravasation into an intramuscular hematoma posterior to the
mid femur. Given these findings, vascular surgery was consulted.
It was their opinion that no surgical intervention was required.
An ACE wrap was applied to the patient's leg to provide
compression to the hematoma. Serial vascular checks were
completed. Because there was never an alteration in his pulses,
he did not require further evaluation with angiography. The
intimal flap did not require anticoagulation.
Aside from the above injuries, Mr. ___ has done extremely
well while an inpatient. He has been hemodynamically stable.
Pain control has been achieved with the use of narcotic and
non-narcotic analgesics. Case management has worked closely
with representatives in ___ to facilitate Mr. ___
transfer back to home. Arrangements are being made for transfer
to ___ via airflight with a registered nurse. The patient
will require further rehabilitation with physical therapy, which
could be met at a ___ facility with ___ services.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Aspirin 325 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN
Breakthrough pain
5. Cephalexin 500 mg PO Q12H Duration: 5 Days
post-op prophylaxis, non-MRSA dosing
6. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Fracture of the right ___ metacarpal
2. Right distal medial femur fracture
3. Right knee dislocation
4. Left subgaleal hematoma
5. Posterior right thigh hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to ___ in ___,
___ after you were hit by a car. You sustained the
following injuries:
1. Fractures of the right ___ metacarpal (hand) bone
2. Right distal femur fracture
3. Right knee dislocation
4. Left subgaleal hematoma
5. Posterior right thigh hematoma
Various teams were consulted to address the injuries listed
above. Their recommendations are as follows:
1. Fractures of the right ___ metacarpal (hand) bone
You were taken to the operating room on ___ for repair of
this fracture. A cast was applied after the fixation was
complete. Please see "cast care" below for further information.
2. Right femur fracture
This fracture was non-operative. There is no intervention
required at this time. You will need future follow up upon
return to ___.
3. Right knee dislocation
The fracture has been reduced ("put back into place). Until you
are seen by a physician in ___, you need to keep the brace,
called a
___ brace, on at all times (except for bathing) and locked
in extension (straight and not bent at the knee). You should
not bear any weight on this leg. You will use crutches to
ambulate as instructed by physical therapy.
4. Left subgaleal hematoma
This is basically a swelling and blood clot of your scalp. This
has since resolved and their is no further required
intervention.
5. Posterior right thigh hematoma
This blood clot formed during your initial injury. At this
time, there is no further intervention required.
CAST CARE: WHAT YOU SHOULD KNOW
Take your medicine as directed. Your caregiver ___ check if the
bones are healing well and if there are other problems. You may
need more x-rays to check how your bones are healing.
Protecting the cast from damage:
o Check for any cracks, dents, dimples, holes, or flaking areas
on the cast every day.
o Do not break off rough edges or trim the cast. Let your
caregiver do this for you.
o Do not let anyone push down or lean on any part of the cast
because it may break.
o Keep the cast clean and dry.
Keeping the cast clean and dry: Keep the cast clean and dry to
prevent it from getting soft and weak. The cast may not be able
to hold your body parts in place if it breaks or changes shape.
If this happens, the body area in the cast may not heal well. Do
the following:
o Cover your cast with a towel or a large T-shirt when you are
eating. This will help prevent food and drinks from spilling on
or into the cast.
o Keep dirt, sand, and powder away from the inside of your cast.
o Wrap the cast with towels or plastic trash bags while you take
a bath. Wash the skin that is not covered by the cast with soap
and water every day. Certain casts can get wet or even soak in
water. Ask your caregiver if your cast needs to be kept away
from water, or if it can go in water.
o You may use a hair dryer set on the lowest heat setting to dry
a cast that gets wet. This may dry the cast faster than just
letting it dry by itself. Make sure that the hair dryer is not
blowing air that is too hot or you may get burned.
o Use a mild detergent and a washcloth to wipe dirt and grime
off the cast.
Caring for the edges of the cast: You or your caregiver may fix
the cast edges to keep them smooth. This will help stop your
skin from scraping against rough edges on the cast. Do the
following:
o Cut pieces of waterproof tape about four inches long.
o Place one end of the tape under the inside edge of the cast
and wrap it onto its outside surface.
o Overlap the tape strips until the edges of the cast are
completely covered.
o Do not pull or fix any of the padding inside the cast. This
could cause blisters and wounds.
Keeping yourself comfortable:
o Find a relaxing position while sitting or lying down. Prop
yourself with small pillows or a rolled towel, or use a bean-bag
chair. Do not rest any body part on a hard surface for long
periods of time. This may cause pressure sores. Ask caregivers
for more information on preventing pressure sores.
o If your skin under the cast is itchy, blow cool air under the
cast. You may also gently stroke your skin outside the cast with
a piece of cotton or cloth. Do not use a sharp or pointed object
to scratch the skin under the cast. This may cause wounds that
can get infected, or you may lose the item inside the cast.
o Raise the affected arm or leg a bit higher than your chest to
decrease any swelling. You may also wrap some ice in a small
towel, and put it near the painful areas.
MEDICATIONS:
Attached is a list of medications that you were taking at time
of discharge. The health care facility in ___ will assess
the need for those medications once you arrive. In the
meantime, you may need medications to help control you pain.
Also, while taking narcotic pain medications (such as
oxycodone), you may become constipated. You should take a stool
softener, such as Colace, to prevent this complication. Lastly,
oxycodone can cause cause drowsiness. Be careful while
ambulating with crutches, operating mechanical equipment, etc.
while taking this medication.
Followup Instructions:
___
|
19875502-DS-15
| 19,875,502 | 28,825,856 |
DS
| 15 |
2189-08-28 00:00:00
|
2189-08-29 13:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Acute onset L-sided weakness
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
___ is a ___ year old man with a history of
multiple prior CVAs of unclear etiology, who presents with acute
onset left sided weakness.
Per the patient, he was otherwise in his usual state of health
until this evening. He was climbing the stairs, and near the
top,
he acutely felt left sided weakness. Most of his weakness was
described in his left arm, with him having difficulty raising
the
arm as well as extending his fingers. He also thinks he had mild
left leg weakness as well, but he did not fall and was able to
finish climbing the stairs. He was able to get to a sofa, but
because of his continued weakness, as well as prior history of
stroke, he became worried and called EMS. He was initially
transported to ___, where he had a NIHSS of 2 for left arm
and face weakness. His vitals were within normal limits, e.g.
normal blood pressure. A CT scan showed a right frontoparietal
hemorrhage. He was subsequently transferred to ___ for further
management.
Of note, he denies a headache at the time of his symptoms, as
well as abnormal movements. He does report cognitive decline,
which he attributes to prior strokes. The remainder of his ROS
is
otherwise negative.
Past Medical History:
4 prior CVAs, unclear etiology, all happened several years ago.
Social History:
___
Family History:
Mother with cancer.
Physical Exam:
Vitals T 96.6 HR 69 BP 127/67 RR 17 O2 97% RA
General: NAD
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 x 3. Able to relate
history with some difficulty. Attentive, able to name ___
backward with some difficulty. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact to high and low frequency items. No paraphasias.
No dysarthria. Normal prosody. Able to register 3 objects and
recall ___ at 5 minutes. No apraxia. No evidence of hemineglect.
No left-right confusion. Able to follow both midline and
appendicular commands.
- Cranial Nerves: PERRL 4->3 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
- Reflexes: Positive pec jerk on left, crossed adductor on left
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2 2 2 2+ 1
Plantar response extensor on right, flexor on left
- Sensory: 70% on right arm to temperature sensation, 80% on
left
leg. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: deferred
Pertinent Results:
___ 05:45AM GLUCOSE-111* UREA N-13 CREAT-1.0 SODIUM-141
POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-26 ANION GAP-13
___ 05:45AM CK(CPK)-165
___ 05:45AM CK-MB-4 cTropnT-<0.01
___ 05:45AM MAGNESIUM-2.4 CHOLEST-143
___ 05:45AM %HbA1c-5.3 eAG-105
___ 05:45AM TRIGLYCER-98 HDL CHOL-55 CHOL/HDL-2.6
LDL(CALC)-68
___ 05:45AM TSH-0.99
___ 05:45AM WBC-8.4 RBC-4.53* HGB-13.6* HCT-40.9 MCV-90
MCH-30.0 MCHC-33.3 RDW-13.8 RDWSD-46.0
___ 05:45AM PLT COUNT-194
___ 09:45PM GLUCOSE-111* UREA N-14 CREAT-1.2 SODIUM-141
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15
___ 09:45PM estGFR-Using this
___ 09:45PM WBC-8.6 RBC-4.52* HGB-13.7 HCT-41.1 MCV-91
MCH-30.3 MCHC-33.3 RDW-13.6 RDWSD-45.3
___ 09:45PM NEUTS-68.2 LYMPHS-18.4* MONOS-8.8 EOS-3.3
BASOS-0.8 IM ___ AbsNeut-5.85 AbsLymp-1.58 AbsMono-0.75
AbsEos-0.28 AbsBaso-0.07
___ 09:45PM PLT COUNT-206
___ 09:45PM ___ PTT-29.1 ___
MRI Head ___
IMPRESSION:
1. Right frontal and parietal subarachnoid hemorrhage is again
demonstrated.
The extent of hemorrhage is better appreciated on MRI than on
the preceding
CT, as both acute and subacute subarachnoid hemorrhage is
visible on MRI.
2. No evidence for parenchymal blood products to clearly
indicate amyloid
angiopathy.
CTA H+N
IMPRESSION:
1. Unchanged right frontal/parietal subarachnoid hemorrhage. No
new
hemorrhage.
2. No evidence for an arteriovenous fistula in the region of the
right
subarachnoid hemorrhage.
3. 2 mm medially directed aneurysm at the junction of the left
anterior
cerebral artery with a hypoplastic anterior communicating
artery.
4. Nonvisualization of the right ___. Large left ___ with
branches
extending into the right ___ territory. Two foci of mild
narrowing in the
left ___, including to the right of midline.
5. Calcified plaque mildly narrowing the right vertebral artery
origin.
6. Emphysema in the included upper lungs.
7. 8 mm right thyroid nodule. According to current ___
College of
Radiology guidelines, no follow up is needed in the absence of
specific
personal risk factors for thyroid malignancy.
RECOMMENDATION(S): The 2 mm left anterior cerebral artery
aneurysm is not
related to the right frontal/parietal subarachnoid hemorrhage,
and it should
be followed in the outpatient setting to assess stability.
Brief Hospital Course:
___ y/o M w/o HTN, prior CVA x 4, who presents following a fall
with transient acute onset of L sided weakness, found to have
traumatic right SAH.
#Traumatic SAH#
- Patient history was able to further be gathered and differed
from admission history. He clearly endorses a fall with
headstrike preceding his ? left side weakness. He was initially
evaluated at OSH where he was found to have a right
fronto-parietal lobe SAH hemorrhage on CT. Vessel imaging was
benign and without evidence of aneurysm. A small chronic right
cerebellar infarct was noted. There were also signs of white
matter changes suggestive of small vessel ischemic disease and
global atrophy.
He was admitted to the Neurology service for further workup
(prior to history of proceeding trauma). In the morning, pt
clarified that he hit the right side of his head after getting
tangled in his dog's leash, without loss of consciousness. He
reports having clumsiness/weakness of his left leg since his
prior stroke ___ years ago. On neurological exam, he was
essentially non-focal with a slight increase in tone on the left
leg and arm, suggestive of mild spasticity, reportedly chronic.
He was subsequently discharged with plan for outpatient
neurology f/u.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Finasteride 5 mg PO DAILY
4. Memantine 10 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Finasteride 5 mg PO DAILY
4. Memantine 10 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Traumatic Subarachnoid Hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized following a fall due to symptoms of
transient left sided weakness resulting from a traumatic
subarachnoid hemorrhage , a condition where a head injury can
result in a small amount of blood on the SURFACE of the brain.
The brain is the part of your body that controls and directs all
the other parts of your body, so this can result in a variety of
symptoms. Fortunately, your symptoms improved and otherwise did
well.
No changes were made to your medications during this
hospitalization.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19875661-DS-11
| 19,875,661 | 21,531,623 |
DS
| 11 |
2177-11-17 00:00:00
|
2177-11-17 15:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
erector spinae catheter placement
Epidural catheter placement
History of Present Illness:
Ms ___ is a ___ with a history of AF on coumadin, COPD, CAD,
HTN who presents with multiple rib fx after a fall in her
bathroom that she sustained while attempting to use a plunger.
She did not hit her head or sustain LOC. She then presented to
an OSH where she underwent a CT scan of the chest and was given
10mg PO vitamin K for warfarin reversal. She was transferred to
___ for further management. Upon arrival she was able to
protect her airway though was requiring 4LNC to maintain sats in
the mid ___. She complains of significant pain to her left and
right chest. OSH imaging showed R 10th rib fx, L ___ rib
fxs, and a small hemopneumothorax that did not require chest
tube placement. Her initial labs were concerning for a 6 point
hct drop from her OSH labs to 34, as well as INR of 2.7. Patient
was initially admitted to the TSICU for close monitoring of H/h
and pain control. While in the TSICU, she had an epidural
catheter placed that had to be discontinued due to hypotension.
Erector spinae catheter was then placed. Patient had adequate
pain control with that and stable H/h. She was therefore
transferred to the floor on ___. On ___, she reportedly had
worsening tachypnea and oxygen requirement (on 3L NC) so was
transferred back to the TSICU for close monitoring.
Past Medical History:
PMH: COPD, CAD, CHF, HTN, Afib on Coumadin, OSA, OA
PSH: appendectomy, splenectomy, CABG
Social History:
___
Family History:
noncontributory
Physical Exam:
___ HR83 BP90/31 RR14 96%6L
Gen: NAD, AOx3
CV: regular rate, irregular rhythm
Resp: tachypneic, equal breath sounds, decreased at bases,
bilateral crackles
Abdomen: soft, distended, tympanic to percussion
Ext: warm and well-perfused, pitting edema of all extremities
Pertinent Results:
CXR Portable ___
FINDINGS:
Median sternotomy wires are intact. Multiple surgical clips are
seen
projecting over the mediastinum. Heart size is mildly enlarged.
Tortuosity
of the descending thoracic aorta. Rightward deviation of the
trachea, likely
secondary to patient rotation. Mild bibasilar atelectasis is
noted. Focal
opacification at the left lung base is likely due to combination
of pleural
fluid and likely pulmonary contusion, as better seen on CT chest
from ___. Small left pleural effusion. Subtle pleural
marking along the
left apex, likely representing small hemo-pneumothorax.
Multiple left-sided
rib fractures are again demonstrated.
IMPRESSION:
1. Multiple left-sided rib fractures with equivocal trace left
hemopneumothorax.
2. Focal opacification at the left lung base, likely due to
combination of
pleural fluid and likely pulmonary contusion, as better seen on
CT chest from
outside hospital performed on ___.
3. Rightward deviation of the trachea, most likely related to
patient
rotation.
KUB ___
FINDINGS:
There are dilated loops of large or small bowel. The small
bowel is dilated
to 3.8 cm. The transverse colon is dilated to 6.1 cm. There is
air in the
rectum.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or
radiopaque foreign
bodies. Surgical clips are identified in the epigastrium.
IMPRESSION:
Dilated small and large bowel consistent with ileus.
CT Chest w/o Contrast ___
FINDINGS:
CHEST PERIMETER: No thyroid findings require any further imaging
evaluation.
No supraclavicular or axillary adenopathy. Breast evaluation is
reserved
exclusively for mammography. No soft tissue abnormality in the
chest wall
despite multiple left rib fractures. Study is not designed for
evaluation of
the abdomen but there is no adrenal mass or immediate subphrenic
collection.
CARDIO-MEDIASTINUM:Hiatus hernia is small. Esophagus is
unremarkable.
Atherosclerotic calcification is mild in head and neck vessels.
Patient has
had median sternotomy for CABG.. Sternum is well-healed and
there are no
findings to suggest wound complications. Native coronary
arteries are heavily
calcified. Aorta and pulmonary arteries are normal size.
Cardiac evaluation
would require echocardiography. Pericardium is physiologic.
THORACIC LYMPH NODES: None enlarged.
LUNGS, AIRWAYS, PLEURAE: Moderate size layering nonhemorrhagic
left pleural
effusion has enlarged since ___ when it was partially
hemorrhagic.
Left lower lobe is now entirely collapsed, although there is no
responsible
bronchial obstruction.
Two small regions of new consolidation at the right apex are
active or
residual pneumonia, ___. Another small region of
peribronchial
infiltration with a ground-glass halo, right upper lobe, 5:72
could be
residual edema or either active or residual pneumonia. Right
middle lobe
atelectasis above the elevated right hemidiaphragm has
increased. No
bronchial obstruction present. Mild subpleural atelectasis in
the right lower
lobe is new.
CHEST CAGE: More than half a dozen fractures lateral and
posterolateral left
middle and lower ribs are no more displaced today than on
___,
including the most severe, proximal left tenth rib, displaced
more than the
width of the rib, 5:215. Nevertheless there is no associated
fluid or soft
tissue abnormality in either the chest wall or the extrapleural
space.
Moderate loss of height lower thoracic vertebral body due to
upper endplate
depression, no vertebral canal compromise, unchanged, probably
chronic,
10:103.
IMPRESSION:
New left lower lobe collapse accompanied by increase in moderate
nonhemorrhagic layering left pleural effusion.
Several very small foci possible pneumonia, right lung.
Multiple, mid and lower left rib fractures, stable since ___, no
evidence of associated bleeding.
Transthoracic Echo ___
CONCLUSION:
The left atrium is elongated. The right atrium is mildly
enlarged. There is no evidence for an atrial septal
defect by 2D/color Doppler. The estimated right atrial pressure
is ___ mmHg. There is mild symmetric
left ventricular hypertrophy with a normal cavity size. There is
suboptimal image quality to assess
regional left ventricular function. Overall left ventricular
systolic function is hyperdynamic. The
visually estimated left ventricular ejection fraction is >=75%.
Left ventricular cardiac index is
normal (>2.5 L/min/m2). There is no resting left ventricular
outflow tract gradient. No ventricular septal
defect is seen. Normal right ventricular cavity size with low
normal free wall motion. Tricuspid annular
plane systolic excursion (TAPSE) is depressed. The aortic sinus
diameter is normal for gender. The
aortic arch diameter is normal with a normal descending aorta
diameter. There is no evidence for an
aortic arch coarctation. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve
stenosis. There is no aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral
valve prolapse. There is moderate mitral annular calcification.
The transmitral E-wave deceleration time
is prolonged (>250ms). There is physiologic mitral
regurgitation. Due to acoustic shadowing, the
severity of mitral regurgitation could be UNDERestimated. The
tricuspid valve leaflets are mildly
thickened. There is moderate [2+] tricuspid regurgitation by
color Doppler; however, there appears to be
systolic flow reversal in the hepatic veins suggestive of severe
tricuspid regurgitation. There is moderate
to severe pulmonary artery systolic hypertension. .There is no
pericardial effusion. Bilateral pleural
effusions are present.
Brief Hospital Course:
Patient admitted to the trauma surgical ICU for respiratory
management in the setting of her traumatic injuries. She was
given 2U FFP and Vitamin K in the emergency department. She was
started on a Dilaudid PCA for pain control. On ___ she was
again given FFP and vitamin K in an effort to reduce her INR so
she could have an epidural placed, however her INR was still
1.5. She was given liquids which she tolerated. The following
day, ___, her INR was 1.2 and an epidural was placed. She did
have a ground level fall at the time of the epidural placement
without headstrike and was neuro intact with no further injuries
identified on exam. She was started on lasix diuresis. On ___
she had a hypotensive episode with bilateral parasthesias of the
lower extremities in the setting of her epidural which was then
discontinued with resolution of her symptoms and hypotension.
The epidural was removed ___. On ___, an erector spinae
catheter was placed by APS, she was given an aggressive bowel
regimen and had a BM, and was transferred to the floor.
On ___, the patient had an acute worsening of her respiratory
status, thought to be multi-factorial with differential
including splinting, COPD exacerbation, CHF exacerbation and
pneumonia. She was transferred to the intensive care unit for
respiratory monitoring and started on IV diuresis and
antibiotics. Her respiratory status stabilized and she was
weaned from supplemental oxygen to room air. She was also noted
to have abdominal distension with KUB suggesting ileus, and NGT
was placed with >1L feculent appearing output.
During the course of her second ICU admission, Ms ___ was
noted to have a pleural effusion that would likely require
placement of a pigtail cathether in order to aid her respiratory
distress. In conversation with the patient and her family
members as well as with the palliative care service, the
decision was made to avoid escalation of care and initiation of
further procedures. Ultimately, the patient decided she would
like to transition to completely comfort focused care. In
keeping with her wishes, all preventative and non-comfort
focused medicines and interventions were ceased. This included
cessation of lab draws, telemetry, and anticoagulation
medications.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze/shortness
of breath
2. Levothyroxine Sodium 125 mcg PO DAILY
3. FLUoxetine 40 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Torsemide 80 mg PO QAM
6. Torsemide 60 mg PO 1400DAILY
7. Klor-Con (potassium chloride) 20 mEq oral DAILY
8. TraZODone 50 mg PO QHS
9. Aspercreme (lidocaine) (lidocaine;<br>lidocaine HCl) 4 %
topical DAILY
10. Aquaphor Ointment 1 Appl TP HS BLE q HS
11. Hydrocortisone (Rectal) 2.5% Cream ___AILY:PRN as
directed
12. Lisinopril 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen IV 1000 mg IV Q8H
2. Acetylcysteine 20% ___ mL NEB Q4H:PRN wheezing
3. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
4. CefTAZidime 1 g IV Q12H Duration: 2 Days
5. Docusate Sodium 100 mg PO BID
6. Ipratropium-Albuterol Neb 1 NEB NEB Q4H wheezing
7. Ketorolac 15 mg IV Q8H:PRN Pain - Moderate Duration: 3 Days
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Morphine Sulfate ___ mg IV Q3H:PRN BREAKTHROUGH PAIN
10. OLANZapine (Disintegrating Tablet) 2.5 mg PO BID:PRN
anxiety, insomnia
11. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN moderate
pain, increased WOB
12. Polyethylene Glycol 17 g PO DAILY
13. Senna 17.2 mg PO QHS
14. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q4H:PRN
congestion
15. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze/shortness
of breath
16. Aquaphor Ointment 1 Appl TP HS BLE q HS
17. Aspercreme (lidocaine) (lidocaine;<br>lidocaine HCl) 4 %
topical DAILY
18. FLUoxetine 40 mg PO DAILY
19. Torsemide 80 mg PO QAM
20. Torsemide 60 mg PO 1400DAILY
21. TraZODone 50 mg PO QHS
Discharge Disposition:
Extended Care
Discharge Diagnosis:
rib fractures, hemothorax, pneumonia
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 ___,
You were admitted to the hospital after a fall and were found to
have multiple rib fractures and some bleeding. Your pain was
managed with pain medications and a catheter in your back. You
experienced some difficulty breathing during your admission and
you were transferred to the intensive care unit for closer
monitoring and support of your breathing as well as treatment
for your pneumonia. You are now ready to be discharged to the
___ facility to continue ensuring your comfort.
* Your injury caused multiple 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.
* 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.
We wish you all the best,
Your ___ care team
Followup Instructions:
___
|
19875974-DS-21
| 19,875,974 | 26,922,347 |
DS
| 21 |
2117-11-05 00:00:00
|
2117-11-05 14:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Type B aortic dissection
Major Surgical or Invasive Procedure:
___:
1. Bilateral femoral artery exposure with catheter
placement in the proximal thoracic aorta.
2. Endovascular aortic fenestration using Pioneer catheter.
3. Intravascular ultrasound.
4. Thoracic aortic stent graft.
5. Right renal artery stenting.
6. Right iliac, femoropopliteal thromboembolectomy.
7. Right lower extremity 4-compartment fasciotomy.
8. Right thigh complete fasciotomy.
History of Present Illness:
___ M presents as an OSH transfer for Type B aortic
dissection and pulseless RLE. Patient presented to ___ with abdominal pain radiating to the back
associated with decreased sensation of his lower extremities.
The progressed to RLE paresis. In the ED here, at ___ ,he was
found to have no pulses of his RLE with a cool foot. CTA
demonstrates a type B
aortic dissection from the take-off L subclavian with a
concentric filling defect within the proximal left subclavian
artery. The dissection extends throughout the thoracic aorta.
The true and false lumen enhance equally. The dissection
extends
into the upper abdomen and extends into both iliac afteries.
There is moderate narrowing of the left EIA. There is complete
occlusion of the distal right CIA. There is reconstitution of
the distal R internal iliac artery. There is small narrowing of
the lumen. There is a dissection extending into the right renal
artery with enhancement of the right kidney. The dissection
likely extends into the left kidney with minimal enhancement.
the left renal artery does reconstitute distal to the proximal
severe narrowing. He is taken emergently to the OR for repair.
Past Medical History:
None per patient (was not under care of physician ___
Social History:
___
Family History:
unknown
Physical Exam:
VSS, afebrile
Gen: Thin, frail male, appearing older than stated age.
Card: RRR
Lungs: CTA bilat
Abd: Soft, no masses or tenderness
Neuro: Alert and oriented x 3, Full strength in the bilateral
upper
extremities. No movement in bilateral lower extremities - ___
strength. No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception in bilateral upper extremities.
No sensation, including proprioception in the bilateral lower
extremities. Senory level is just above umbilicus, approximately
T8-T9.
Extremities: Bilateral fasciotomy sites healing well - packed
with wet to dry.
Pertinent Results:
___ 12:41PM BLOOD Glucose-135* UreaN-10 Creat-1.0 Na-137
K-5.8* Cl-107 HCO3-20* AnGap-16
___ 01:45AM BLOOD Glucose-109* UreaN-12 Creat-1.0 Na-142
K-3.9 Cl-111* HCO3-24 AnGap-11
___ 01:39AM BLOOD Glucose-127* UreaN-20 Creat-1.9* Na-142
K-4.4 Cl-107 HCO3-21* AnGap-18
___ 02:15PM BLOOD Glucose-118* UreaN-24* Creat-2.6* Na-142
K-4.1 Cl-107 HCO3-21* AnGap-18
___ 11:33AM BLOOD Glucose-118* UreaN-37* Creat-4.1* Na-142
K-4.3 Cl-108 HCO3-23 AnGap-15
___ 12:19AM BLOOD Glucose-130* UreaN-48* Creat-5.2*# Na-140
K-4.3 Cl-106 HCO3-22 AnGap-16
___ 05:10AM BLOOD Glucose-120* UreaN-81* Creat-6.2* Na-138
K-5.1 Cl-103 HCO3-23 AnGap-17
___ 02:25AM BLOOD Glucose-116* UreaN-99* Creat-6.9* Na-137
K-5.2* Cl-102 HCO3-22 AnGap-18
___ 04:50AM BLOOD Glucose-108* UreaN-116* Creat-6.8* Na-137
K-4.8 Cl-99 HCO3-25 AnGap-18
___ 06:04AM BLOOD Glucose-117* UreaN-127* Creat-6.5* Na-135
K-4.3 Cl-97 HCO3-25 AnGap-17
___ 08:30AM BLOOD Glucose-110* UreaN-129* Creat-5.5* Na-136
K-4.2 Cl-94* HCO3-27 AnGap-19
___ 07:45AM BLOOD Glucose-120* UreaN-117* Creat-4.1*#
Na-135 K-4.4 Cl-96 HCO3-27 AnGap-16
___ 06:40AM BLOOD Glucose-112* UreaN-96* Creat-3.1* Na-136
K-4.7 Cl-99 HCO3-28 AnGap-14
___ 06:10AM BLOOD Glucose-104* UreaN-75* Creat-2.2* Na-136
K-4.6 Cl-100 HCO3-29 AnGap-12
___ 06:50AM BLOOD Glucose-112* UreaN-57* Creat-1.7* Na-139
K-5.0 Cl-102 HCO3-27 AnGap-15
___ 06:16AM BLOOD WBC-18.6* RBC-3.78* Hgb-12.0* Hct-36.9*
MCV-98 MCH-31.7 MCHC-32.4 RDW-12.2 Plt ___
___ 01:45AM BLOOD WBC-10.0 RBC-2.94* Hgb-9.3* Hct-28.3*
MCV-96 MCH-31.6 MCHC-32.8 RDW-13.6 Plt ___
___ 01:39AM BLOOD WBC-12.7* RBC-3.42* Hgb-10.6* Hct-32.4*
MCV-95 MCH-31.0 MCHC-32.7 RDW-14.8 Plt ___
___ 05:20AM BLOOD WBC-11.0 RBC-2.98* Hgb-9.2* Hct-28.4*
MCV-95 MCH-30.8 MCHC-32.3 RDW-14.7 Plt ___
___ 12:19AM BLOOD WBC-13.6* RBC-2.94* Hgb-8.8* Hct-27.9*
MCV-95 MCH-30.1 MCHC-31.7 RDW-14.4 Plt ___
___ 05:10AM BLOOD WBC-11.7* RBC-2.85* Hgb-8.8* Hct-27.8*
MCV-98 MCH-30.9 MCHC-31.6 RDW-14.5 Plt ___
___ 02:25AM BLOOD WBC-11.0 RBC-3.13* Hgb-9.6* Hct-30.4*
MCV-97 MCH-30.8 MCHC-31.8 RDW-14.5 Plt ___
___ 04:50AM BLOOD WBC-12.4* RBC-3.07* Hgb-9.4* Hct-28.9*
MCV-94 MCH-30.6 MCHC-32.5 RDW-13.7 Plt ___
___ 06:04AM BLOOD WBC-15.0* RBC-2.91* Hgb-9.0* Hct-27.1*
MCV-93 MCH-30.8 MCHC-33.2 RDW-13.6 Plt ___
___ 08:30AM BLOOD WBC-16.5* RBC-3.18* Hgb-9.7* Hct-30.8*
MCV-97 MCH-30.6 MCHC-31.7 RDW-14.1 Plt ___
___ 07:45AM BLOOD WBC-16.3* RBC-3.03* Hgb-9.3* Hct-29.5*
MCV-97 MCH-30.8 MCHC-31.6 RDW-14.0 Plt ___
___ 06:40AM BLOOD WBC-17.6* RBC-2.99* Hgb-9.0* Hct-29.3*
MCV-98 MCH-30.2 MCHC-30.8* RDW-13.8 Plt ___
___ 06:10AM BLOOD WBC-18.4* RBC-3.03* Hgb-9.2* Hct-29.8*
MCV-99* MCH-30.4 MCHC-30.9* RDW-13.7 Plt ___
___ 06:50AM BLOOD WBC-18.8* RBC-2.69* Hgb-8.1* Hct-26.8*
MCV-100* MCH-30.2 MCHC-30.4* RDW-13.9 Plt ___
___ 12:41 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
DUPLEX DOP ABD/PEL LIMITED Study Date of ___ 1:29 ___
Bilaterally symmetric systolic flow is visualized in right and
left main renal
arteries and intrarenal arteries with no sonographically evident
diastolic
flow, consistent with high-resistance parenchymal beds.
Appropriate flow noted
in bilateral main renal veins.
These findings suggest high parenchymal resistance may be due to
acute tubular
necrosis or other intrinsic renal interstitial disease or edema
in bilateral
kidneys.
UNILAT LOWER EXT VEINS LEFT Study Date of ___ 11:57 AM
No evidence of deep venous thrombosis in the left lower
extremity.
RENAL U.S. Study Date of ___ 11:58 AM
Patent renal arteries bilaterally with unchanged waveforms and
velocities. Unchanged echogenic appearance of both kidneys. No
hydronephrosis.
___ 5:54 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 4:49 pm BLOOD CULTURE Source: Line-rij.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:28 pm BLOOD CULTURE Source: Line-16 guage.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Mr. ___ was admitted with an extensive type B dissection,
cool, pulseless RLE and compartment syndrome and was taken
emergently to the OR on ___ where he underwent:
1. Bilateral femoral artery exposure with catheter
placement in the proximal thoracic aorta.
2. Endovascular aortic fenestration using Pioneer catheter.
3. Intravascular ultrasound.
4. Thoracic aortic stent graft.
5. Right renal artery stenting.
6. Right iliac, femoropopliteal thromboembolectomy.
7. Right lower extremity 4-compartment fasciotomy.
8. Right thigh complete fasciotomy.
Post operatively he was taken to the CVICU intubated. He was
montiored closely. His creatinine and CKs were rising and he was
started on a bicarb drip for rhabdomyolysis. On POD 1 it was
noted that he was not moving his lower extremities. His lumbar
drain remained in place and was functioning well. Neurosurgery
and neurology got involved and felt that the pt had a spinal
cord infarct around the level of t8-t9. With his rising SCr and
CKs, he was aggressively hydrated. On ___ a nephrology consult
was obtained for acute kidney injury. They suggested that we
diurese with lasix and continue to monitor, feeling that his
kidney's would recover. On ___ his lumbar drain was removed by
neurosurgery. His creatinine began trending down and his urine
output remained great. His meds were oralized and he tolerated a
regular diet. VAC dressings were applied to his fasciotomy
sites. On ___ he was transfered to the VICU. He continued to
be monitored closely. He worked with ___ and OT and began working
on transfers to a wheel chair. His creatinine continued to
improve and the renal team signed off, letting the patient know
that they expected him to make a full renal recovery. On ___
his indwelling foley catheter was removed and straight cath-ing
q4h was initiated. The pt began teaching on self-cathing. Of
note his white blood cell count was elevated, but there was no
source of infection found and no fevers. This was thought to be
benign. Mr. ___ was stable for discharge to a rehab
facility on ___. He will continue to pt and ot and
catherterization training. He will have wound VACs to his
fasciotomy sites at rehab and will follow up in ___ clinic
in 1 week for wound checks.
Medications on Admission:
none
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection
injection Injection BID (2 times a day).
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day: hold for hr<50, sbp<95.
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): decrease dose as indicated.
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for sob/wheezing.
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours.
10. ipratropium-albuterol ___ mcg/actuation Aerosol Sig: ___
Puffs Inhalation Q6H (every 6 hours) as needed for SOB.
11. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO HS
(at bedtime).
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for constipation.
14. STRAIGHT CATH
EVERY 4 HOURS
please continue teaching pt to self straight cath
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Type B thoracoabdominal aortic dissection, acute with
visceral and right leg malperfusion
2. Bilateral lower extremity paralysis secondary to spinal cord
infacrction at level of T8-T9
3. Acute kidney injury - resolving
4. HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.(___ lift - pt is paraplegic)
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Discharge Instructions
You were admitted with a large dissection in your aorta which
started high in the chest, and went down through your abdomen
and into the iliac arteries in your lower extremities. You
underwent emergent surgery where we put a stent graft into your
aorta, as well as your right renal artery, and opened your right
iliac and femoropopliteal artery to remove thrombus(clot). You
then had fasciotomies of both legs (cuts to release pressure).
Unfortunately as a result of your dissection, you had a spinal
cord infarction and you're now paralyzed from the level of
T8-T9, down (your lower extremities).
Medications:
Take Aspirin 325mg (enteric coated) once daily
Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
You were started on numerous new medications that you will
need to take for the rest of your life. Do not stop any
medications without talking to your PCP or ___ doctor
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when leave:
You are going to a rehabilitation facility where you will get
___ and medical care.
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
What activities you can and cannot do:
Your groin incisions 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 that is draining, as needed
Your leg fasciotomy sites will be dressed with wound
VACs to help with closure.
What to report to office:
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
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call ___ for
transfer to closest Emergency Room.
Followup Instructions:
___
|
19876093-DS-17
| 19,876,093 | 26,612,181 |
DS
| 17 |
2120-01-24 00:00:00
|
2120-01-24 13:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ___
Allergies:
Sulfa (Sulfonamide Antibiotics) / nasal steroids / Niaspan
Extended-Release / ACE Inhibitors / eggs
Attending: ___.
Chief Complaint:
Renal Failure
Major Surgical or Invasive Procedure:
___ Temporarily HD Line Placement
___ Tunneled HD Line Placement
History of Present Illness:
Ms. ___ is an ___ female with chronic renal
insufficiency, creatinine 4.6 in ___, chronic hematuria,
unrevealing urology evaluation, referred from nephrologist for
evolving renal failure and probable renal biopsy. Patient
reportedly was instructed by Dr. ___ to seek emergency care
for a creatinine 9.0 and bicarbonate of 13, though no recent
laboratory studies are available in ___
medical record. Creatinine has ranged from ___ for most of ___,
___ for much of ___, then 4.6, as of ___. She has
chronic near nephrotic-range proteinuria by serial urinalysis
estimates too. She, moreover, had intermittent gross hematuria
for months, yet CT abdomen/pelvis, cystoscopy, and urine
cytology were all not explanatory. Emergency department
contacted Dr. ___ for collateral, but covering
physician did not have access to her laboratory studies. She is
afebrile and hemodynamically stable on arrival. CBC is notable
for leukocytosis to 15.0 with a neutrophilic predominance,
normocytic anemia with hemoglobin to 8.1, normal platelets. BUN
89, creatinine 9.9. Sodium 134. Potassium 4.3. Bicarbonate 16.
Calcium 7.9. Phosphorus 8.5. INR 2.4. Troponin undetectable.
Moderate blood, 3+ protein, 34 RBC, 23 WBC on urinalysis. Renal
ultrasound revealed bilateral cortical thinning and probable
non-obstructing right nephrolith.
REVIEW OF SYSTEMS: Constitutionally, she has felt "lousy" for at
least a month, meaning asthenia and fatigue. In fact, "[She]
can't do anything around the house now. "[Her] husband now does
everything." She has new insomnia and is napping during the day.
She notes "chills," but denies fever, rigors, night sweats,
anorexia, or weight loss. She had epistaxis three days ago,
requiring cauterization at ___ emergency
department. She denies confusion, headache, or visual
disturbance. She has difficulty breathing when ambulating "off
and on," attributed to COPD, but this is chronic, and not worse
than typical. She developed a non-productive cough three days
ago after visiting said emergency department. One of her
grandchildren had a viral URI and she in turn had pharyngitis
for a week or so, but this resolved. She otherwise denies chest
pain or palpitations. She has no gastrointestinal distress of
lower urinary tract symptoms. She is not taking nitrofurantoin
and denies ever having symptoms of a urinary tract infection.
She has not appreciated a new rash or arthralgias. She last had
hematuria a week ago. She is still urinating multiple times per
day. It was translucent just minutes ago. She has chronic lower
extremity edema, which she attributes to a prior lower extremity
bypass. She denies ibuprofen, naproxen, or other NSAID use. She
only ever takes acetaminophen.
Past Medical History:
-Chronic kidney disease, stage IV-V.
-Peripheral vascular disease post left CFA endarterectomy,
CFA-BKP PTFE bypass, left CIA and EIA stents. Anticoagulated
with
warfarin.
-Right carotid endarterectomy.
-Recurrent C. difficile colitis.
-Recurrent urinary tract infection.
-Hypertension.
-Hyperlipidemia.
-Hysterectomy.
-COPD.
Social History:
___
Family History:
Mother died at age ___ DM2.
Father died in ___ unknown cancer.
Asthma.
No known familial history of renal failure.
Physical Exam:
==============================
ADMISSION PHYSICAL EXAMINATION
==============================
VITALS: T 98.6, HR 75, BP 161/74, 20, 90% RA.
GENERAL: Elderly female in no apparent distress. Lying
comfortably.
HEENT: Anicteric sclerae. Periorbital edema. Oropharynx clear.
NECK: No cervical lymphadenopathy. JVP undetectable.
CV: Regular rate and rhythm. S1/S2. Systolic murmur across
precordium.
PULM: Unlabored. Late inspiratory bibasilar crackles.
ABDOMEN: Soft, non-tender, non-distended. No hepatosplenomegaly
appreciated.
GU: No CVA tenderness.
EXT: Warm, well perfused, pulses palpable and symmetric. ___
pitting pretibial edema.
SKIN: Within normal limits.
NEURO: Asterixis. Otherwise non-focal.
==============================
DISCHARGE PHYSICAL EXAMINATION
====================OBJECTIVE:
24 HR Data (last updated ___ @ 314)
Temp: 98.4 (Tm 98.7), BP: 150/69 (127-194/66-77), HR: 94
(94-121), RR: 18 (___), O2 sat: 94% (92-94), O2 delivery: RA
GENERAL: WDWN older woman laying in bed in NAD, breathing
comfortably on room air
HEENT: NCAT, sclerae anicteric, normal conjunctivae, RIJ TDC in
place
NECK: Supple, JVP not visible at @90 degrees
CARDIAC: RRR, normal S1/S2, II/VI crescendo-decrescendo loudest
at RUSB and radiating to carotids
LUNGS: Diffuse upper airway rhonchi auscultated over anterior
lung fields
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: Warm, no ___ edema
NEUROLOGIC: AOx3 ==========
Pertinent Results:
==============
ADMISSION LABS
==============
___ 03:25PM BLOOD WBC-15.0* RBC-2.90* Hgb-8.1* Hct-24.8*
MCV-86 MCH-27.9 MCHC-32.7 RDW-16.3* RDWSD-51.7* Plt ___
___ 03:25PM BLOOD Neuts-72.4* Lymphs-17.7* Monos-7.5
Eos-0.9* Baso-0.4 Im ___ AbsNeut-10.86* AbsLymp-2.65
AbsMono-1.12* AbsEos-0.14 AbsBaso-0.06
___ 03:34PM BLOOD ___ PTT-44.2* ___
___ 03:25PM BLOOD Glucose-117* UreaN-89* Creat-9.9*#
Na-134* K-4.3 Cl-98 HCO3-16* AnGap-20*
___ 03:25PM BLOOD Albumin-2.4* Calcium-7.9* Phos-8.5*
Mg-2.1
===============
PERTINENT LABS
===============
___ 05:55AM BLOOD Ret Aut-2.9* Abs Ret-0.09
___ 03:25PM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:55AM BLOOD Folate-16
___ 08:39AM BLOOD calTIBC-164* Hapto-567* Ferritn-258*
TRF-126*
___ 04:00AM BLOOD PTH-179*
___ 06:00AM BLOOD Cortsol-13.1
___ 04:00AM BLOOD 25VitD-13*
___ 08:39AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 08:39AM BLOOD ANCA-NEGATIVE B
___ 08:39AM BLOOD ___
___ 03:30PM BLOOD FreeKap-115.3* FreeLam-70.6* Fr K/L-1.63
___ 08:39AM BLOOD PEP-BASED ON I IgG-524* IgA-149 IgM-80
IFE-NO MONOCLO
___ 08:39AM BLOOD C3-153 C4-29
___ 08:39AM BLOOD HIV Ab-NEG
___ 08:39AM BLOOD HCV Ab-NEG
ANTI-GBM
Test Result Reference
Range/Units
GLOMERULAR BASEMENT MEMBRANE <1.0 AI
ANTIBODY (IGG)
Value Interpretation
----- --------------
<1.0 No Antibody Detected
> or = 1.0 Antibody Detected
THIS TEST WAS PERFORMED AT:
___ ___
___
================
DISCHARGE LABS
================
===========================
REPORTS AND IMAGING STUDIES
===========================
___ Renal US
IMPRESSION:
1. Possible 1.3 x 0.4 cm nonobstructing stone in the interpolar
region of the right kidney. No hydronephrosis.
2. Similar findings suggestive of underlying medical renal
disease, including increased cortical echogenicity and thinning.
___ CXR
FINDINGS:
PA and lateral views of the chest show the costophrenic angles
to be sharp.
The heart is borderline in size. Atherosclerotic vascular
calcifications are
seen in the thoracic and abdominal aorta. No pneumothorax.
There is bilateral
interstitial pulmonary edema more on the right than the left.
IMPRESSION:
Interstitial pulmonary edema.
___ Renal US
IMPRESSION:
1. 4 mm nonobstructing calculus in the left lower pole kidney.
2. No hydronephrosis.
3. Echogenic appearance of the kidneys suggests chronic medical
renal disease.
___ CXR
IMPRESSION:
Diffuse infiltrative pulmonary abnormality has improved in all
areas.
Asymmetric distribution suggested either edema due to to mitral
regurgitation
or, alternatively, widespread infection.
Heart size normal. Pleural effusions small if any. New right
supraclavicular
dialysis catheter ends in the right atrium. No pneumothorax.
Configuration
of the trachea suggest and may be a small associated hematoma
just above the
thoracic inlet. Clinical examination advised.
RECOMMENDATION(S): Please examine the neck for any evidence of
bleeding.
CT CHEST ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE AND CHEST WALL:
The thyroid is heterogeneous with a 1.8 cm nodules to the left,
somewhat is of
fatigue (302:1). No enlarged lymph nodes in either axilla or
thoracic inlet.
No abnormalities on the chest wall. Moderate atherosclerotic
calcifications
in the head and neck arteries. Large-bore catheter in the right
jugular vein
with tip in the lower SVC.
HEART AND VASCULATURE:
The heart is normal size and shape. No pericardial effusion.
Moderate
atherosclerotic calcifications in the coronary arteries and
aorta, none mild
in the aortic valve. The pulmonary arteries and aorta are
normal caliber
throughout.
MEDIASTINUM AND HILA:
The esophagus is unremarkable. Small mediastinal lymph nodes,
the largest
measuring up to 1.2 cm in the right lower paratracheal station.
No hilar
lymphadenopathy.
PLEURA:
No pleural effusions. No apical scarring bilaterally.
LUNGS:
The airways are patent to the subsegmental levels. No
bronchiectasis or mucus
plugging. Mild bronchial wall thickening. Mild interlobular
septal
thickening associated to scattered ground-glass opacities
bilaterally. More
nodular ground-glass opacities are noted in the left lower lobe
(302:120).
There is moderate background centrilobular and paraseptal
emphysema, upper
lobe predominant. 5 mm and 3 mm subpleural nodule in the middle
lobe (302:78
and 102).
CHEST CAGE:
Mild dorsal spondylosis. No acute fractures. No suspicious
lytic or
sclerotic lesions.
UPPER ABDOMEN:
The limited sections of the upper abdomen show severe
atherosclerotic disease
in the intra-abdominal vessels. Left adrenal myelolipoma
measuring 2.0 cm
(02:54).
IMPRESSION:
No evidence of mediastinal bleeding. Appropriately placed
hemodialysis
large-bore catheter in the right jugular vein.
Moderate bilateral pulmonary edema with likely reactive
mediastinal
lymphadenopathy.
There are nodular ground-glass opacities in the left lower lobe
that might
represent superimposed infectious/inflammatory process.
CT ABDOMEN ___
FINDINGS:
LOWER CHEST: Scattered ground-glass opacities are seen
bilaterally with
increased nodularity in the left lower lobe, similar to prior
study. No
pleural or pericardial effusion
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation
throughout.
There is no evidence of focal lesions within the limitations of
an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic
biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions within the limitations of an unenhanced scan.
There is no
pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right adrenal gland is normal in size and shape.
A 1.9 x 1.7 cm
fat containing lesion is seen arising from the left adrenal
gland consistent
with an adrenal myelolipoma.
URINARY: The kidneys are of symmetric size. Bilateral kidneys
demonstrate
cortical thinning. A 1 cm lesion of intermediate density is
seen arising from
the upper pole of the right kidney, previously characterized as
a cyst. There
is no hydronephrosis. Nonobstructing stones are seen in the
right kidney
measuring up to 4 mm in the interpolar region. A nonobstructing
stone in the
lower pole of the left kidney measures 3 mm. There is no
perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber and wall thickness throughout. Diverticulosis of
the colon is
noted, without evidence of wall thickening and fat stranding.
The appendix is
normal.
PELVIS: The urinary bladder is decompressed. The distal ureters
are
unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal
abnormality is
seen.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive
atherosclerotic
disease is noted. A left common and external iliac artery stent
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Bilateral nonobstructing renal calculi measuring up to 4 mm.
2. No acute intra-abdominal abnormality.
3. 1.9 cm left adrenal myelolipoma.
============
MICROBIOLOGY
============
___ Urine Culture
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 2:40 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
INRS
___ 03:34PM BLOOD ___ PTT-44.2* ___
___ 08:39AM BLOOD ___ PTT-40.9* ___
___ 08:06AM BLOOD ___ PTT-42.5* ___
___ 03:53AM BLOOD ___ PTT-42.1* ___
___ 04:00AM BLOOD ___ PTT-30.7 ___
___ 05:55AM BLOOD ___ PTT-27.5 ___
___ 06:00AM BLOOD ___ PTT-31.4 ___
___ 06:38AM BLOOD ___ PTT-33.7 ___
___ 07:45AM BLOOD ___ PTT-36.7* ___
___ 06:40AM BLOOD ___ PTT-39.3* ___
___ 07:30AM BLOOD ___
___ 05:55AM BLOOD ___ PTT-40.9* ___
___ 06:00AM BLOOD ___ PTT-39.2* ___
___ 05:05PM BLOOD ___ PTT-37.4* ___
___ 05:50AM BLOOD ___ PTT-36.3 ___
___ 08:15AM BLOOD ___ PTT-40.3* ___
___ 06:26AM BLOOD ___ PTT-41.6* ___
___ 06:00AM BLOOD ___
___ 07:40AM BLOOD ___
___ 10:30AM BLOOD ___
DISCHARGE LABS
___ 07:30AM BLOOD WBC-13.3* RBC-2.62* Hgb-7.1* Hct-22.3*
MCV-85 MCH-27.1 MCHC-31.8* RDW-16.1* RDWSD-50.3* Plt ___
___ 10:30AM BLOOD ___
___ 07:30AM BLOOD Glucose-89 UreaN-36* Creat-5.8*# Na-132*
K-3.7 Cl-97 HCO3-25 AnGap-10
___ 07:30AM BLOOD Calcium-7.2* Phos-2.7 Mg-1.8
Brief Hospital Course:
PATIENT SUMMARY
====================
___ with history of CKD with nephrotic-range proteinuria,
chronic hematuria, and HTN who was admitted to the MICU for
acute hypoxic respiratory failure in the setting of worsening
renal insufficiency s/p urgent iHD initiation for volume
overload, s/p tunneled HD line on ___. She developed a hospital
acquired pneumonia and finished a course of IV antibiotics. She
developed a-fib with RVR following dialysis, which resolved
following resumption of beta blocker (atenolol switched to
metoprolol).
ACUTE ISSUES:
=============
#Acute-on-chronic renal failure
#CKD stage V
#Nephrotic syndrome
Unknown etiology of chronic renal failure and nephrotic
syndrome.
Patient had rapid decline over the past few months, also of
unclear
cause. Negative work-up with normal C3/C4, negative ___, ANCA,
HIV, and hepatitis serologies, and normal serum FLC ratio,
negative anti-GBM. Course c/b volume overload, metabolic
acidosis, hyperphosphatemia, uremia, and oliguria with poor
diuretic response. S/p urgent iHD initiation (___) for
volume overload and ___ tunneled HD line on ___. PPD
negative; HBV non-immune. Patient on TTS schedule for HD while
inpatient. Started on low-dose midodrine 5MG prior to HD as
needed. Also started on ESA with HD for anemia (see below). She
was started on HD and discharged to rehab once outpatient HD was
setup.Patient will require Hep B vaccination series after
discharge.
#Orthostasis
Patient noted to have persistent symptomatic orthostasis while
inpatient. Likely multifactorial in setting of volume removal
during HD, and autonomic instability. Normal cortisol level.
Patient on low-dose midodrine before HD as needed. Additional
medical therapy limited by severe supine hypertension and
amlodipine was started on non-HD days per renal. Symptomatic
orthostasis resolved with holding anti-hypertensives,
discontinuing tamsulosin, and placement of compression
stockings, although patient continued to have positive
orthostatic vital signs.
#Hypoxia
#Volume overload
#H/o COPD (not on home O2)
Hypoxia likely secondary to volume overload (with
interstitial edema seen on CXR), HAP (see below), and possibly
with component of OSA given nocturnal hypoxia. Last TTE in
___ with normal LVEF. Worsening hypoxia prompted MICU
transfer for urgent initiation of HD on ___. Respiratory status
and hypoxia resolved with fluid removal via HD. Weaned to room
air with fluid removal during HD. Patient subsequently euvolemic
to dry with intermittent orthostasis as above. Based on history
of COPD, SaO2 of 88-92% was targeted. Patient continued to have
intermittent nocturnal desats to high ___, and may benefit from
outpatient sleep study. Patient continued on home inhalers while
inpatient.
#HAP
While inpatient, noted to have cough, leukocytosis, low-grade
temperatures, with LLL GGO more nodular in appearance from other
infiltrates, overall suggestive of HAP. Started empiric therapy
on ___ with vancomycin/levofloxacin. MRSA swab negative,
discontinued vancomycin. Completed levofloxacin course.
Subsequently remained afebrile, no sputum production, low
suspicion for ongoing
infection, although WBC remained elevated.
#Nausea, vomiting
Patient with intermittent nausea, non-bloody vomiting while
inpatient. ___ be in setting of antibiotic initiations,
constipation,
nephrolithiasis, and/or uremia. Low suspicion for ACS or anginal
equivalent given timing of onset (not provoked by exertion or
fluid shifts during HD), spontaneous resolution, and absence of
any ischemic changes on EKG. Generally resolved after HD,
suggestive of uremic etiology.
#AFib
Noted during HD. Likely triggered by fluid shifts, also may be
in
setting of infection, beta blocker withdrawal while holding home
atenolol. Switched to metoprolol, with rates well-controlled.
Patient on warfarin on admission for vascular grafts; discussed
with patient's vascular surgeon, and based on this indication
did not switch to DOAC while inpatient. INRs labile while
inpatient. INR remained >3 despite holding doses, peaking at
4.1. Will need continued monitoring and management of warfarin
dosing, INR at discharge 2.0
#Acute-on-chronic normocytic anemia
#Chronic hematuria
Baseline Hgb ~10. Likely anemia of chronic renal disease and
inflammation, exacerbated by chronic hematuria. Found to be
iron-deficient (Tsat 9.7%). B12-replete. She required multiple
transfusions during her hospitalization with no signs of
new/acute blood loss. Overall, anemia thought to be
multifactorial from ESRD, chronic disease, phlebotomy, and
hematuria, possibly worsened by supratherapeutic INR. Started on
ESA with HD by nephrology while inpatient.
#Bilateral nephrolithiasis
#Flank pain, resolved
Serial renal ultrasounds demonstrated R-sided non-obstructing
and
then L-sided non-obstructing nephrolithiasis without
hydronephrosis. 1.3x0.4cm on R, 4mm on L. ___ be contributing to
chronic hematuria as above. Patient reporting intermittent
continued flank pain. CTAP notable for bilateral renal stones up
to 4mm in size. Flank pain resolved. Would consider outpatient
urology workup.
CHRONIC/STABLE ISSUES:
======================
#PVD s/p bypass grafts in ___
Home warfarin briefly held for supratherapeutic INR and tunneled
HD line placement. See above for further detail on labile INRs.
Discussed warfarin indication with patient's outpatient vascular
surgeon, who expressed that patient would be at high risk of
graft closure off warfarin. Continued statin and ASA while
inpatient for PVD.
#GERD
- continued home ranitidine 150mg qd
TRANSITIONAL ISSUES
[ ] Patient will require hep B vaccination as she is non immune
[ ] Patient with labile INR while inpatient, prior dose 2 mg
daily likely too much given supratherapeutic INRs on this dose.
Recommend starting 0.5-1mg daily at rehab based on INR (goal
___ and titrating from there. INR on discharge 2.0, but no
warfarin given on this day
[] Hematuria inpatient and will need urology follow up with
prior physician
[] Consider starting midodrine on HD days if patient develops
hypotension on dialysis.
[] Patient requires warfarin per vascular surgeon who performed
bypass grafts for lower extremity PVD, not a candidate for DOAC
given this in combination with ESRD
[] Patient prefers to be given duonebs when short of
breath/coughing
Incidental finding: 1.9 cm left adrenal myelolipoma
Name of health care proxy: ___
Relationship: Husband
Phone number: ___
Code status: full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Atenolol 75 mg PO QAM
3. Atenolol 50 mg PO QPM
4. Hydrochlorothiazide 25 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN Shortness of breath,
wheezing
7. Rosuvastatin Calcium 40 mg PO QPM
8. Aspirin 81 mg PO DAILY
9. Cetirizine 10 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Ranitidine 150 mg PO BID
12. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN Cough
2. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q6H:PRN sore throat
3. Dextromethorphan Polistirex ___ mg PO Q12H:PRN cough
4. GuaiFENesin ___ mL PO Q6H:PRN Cough
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Nephrocaps 1 CAP PO DAILY
7. Polyethylene Glycol 17 g PO DAILY
8. Ramelteon 8 mg PO QHS insomnia
9. Senna 17.2 mg PO BID
10. Tiotropium Bromide 1 CAP IH DAILY
11. amLODIPine 5 mg PO ASDIR
12. Ranitidine 150 mg PO DAILY
13. ___ MD to order daily dose PO DAILY16
14. Albuterol Inhaler 2 PUFF IH Q4H:PRN Shortness of breath,
wheezing
15. Aspirin 81 mg PO DAILY
16. Cetirizine 10 mg PO DAILY
17. Fluticasone Propionate 110mcg 2 PUFF IH BID
18. Rosuvastatin Calcium 40 mg PO QPM
19. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Nephrotic Syndrome
Renal Failure
SECONDARY DIAGNOSIS
===================
___ Acquired Pneumonia
COPD
Orthostatic Hypotension
Vomiting
Atrial Fibrillation
Anemia
Hematuria
Nephrolithiasis
Peripheral Vascular Disease
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for kidney failure.
What was done for me while I was in the hospital?
- You had low oxygen levels and difficulty breathing due to
fluid accumulation caused by your kidney failure. You were
transferred to the ICU for urgent initiation of dialysis. You
had a tunneled dialysis catheter placed, and were started on
dialysis. The excess fluid in your body was removed via
dialysis, and your oxygen levels and breathing improved.
- You developed fast, irregular heart rates (atrial
fibrillation) during dialysis, and were started on a medication
called metoprolol to prevent this.
- You developed pneumonia and were treated with antibiotics.
- You had low blood pressures with standing. Several of your
home blood pressure medications were stopped (atenolol,
amlodipine, hydrochlorothiazide) and compression stockings were
placed.
- You were evaluated by physical therapy, who recommended
discharge to a rehab facility to help build up your strength.
What should I do when I leave the hospital?
- Continue to take all of your medications as prescribed.
- Attend all of your follow-up appointments.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19876231-DS-13
| 19,876,231 | 25,241,919 |
DS
| 13 |
2124-05-21 00:00:00
|
2124-05-21 23:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
FROM ADMISSION NOTE
___ year old gentleman with history of diabetes, hypertension,
CKD
III (Cr 1.9-2.1) who presents with 4 days of diarrhea, anorexia.
Since ___, patient has been experiencing ___
episodes of nonbloody diarrhea and nausea, with one episode of
vomiting 4 days ago, and poor oral intake (1 bowl of soup
daily).
He continued to take his home medications including lisinopril
20
mg daily and furosemide 20 mg daily. He has had no NSAID use. He
has had no sick contacts, and no one else around him has had
diarrhea. He wonders if it is related to the black eyed peas
that
he had made for New ___, but his family members also had the
same food. No unusual food or water exposures.
Over the last three days, he has noticed significantly less
urine
output, without dysuria, gross hematuria, feeling of incomplete
voiding. He notes that his urine appears much darker. Family
notes that he is more confused than baseline, and has been
telling them things that did not actually happen (for instance,
that somebody in the house was trying to feed him, this did not
happen). He denies feeling more confused.
Initially presented to urgent care where he was found to have
acute renal failure with K 6.1 and Cr 8.1, and was transferred
to
us for further care.
In the ED, initial VS were: 97.7 78 144/58 16 96% RA
Exam notable for: Mild bibasilar crackles, AAO ×3, able to do
days of week backwards, slow speech and delayed response time to
questions
EKG per my read: Sinus rhythm, rate 75, LAD, question LAFB,
prolonged PR interval, LVH, no peaked T waves
Labs showed:
133 | 102 | 126
---------------- Glu 182, Anion gap = 23
7.3 | 9 | 8.3
After 1 L NS
135 | 104 | 126
---------------- Glu 167, Anion gap = 21
6.4 | 10 | 8.3
Ca 8.5, Mg 2.5, P 8.1
vBG 7.___
WBC 9.5 Hgb 13.0 Plt 197
Imaging showed:
Renal ultrasound: No hydronephrosis. No evidence of acute
pathology.
Consults: Renal consulted, thought that this was likely
secondary
to
prerenal etiology and loss of autoregulation because of ACEI
use.
No urine output yet since ER visit. Recommended fluid
resuscitation, with close monitoring of breath status, UOP.
-Repeat BMP ___ hours after IVF.
-Send UA, Urine pr/Cr, lytes, osm
-Renal US
For his hyperkalemia, thought secondary to ___ and acidosis,
recommend sodium bicarbonate, ideally IV, if IV not available,
1300 mg 3 times daily, insulin and glucose to temporize. If
patient still have persistent hyperkalemia of IVF, and starts to
make urine, can consider diuretics. But will try to avoid it.
Recommend check guaiacs to rule out a GI bleeding causing
hyperkalemia.
Patient received:
Calcium Gluconate 2 g IV
Regular insulin 10 UNIT IV ONCE
Dextrose 50% 25 gm IV ONCE Duration: 1 Dose Inactive
Sodium Bicarbonate 100 mEq IV ONCE Duration: 1 Dose
Of note, he presented ___ years ago to the ___ with similar
symptoms and ended up admitted for acute renal failure requiring
CRRT, did not require intubation. Per review of ___ notes, he
presented with 7 days of malaise and confusion, at that time
with
creatinine 16.39, BUN 176, K 7.1 and metabolic acidosis (HCO3 6)
requiring MICU stay and CRRT. At time of discharge, continued to
have broad differential including pre-renal (w/ intermittent SBP
in ___ v. intrinsic, with extensive work up including negative
hepatitis panel, negative ___, SPEP w/ M-spike c/w known MGUS,
normal C3, and elevated C4 at 47.
Past Medical History:
FROM ADMISSION NOTE
Diabetes, on insulin, HgbA1c 8.3%
Colon cancer s/p hemicolectomy and chemotherapy
Hypercholesterolemia
CKD III thought secondary to diabetic nephropathy
Hypertension
Anemia
MGUS
Social History:
___
Family History:
FROM ADMISSION NOTE
FH: Father died of CA age ___
Mother had late onset DM
No know anesthetic complications.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=====================
VS: ___ 2154 Temp: 97.7 PO BP: 116/58 HR: 82 RR: 18 O2
sat:
99% O2 delivery: RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs, old chemo port
site on R chest
LUNGS: Decreased BS at bases, no wheezes, rales, rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, trace edema in ankles
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, able to do
days of week backwards but unable to do even 1 serial 7 (per
patient math was never his strong suit)
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
=====================
VITALS: T 98.4, HR 63, BP 121/65, RR 20, O2 97% RA
GENERAL: NAD, lying comfortably in bed
HEENT: anicteric sclera, MMM, oropharynx clear
NECK: supple, no LAD, JVD flat
CV: RRR, S1/S2, no m/r/g
PULM: unlabored, decreased breath sounds at bases
GI: soft, normoactive, non-distended, non-tender
EXT: WWP, without edema
NEURO: awake, alert, attentive, oriented, no asterixis,
otherwise
non-focal
SKIN: axillae dry, no tenting
Pertinent Results:
ADMISSION LABS
=============
___ 04:00PM BLOOD WBC-8.8 RBC-4.60 Hgb-13.7 Hct-44.9 MCV-98
MCH-29.8 MCHC-30.5* RDW-13.5 RDWSD-48.5* Plt ___
___ 04:00PM BLOOD Neuts-64.8 Lymphs-18.6* Monos-11.0
Eos-5.2 Baso-0.2 Im ___ AbsNeut-5.73 AbsLymp-1.64
AbsMono-0.97* AbsEos-0.46 AbsBaso-0.02
___ 03:47PM BLOOD Glucose-182* UreaN-126* Creat-8.3*
Na-133* K-7.3* Cl-102 HCO3-8* AnGap-23*
___ 05:07PM BLOOD Glucose-167* UreaN-126* Creat-8.3* Na-135
K-6.4* Cl-104 HCO3-10* AnGap-21*
___ 03:47PM BLOOD Calcium-8.5 Phos-8.5* Mg-2.6
___ 05:07PM BLOOD Calcium-8.5 Phos-8.1* Mg-2.5
___ 05:10PM BLOOD PTH-110*
___ 05:14PM BLOOD ___ pO2-41* pCO2-36 pH-7.12*
calTCO2-12* Base XS--18
___ 07:47PM URINE Color-Straw Appear-Hazy* Sp ___
___ 07:47PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 07:47PM URINE RBC-1 WBC-2 Bacteri-FEW* Yeast-NONE Epi-2
___ 07:47PM URINE CastHy-19*
PERTINENT LABS
=============
___ 12:07AM BLOOD Glucose-156* UreaN-125* Creat-7.1*#
Na-137 K-5.7* Cl-106 HCO3-10* AnGap-21*
___ 07:35AM BLOOD Glucose-159* UreaN-125* Creat-6.9* Na-136
K-5.6* Cl-106 HCO3-11* AnGap-18
___ 02:11PM BLOOD Glucose-169* UreaN-120* Creat-5.8*#
Na-138 K-5.0 Cl-104 HCO3-16* AnGap-18
___ 12:07AM BLOOD Calcium-8.6 Phos-7.1* Mg-2.5
___ 07:35AM BLOOD Calcium-8.6 Phos-7.3* Mg-2.6
___ 02:11PM BLOOD Calcium-8.3* Phos-6.0* Mg-2.5
___ 09:23AM BLOOD ___ pO2-164* pCO2-27* pH-7.26*
calTCO2-13* Base XS--13
___ 02:04PM BLOOD ___ pO2-181* pCO2-33* pH-7.28*
calTCO2-16* Base XS--9
___ 09:23AM BLOOD Lactate-1.1 Na-134 K-5.2*
___ 02:04PM BLOOD K-5.6*
DISCHARGE LABS
=============
___ 05:50AM BLOOD WBC-6.8 RBC-3.68* Hgb-11.1* Hct-34.2*
MCV-93 MCH-30.2 MCHC-32.5 RDW-13.3 RDWSD-45.1 Plt ___
___ 05:50AM BLOOD Glucose-105* UreaN-96* Creat-4.2*# Na-140
K-4.5 Cl-107 HCO3-20* AnGap-13
___ 05:50AM BLOOD Calcium-8.3* Phos-4.7* Mg-2.3
IMAGING/STUDIES
==============
RENAL US (___)
IMPRESSION:
No hydronephrosis. No evidence of acute pathology.
Brief Hospital Course:
___ male with CKD stage III, insulin-dependent diabetes
type II, hypertension, MGUS, and remote history of acute renal
failure of uncertain etiology requiring ICU-level care for
continuous renal replacement therapy now admitted for acute
renal failure secondary to volume contraction in the context of
presumptive viral gastroenteritis.
#) Acute on chronic kidney injury, anuric
CKD stage III secondary to diabetic versus hypertensive
nephropathy. Patient presented with anuria, found to have
creatinine 8.3 at admission from baseline creatinine 1.9-2.0.
Complicated by hyperkalemia to 7.3 and mixed anion-gap metabolic
acidosis and non-anion gap metabolic acidosis. FeNa 0.5%,
despite diuretics, and FeUrea 11.4% suggestive of pre-renal
etiology in the context of anorexia and GI losses, then
exacerbated by continued use of home diuretics and ACE
inhibitor. Dry on exam without oxygen requirement. Urine
sediment with hyaline casts as well as granular type, in keeping
with suboptimal perfusion. Renal ultrasound without
hydronephrosis. History of MGUS; however, not evoking myeloma
kidney or other intrinsic cause, given rapid improvement in all
renal parameters with hydration. Urine output promptly improved
after one liter isotonic fluid at admission and a second admixed
with bicarbonate on hospital day 1. Creatinine likewise halved
to 4.2 by discharge. Potassium and bicarbonate, moreover, fell
to 4.5 and climbed to 20, respectively, with renal recovery, as
above, and sodium bicarbonate 1300 mg PO TID. Sevelamer
transiently added for hyperphosphatemia. Patient soon tolerated
oral intake, drinking to thirst. Home Lasix and lisinopril held
at discharge. He will follow up with renal 3 days after
discharge and will have repeat labs.
#) Viral gastroenteritis: four-day history of anorexia, nausea,
vomiting, diarrhea, all resolved. Self-limited nature suggestive
of viral gastroenteritis. No indication for stools studies in
the absence of diarrhea. Quickly tolerated oral intake, as
above.
#) IDDM2: A1C 8.3% (___): at admission, home NPH 18U BID
dose-reduced by 25% = 13U BID. Corrective scale substituted for
home regular insulin 20U BID AC. Discharged on home insulin
regimen.
#) MGUS: repeat SPEP, UPEP deferred until resolution of ___.
TRANSITIONAL ISSUES:
[ ]Ensure follow-up with ___ nephrology.
[ ]Check electrolytes and kidney function; at discharge:
-BUN = 96
-Creatinine = 4.2
-Potassium = 4.5
-Bicarbonate = 20
[ ]Lasix and lisinopril held in the context of ___ consider
restarting after complete resolution ___ and maintained
adequate oral hydration
[ ]Repeat SPEP, UPEP, quantitative immunoglobulins, and free
light chains after resolution ___
[ ]PCV-13 administered; due for PPSV23 at least eight weeks
later
Greater than 30 minutes spent in care coordination and
counseling on the day of discharge.
CONTACT: ___, wife (___)
CODE: Full, presumed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Lisinopril 20 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. NPH 18 Units Breakfast
NPH 18 Units Bedtime
Regular 20 Units Breakfast
Regular 20 Units Bedtime
Discharge Medications:
1. Sodium Bicarbonate 1300 mg PO TID
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth three times a
day Disp #*30 Tablet Refills:*0
2. NPH 18 Units Breakfast
NPH 18 Units Bedtime
Regular 20 Units Breakfast
Regular 20 Units Bedtime
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Vitamin D ___ UNIT PO DAILY
7. HELD- Furosemide 20 mg PO DAILY This medication was held. Do
not restart Furosemide until instructed by your kidney doctor.
8. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do
not restart Lisinopril until instructed by your kidney doctor.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Acute renal failure
SECONDARY:
-Hyperkalemia
-Metabolic acidosis
-Gastroenteritis, viral
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
-You were not urinating, and we found that your kidneys were not
functioning well.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You received fluids and your kidney function improved.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-Please follow-up with your primary care physician, ___.
___. You will need to call ___ to schedule an
appointment.
-It is very important that you follow-up with a kidney doctor at
___. Please find your appointment listed below.
-Do not restart lisinopril or furosemide (Lasix) until
instructed by the kidney doctor.
-___ the future, if you are dehydrated and unable to drink
fluids, temporarily stop your Lasix and lisinopril and let your
primary care physician know immediately.
-Take all of your other medications as prescribed.
-Call or return to the emergency department if you are not
urinating.
We wish you all the best,
Your ___ care team
Followup Instructions:
___
|
19876293-DS-15
| 19,876,293 | 27,053,236 |
DS
| 15 |
2187-04-23 00:00:00
|
2187-04-23 11:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F with h/o AFib on Coumadin presenting as transfer from OSH
s/p fall resulting in multiple injuries. Per ED/ EMS report, the
patient fell down ___ stairs at home, with +LOC. Physical exam
and imaging revealed left temporal/partietal+R frontal SAH, left
___ rib fractures, a small left pneumothorax, left clavicular
fracture, left scapula fracture, and left distal
radius/ ulnar styloid/ metacarpal fractures ___ and ___.
Past Medical History:
Afib on coumadin, CVA
Social History:
___
Family History:
noncontributory
Physical Exam:
Discharge physical exam:
Vitals: 98.4 76 95/48 18 94 on 4L
General: AOx3, NAD, lying in bed
HEENT: surgical pupils (nonreactive), EMOI, right eyelid ptosis
Cardiac: normal rate, irregularly irregular rhythm
Pulm: no respiratory distress
Abd: soft, nontender, nondistended
Extremities: left forearm in cast, left arm in sling,
extremities without cyanosis or edema
Pertinent Results:
___ 04:50AM BLOOD WBC-8.2 RBC-2.46* Hgb-8.0* Hct-25.2*
MCV-102* MCH-32.6* MCHC-31.9 RDW-15.9* Plt Ct-70*
___ 04:50AM BLOOD Glucose-116* UreaN-21* Creat-0.7 Na-140
K-3.9 Cl-105 HCO3-27 AnGap-12
Imaging:
___: CT ABD & PELVIS WITH CONTRAST
Left lower rib fractures. Small left anterior hemopneumothorax.
Small left hemorrhagic effusion. No acute intra-abdominal
process. Nodular liver consistent with cirrhosis.
___: OSH C-SPINE
1. No evidence of acute cervical spine fracture or traumatic
malalignment
2. Fractures of the left first, second and third rib is an the
left clavicle.
___: PELVIS (AP ONLY); FEMUR (AP & LAT) LEFT
No fracture or dislocation.
___: LEFT WRIST RADIOGRAPHS
Fractures of the distal radius, ulna and third and fourth
metacarpals.
___: CT HEAD W/O CONTRAST
1. Stable right frontal SAH.
2. Interval mild increase in one of the foci of the left
anterior temporal SAH (2:10).
3. Left temporal SAH located more posteriorly at the level of
the Sylvian
fissure is smaller (2:13).
4. No new hemorrhage.
5. Thin lucent line in left occipital bone-? Related to suture
or subtle
fracture. (se 3, im 6)
6. A small lucent focus in the right occipital bone along the
inner table is stable compared to recent study; no remote
priors.
Brief Hospital Course:
Ms. ___ was admitted to the trauma ICU for close
observation of of her injuries. In total, she suffered from the
following injuries: b/l SAH, L ___ rib fxs with small
hemopneumothorax, L scapula fx, L clavicle fx, L distal radius,
ulna and ___ metacarpal fxs. Her INR was 2.2 on admission
and her warfarin was held. She was transferred out of the ICU to
the floor after confirmation of hemodynamic stability. Her pain
was well controlled and her oxygen status was improving.
However, she continued to have poor techique with incentive
spirometry despite multiple instruction. It was thereby
difficult to fully evaluate her abily to determine her
inspiratory capacity.
Neurosurgery was consulted regarding her b/l SAH and recommended
Keppra and holding coumadin until patient is seen in outpatient
follow-up. Aspirin is to be restarted on ___. She will be seen
in ___ clinic in 1 month with a noncontrast head CT and
the decision will be made whether or not to restart
anticoagulation. Orthopedics recommended nonoperative management
of left upper extremity injury. A cast was placed on her left
extremity and her left arm was placed in a sling. She has
follow-up in ___ clinic in 2 weeks for outpatient management
and monitoring of her left arm fractures. At time of discharge,
she was resting comfortably and tolerating a regular diet. ___
evaluated patient and ___ rehab. She was discharged to
rehab with agreement with the treatment plans.
Medications on Admission:
ASA 81', lisinopril 15', pilocarpine R eye 1%'', timolol 0.25% R
eye', coumadin 4', lasix 10', lopressor 25'', potassium 10',
tylenol prn
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Digoxin 0.125 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Ezetimibe 10 mg PO DAILY
5. Famotidine 20 mg PO DAILY
6. Heparin 5000 UNIT SC TID
7. LeVETiracetam 500 mg PO BID
Please continue until outpatient visit with neurosurgery.
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Metoprolol Tartrate 25 mg PO BID
10. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp
#*40 Tablet Refills:*0
11. Pilocarpine 1% 1 DROP RIGHT EYE BID
12. Senna 8.6 mg PO BID:PRN Constipation
13. Simvastatin 10 mg PO DAILY
14. Timolol Maleate 0.25% 1 DROP RIGHT EYE DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
bilateral sub-arachnoid hemorrhages, L ___ rib fxs with small
hemopneumothorax, L scapula fx, L clavicle fx, L distal radius,
ulna and ___ metacarpal fxs
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 hospitalized after you accident for management of the
following injuries: bilateral sub-arachnoid hemorrhages, L ___
rib fxs with small hemopneumothorax, L scapula fx, L clavicle
fx, L distal radius, ulna and ___ metacarpal fxs. Your left
arm fractures were management nonoperatively with a cast and
support with a sling. You have scheduled follow-up appointments
with the appropriate surgical services.
Please hold your coumadin for 1 month until follow-up with
neurosurgery. You may restart your aspirin on ___. Continue
Keppra until you follow-up with neurosurgery
Further information regarding your rib fractures:
* Your injury caused ___ 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).
Sincerely,
___ Acute Care Surgery
Followup Instructions:
___
|
19876585-DS-4
| 19,876,585 | 20,445,129 |
DS
| 4 |
2157-11-02 00:00:00
|
2157-11-02 13:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ a history of alcohol abuse and is withdrawal seizures
presents with altered mental status. Patient last remembers
driving his friend's car towards ___ to pick him up.
Approximately a ___ hours later he was found wandering the
street by his friend. He reports he was cold, wet, and shivering
from the rain. He does not remember how he got there or where he
parked car. Denies having bitten his tongue, fecal or urinary
incontinence. He quit drinking 2 days prior (last drink he
thinks was on ___. He admits to heavy drinking, usually on
the order of about four 12 oz glasses of gin. He often
experiences tremulousness, for which he takes a shot first thing
in the morning. Denies any recent fevers, chills, chest pain,
shortness of breath, cough, dysuria, abdominal pain, nausea,
vomiting. He does not recall if he fell today, but he has a
small cut anterior to his right ear. Denies hearing loss or
headache.
He reports two similar episodes, which he attributed to
seizures. Both episodes occurred after he stopped drinking.
About ___ years ago, when he got divorced, he was not eating,
but drinking a lot of alcohol, he blacked out. He detoxed then
completed outpatient counseling for ___ year. About ___ years ago,
he woke up on the front lawn of his brother's house in ___.
In the ED intial vitals were: 97.6 109 146/98 22 99%
- Labs were significant for Lactate:3.9, negative tox screen
including ETOH
- EKG revealed ?afib with no priors
- Patient was given 2L normal saline, thiamine, folate,
multivitamin, diazepam 10mg
Vitals prior to transfer were: 0 80 127/75 16 97% RA
On the floor, complains of chronic diffuse body aches. No other
complaints.
Review of Systems:
(+) chronic diffuse body aches
(-) 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:
- ETOH dependence, withdrawal seizures
- Back pain
- Cervical radiculitis / right shoulder pain
Social History:
___
Family History:
- Half brother - died of ___ lymphoma
- Half sister - HTN, obesity
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals - T: 98.2 BP: 135/81 HR: 85 RR: 16 02 sat: 97%RA
GENERAL: NAD, alert, oriented
HEENT: +Dry crusted blood coming out of right ear above the ear
canal - hearing intact, otherwise no evidence of trauma. EOMI
without nystagmus. No scleral icterus. MMM, neck is supple
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: + upper airway noises transmitted, otherwise CTAB, no
wheezes, rales, rhonchi, breathing comfortably without use of
accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, +fine tremor bilaterally, no asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
========================
Vitals: 98.0 139/86 76 20 99% on RA
General: Alert, oriented, no acute distress
HEENT: R ear with external cut, dried blood
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: normoactive bowel sounds, soft, nontender, nondistended
Ext: no ___ edema bilaterally
Pertinent Results:
ADMISSION LABS
===============
___ 05:14PM BLOOD WBC-6.8 RBC-4.76 Hgb-16.5 Hct-50.1
MCV-105* MCH-34.6* MCHC-32.9 RDW-12.3 Plt ___
___ 05:14PM BLOOD Neuts-86.2* Lymphs-7.4* Monos-5.4 Eos-0.5
Baso-0.4
___ 05:14PM BLOOD Plt ___
___ 06:45AM BLOOD ___ PTT-32.6 ___
___ 05:14PM BLOOD Glucose-132* UreaN-4* Creat-0.6 Na-134
K-4.7 Cl-95* HCO3-25 AnGap-19
___ 05:14PM BLOOD ALT-104* AST-184* CK(CPK)-191
AlkPhos-159* TotBili-0.8
___ 05:14PM BLOOD Calcium-10.0 Phos-2.7 Mg-2.0
___ 05:18PM BLOOD Glucose-118* Lactate-3.9*
DISCHARGE LABS
===============
___ 06:50AM BLOOD WBC-3.3* RBC-4.14* Hgb-14.4 Hct-43.4
MCV-105* MCH-34.8* MCHC-33.1 RDW-12.2 Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-84 UreaN-6 Creat-0.6 Na-144 K-3.5
Cl-105 HCO3-24 AnGap-19
___ 06:50AM BLOOD ALT-74* AST-103* LD(LDH)-202 AlkPhos-127
TotBili-1.0
RADIOLOGY
==========
CT HEAD ___
No acute intracranial process.
CHEST X-RAY ___
No acute cardiopulmonary process. No rib fracture identified on
this non-dedicated exam. If desired, a rib series can be
performed.
EKG:
___ @ 1704: afib, hr ___ @ ___: sinus rhythm, hr 95, normal axis, intervals, TWI in
V1
RUQ U/S ___
Coarsened hepatic architecture. No concerning liver lesion
identified.
Brief Hospital Course:
___ year old male with a past medical history significant for
extensive alcohol abuse, question of withdrawl seizures and
chronic pain on vicodin who presented to the ED due to
confusion.
ACTIVE ISSUES
=============
# AMS
In the setting of this patient acutely stopping alcohol, his
period of black out and his elevated lactate and CPK upon
arrival, his AMS and confusion most likely represents a
withdrawl seizure and post ictal state. He also notes that he
has had episodes like this in the past. Was monitored during
admission and had no further episodes of seizure like activity
or confusion. Alcohol withdrawl was treated as below.
# Alcohol abuse/withdrawl
The patient notes a long history of alcohol abuse, multiple
social issues and has attempted in the past to stop drinking.
Last drink was ___ night ___. He was maintained on a
CIWA scale as well as thiamine/folic acid/multivitamin during
admission. He was given diazepam in the ED upon arrival on
___ but did not require any further doses during his
hospitalization.
# Elevated LFTs
Pattern fits with ongoing alcohol use. RUQ ultrasound showed
coarsened hepatic architecture without any lesions. Hepatitis
serologies were pending at discharge.
CHRONIC ISSUES
==============
# Chronic pain
Patient has a history of chronic pain (shoulder) for which he
take Vicodin at home (prescribed by PCP). Was held during
admission but restarted upon dischage.
TRANSITIONAL ISSUES
=====================
- was treated for alcohol withdrawl with a Diazepam CIWA scale
- RUQ ultrasound showed coarsened hepatic architecture w/o any
liver lesions identified
- hepatitis serologies pending at time of discharge, please
followup
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrocodone-Acetaminophen (5mg-500mg) Dose is Unknown PO
Frequency is Unknown
Discharge Medications:
1. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO DAILY
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Alcohol Withdrawl
SECONDARY
Alcohol Abuse
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 after an episode of confusion with concern for an
alcohol withdrawl seizure. During your admission, you were
treated with medications for your alcohol withdrawl. You did
not have any further episodes of confusion or seizures during
your hospital stay.
We recommend that you obstain from alcohol, as it is detrimental
to your health.
Followup Instructions:
___
|
19876636-DS-7
| 19,876,636 | 25,552,151 |
DS
| 7 |
2175-10-28 00:00:00
|
2175-10-28 20:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
==============
___ 07:15PM BLOOD WBC-20.9* RBC-4.42* Hgb-13.6* Hct-40.8
MCV-92 MCH-30.8 MCHC-33.3 RDW-13.2 RDWSD-45.1 Plt ___
___ 07:15PM BLOOD Neuts-81.9* Lymphs-11.4* Monos-6.1
Eos-0.0* Baso-0.1 Im ___ AbsNeut-17.10* AbsLymp-2.37
AbsMono-1.27* AbsEos-0.00* AbsBaso-0.03
___ 07:15PM BLOOD Glucose-104* UreaN-15 Creat-0.9 Na-139
K-3.2* Cl-98 HCO3-27 AnGap-14
___ 07:15PM BLOOD ALT-46* AST-71* AlkPhos-52 TotBili-0.3
___ 07:15PM BLOOD Lipase-42
___ 07:15PM BLOOD cTropnT-<0.01
___ 07:15PM BLOOD Albumin-4.3 Calcium-9.3 Phos-2.5* Mg-1.5*
___ 07:15PM BLOOD Ethanol-64*
___ 08:37PM BLOOD ___ pO2-59* pCO2-44 pH-7.43
calTCO2-30 Base XS-3
___ 07:23PM BLOOD Lactate-2.0
IMAGING:
========
CHEST (PA & ___
No acute intrathoracic process.
LIVER OR GALLBLADDER US ___
FINDINGS:
LIVER: Coarsened liver with slightly nodular contour consistent
with reported/known cirrhosis. There is no focal liver mass.
The main portal vein is patent with hepatopetal flow. There is
no ascites.
BILE DUCTS: There is unchanged intrahepatic biliary ductal
dilation.
CHD: Chronically dilated measuring up to 1.6 cm.
GALLBLADDER: Echogenic nonshadowing material within the lumen of
the gallbladder is most suggestive of sludge. No definite
gallstones. No evidence of acute cholecystitis.
PANCREAS: Not well visualized.
SPLEEN: Status post splenectomy with splenosis in the left upper
quadrant measuring up to 7.4 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 12.2 cm. A simple cyst arising from the lower
pole of the right kidney is again seen containing a single thin
septation.
Left kidney: 10.7 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal limits.
IMPRESSION:
1. Hepatic cirrhosis. No ascites.
2. Gallbladder sludge.
3. Stable biliary ductal dilation.
DISCHARGE LABS:
==============
___ 10:06AM BLOOD WBC-14.5* RBC-4.67 Hgb-14.4 Hct-43.7
MCV-94 MCH-30.8 MCHC-33.0 RDW-13.2 RDWSD-44.9 Plt ___
___ 10:06AM BLOOD Glucose-137* UreaN-23* Creat-0.9 Na-137
K-4.3 Cl-96 HCO3-29 AnGap-12
___ 10:06AM BLOOD ALT-93* AST-92* LD(LDH)-170 AlkPhos-58
TotBili-0.3
___ 10:06AM BLOOD Albumin-4.4 Calcium-10.3 Phos-3.5 Mg-1.7
Brief Hospital Course:
PATIENT SUMMARY
=================
Mr ___ is a ___ year old man with HCV/EtOH cirrhosis s/p
___, chronic pancreatitis, splenectomy, and asthma who
presented with dyspnea and altered mental status secondary to
alcohol withdrawal and suspected COPD exacerbation in setting of
ongoing cigarette smoking.
TRANSITIONAL ISSUES
====================
[] Please discuss transition to suboxone for chronic opioid
dependence
[] Recommend PFTs to be pursued as an outpatient to confirm
presumptive diagnosis of COPD
[] Please evaluate for signs of encephalopathy.
Lactulose/rifaximin were held at time of discharge because his
AMS was attributed to alcohol withdrawal, but there was [low]
concern for potential he could have had concomitant hepatic
encephalopathy given cirrhosis history.
[] Please continue to counsel patient on smoking cessation. He
was provided nicotine lozenges and patches at discharge
[] Patient is not Hep B immune and was ordered for the high dose
vaccine as an outpatient since he is asplenic, but it does not
appear that he has received the dose yet.
MEDICATION CHANGES:
- NEW:
- Nicotine mini-lozenges
- Albuterol
- Tiotropium
- Prednisone (for COPD exacerbation)
- Azithromycin (for COPD exacerbation)
- STOPPED: NONE
- CHANGED: NONE
ACUTE ISSUES
=============
#Dyspnea
#COPD exacerbation
Concerned for COPD exacerbation as improved with Duonebs, >50
pack-year smoking history. Treated with 5 days of prednisone and
azithromycin and duonebs while inpatient. Discharged with
tiotropium and nebulized albuterol.
# Alcohol use disorder with relapse
# Alcohol withdrawal
EtOH detectable on admission serum tox. Patient was maintained
on CIWA. His scores down-trended and he had not required
lorazepam in >24 hours prior to discharge. He was discharged 4
days after his last drink. He was seen by addiction psychiatry
during his admission.
# Acute metabolic encephalopathy
Most likely due to alcohol withdrawal. Given history of
cirrhosis, he was initially treated empirically for hepatic
encephalopathy with lactulose and rifaximin. These were stopped
prior to discharge, however, as patient had no history of
decompensated cirrhosis and suspicion was much higher for
alcohol withdrawal. Mental status was back to baseline prior to
discharge and he never had clear asterixis on exam during this
hospitalization to suggest hepatic encephalopathy.
# EtOH/hepatitis C cirrhosis s/p treatment
# Biliary stricture s/p stent
Admission MELD-Na 8, Childs Class A. RUQUS on admission with
stable biliary dilatation with gallbladder sludge and no stone,
patent portal vein, and no ascites.
#Transaminitis
Likely due to chronic liver disease and recent alcohol
ingestion.
CHRONIC ISSUES
===============
# Dysphagia
# GERD
- Continued home omeprazole
# Chronic pain
# Chronic opioid use/dependence disorder
- Continued home oxycodone 15mg Q4H
- He expressed an interest in rapidly tapering opioids as
outpatient and starting vivitrol injections in the next ___
months. Given his long-standing opioid pain medication use, we
suspect that the very rapid taper he is proposing may prove very
challenging. As such, we brought up idea of suboxone as a bridge
to ultimately getting off opioids, which he says is his goal,
with the added benefit that the frequency of suboxone dosing is
much less than oxycodone as he is taking it. He said he would
consider it, but was not willing to commit to initiating this
change prior to discharge.
# Tobacco use/dependence disorder
# Active smoking
-Counseled smoking cessation
-Provided Rx's for nicotine patch & PRN lozenge
.
.
.
.
Time in care: >30 minutes in discharge-related activities on the
day of discharge.
.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Nicotine Patch 14 mg/day TD DAILY
3. Nortriptyline 150 mg PO QHS
4. Omeprazole 40 mg PO DAILY
5. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN Pain -
Moderate
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Thiamine 100 mg PO DAILY
8. Naloxone Nasal Spray 4 mg IH ONCE:PRN opiate overdose
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/ wheeze
11. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN Allergies
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Shortness of
breath
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 Cap Nebulized
Every 6 hours as needed for shortness of breath Disp #*56 Vial
Refills:*0
2. Azithromycin 250 mg PO DAILY Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth once per day Disp
#*3 Tablet Refills:*0
3. Nicotine Lozenge 2 mg PO Q2H:PRN Nicotine craving
RX *nicotine (polacrilex) ___ the lozenge in your mouth,
occasionally moving it side to side Every 2 hours as needed Disp
#*2 Box Refills:*0
4. PredniSONE 40 mg PO DAILY Duration: 5 Days
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
5. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 2
inhalations Once daily Disp #*3 Blister Refills:*0
6. Nicotine Patch 21 mg/day TD DAILY
RX *nicotine 21 ___ patch on skin Once daily Disp
#*28 Patch Refills:*0
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/ wheeze
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN Allergies
9. FoLIC Acid 1 mg PO DAILY
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Naloxone Nasal Spray 4 mg IH ONCE:PRN opiate overdose
12. Nortriptyline 150 mg PO QHS
13. Omeprazole 40 mg PO DAILY
14. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN Pain -
Moderate
15. Senna 8.6 mg PO BID:PRN Constipation - First Line
16. Thiamine 100 mg PO DAILY
17.Nebulizer
Please provide patient with nebulizer for treatment of CODP
Length of need: ___ year
J___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Alcohol withdrawal
Secondary diagnoses:
Chronic obstructive pulmonary disease exacerbation
Chronic 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 privilege taking care of you at ___
___.
WHY WAS I IN THE HOSPITAL?
You were admitted to the hospital for evaluation of confusion
and shortness of breath.
WHAT HAPPENED TO ME IN THE HOSPITAL?
-You are treated for alcohol withdrawal.
You were treated for a chronic obstructive pulmonary disease
(COPD) exacerbation. This is a lung disease that is very common
among people who smoke cigarettes. Your shortness of breath
improved with this treatment.
You were given laxatives due to concern that your liver disease
is leading to a buildup of toxins in your body.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Continue to take all your medicines and keep your appointments.
-Continue taking her prednisone for 2 more days and your
azithromycin (antibiotic) for 3 more days.
We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19877091-DS-19
| 19,877,091 | 23,067,854 |
DS
| 19 |
2184-05-12 00:00:00
|
2184-05-15 21:56:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / walnuts and peaches
Attending: ___.
Chief Complaint:
elevated BP
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with a past medical history
of hypertension and breast cancer s/p mastectomy, who presented
to the ED with elevated blood pressure and was found to be
hyponatremic.
Per her daughter she has had an itchy throat and cough since
___ or ___ of last week. The cough is productive of
clear sputum. She has not had any associated fevers or shortness
of breath. She also denies night sweats or weight loss. She saw
her PCP who felt that her symptoms were likely viral URI with
possible contribution from seasonal allergies. Rapid strep was
negative. She prescribed Flonase and zyrtec. The patient felt
that zyrtec was not helping and so began taking Benadryl.
The patient reports that her cough has worsening and has become
more bothersome. She has tried to stay hydrated by drinking
extra
water. Normally she drinks 8 cups of water a day but over the
past few days has been drinking at least two extra cups. She
feels that she has kept up with her diet and her PO intake has
not changed.
She was considering returning to see her PCP for her
___ cough but then yesterday noticed her blood
pressure
at home to be very high to the 200s systolic (asymptomatic). She
had no associated fevers or visual changes. She presented to the
ED where initial BP was 199/99 but normalized to SBPs 150s
without intervention.
On the floor she feels well apart from her cough.
Past Medical History:
PMH:
- invasive ductal carcinoma, grade 3, ER/PR(-), HER2/neu(-)
- HTN
- 2+ MR, ___ AR
- osteopenia
- neuropathy
- Bell's palsy
- glaucoma
PSH:
Left total mastectomy;Left axillary sentinel node mapping and
biopsy.
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
Admission Physical 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, no S3, no S4. No JVD.
RESP: Scattered intermittent wheezes. Frequent cough productive
of clear sputum
GI: Abdomen soft, non-distended, non-tender to palpation
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, right facial droop (per daughters
longstanding), gaze conjugate with EOMI, speech fluent, moves
all
limbs, sensation to light touch grossly intact throughout
PSYCH: pleasant, appropriate affect
Discharge Physical 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, no S3, no S4. No JVD.
RESP: Scattered intermittent wheezes. Frequent cough productive
of clear sputum
GI: Abdomen soft, non-distended, non-tender to palpation
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, right facial droop (per daughters
longstanding), gaze conjugate with EOMI, speech fluent, moves
all
limbs, sensation to light touch grossly intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission Labs:
===============
___ 04:01AM BLOOD WBC-4.4 RBC-4.16 Hgb-12.2 Hct-35.4 MCV-85
MCH-29.3 MCHC-34.5 RDW-13.4 RDWSD-41.8 Plt ___
___ 03:46AM BLOOD Glucose-101* UreaN-7 Creat-0.5 Na-125*
K-4.5 Cl-86* HCO3-23 AnGap-16
Imaging:
========
___ CXR:
No acute process
Discharge Labs:
===============
___ 04:01AM BLOOD Glucose-98 UreaN-13 Creat-0.4 Na-131*
K-3.8 Cl-92* HCO3-30 AnGap-9*
___ 04:01AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.5
Brief Hospital Course:
Ms. ___ is an ___ female with a past medical history of
hypertension and breast cancer s/p mastectomy, who presented to
the ED with elevated blood pressure and was found to be
hyponatremic.
ACUTE/ACTIVE PROBLEMS:
# Hyponatremia: presented with hyponatremia initially 125 and as
low as 118. Urine Na was 57, somewhat difficult to interpret
given she had taken 10mg of Lasix earlier in the day. However,
she has a history of hyponatremia in the past (127, at which
point HCTZ was stopped). Her hyponatremia was felt to most
likely be consistent with chronic SIADH with worsening
hyponatremia secondary to her increased fluid intake over the
past few days. She had been drinking more fluid in an attempt to
treat her cough. Home Lasix was held. She was placed on a 1L
fluid restriction and Na had improved to 134 by time of
discharge, a value consistent with multiple prior outpatient
values. She was discharged on a 1.5L fluid restriction and
instructed to maintain adequate sodium and solute intake (ensure
supplements recommended)
# Cough:
# Viral URI:
# Bronchitis:
CXR was negative for pneumonia. She had no fever, leukocytosis,
or shortness of breath. She had scattered wheezes on exam and
recent URI symptoms. Her cough was overall felt to likely to
secondary to viral bronchitis. She was treated symptomatically
with Flonase, cough syrup, and duonebs
# Hypertensive urgency: hypertensive to 199/99 on presentation
but resolved without intervention. She was normotensive during
admission and was continued on home amlodipine and metoprolol
Transitional Issues:
- needs chem panel checked on ___
- home KCl and Lasix held at discharge (KCl held since she did
not require repletion here). Please restart KCl if potassium low
on recheck in two days
- discharged on 1.5L fluid restriction
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 200 mg PO TID
2. amLODIPine 2.5 mg PO DAILY
3. Potassium Chloride 60 mEq PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Furosemide 10 mg PO EVERY OTHER DAY
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Magnesium Oxide 250 mg PO DAILY
9. Fluticasone Propionate NASAL 2 SPRY NU BID
Discharge Medications:
1. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL ___ mL by
mouth four times a day Refills:*0
2. amLODIPine 2.5 mg PO DAILY
3. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU BID
5. Gabapentin 200 mg PO TID
6. Magnesium Oxide 250 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. HELD- Furosemide 10 mg PO EVERY OTHER DAY This medication
was held. Do not restart Furosemide until you speak to your
primary care doctor
10. HELD- Potassium Chloride 60 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until you speak to
your primary care doctor
11.Outpatient Lab Work
Please check chem 7 panel (Na, K, Cl, HCO3, BUN, Cr, glucose)
Results should be faxed to attn: Dr. ___ ___
ICD ___.1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hyponatremia
Cough
Viral bronchitis
Hypertensive urgency
Secondary:
Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came in with low sodium levels. We think this was due to
drinking too much water at home. When you go home you should
make sure not to drink more than 1.5L of fluid a day. You should
also make sure to eat enough salt. Ensure supplements can also
help increase sodium levels.
You also had a cough, which is most likely due to bronchitis.
You can continue taking cough medication as needed.
It will be very important to have your sodium levels checked on
___. We are sending you a prescription that you can
take to the lab.
It was a pleasure taking care of you, and we are happy that
you're feeling better!
Followup Instructions:
___
|
19877618-DS-4
| 19,877,618 | 20,429,194 |
DS
| 4 |
2185-02-25 00:00:00
|
2185-02-26 22:22:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Augmentin
Attending: ___.
Chief Complaint:
Nausea, vomiting, rigors, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Dr. ___ is a ___ with history of ileocolonic/perianal Crohn's
disease complicated by left upper ischiorectal fossa abscess in
___, right gluteal abscess in ___, and persistent perianal
fistula status post multiple intestinal resections last in ___
who presented with nausea/vomiting, rigors, and fever following
routine colonoscopy on the day of admission. He was in his usual
state of health until the day of admission, when he underwent
routine screening colonoscopy, demonstrating ulcer in the
neo-terminal ileum and anal stricture amenable to digital
dilation, but otherwise unremarkable. Approximately 30 minutes
after completion of colonoscopy, he represented to the endoscopy
suite with nausea and small-volume nonbloody, nonbilious emesis
and rigors and was found to be febrile to 99.9-102.5 with heart
rate of 130s-140s and blood pressure of 120s-150s/90s-100s and
benign abdominal exam. Following evaluation by his
gastroenterologist Dr. ___ was referred to the ED for
CT abdomen/pelvis, IV fluids, and antibiotic therapy, given
concern for likely bacterial translocation.
In the ___ ED, he was febrile to 104.1 and persistently
tachycardic to 140s (sinus) with stable blood pressure.
Admission labs were notable for white blood cell count of 8.0
(92% neutrophils), creatinine of 2.1 (baseline 1.6-1.7), and
lactate of 1.8. CXR was negative, and CT abdomen/pelvis was
without acute intraabdominal process or free air. He received 2L
IV normal saline, ciprofloxacin, metronidazole, and
acetaminophen prior to transfer to the floor.
On arrival to the floor, he continues to rigor slightly, but
indicates that he felt better than he had earlier. He denies
upper respiratory symptoms, cough, shortness of breath,
abdominal pain, loose stools, hematochezia, melena, or urinary
symptoms.
Review of Systems:
(+) As above.
(-) Night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, diarrhea, constipation, bright red blood per
rectum, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Crohn's disease
Chronic kidney injury
Chronic normocytic anemia
Social History:
___
Family History:
He has a brother and 2 sisters, all of whom are healthy.
Physical Exam:
On admission:
Vitals - VS: 100.0 112/68 P92 RR20 O2 sat 100%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
At discharge:
Vitals: 101.7/98.8, 112/63, 92, 20, 100% RA
Otherwise unchanged.
Pertinent Results:
On admission:
___ 02:30PM BLOOD WBC-8.0 RBC-4.03* Hgb-12.1* Hct-34.8*
MCV-86 MCH-30.0 MCHC-34.7 RDW-12.8 Plt ___
___ 02:30PM BLOOD Neuts-92.0* Lymphs-5.2* Monos-1.6*
Eos-1.1 Baso-0.1
___ 02:30PM BLOOD ___ PTT-25.5 ___
___ 02:30PM BLOOD Glucose-132* UreaN-15 Creat-2.1* Na-141
K-3.6 Cl-107 HCO3-25 AnGap-13
___ 02:30PM BLOOD ALT-19 AST-28 LD(LDH)-122 CK(CPK)-249
AlkPhos-70 TotBili-3.2* DirBili-0.2 IndBili-3.0
___ 02:39PM BLOOD Lactate-1.8
___ 04:45PM URINE Color-Straw Appear-Clear Sp ___
___ 04:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
At discharge:
___ 08:05AM BLOOD WBC-12.2*# RBC-3.80* Hgb-11.3* Hct-33.4*
MCV-88 MCH-29.8 MCHC-33.9 RDW-13.1 Plt ___
___ 08:05AM BLOOD ___ PTT-29.1 ___
___ 08:05AM BLOOD Glucose-86 UreaN-12 Creat-2.1* Na-142
K-4.1 Cl-109* HCO3-25 AnGap-12
___ 08:05AM BLOOD ALT-15 AST-25 AlkPhos-56 TotBili-3.0*
___ 08:05AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.5*
Microbiology:
Blood cultures ___ x2, ___ x2): No growth to date.
Pathology:
Colonic mucosal biopsies (___):
1. Anastomosis:
Within normal limits.
2. 50 cm:
Within normal limits.
3. 40 cm:
Within normal limits.
4. 30 cm:
Within normal limits.
5. 20 cm:
Within normal limits.
6. 10 cm:
Within normal limits.
7. Distal rectum:
Focal cryptitis.
No granuloma or dyplasia seen.
Imaging:
Colonoscopy (___):
Ulcer in the neo-terminal ileum
An anal stricture was felt and digitally dilated with a finger.
The colonoscope was subsequently easily passed.
Liquid and particulate stool was seen in the colon. Extensive
washing and flushing was performed.
Otherwise normal colonoscopy to neo-TI
EKG (___):
Sinus tachycardia with increase in rate as compared with
previous tracing
of ___. There is diffuse ST-T wave flattening and new ST
segment depression in leads V4-V6 with biphasic T waves. Rule
out active lateral ischemic process. Clinical correlation is
suggested.
IntervalsAxes
___
___
Portable CXR (___):
No evidence of cardiopulmonary process or pneumoperitoneum.
CT abdomen/pelvis with PO contrast (___):
No acute intra-abdominal process. No bowel obstruction. No
intra-abdominal free air.
Brief Hospital Course:
Dr. ___ is a ___ with history of ileocolonic/perianal Crohn's
disease complicated by left upper ischiorectal fossa abscess in
___, right gluteal abscess in ___, and persistent perianal
fistula status post multiple intestinal resections last in ___
who presented with nausea/vomiting, rigors, and fever following
routine colonoscopy on the day of admission.
Active Issues:
# Sepsis with likely gastrointestinal source: He presented with
fever to 104.1 and tachycardia to 140s, with subsequent
development of leukocytosis to 12.2 following routine
colonoscopy without obvious complications, likely reflecting
bacterial translocation across the gut. Perforation was felt to
be less likely in the setting of benign abdominal exam and
unrevealing CT abdomen/pelvis on admission, with similarly low
suspicion for abscess. Infectious work-up was otherwise
unremarkable, including no clear signs of sinusitis or
endocarditis, negative urinalysis and CXR, and blood cultures
with no growth to date. Malignant hyperthermia in the setting of
procedural anesthetic use also was considered, but felt to be
unlikely, given that fentanyl and midazolam would be atypical
causal agents and CK was reassuring. Following IV fluid
resuscitation and initial treatment with ciprofloxacin and
metronidazole in the ED, empiric antibiotic therapy was
broadened to cefepime and metronidazole overnight on admission
due to persistent fevers despite resolution of tachycardia and
continued hemodynamic stability. While he felt generally well
with benign abdominal exam, he experienced ongoing intermittent
fever to 101 at discharge, opting to return home in order to
attend the thesis defense of his graduate student advisee rather
than remain in the hospital for more extended surveillance after
discussion of risks and benefits. He was discharged on a 10 day
empiric course of ciprofloxacin, metronidazole, and
trimethoprim/sulfamethoxazole at the suggestion of his primary
gastroenterologist, Dr. ___ advised to be in contact
with Dr. ___ prior to completion of this regimen to confirm
resumption of his chronic antibiotic regimen thereafter,
including levofloxacin and metronidazole alternating with
trimethoprim/sulfamethoxazole. He was counseled to return to the
ED in the event of worsening symptoms in the meantime. He
received a script for outpatient labwork, including complete
blood count, to be obtained on follow up with his primary care
physician ___ and sent to his primary care physician for
review.
# Acute-on-chronic kidney injury: Creatinine was 2.1 on
presentation, up from 1.6-1.8 at baseline, likely reflecting
prerenal azotemia in the setting of bowel preparation for
colonoscopy and brief emesis prior to presentation. Chronic
kidney injury was felt by the nephrology service to be due to
elevated muscle mass on last evaluation in ___. Creatinine
remained stable at 2.1 at discharge following gentle IV fluid
resuscitation and encouragement of PO intake. He received a
script for outpatient labwork, including creatinine, to be
obtained on follow up with his primary care physician ___
and sent to his primary care physician for review.
# Crohn's disease: Routine screening colonoscopy on the day of
admission revealed an ulcer in the neo-terminal ileum and an
anal stricture that was dilated with a finger, with associated
pathology unremarkable. There was no evidence of flare
throughout admission.
Inactive Issues:
# Chronic normocytic anemia: Hematocrit remained stable at 33.4
to 34.8 throughout admission, consistent with recent baseline in
the setting of anemia of chronic inflammation on last hematology
evaluation in ___. There were no signs or symptoms of acute
blood loss throughout admission, with colonoscopy on the day of
admission reassuring against lower gastrointestinal bleeding.
Transitional Issues:
* He was discharged on a 10 day empiric course of ciprofloxacin,
metronidazole, and trimethoprim/sulfamethoxazole at the
suggestion of his primary gastroenterologist, Dr. ___
advised to be in contact with Dr. ___ prior to completion
of this regimen to confirm resumption of his chronic antibiotic
regimen thereafter, including levofloxacin, as well as
metronidazole alternating with trimethoprim/sulfamethoxazole.
* He received a script for outpatient labwork, including
complete blood count and Chem7, to be obtained on follow up with
his primary care physician ___ and sent to his primary care
physician for review.
* Pending studies: Blood cultures ___ x2 and ___ x2).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Infliximab 560 mg IV Q6WEEKS
2. Levofloxacin 500 mg PO Q24H
3. Sulfameth/Trimethoprim DS 1 TAB PO BID
4. Probiotic Complex
(L.acid-B.bifidum-B.animal-FOS;<br>lactobacillus combo no.6)
unknown oral daily
Discharge Medications:
1. Infliximab 560 mg IV Q6WEEKS
2. Probiotic Complex
(L.acid-B.bifidum-B.animal-FOS;<br>lactobacillus combo no.6) 0
mg ORAL DAILY
3. Outpatient Lab Work
ICD-9 code: ___
Please check CBC and Chem7 and send to Dr. ___ (phone:
___ fax: ___ for review.
4. Sulfameth/Trimethoprim DS 1 TAB PO BID
Please continue for 10 days, then speak with Dr. ___
alternating with metronidazole.
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Please continue for 10 days, then speak with Dr. ___
alternating with Bactrim.
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
6. Ciprofloxacin HCl 500 mg PO Q12H
Please continue for 10 days, then speak with Dr. ___
returning to levofloxacin.
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Sepsis of likely gastrointestinal origin
Acute-on-chronic kidney injury
Secondary:
Crohn's disease
Chronic normocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ was a pleasure taking part in your care during your admission
to ___. As you know, you were
admitted for evaluation of fevers, nausea, vomiting, and rapid
heart rate following screening colonoscopy. Given that your
symptoms developed soon after colonoscopy, it is likely that
they were due to movement of bacteria out of the gut in the
setting of the procedure. There was no evidence of new infection
on CT scan. Your symptoms improved with antibiotics, intravenous
fluids, and initial bowel rest, and your were tolerating an oral
diet by the time of discharge, though you continued to
experience fevers.
In discussion with your gastroenterologist Dr. ___ are
now discharged on a broad-spectrum oral antibiotic regimen,
including ciprofloxacin, Bactrim, and metronidazole (Flagyl),
which you should continue for 10 days unless directed otherwise
by your Dr. ___ please be in touch with Dr. ___
(___) within the week to confirm the duration of your
broad-spectrum antibiotic course, after which point you likely
will return to your typical regimen of levofloxacin and Bactrim
alternating with metronidazole.
In addition, your kidney function was found to be decreased
slightly from baseline, likely reflecting fluid losses from
colonoscopy preparation and vomiting.
It is important that you follow up with primary care doctor and
gastroenterologist to ensure continued resolution of your
symptoms. Please return to the emergency department in the event
of worsening or unimproving symptoms in the interim.
Followup Instructions:
___
|
19877618-DS-5
| 19,877,618 | 23,626,715 |
DS
| 5 |
2186-12-26 00:00:00
|
2186-12-26 12:54:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
Augmentin
Attending: ___.
Chief Complaint:
Right ureteral stones
Major Surgical or Invasive Procedure:
R stent placement and rectal dilation
History of Present Illness:
___ male with history of Crohn's
disease, perianal abscesses with recent nephrolithiasis who
presents with ___ days of right flank pain and elevated
creatinine. The patient reports passing kidney stones over the
past 6 months, which was initially precipitated by an
exacerbation of anal stricture disease, constipation, and
dehydration. He has passed stones up to 5-6 mm and has not
required intervention. About ___ days ago he experienced right
flank pain consistent with prior stone passage. He had been
managing his pain with regular low dose ibuprofen up until 24
hours ago. Labs were obtained as an outpatient yesterday with Cr
elevated to 3.6 from baseline 1.4-1.5. A renal US was then
obtained revealing a 6 mm right mid-ureteral stone with
associated hydronephrosis. Currently the patient reports ___
pain, up to ___ without tylenol. He denies fever, chills, N/V,
hematuria, frequency, urgency.
Past Medical History:
-Crohn's disease as above
-B12 deficiency,
-pericarditis
-history of abnormal liver function tests
-elevated creatinine
-migranes
-nephrolithiasis
-anal stricture dilated digitally at colonoscopies.
Social History:
___
Family History:
He has a brother and 2 sisters, all of whom are healthy.
Physical Exam:
NAD
Equal chest rise b/l
Abd soft NTND
No CVA tenderness
Ext WWP
Pertinent Results:
___ 08:50PM GLUCOSE-84 UREA N-20 CREAT-3.5* SODIUM-138
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-18* ANION GAP-18
___ 07:17PM LACTATE-1.0
___ 07:15PM GLUCOSE-84 UREA N-21* CREAT-3.5* SODIUM-137
POTASSIUM-5.6* CHLORIDE-107 TOTAL CO2-17* ANION GAP-19
___ 07:15PM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-2.0
___ 04:50PM URINE HOURS-RANDOM
___ 04:50PM URINE UHOLD-HOLD
___ 04:50PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
Brief Hospital Course:
Patient was admitted was admitted to the Urology service and
underwent right ureteral stent placement for multiple right
distal ureteral stones. No concerning intraoperative events
occurred; please see dictated
operative note for details. He patient received ___
antibiotic prophylaxis. Patient's postoperative course was
uncomplicated. He remained afebrile throughout his hospital
stay. At discharge, the patient's pain well controlled with
oral pain medications, tolerating regular diet, ambulating
without assistance, and voiding without difficulty. He was oral
pain medications on discharge and flomax. He was given explicit
instructions to follow up with nephrologist this week for Cr
check and also to follow up here after returning from ___ in
one month for definitive stone treatment.
Medications on Admission:
CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) 1,000
mcg/mL injection solution. ___ micrograms IM monthly PLEASE
DISPENSE MULTIDOSE VIAL IF AVAILABLE
INFLIXIMAB [REMICADE] - Remicade 100 mg intravenous solution.
10mgs/kg every 6 weeks 700mg dose (73kg) - (Prescribed by
Other
Provider)
METRONIDAZOLE - metronidazole 250 mg tablet. 1 tablet(s) by
mouth
three times a day
SULFAMETHOXAZOLE-TRIMETHOPRIM - sulfamethoxazole 800
mg-trimethoprim 160 mg tablet. 1 tablet(s) by mouth twice a day
TADALAFIL [CIALIS] - Cialis 20 mg tablet. TAKE 1 TABLET BY MOUTH
EVERY DAY AS NEEDED
Discharge Medications:
Home:
CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) 1,000
mcg/mL injection solution. ___ micrograms IM monthly PLEASE
DISPENSE MULTIDOSE VIAL IF AVAILABLE
INFLIXIMAB [REMICADE] - Remicade 100 mg intravenous solution.
10mgs/kg every 6 weeks 700mg dose (73kg) - (Prescribed by
Other
Provider)
METRONIDAZOLE - metronidazole 250 mg tablet. 1 tablet(s) by
mouth
three times a day
SULFAMETHOXAZOLE-TRIMETHOPRIM - sulfamethoxazole 800
mg-trimethoprim 160 mg tablet. 1 tablet(s) by mouth twice a day
TADALAFIL [CIALIS] - Cialis 20 mg tablet. TAKE 1 TABLET BY MOUTH
EVERY DAY AS NEEDED
New:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
4. Tamsulosin 0.4 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Ureteral stones
Discharge Condition:
Stable condition and ready for discharge; fully ambulatory
Discharge Instructions:
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative
- Do not take any NSAIDs. These are medications like ibuprofen
(advil, motrin)
- Set up an appointment for a creatinine check and office visit
with your nephrologist this week
Followup Instructions:
___
|
19877635-DS-19
| 19,877,635 | 21,648,057 |
DS
| 19 |
2130-05-09 00:00:00
|
2130-05-17 22:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ HTN, HLD, CAD (s/p angioplasty), dementia who presents
from home with failure to thrive.
The patient previously lived alone with ___ services. At
baseline, was ambulatory with a walker and one-person assist,
and used a wheelchair for longer trips. The patient was
dependent of ADLs at baseline, but was able to mobilize to get
around her apartment, assist in self care, and converse
minimally but cogently with others.
Her daughter reports that about a week ago, she took a turn for
the worse. Apparently pt has been mobilizing less and has been
unable to get to the bathroom. She has seemed weak. More
confused. This was reportedly a somewhat sudden change.
The patient was brought to the ED with goal of finding an easily
reversible problem vs pursuing nursing home placement, whichever
was appropriate.
In the ___ ED:
VS 99.3, 84, 164/80, 96% RA
Exam notable for oriented to name only, speech nonsensical, able
to follow basic commands, no gross motor deficits
Labs notable for WBC 13.6, Hb 12.1, plt 216, Cr 1.1, Lactate
1.6, UA negative for UTI
CT head without acute process, cannot exclude NPH
CXR without acute process
Past Medical History:
HTN
HLD
essential tremor
cardiac cath and angioplasty
RBBB
Essential tremor
Migraines
Gastric ulcer and UGI bleed
Constipation
Gallstones
Nephrolithiasis
Glaucoma
Mixed urinary incontinence
Dementia
PPD positive
Hip fracture
SURGICAL HISTORY
Umbilical hernia repair
C section
Bilateral cataract surgery
Social History:
___
Family History:
Mother died of rheumatic heart disease.
Physical Exam:
DISCHARGE EXAM:
VITALS: last 24-hour vitals were reviewed.
GEN: elderly female lying in bed, initally resting comfortably,
awakens to verbal stimuli, comfortable appearing, no acute
distress
HEENT: PERRL with disconjugate gaze, anicteric, conjunctiva
pink,
oropharynx without
lesion or exudate, edentulous, 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, R posterior exam limited by positioning
GI: soft, nontender, without rebounding or guarding,
nondistended
with hypoactive bowel sounds, no hepatomegaly appreciated
EXTREMITIES: no clubbing, cyanosis, or edema
GU: no foley
SKIN: no rashes, petechiae, lesions, or echymoses; warm to
palpation
NEURO/PSYCH: alert and oriented to person only, unable to name
location or year. Low frequency, high amplitude intention
tremor.
Intermittently responds appropriately to conversation.
Pertinent Results:
ADMISSION LABS
___ 12:49PM BLOOD WBC-13.6* RBC-4.04 Hgb-12.1 Hct-36.5
MCV-90 MCH-30.0 MCHC-33.2 RDW-14.0 RDWSD-45.7 Plt ___
___ 12:49PM BLOOD Glucose-118* UreaN-23* Creat-1.1 Na-135
K-4.3 Cl-94* HCO3-27 AnGap-14
___ 01:02PM BLOOD Lactate-1.6
CT HEAD ___
1. No acute intracranial process.
2. Prominence of the ventricles is progressed since ___.
Difficult to
exclude NPH in the appropriate clinical setting.
CXR
No signs of pneumonia.
Brief Hospital Course:
___ w/ HTN, dementia presenting with failure to thrive at home.
She has been mobilizing less, unable to get to the bathroom. On
evaluation by ___ she is sufficiently deconditioned that she
wasn't able to get out of bed and would be unable to safely
function in her own home, even with maximal services.
# Progressive dementia, at least in part vascular
# Failure to thrive:
UA without evidence of UTI. CXR shows no pneumonia. On exam
she has no localizing symptoms of infection. Although she had a
mild white count on arrival, vitals were otherwise inconsistent
with sepsis on multiple checks. There were no notable metabolic
derangements. Thus, metabolic encepghalopathy was felt to be
unlikely.
It is likely that her mental status has deteriorated due to a
new pathology or whether her decline in functioning - physical
and cognitive - reflects an expected step-wise progression of
vascular dementia. Meds were optimized to slow progression of
vascular dementia. She is continued on aspirin and her
atorvastatin is increased back to 40 (was on 20, formerly 80
mg). Blood pressure is a major vascular risk factor in this
patient (SBP was occasionally as high as 190) so her amlodipine
was increased.
Although large ventricles on head CT most likely represent
involutional changes in the settings of her small-vessel
cerebrovascular disease, NPH is hard to exclude. Notably, her
gait cannot be evaluated as her strength and mobility are so
limited. Discussed with her daughter ___ whether she might
pursue workup of this, knowing that this would only be
productive if shunt were pursued. She expressed that this was
not within the goals of care.
# Hypertension
Continued on home HCTZ 25 mg and Imdur 60. Amlodipine
increased from 5 to 10 mg.
# CAD:
Atorvastatin was increased to 40 mg daily and ASA was
continued. She is on Imdur 60 mg and Ranexa for her history of
angina.
# Essential tremor:
Due to declining mental function, would suggest slow
withdrawal of her home primidone (a barbiturate). Dose was
reduced by 20%. Continue home propranolol.
# Medication reconciliation:
- Will need complete med rec with pt's daughter and PCP in am -
current list is based on OMR medication history
#Code: DNR/DNI
#HCP: Daughter, ___ ___
*******************
TRANSITIONAL ISSUES
*******************
1) Amlodipine increased. Please follow up BP control.
2) Consider weaning primidone to help with mental status
(barbiturate).
3) If she proves difficult to rehabilitate and is not exerting
herself regularly, consider withdrawing ranolazine.
4) Her daughter will bring in the home med list, which may
contain meds not on this summary. Please add any missing home
meds, if indicated.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Topiramate (Topamax) 50 mg PO DAILY
2. Ranexa (ranolazine) 500 mg oral BID
3. Propranolol 10 mg PO BID
4. PrimiDONE 62.5 mg PO TID
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. amLODIPine 5 mg PO DAILY
9. Travatan Z (travoprost) 0.004 % ophthalmic (eye) unknown
10. Carteolol 1% Ophth Soln Dose is Unknown BOTH EYES BID
11. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN Pain
2. Atorvastatin 40 mg PO QPM
3. PrimiDONE 50 mg PO TID
4. Senna 8.6 mg PO BID:PRN Constipation
5. amLODIPine 10 mg PO DAILY
6. Carteolol 1% Ophth Soln 1 DROP BOTH EYES BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Propranolol 10 mg PO BID
10. Ranexa (ranolazine) 500 mg oral BID
11. Topiramate (Topamax) 50 mg PO DAILY
12. Travatan Z (travoprost) 0.004 % ophthalmic (eye) unknown
13. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Failure to thrive
Vascular dementia
Hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound (to chair with two person max assist)
Discharge Instructions:
You came to the hospital with failure to thrive at home. We did
not find a readily reversible cause of your decline. You are
being discharged to rehab.
Followup Instructions:
___
|
19877772-DS-11
| 19,877,772 | 26,026,055 |
DS
| 11 |
2184-05-19 00:00:00
|
2184-05-20 16:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
chloramphenicol
Attending: ___.
Chief Complaint:
cough, fevers, malaise
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ yo M, from ___, with sickle cell disease,
complicated by retinopathy, acute chest in ___ complicated
by respiratory failure, intubation, "coma," hx of bilateral
sensory neural hearing loss, possible seizure hx, presenting
with 2 days of fevers, chills, productive cough, and general
malaise.
Mr. ___ was previously treated at ___ since coming to ___.
He transferred to ___ in ___ to establish care with Dr. ___
___ Dr. ___ as ___ did not have ASL interpreters. ___
reports 2 days of fevers, chills, malaise, and productive cough.
No sick contacts. He called Dr. ___ and was told to
present to the ED.
In ED initial VS: 100.2, 110, 137/58, 18, 100% RA
- Exam: looking very uncomfortable. Mentating well, but in pain.
- Labs significant for: wbc 3.9, Hgb 10.2, plt 231. Cr 0.7. INR
1.3. Abs Retic 0.07. Flu negative.
- Patient was given: 2L NS, 1g CTX, Azithro 500mg IV, Duoneb,
acetaminophen
- Imaging notable for: patchy opacities at the lung base
concerning for acute chest syndrome
- Hematology aware patient is here.
- While in the ED, patient febrile to 103.1.
On arrival to the MICU, patient reports having a dry mouth,
feeling thirsty and hungry. He has a headache, neck ache, sore
throat. He has had a cough for 2 days, with productive sputum.
He also has some pain in bilateral calves. He has a girlfriend
who he is sexually active with, they don't use condoms, last HIV
test was ___ years ago. No sick contacts. No recent travel.
REVIEW OF SYSTEMS: Denies chest pain, abdominal pain, diarrhea,
bladder pain.
Past Medical History:
-- Seizures; records indicate use of Keppra in the past, but he
states that he is no longer taking this. It's possible that
Keppra use related to his ___ hospitalization when he says
he was in "coma" with need for exchange transfusion.
-- Nonspecific reaction to tuberculin skin test.
-- Sensorineural hearing loss since age ___ when treated with an
ototoxic agent for high fevers while living in ___.
-- Closed fracture of dorsal (thoracic) vertebra.
-- Retinopathy.
-- Labyrinthitis.
-- Other specific developmental learning difficulties.
-- Myopia.
-- ___ heart AV block.
-- Developmental expressive writing disorder.
-- Acute chest syndrome; he reports having exchange transfusion
only once in his lifetime, and this was during his ___ ___
hospitalization, as noted above.
-- Vitamin D deficiency.
-- Acute respiratory failure with hypoxia.
-- ARDS.
-- Sepsis.
-- Thrombocytopenia, thrombocytosis (per his ___ record).
-- Non-ST elevation myocardial infarction (NSTEMI), type 2.
-- thoracic vertebral body crush fractures
-- left arm weakness after hospitalization in ___, improved
with ___
Social History:
___
Family History:
Father had cancer. Grandmother had diabetes.
Physical Exam:
========================
PHYSICAL EXAM:
========================
VITALS: T 100.5, 121/60, HR 111, 97RA
GENERAL: Alert, oriented, no acute distress, coughing with
productive sputum frequently
HEENT: PERRL, EOMI, Sclera anicteric, dry MM, no visible
erythema of posterior oropharynx or tonsillar exudate.
NECK: supple, no LAD, but tender diffusely to palpation
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, no edema.
Tender to palpation in bilateral calves. Right calf larger than
left calf. No pain in bilateral hips, knees, ankles, or feet.
SKIN: warm, no rashes
NEURO: CN II-XII intact, ___ strength in left arm and leg, ___
strength in right arm and leg. Per chart, this is baseline.
============================
DISCHARGE EXAM:
============================
Vitals: 98.3 PO 102 / 56 75 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,
allops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no ebound 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:
==========================
___ 09:20PM BLOOD WBC-3.9* RBC-2.40* Hgb-10.2* Hct-27.4*
MCV-114* MCH-42.5* MCHC-37.2* RDW-13.6 RDWSD-56.5* Plt ___
___ 09:20PM BLOOD Neuts-77* Bands-7* Lymphs-9* Monos-7
Eos-0 Baso-0 ___ Myelos-0 NRBC-5* AbsNeut-3.28
AbsLymp-0.35* AbsMono-0.27 AbsEos-0.00* AbsBaso-0.00*
___ 09:20PM BLOOD ___ PTT-27.1 ___
___ 07:10PM BLOOD Glucose-102* UreaN-8 Creat-0.7 Na-138
K-4.5 Cl-100 HCO3-23 AnGap-20
___ 06:10AM BLOOD ALT-22 AST-23 LD(LDH)-228 AlkPhos-75
TotBili-3.2* DirBili-0.5* IndBili-2.7
___ 06:10AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.7
___ 01:01AM BLOOD ___ pO2-58* pCO2-30* pH-7.46*
calTCO2-22 Base XS-0
==========================
DISCHARGE LABS:
==========================
___ 08:20AM BLOOD WBC-6.6 RBC-2.39* Hgb-10.0* Hct-26.9*
MCV-113* MCH-41.8* MCHC-37.2* RDW-13.3 RDWSD-54.7* Plt ___
___ 08:20AM BLOOD Plt ___
___ 08:20AM BLOOD Glucose-89 UreaN-8 Creat-0.5 Na-132*
K-4.5 Cl-105 HCO3-21* AnGap-11
___ 08:20AM BLOOD ALT-16 AST-18 LD(LDH)-295* AlkPhos-74
TotBili-2.3*
___ 08:20AM BLOOD Calcium-9.1 Phos-2.7 Mg-1.9
=====================
IMAGING:
=====================
___
FINDINGS:
Lung volumes are low. Heart size is mildly enlarged.
Mediastinal and hilar contours are normal. The pulmonary
vasculature is not engorged. Patchy opacities within the lung
bases are noted without focal consolidation. No pleural effusion
or pneumothorax is detected. No acute osseous abnormalities
visualized.
IMPRESSION:
Patchy opacities within the lung bases are concerning for acute
chest syndrome in the correct clinical context with infection
not excluded. Mild cardiomegaly.
___
CT NECK
IMPRESSION:
1. Cervical lymphadenopathy as described in the findings,
possibly reactive. No abscess formation.
2. Moderate paranasal sinus disease.
3. Manubrium, sternum, and vertebral body avascular necrosis in
the setting of sickle cell disease.
4. Please refer to separate report for same-day CT chest for
complete
description of the thoracic findings.
___
CT CHEST W/O CONTRAST
IMPRESSION:
1. Mild perivascular ground glass opacities, nonspecific,
potentially related to microvascular occlusion in the setting of
sickle cell, mild pulmonary edema, or other
infectious/inflammatory etiology.
2. Multiple foci of atelectasis/scarring as above.
3. Additional chronic sequelae of sickle cell disease as above.
___
UNILATERAL ___ US
IMPRESSION:
No evidence of deep venous thrombosis in the right or left
lower extremity veins.
Brief Hospital Course:
___ yo M with sickle cell disease complicated by retinopathy,
acute chest in ___ resulting in respiratory failure and
intubation, hx of bilateral sensory neural hearing loss,
possible seizure hx, who presented with 2 days of fevers,
chills, productive cough, and general malaise found to have
acute chest syndrome.
#MILD ACUTE CHEST SYNDROME
Patient presented with acute onset respiratory sx (fevers,
chills, productive cough) with multiple opacities on CXR and CT
chest, concerning for acute chest syndrome v. pneumonia. He is
not requiring O2 and his hemoglobin is above his threshold for
transfusion and exchange was not indicated. CT showed mild
perivascular ground glass opacities. Legionella and flu is
negative. He was in the MICU where they were treating him with
vanc/ceftriaxone/azithromycin and he will be discharged on
levaquin for full 7 day course.
#PROLONGED ___: Patient presented with elevated INR to 1.3,
1.5 with no signs of bleeding and no previous record of elevated
___. Normal PTT. Unclear etiology as patient has no
anticoagulant use, no evidence of DIC, no liver disease. ?APLS
or Factor deficiency. Patient received vitamin K in the MICU.
#NECK PAIN: Patient had pharyngeal pain and tenderness of the
neck on palpation. CT neck showed cervical lymphadenopathy,
likely reactive and did not show any abscess or fluid
collection.
#Right Calf Swelling/Pain: Patient had ___ which did not show
DVT. Pain has resolved.
#Code: full
#Communication: HCP: ___ (mom) ___
TRANSITIONAL ISSUES
===================
[] Prolonged ___: Unclear if this is new or chronic but
patient has no signs of liver disease and patient is eating well
so does not seem to be nutritional. Please repeat ___ and
consider further work up.
[] New Medications:
-Levofloxicin 750 mg daily for 7 days (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Hydroxyurea ___ mg PO DAILY
3. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
4. Vitamin D ___ UNIT PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Levofloxacin 750 mg PO Q24H Duration: 3 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
2. Cyanocobalamin 1000 mcg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Hydroxyurea ___ mg PO DAILY
5. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
6. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Acute Chest Syndrome
Sickle Cell 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 came to the hospital because you had fevers, chills, and a
cough. We did a CT scan of your chest which showed that you had
"acute chest syndrome," which is when your sickle red blood
cells clog up your blood vessels. We treated you with
antibiotics and you should continue to take these when you get
home. Please take all the pills even if you feel better.
You need to follow up with your primary care doctor and blood
doctor, ___ you leave the hospital.
We wish you the best,
Your care team at ___
Followup Instructions:
___
|
19877772-DS-12
| 19,877,772 | 28,508,244 |
DS
| 12 |
2185-06-02 00:00:00
|
2185-06-02 12:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
chloramphenicol
Attending: ___.
Chief Complaint:
CC: R sided chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ with hx of sick cell disease complicated by retinopathy
and acute chest syndrome, sensorineural hearing loss since age ___
presenting with R lower chest pain and SOB. History is obtained
with assistance of iPad with video ASL interpreter. Pt describes
onset of pleuritic R lower chest pain and SOB on the afternoon
of
presentation at 2:30 pm, with radiation to R back, similar to
prior sickle cell pain crises. Pain started while he was
driving,
with gradual onset, rising from ___. Described as
squeezing pain, R sided, with associated SOB, squeezing pain
with
inspiration. This pain is similar to an episode "a couple of
years ago," but subsequently denies similarity to episode of
severe illness at ___ in ___. He denies cough, F/C, headaches,
rhinorrhea, sore throat. He feels dehydrated. He has been eating
and drinking normally. Denies abdominal pain, nausea, vomiting,
diarrhea, constipation, dysuria, ___ edema, drenching night
sweats.
This is his first hospitalization for sickle cell disease this
year, and he believes a total of 4 hospitalizations over the
preceding ___ years. At home, he takes ibuprofen for pain, and
oxycodone for breakthrough pain. He did not try taking ibuprofen
or oxycodone prior to coming to the ED, as he came directly from
work to the ED, as advised by his PCP's office.
In the ___ ED:
VS 98.0, 67, 115/75, 100% RA
Exam notable for RUQ TTP with ___ sign
Labs notable for WBC 9.8, Hb 9.8, Plt 309, Retic 12.4, ALT 18,
AST 54, Alk phos 41, Tbili 4.3
D-dimer 1212
CTA without PE or infiltrate
RUQ u/s with cholelithiasis, without evidence of cholecystitis
Received:
Morphine sulfate 4 mg IV x2
1L NS
On arrival to the floor, he describes pain as ___. Morphine
in
ED provided no relief. He reports taking his hydroxyurea, 4
capsules once daily as prescribed. He misses doses 4 times every
week. He states that he does not take it consistently because he
does not like taking it, and notes that it causes diarrhea.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI
Past Medical History:
-- Seizures; records indicate use of Keppra in the past, but he
states that he is no longer taking this. It's possible that
Keppra use related to his ___ hospitalization when he says
he was in "coma" with need for exchange transfusion.
-- Nonspecific reaction to tuberculin skin test.
-- Sensorineural hearing loss since age ___ when treated with an
ototoxic agent for high fevers while living in ___.
-- Closed fracture of dorsal (thoracic) vertebra.
-- Retinopathy.
-- Labyrinthitis.
-- Other specific developmental learning difficulties.
-- Myopia.
-- ___ heart AV block.
-- Developmental expressive writing disorder.
-- Acute chest syndrome; he reports having exchange transfusion
only once in his lifetime, and this was during his ___ ___
hospitalization, as noted above.
-- Vitamin D deficiency.
-- Acute respiratory failure with hypoxia.
-- ARDS.
-- Sepsis.
-- Thrombocytopenia, thrombocytosis (per his ___ record).
-- Non-ST elevation myocardial infarction (NSTEMI), type 2.
-- thoracic vertebral body crush fractures
-- left arm weakness after hospitalization in ___, improved
with ___
Social History:
___
Family History:
Father had cancer. Grandmother had diabetes.
Physical Exam:
GEN: alert and interactive, comfortable, no acute distress,
smiles intermittently during history
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, dry mucus membranes
LYMPH: bilateral supraclavicular lymphadenopathy, nontender, <1
cm in diameter, smooth
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, nontender, without rebounding or guarding,
nondistended
with normal active bowel
sounds, no hepatomegaly, negative ___ sign
EXTREMITIES: no clubbing, cyanosis, or edema
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: alert and interactive, cranial nerves II-XII grossly
intact, strength and sensation grossly intact
Pertinent Results:
Admit Labs
___ 07:05PM BLOOD WBC-9.8 RBC-2.77* Hgb-9.8* Hct-27.4*
MCV-99* MCH-35.4* MCHC-35.8 RDW-18.8* RDWSD-66.6* Plt ___
___ 07:05PM BLOOD Ret Man-12.4* Abs Ret-0.34*
___ 07:05PM BLOOD Glucose-86 UreaN-8 Creat-0.6 Na-138
K-5.6* Cl-104 HCO3-20* AnGap-14
___ 07:05PM BLOOD ALT-18 AST-54* AlkPhos-41 TotBili-4.3*
DirBili-0.3 IndBili-4.0
___ 05:55AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.0
___ 10:51PM BLOOD D-Dimer-1212*
___ 04:45PM BLOOD Hapto-<10*
CTA Chest
COMPARISON: CT chest ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified
to the
subsegmental level without filling defect to indicate a
pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of
dissection or
intramural hematoma. The heart, pericardium, and great vessels
are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or
hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There similar scattered areas of subsegmental
atelectasis and
parenchymal scarring. Otherwise, the remaining lungs are clear
without masses
or areas of parenchymal opacification. The airways are patent
to the level of
the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: Again demonstrated, H-shaped configurations of the
vertebral bodies,
sclerotic appearance of the sternum and ribs, and atrophied
spleen consistent
with patient's known history of sickle cell disease. Otherwise,
no suspicious
osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Discharge Labs
___ 05:55AM BLOOD WBC-5.5 RBC-2.60* Hgb-9.2* Hct-25.4*
MCV-98 MCH-35.4* MCHC-36.2 RDW-18.1* RDWSD-64.9* Plt ___
___ 05:55AM BLOOD Ret Aut-12.6* Abs Ret-0.31*
___ 05:55AM BLOOD Glucose-80 UreaN-6 Creat-0.5 Na-140 K-4.5
Cl-104 HCO3-24 AnGap-12
___ 05:55AM BLOOD ALT-15 AST-24 LD(LDH)-309* AlkPhos-44
TotBili-4.8* DirBili-PND
___ 05:55AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.0
___ 05:55AM BLOOD Hapto-<10*
Brief Hospital Course:
___ with hx of sick cell disease complicated by
retinopathy and acute chest syndrome, sensorineural hearing loss
since age ___ presenting with vasoocclusive pain episode rapidly
improved.
# R chest pain
# SOB
# Vasoocclusive pain episode
# Sickle cell disease
# Anemia
Presented with severe right sided chest pain and found to be in
sickle crisis. He underwent a CTA chest which was negative for
any acute pulmonary embolism. He was admitted to medicine for
pain control and IVF. Troponins were checked and negative. He
was stabilized on toradol and PO dilaudid ___ mg. Initially he
was requiring 2L NC which was rapidly weaned off. His labs
showed evidence of hemolysis with haptoglobin <10, elevated
indirect bilirubin. He had a RUQUS which showed many gallstones
but no signs of cholecystitis or obstruction. His bilirubin was
4.8 on discharge. Wanted to monitor hemolysis labs including
bilirubin for one more day but patients symptoms had completely
resolved and he asked to be discharged with close follow up. We
discussed the risks including that he could continue to hemolyze
and would need to return to the hospital. His Hgb was stable at
9.2 at discharge. He will have his labs rechecked tomorrow as an
outpatient. We also discussed the importance of taking
hydroxyurea daily.
>30 minutes spent on complex discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 1000 mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Hydroxyurea ___ mg PO DAILY
4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
5. Vitamin D ___ UNIT PO DAILY
6. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Hydroxyurea ___ mg PO DAILY
4. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
5. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
6. Vitamin D ___ UNIT PO DAILY
7.Outpatient Lab Work
Dx: Hemolytic Anemia D59.9
CBC, LFTS, Indirect and direct bilirubin
Please page Dr. ___ with concerning result ___
Discharge Disposition:
Home
Discharge Diagnosis:
Sickle Cell Crisis
Hemolytic Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after you had pain and were
found to be a sickle cell crisis. You were treated with pain
medications and intravenous fluids and with this you improved.
You were found to be hemolyzing your red blood cells making your
bilirubin high. We wanted to monitor your bilirubin for another
day but you were feeling well and wanted to go home. It is very
important to get your blood drawn tomorrow and if your bilirubin
is higher or your blood count is lower you will need to return
to the hospital.
As we discussed it is very important you take your hydroxyurea
everyday to help stop further sickle cell crisis.
It was a pleasure caring for you,
Your ___ Team
Followup Instructions:
___
|
19877807-DS-18
| 19,877,807 | 24,430,400 |
DS
| 18 |
2144-10-19 00:00:00
|
2144-10-19 20:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Pelvic Inflammatory Disease failing outpatient regimen
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ G1P1 with history of opioid
use disorder on methadone, fibromyalgia, and recurrent PID who
presents with 3 week history of lower abdominal pain. Pt reports
that the pain started approximately 3 weeks ago. It starts just
right of the suprapubic region, wrapping around to the left and
to her back. She was diagnosed with PID by her primary physician
and was given a 2 week course of PO antibiotics. She then had a
recurrence of the pain and presented to ___,
where she was recommended for admission for IV antibiotics given
failed outpatient therapy. She left AMA given difficulties with
obtaining childcare. She had a prescription for PO cipro/flagyl,
which she took for 3 days with no significant improvement in
pain. She then presented to ___ on ___ and was recommended
for transfer to ___ for GYN consult given concern for ongoing
PID, failing outpatient management, and for r/o ___ and torsion.
At ___, a CT A/P was performed showing a normal appendix
and a 3cm L ovarian cyst. A pelvic US re-demonstrated the L
ovarian cyst with normal flow, no e/o ___.
On evaluation of the patient, she re-iterates the location of
her pain which has not changed significantly since 3 weeks ago
however the intensity has worsened. She rates it at an ___. Her
back pain is the most concerning at this time. Of note, she has
history of 2 discectomies but reports that at baseline she does
not have significant back pain. She reports some associated
nausea and vomiting. She denies any fevers but does report
chills. She denies any CP/SOB, dysuria, changes to bowel habits,
or abnormal vaginal discharge. She at baseline has periods every
4 months, irregular and did have some bleeding 2 days ago. She
had a negative urine HCG at ___.
Past Medical History:
Anxiety/Depression
Fibromyalgia
Hiatal hernia
h/o acute renal failure ___ NSAID overuse
Social History:
___
Family History:
NC
Physical Exam:
Gen: resting comfortably, NAD
Cardiac: RRR
Pulmonary: CTAB
Abdomen: mildy tender to deep palation, ND, no r/g
Pertinent Results:
___ 07:55AM URINE HOURS-RANDOM
___ 07:55AM URINE UCG-NEGATIVE
___ 07:55AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 07:55AM URINE RBC-5* WBC-0 BACTERIA-FEW* YEAST-NONE
EPI-6
___ 07:55AM URINE MUCOUS-RARE*
___ 06:25AM GLUCOSE-100 UREA N-10 CREAT-0.6 SODIUM-138
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-21* ANION GAP-14
___ 06:25AM estGFR-Using this
___ 06:25AM ALT(SGPT)-20 AST(SGOT)-23 ALK PHOS-55 TOT
BILI-0.5
___ 06:25AM LIPASE-13
___ 06:25AM ALBUMIN-3.7
___ 06:25AM WBC-6.7 RBC-3.95 HGB-12.2 HCT-35.7 MCV-90
MCH-30.9 MCHC-34.2 RDW-12.3 RDWSD-40.9
___ 06:25AM NEUTS-35.1 ___ MONOS-8.8 EOS-5.9
BASOS-0.4 IM ___ AbsNeut-2.36 AbsLymp-3.33 AbsMono-0.59
AbsEos-0.40 AbsBaso-0.03
___ 06:25AM PLT COUNT-224
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology
service after evaluation in the ED for pelvic inflammatory
disease. On arrival, she was afebrile with a WBC of 6.7. She was
started on IV gentamicin and clindamycin given the patient's
allergies and continued for 24 hours. Patient's pain was
controlled with dilaudid, duloxetine, gabapentin, and Tylenol.
She continued on 54mg of Methadone for her opiod addiction and
continued on her home medications for her anxiety and
fibromyalgia. Given the characterization of the patient's pain,
the differential was expanded to include acute on chronic pelvic
pain and was treated with vaginal diazepam. Patient noted much
improvement on therapy. She was transitioned to PO doxycycline
and flagyl.
By hospital day 3, she was tolerating a regular diet, voiding
spontaneously, ambulating independently, and pain was controlled
with oral medications. Patient was discharged with 3 tablets of
valium and instructed to follow-up with pharmacy for compound
medication. She was then discharged home in stable condition
with instructions to make an appointment to see Dr. ___
___ at ___ in ___ next week.
Medications on Admission:
Cymbalta
Abilify
Prilosec
Neurontin
Methadone 54mg daily (confirmed by RN with prescriber)
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*40 Tablet Refills:*1
2. Diazepam 5 mg PO Q6H:PRN pelvic pain Duration: 3 Doses
Please place vaginally as instructed.
RX *diazepam 5 mg 1 tablet by vagina Every 6 hours as needed
Disp #*3 Tablet Refills:*0
3. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice daily
(every 12 hours) Disp #*26 Tablet Refills:*0
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth Twice daily
Disp #*22 Tablet Refills:*0
4. MedroxyPROGESTERone Acetate 10 mg PO DAILY Duration: 10 Days
RX *medroxyprogesterone 10 mg 1 tablet(s) by mouth Once daily
Disp #*10 Tablet Refills:*0
5. MetroNIDAZOLE 500 mg PO BID
Please take with food.
RX *metronidazole 500 mg 1 tablet(s) by mouth Twice daily Disp
#*12 Tablet Refills:*0
RX *metronidazole 500 mg 1 tablet(s) by mouth Twice daily Disp
#*22 Tablet Refills:*0
6. ARIPiprazole 5 mg PO DAILY
7. DULoxetine 60 mg PO DAILY
8. Gabapentin 400 mg PO TID
9. Methadone 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
pelvic inflammatory disease, refractory to outpatient management
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the Gynecology service for treatment of
pelvic inflammatory disease and chronic pelvic. You received IV
antibiotics, and then were transitioned to oral doxycycline and
vaginal diazepam. You are doing well, and the team now feels you
are ready to go home.
Please continue to take your antibiotics as prescribed until you
complete the course. You last day will of antibiotics will be
___.
Constipation:
* Drink ___ liters of water every day.
* Incorporate 20 to 35 grams of fiber into your daily diet to
maintain normal bowel function. Examples of high fiber foods
include:
Whole grain breads, Bran cereal, Prune juice, Fresh fruits and
vegetables, Dried fruits such as dried apricots and prunes,
Legumes, Nuts/seeds.
* Take Colace stool softener ___ times daily.
* Use Dulcolax suppository daily as needed.
* Take Miralax laxative powder daily as needed.
* Stop constipation medications if you are having loose stools
or diarrhea.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19879535-DS-17
| 19,879,535 | 28,964,260 |
DS
| 17 |
2123-03-18 00:00:00
|
2123-03-18 16:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Pulmonary embolism
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with HTN, pancreatic cancer with new diagnosis
of pulmonary embolism. He was in his usual state of health
until a few days prior to admission. At that time he developed
some mild chest tightness and dyspena with exertion. He denies
dyspnea/shortness of breath at rest, syncope, hemoptysis, cough,
blood per rectum or in stools or other symptoms.
He had a scheduled CT chest with contrast which showed new
pulmonary embolism (right main PA extending through lobar,
segmental and subsegmental involvement and left subsegmental
arteries). No assessment of right heart strain was made. He
otherwise felt well. He was contacted by his oncologist who
recommended evaluation in the emergency department. Initially
the patient refused but later presented to the ED for
evaluation.
In the ED, initial vitals were: Pain 0, T 99.3, HR 95, BP
146/104, RR 20, SvO2 94% RA. He was guaiac negative. He was
started on a heparin drip and admitted to OMED for further
evaluation and management.
On admission, he felt okay. He is overwhelmed by diagnosis and
functional decline over the last 10 months. He denies any
shortness of breath, and notes mild abdominal pain.
Past Medical History:
Oncologic History:
-40 pounds weight loss unintentionally, secondary to decreased
appetite and abdominal pain, but no early satiety, nausea,
vomiting, melena or bright red blood per rectum.
-He presented to his primary care doctor who is Dr. ___ in
___ complaining of a few weeks of abdominal discomfort.
Dr. ___ a CT abdomen and pelvis, which was performed
on ___. It showed a heterogeneous mass in the head of
pancreas measuring 4.8 cm x 6.4 cm x 4.5 cm with a dilated main
pancreatic duct measuring 11 mm with associated atrophy of the
distal pancreas. The mass encased the gastroduodenal artery.
There was also adjacent fat stranding which abutted the superior
mesenteric vein more than the superior mesenteric artery,
indicative of possible encasement. There was also an 8mm
peripancreatic lymph node.
-Subsequent to this, the patient underwent an FNA of the
pancreatic mass on ___ with pathology revealing
adenocarcinoma.
-Subsequently, the patient was admitted from ___ to ___ for an ERCP with stenting of the common bile duct due to
pruritis and jaundice. During this procedure, there was also an
incidental notation of a large duodenal ulcer. The common bile
duct brushings were however, were negative for malignant cells.
The EUS did show involvement of the portal vasculature.
-On ___, the patient had a consultation with Dr. ___
of ___ surgery and the patient was informed that
due to the involvement of vasculature, namely CT evidence
suggestive of SMA encasement, he is not a suitable surgical
candidate.
-___: Initiated on gemcitabine/nab-paclitaxel
-___: CT Chest/A/P:
*Slight interval decrease in size of low density heterogeneously
enhancing pancreatic head tumor, which partially encases but
does not obstruct the superior mesenteric vessels. No change
single portocaval node.
*Interim replacement of plastic biliary stent with self
expanding metallic stent which appears in good position. No
biliary or duodenal obstruction.
*Previously described hepatic hypodensities are either
non-evident or less evident on the current exam. Note also made
of two vascular enhancing lesions at the dome likely to
represent hemangiomas. Unchanged findings include
atherosclerosis, aneurysmal femoral arteries, prostatic
enlargement, non-obstructive renal stones and chronic bone
changes as described.
-___: C3D15 held due to neutropenia
___
-CT Chest/Abdomen/Pelvis:
*No mets in thoracic area
*LIVER: At the liver dome, there are 2 hyper-enhancing lesions
seen previously, unchanged in size and appearance, likely
hemangiomas. The minimal density regularity at the inferior
right lobe peripherally is not well seen on today's exam.
Likewise, the 4 mm hyperdensity in the anterior left lobe is
also not well visualized. No additional liver lesion is
identified. There is persistent pneumobilia, secondary to a
patent CBD stent. There is no intrahepatic biliary duct
dilatation. The gallbladder is unremarkable and the portal vein
is patent. The slight irregularity of the contour of the
anterior wall of the portal vein is unchanged since the prior
study.
*PANCREAS: At the head of the pancreas, the heterogeneously
enhancing, mostly hypodense mass is not significantly changed in
size, measuring 3.8 x 3.4 cm, previously 3.8 x 3.7 cm. However,
the focal extension of the mass at the uncinate processinto the
mesenteric root is improved on today'sstudy. The body and tail
of the pancreas are largely atrophic and the main pancreatic
duct remains markedly dilated measuring up to 1.4 cm, slightly
increased since prior study. RETROPERITONEUM AND ABDOMEN: The
previously seen portal caval lymph node measures 3.4 x 0.7 cm,
unchanged in size. There are stable scattered prominent
mesenteric lymph nodes, none are enlarged by CT size criteria.
No additional lymphadenopathy is identified.
-___: C5D1: Changed regimen to q2week (D1 and D15) instead
of D1, 8, 15 due to patient inability to tolerate frequent
chemo/quality of life
-___: CT Torso
*No evidence of intrathoracic malignancy. Stable 17-mm
subcarinal lymph node without other evidence of LAD
*Stable size of mass in the head of the pancreas. Vascular
involvement is also stable. There is atrophy of the body and
tail of the pancreas with dilatation of the pancreatic duct.
*No definite evidence for metastatic disease. Enhancing lesion
in the dome of the liver is consistent with a hemangioma and
stable in size.
-___: CT Torso
*Slight increase in size in the hypo attenuating mass within the
head of the pancreas, measuring 3.3 x 4.8 cm, previously 3.1 x
3.9 cm in a similar plane. The degree of pancreatic ductal
dilation with abrupt tapering at the margin of the mass is
similar. A dependent calcification is seen within the obstructed
main pancreatic duct. The gastroduodenal artery is partially
encased by tumor and remains
patent. Tumor encompasses approximately 30% circumference of the
superior mesenteric artery, an unchanged finding. The portal
vein, superior mesenteric vein, and splenic vein remain patent.
A metallic common bile duct stent is in place with resultant
pneumobilia. There is been slight increase in size of a node
adjacent to the common hepatic artery which measures 1 cm
previously 8 mm. A portacaval node that measures 6 mm in short
axis dimension, is unchanged. Lesion in hepatic segment ___
junction that measures 7 mm and is hyperdense on the portal
venous phase images is unchanged in size and may represent a
hemangioma ; a second smaller lesion in segment 7 previously
seen is less well appreciated on the present study. No new focal
liver lesions are identified
-___: C9D1 (q2 week regimen) of gemcitabine/nab-paclitaxel
-___: C9D22 (q2 week regimen) of gemcitabine/nab-paclitaxel
PAST MEDICAL HISTORY:
HTN
HLD
Sciatica, back pain
PTSD with psychosis
Eczema
BPH
R uretral nephrolithiasis
Remote right orchiectomy
Social History:
___
Family History:
His uncle had cancer with yellowing of the skin; it is unclear
if it was pancreatic cancer or not.
Physical Exam:
General: no apparent distress, chronically ill appearing
Vitals: 98.2 138/82 84 16 96%RA
HEENT: Anicteric, MMM
Cardiac: RRR, no murmurs/gallops
Pulm: CTA-B, speaks full sentences
Abd: soft, nontender, nondistended, positive bowel sounds
Ext: wwp, no edema, no calf tenderness, pulses intact
Skin: Warm/dry.
Neuro: Oriented x 3. Speech fluent. Moves all extremities and
ambulates
Pertinent Results:
==================================
Labs
==================================
___ 05:00PM BLOOD WBC-4.6 RBC-3.35* Hgb-10.4* Hct-30.6*
MCV-91 MCH-31.0 MCHC-34.0 RDW-15.6* Plt ___
___ 07:20AM BLOOD WBC-4.9 RBC-3.44* Hgb-10.1* Hct-31.5*
MCV-92 MCH-29.2 MCHC-31.9 RDW-15.9* Plt ___
___ 05:00PM BLOOD ___ PTT-26.8 ___
___ 11:05AM BLOOD PTT-47.7*
___ 05:00PM BLOOD Glucose-110* UreaN-21* Creat-1.0 Na-140
K-3.8 Cl-103 HCO3-29 AnGap-12
___ 07:20AM BLOOD Glucose-132* UreaN-15 Creat-0.9 Na-140
K-3.6 Cl-105 HCO3-28 AnGap-11
==================================
Radiology
==================================
CT CHEST W/CONTRASTStudy Date of ___ 10:03 AM
FINDINGS:
1. Multiple large pulmonary emboli involving right main
pulmonary artery
extending through the lobar, segmental and subsegmental
branches. Possible
subsegmental involvement on the left. No interventricular
straightening
present. Intravenous contrast reflux into the hepatic veins can
be normal with high- rate contrast injection (part of normal
pancreatic multiphase CT) but may also be indicative of right
heart strain.
2. No evidence of active intrathoracic infection or malignancy.
Brief Hospital Course:
___ year old male with pancreatic cancer admitted with right main
pulmonary artery pulmonary embolism found incidentally on CT
scan. He remained hemodynamically stable and without chest pain,
shortness of breath, hypoxemia, or tachycardia. He was initially
started on a heparin drip. The following day he was
transitioned to Lovenox injections which he performed himself on
the day of discharge and will continue at home. His Megace was
discontinued as it can be prothrombotic. He did not want to try
an alternative appetite stimulant at this time.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
3. Megestrol Acetate 400 mg PO QAM
4. Omeprazole 40 mg PO DAILY
5. OxyCODONE SR (OxyconTIN) ___ mg PO Q12H
6. Docusate Sodium 100 mg PO BID
7. Senna 17.2 mg PO BID:PRN constipation
Discharge Medications:
1. Enoxaparin Sodium 70 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 80 mg/0.8 mL 70 mg SC every twelve (12) hours
Disp #*60 Syringe Refills:*2
2. Senna 17.2 mg PO BID:PRN constipation
3. OxyCODONE SR (OxyconTIN) ___ mg PO Q12H
4. Omeprazole 40 mg PO DAILY
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
6. Docusate Sodium 100 mg PO BID
7. Amlodipine 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
pulmonary embolism
pancreatic cancer
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 for a pulmonary
embolism (blood clot in the lungs). You were started on Lovenox,
a blood thinner. You will continue this medication at home.
Followup Instructions:
___
|
19880183-DS-16
| 19,880,183 | 27,749,884 |
DS
| 16 |
2119-07-26 00:00:00
|
2119-07-26 17:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man with a history of hypertension
and hairy cell leukemia diagnosed in ___ that was treated with
5
doses of cladribine at that time. Unfortunately, this recently
relapsed and he started treatment with ___ of ___ on
___ with five doses of cladribine to be followed by weekly
rituximab for 8 weeks after one month (received 2nd dose on
___.
A few months after finishing his chemotherapy in ___, he
started
experiencing chest pain, which he has been dealing with since
that time. He describes this pain as "burning, crushing,
squeezing" in the left side of the chest that does not radiate.
The pain is not associated with shortness of breath but is
associated with nausea and vomiting.
When the pain comes on, it usually lasts about ___ hours. It can
come on out of the blue. It is also precipitated by eating or
drinking and if he has eaten any significant amount when the
pain
comes on he will vomit. The pain is also associated with
exercise. He can walk without limits as long as he goes slowly
but if he walks too quickly, the pain comes on.
The pain is sometimes relieved by nitroglycerin, sometimes not.
He usually just lets it go away on his own.
He called ___ today because the pain "went to another level."
Of note, the patient reports that he has had an extensive workup
for this issue over the last ___ years including many CT scans,
stress tests, cardiac cath, and EGD that have not identified an
underlying etiology of the chest pain. However, the only record
we have of this workup in our system is a cardiac cath in ___
that showed completely clear coronaries. The cath was performed
by Dr. ___, who the patient identifies as his
cardiologist. However, there are no further notes from Dr. ___
in
our system or in ___ through magic
button.
Patient received 324 mg aspirin in the field by EMS. In the
ambulance, BP was 200/86. On arrival, patient's vitals were 88,
149/78, 16, 99% RA. EKG showed LVH with repolarization
abnormalities without overt signs of ischemia. Troponins were
negative x2. Echo with severe LVH but normal wall motion.
Patient
was initially started on a nitro gtt with improvement in chest
pain. Patient was seen by cardiology who recommended
discontinuing the nitro gtt, increasing his home metoprolol, and
starting losartan for better BP control. Admitted to cardiology
for further management.
Upon arrival to the floor, patient states that his chest pain
has
resolved and he is feeling well.
REVIEW OF SYSTEMS:
A complete ROS was performed and was negative except as noted
above.
Past Medical History:
- hairy cell leukemia, currently C1 cladribine
- (?) benign ethnic neutropenia
- hypertension
- obesity
- atypical chest pain
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
VS: 24 HR Data (last updated ___ @ 1725)
Temp: 97.4 (Tm 97.4), BP: 178/80, HR: 71, RR: 18, O2 sat:
98%, O2 delivery: RA, Wt: 212.52 lb/96.4 kg
GENERAL: alert and interactive, in no acute distress, obese
HEENT: Normocephalic atraumatic. Sclera anicteric.
NECK: JVP not appreciable at 40 degrees
CARDIAC: normal rate, regular rhythm, normal S1 and S2, systolic
murmur
CHEST: No tenderness to palpation of left chest
LUNGS: breathing comfortably on room air, CTAB
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No peripheral edema.
NEURO: A&Ox3
DISCHARGE PHYSICAL EXAMINATION:
===============================
VS: 24 HR Data (last updated ___ @ 902)
Temp: 97.8 (Tm 98.3), BP: 147/79 (133-147/71-79), HR: 96
(72-96), RR: 18, O2 sat: 99% (98-99), O2 delivery: RA, Wt:
210.54 lb/95.5 kg
GENERAL: alert and interactive, in no acute distress, obese
HEENT: Normocephalic atraumatic. Sclera anicteric.
NECK: JVP not appreciable at 40 degrees
CARDIAC: normal rate, regular rhythm, normal S1 and S2, systolic
murmur
CHEST: No tenderness to palpation of left chest
LUNGS: breathing comfortably on room air, CTAB
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No peripheral edema.
NEURO: A&Ox3, attentive, moving all extremities with purpose.
Pertinent Results:
ADMISSION LABS:
===============
___ 11:35AM BLOOD WBC-2.6* RBC-4.87 Hgb-12.7* Hct-39.9*
MCV-82 MCH-26.1 MCHC-31.8* RDW-17.2* RDWSD-50.1* Plt ___
___ 11:35AM BLOOD Neuts-61.8 Lymphs-10.9* Monos-18.3*
Eos-7.4* Baso-1.2* Im ___ AbsNeut-1.59* AbsLymp-0.28*
AbsMono-0.47 AbsEos-0.19 AbsBaso-0.03
___ 11:35AM BLOOD ___ PTT-32.0 ___
___ 11:35AM BLOOD Glucose-104* UreaN-12 Creat-1.1 Na-139
K-4.3 Cl-102 HCO3-22 AnGap-15
___:35AM BLOOD CK(CPK)-175
___ 11:35AM BLOOD cTropnT-<0.01
___ 11:35AM BLOOD CK-MB-3 proBNP-1066*
___ 02:35PM BLOOD cTropnT-<0.01
___ 07:01AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.1
DISCHARGE LABS:
===============
___ 09:40AM BLOOD WBC-1.8* RBC-4.67 Hgb-12.1* Hct-39.0*
MCV-84 MCH-25.9* MCHC-31.0* RDW-17.1* RDWSD-51.8* Plt ___
___ 07:01AM BLOOD ___
___ 09:40AM BLOOD Glucose-108* UreaN-11 Creat-1.1 Na-142
K-4.3 Cl-105 HCO3-26 AnGap-11
STUDIES:
========
TTE (___)
The left atrial volume index is SEVERELY increased. The
estimated right atrial pressure is ___ mmHg. There is moderate
symmetric left ventricular hypertrophy with a normal cavity
size. There is normal regional left
ventricular systolic function. No thrombus or mass is seen in
the left ventricle. Overall left ventricular systolic function
is hyperdynamic. Quantitative biplane left ventricular ejection
fraction is 75 % (normal
54-73%). Left ventricular cardiac index is low normal (2.0-2.5
L/min/m2). There is a mid cavitary gradient (peak 36 mmHg). No
ventricular septal defect is seen. Tissue Doppler suggests an
increased left ventricular
filling pressure (PCWP greater than 18 mmHg). Normal right
ventricular cavity size with normal free wall motion. Tricuspid
annular plane systolic excursion (TAPSE) is normal. The aortic
sinus diameter is normal for
gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal with a normal descending aorta
diameter. There is no evidence for an aortic arch coarctation.
The aortic valve leaflets (?#)
are mildly thickened. There is no aortic valve stenosis. There
is no aortic regurgitation. The mitral valve leaflets are mildly
thickened. There is moderate mitral annular calcification. No
valvular systolic anterior motion (___) is present. There is no
mitral valve stenosis. There is trivial mitral regurgitation.
Due to acoustic shadowing, the severity of mitral regurgitation
could be UNDERestimated. The pulmonic valve leaflets are not
well seen. The tricuspid valve is not well seen. There is
physiologic tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is a trivial
pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
normal regional and hyperdynamic global systolic function.
Mid-cavitary gradient without valvular systolic anterior motion.
Normal RV size and systolic function.
CTPA (___)
1. No evidence of pulmonary embolism or aortic abnormality.
2. Left ventricular hypertrophy.
CXR (___)
No acute cardiopulmonary abnormality.
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[]Started on losartan 50mg daily for hypertension with good
response. Please recheck BMP in 1 week (___). Adjust losartan
as needed for improved BP control.
[]Home metoprolol XL 50mg BID was decreased to 75mg daily to
prevent overly rapid lowering of BP during admission. Please
adjust as appropriate
[]Initially on admission, there was concern for medication
noncompliance as patient had difficulty naming his home
medications and when he was supposed to take them. On repeat
conversation about his medications, patient is able to state he
takes metoprolol 50mg twice daily and that he takes two
"antibiotics" that he should be on because of his chemo - one of
them once daily (Bactrim), the other three times daily
(acyclovir). Unable to name these specific medications but seems
to understand when and how to take them. Would continue to
ensure medication compliance
[]Can consider repeat exercise stress as outpatient to assess
for exaggerated BP response
BRIEF SUMMARY:
==============
Mr. ___ is a ___ man with a history of relapsed
hairy cell leukemia s/p cladribine (___) and now
receiving rituximab (2nd dose ___, and atypical chest
pain for the past ___ years of unclear etiology who now presents
with a flare-up of his chronic chest pain in setting of
hypertensive urgency which resolved with initiation of
antihypertensives.
CORONARIES: clean LHC ___
PUMP: LVEF 75% ___
RHYTHM: sinus
===============
ACTIVE ISSUES:
===============
#Atypical chest pain, resolved
#Hypertensive urgency
#Left ventricular hypertrophy
Chest pain likely iso hypertensive urgency with BP to 200/86 and
underlying LVH. Low suspicion for acute coronary event given
previously normal cardiac cath and reportedly normal stress test
in ___. It seems that his blood pressure has been poorly
controlled mainly in the setting of medication non-compliance as
he reports on admission that he has only been taking metoprolol
prior to admission. He was initiated on losartan 50mg daily and
responded well with SBP improvement to 130-140s, with
improvement in his symptoms of chest pain. Further inpatient
workup was deferred given his rapid improvement with single
agent HTN regimen. His home metoprolol XL 50mg BID was decreased
to 75mg daily to prevent excessively rapid lowering of his BP.
#Medication noncompliance
On admission, there was initial concern that patient was not
taking his home medications properly as he reportedly was only
taking metoprolol prior to admission. We reached out to his
hematologist/oncologist to make them aware that patient was
missing these medications and confirmed that patient should
continue to take these meds. On repeat conversation with patient
prior to discharge - patient was able to state that at home he
takes metoprolol 50mg BID as well as two "antibiotics" that he
should be on because of his chemo - one of them once daily
(Bactrim), the other three times daily (acyclovir). Unable to
name these specific medications but seems to understand when and
how to take them. Confirms that he has these medications at home
and does not need refills. Would continue to ensure medication
compliance
================
CHRONIC ISSUES:
================
#Hairy cell leukemia
Relapsed. s/p cladribine (___) and now receiving
rituximab (2nd dose ___. Due for next dose of rituximab
on ___. Followed by Dr. ___. Continued on home
acyclovir 400mg TID and Bactrim SS tab daily
==================
CORE MEASURES:
==================
# CODE STATUS: full, presumed
# CONTACT: ___ (wife) ___
Discharge time 25 min
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO BID
2. Acyclovir 400 mg PO TID
3. Omeprazole 20 mg PO DAILY
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - Second Line
9. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
Discharge Medications:
1. Losartan Potassium 50 mg PO DAILY
RX *losartan [Cozaar] 50 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
2. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 25 mg 3 tablet(s) by mouth once a day
Disp #*90 Tablet Refills:*0
3. Acyclovir 400 mg PO TID
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Omeprazole 20 mg PO DAILY
8. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - Second Line
9. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11.Outpatient Lab Work
ICD-9: 401.9
Please repeat basic metabolic panel on ___ and fax results to:
Dr. ___ - fax ___
Address: ___, ___
Phone: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Hypertensive urgency
SECONDARY DIAGNOSIS:
====================
Chronic chest pain of unknown etiology
Left ventricular hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
chest pain
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were found to have very high blood pressures up to 200/86.
This was felt to be what was causing your chest pain. You did
not have any signs of a heart attack while you were here which
is reassuring
- You were started on a new blood pressure medication called
losartan and your blood pressures improved to 147/79 before you
left the hospital. It is important that you take this medication
daily to ensure your blood pressure stays within a normal range.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed
including your losartan.
- You should attend the appointments listed below - please call
your primary care physician ___ ___ to
make a follow up appointment with him so that he can adjust your
blood pressure medication
- Please make sure to have your blood drawn in 1 week (during
the week of ___ in order to check your kidney
function. The new blood pressure medication we started you on,
losartan, can affect your kidney function so it will be
important to monitor this.
- Seek medical attention if you have new or concerning symptoms
or you develop chest pain, trouble breathing, severe headaches,
vision changes, swelling in your legs, abdominal distention, or
shortness of breath at night.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19880882-DS-8
| 19,880,882 | 25,252,749 |
DS
| 8 |
2161-03-23 00:00:00
|
2161-03-25 10:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
Labs:
___ 08:50PM BLOOD WBC-4.1 RBC-4.21 Hgb-12.3 Hct-38.4 MCV-91
MCH-29.2 MCHC-32.0 RDW-13.1 RDWSD-43.3 Plt ___
___ 08:50PM BLOOD Glucose-101* UreaN-15 Creat-0.8 Na-142
K-3.9 Cl-105 HCO3-25 AnGap-12
___ 12:00AM BLOOD Triglyc-78 HDL-56 CHOL/HD-2.8 LDLcalc-84
Brief Hospital Course:
Ms. ___ is a ___ ___ woman with HLD presenting
with chest pain that radiated from left shoulder pain that has
been going on for 2 weeks. She underwent a stress ECHO test that
did not show any wall motion abnormalities and was an otherwise
normal test. She will be discharged with PCP follow up for
shoulder pain, which possibly represents underlying impingement
syndrome.
TRANSITIONAL ISSUES:
===================
[ ] Continued management and workup of left shoulder pain.
===============
ACTIVE ISSUES:
===============
#Atypical Chest pain
#Concerns for unstable angina
Patient is presenting with chest pain over the past 2.5 weeks
that has occurred both at rest and with exertion, but radiates
from left shoulder around to center part of chest. Negative
biomarkers and lateral TWI that are stable from priors. Risk
factors include HLD. She was admitted and underwent stress ECHO
test which showed good exercise capacity and the echo did not
show any evidence of wall motion abnormalities. She will be
discharged with close PCP ___ for further management of
her shoulder pain.
#HLD
Continue atorvastatin to 20mg daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Chest Pain
Shoulder impingement syndrome
Secondary
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure caring of you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for chest and shoulder pain
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a stress test which was normal
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take over the counter acetaminophen and/or
ibuprofen as needed for left shoulder pain. Can also consider
topical medications such as lidocaine.
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19880967-DS-24
| 19,880,967 | 24,776,258 |
DS
| 24 |
2174-06-18 00:00:00
|
2174-06-21 09:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Febrile Neutropenia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMHx DM, HTN, cigarette smoker, FLT3+ AML s/p 7+3 now C1D17
HiDAC admitted with syncope and febrile neutropenia.
Patient notes that she does not recall events of past 24 hours
very well. Last night husband reported she ___ speaking
coherently. Took temperature and it was 104 but wanted to wait
10 min before coming to hospital. Subsequently was 101 and
thought it was coming down so did not come in. This morning, she
was walking to bathroom at home and felt weak. She then fell
into her husband's arms and slid down to the floor. The family
relates that she did seem to have LOC and was confused when she
awoke. At that time, she was noted to have a temperature of
100.___oes have a slight dry cough that started on the day
prior to admission. She has also had less oral intake than usual
over the last two days. She has also noted blood sugars in the
300s; these have been high since starting HiDAC. She otherwise
denies any symptoms of HA, rash, SOB, nausea/vomiting/diarrhea
(except later in ED), dysuria, hematuria.
In the ED, her VS were 103.2 121 139/67 20 100% RA. HR
increased to the 230s (BP ___. Her initial ECG was
concerning for wide complex tachycardia, but the rhythm strip
was most consistent with SVT. After several forceful coughs,
her HR spontaneously decreased to 120s and she was in sinus
rhythm. She had a chest x ray that showed a new right lower
lobe pneumonia. She had a head CT that showed no acute
intracranial hemorrhage. Blood and urine cultures were sent.
She received 3L NS, 1 g IV vancomycin, and 2 g IV cefepime, 1g
IV acetaminophen, ___cetaminophen, 6 U lispro, 2 g Mg
sulfate, 4 mg IV Zofran. In the ED, she also had rigors and a
single episode of vomiting clear/brownish nbnb liquid, that was
responsive to IV Zofran.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-___: Started on ___ plus 3 for AML treatment. Daunorubicin
administered at 60mg/m2.
-Day 14 BM was ablated
-Inpatient course c/b febrile neutropenia and cellulitis from
obesity, DM and poor venous return. Discharged on PO
amoxicillin/clavulanic acid on ___ upon recovery of counts.
-___: Day 28 BM biopsy performed after recovery of counts
demonstrated remission.
Cytogenetics was again normal
FLT3 ITD mutation was not detected suggestive of molecular
remission.
-___: Admitted for HiDAC cycle 1. Tolerated well without
any
complications.
PAST MEDICAL/SURGICAL HISTORY:
T2DM
HTN
hepatitis B ___ transfusion)
s/p MVA age ___ with maxillary, mandibular, arm fractures
ectopic pregnancy
s/p 2 C-sections
s/p TAH
Social History:
___
Family History:
Mother alive, lives with them
Father died in his late ___, lung cancer. Psych history.
Not much contact with paternal relatives
Cousin with leukemia Dx age ___, died age ___.
No other known cancers.
Physical Exam:
Admission Physical Examination:
Vitals: 103 128/60 104 20 96%RA
Gen: Pleasant, well appearing, obese woman in NAD
HEENT: No conjunctival pallor, dry MM, palatal petechiae
CV: Tachycardic, II/VI flow murmur loudest at RUSB
LUNGS: CTAB, no wheezes/crackles/rhonchi appreciated
ABD: Obese, soft, nontender throughout
EXT: Venous stasis changes to ___ shins. 2+ pitting edema in ___
___
SKIN: No rashes/lesions appreciated
NEURO: A&Ox3, moving all extremities equally
LINES: R PICC, c/d/i
DISCHARGE EXAM
Vitals: 99.1 ___ 20 92-97% RA
Gen: Pleasant, well appearing, obese woman in NAD
HEENT: No conjunctival pallor, dry MM, palatal petechiae
CV: RRR, no m/r/g
LUNGS: CTAB, no wheezes/crackles/rhonchi appreciated. Patient
intermittently coughing.
ABD: Obese, soft, nontender throughout
EXT: Venous stasis changes to ___ shins. 2+ pitting edema in ___
___
SKIN: No rashes/lesions appreciated
NEURO: A&Ox3, moving all extremities equally
LINES: R PICC, c/d/i
Pertinent Results:
==Admission Labs==
___ 01:40PM BLOOD WBC-0.7* RBC-2.47* Hgb-7.6* Hct-21.8*
MCV-88 MCH-30.8 MCHC-34.9 RDW-14.5 RDWSD-46.5* Plt Ct-14*
___ 01:40PM BLOOD Neuts-1* Bands-0 Lymphs-95* Monos-3*
Eos-0 Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-0.01*
AbsLymp-0.67* AbsMono-0.02* AbsEos-0.00* AbsBaso-0.00*
___ 11:20AM BLOOD ___ PTT-29.1 ___
___ 11:20AM BLOOD Glucose-357* UreaN-15 Creat-0.8 Na-130*
K-3.8 Cl-93* HCO3-22 AnGap-19
___ 11:20AM BLOOD ALT-82* AST-35 AlkPhos-73 TotBili-0.8
___ 11:20AM BLOOD Albumin-3.3* Calcium-8.4 Phos-2.7#
Mg-1.0*
___ 11:37AM BLOOD ___ pO2-40* pCO2-32* pH-7.48*
calTCO2-25 Base XS-0
___ 11:40AM BLOOD Lactate-3.4*
___ 12:05PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:05PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:05PM URINE RBC-4* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-1
==Discharge labs==
___ 12:00AM BLOOD WBC-7.4 RBC-2.38* Hgb-7.0* Hct-21.3*
MCV-90 MCH-29.4 MCHC-32.9 RDW-17.0* RDWSD-55.1* Plt ___
___ 12:00AM BLOOD Neuts-34 Bands-1 Lymphs-13* Monos-43*
Eos-0 Baso-0 ___ Metas-7* Myelos-2* NRBC-2* AbsNeut-2.59
AbsLymp-0.96* AbsMono-3.18* AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Tear
Dr-OCCASIONAL
___ 12:00AM BLOOD Plt ___
___ 12:00AM BLOOD Glucose-221* UreaN-9 Creat-0.6 Na-137
K-3.5 Cl-100 HCO3-28 AnGap-13
___ 12:00AM BLOOD ALT-49* AST-18 LD(LDH)-233 AlkPhos-75
TotBili-0.4
___ 12:00AM BLOOD Calcium-7.9* Phos-4.7* Mg-1.7
==Imaging==
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 diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
CT HEAD W/O CONTRAST Study Date of ___
Images are limited by motion artifact. Within this limitation,
no acute intracranial hemorrhage.
CHEST (PORTABLE AP) Study Date of ___
New right lower lung pneumonia.
Brief Hospital Course:
Ms. ___ is a ___ PMHx DM, HTN, cigarette smoker, FLT3+ AML
s/p 7+3 now C1D17 HiDAC admitted with presyncope and febrile
neutropenia found to have right lower lobe pneumonia.
ACUTE ISSUES
============
#Febrile neutropenia
#Pneumonia:
#Sepsis:
The patient initially presented with a temperature of 103 after
syncopizing at home. On admission, the patient was found to have
a RLL infiltrate noted on CXR, and was treated with vancomycin
and cefepime initially for febrile neutropenia secondary to
pneumonia with a ANC of 0 on admission. With treatment, her
cough improved and her fevers resolved, so her antibiotics were
initially narrowed to cefepime only, then to levofloxacin only
after she continued to remain afebrile. BCx and fungal markers
were unrevealing. She was discharged to complete a 10-day total
course of antibiotics (5 days of levofloxacin after discharge).
#Atrial fibrillation with RVR:
Of note, the patient had a prior episode of SVT while undergoing
induction chemotherapy, but had never been formally diagnosed
with atrial fibrillation. In the ED, she was noted to have a
tachycardia to 220s, thought to be SVT. This spontaneously
converted to NSR. While on the ___ floor, she did experience two
episodes of Afib with RVR, which resolved with 20 mg of
diltiazem IV. Cardiology was consulted, and recommended
increasing her metoprolol and starting her on aspirin 81 mg for
anticoagulation (she isn't on full dose anticoagulation given
her impending bone marrow transplant). A TTE showed no
abnormalities and after increasing her metoprolol to 100 mg
daily she did not have any further arrhythmias. She was
discharged on metoprolol succinate 100 mg po daily and aspirin
81 mg daily.
#Syncope: The patient reportedly syncopized while experiencing a
fever up to 103 prior to admission. She was maintained on
telemetry with no further episodes. Differential includes sepsis
from febrile neutropenia versus SVT.
#DMII: On admission, the patient's metformin was held. She
experienced hyperglycemia requiring an increase in her Lantus
from 24 units to 30 units QHS. Her blood glucose improved but
still remained slightly elevated at discharge. She was
discharged on her home regimen of Lantus 24 units QHS, sliding
scale, and metformin 1000mg po BID.
#AML: Pt completed 7+3 during prior admission, now on HiDAC s/p
C1 (___). Last ___ on ___ suggested remission. She
was maintained on acyclovir and fluconazole prophylaxis, as well
as lamivudine given history of hepatitis B. She underwent a bone
marrow biopsy on the day of discharge, and the results were
pending at the time of writing this summary.
She was found to have a RLL infiltrate noted on CXR, and was
treated with vancomycin and cefepime initially for febrile
neutropenia secondary to pneumonia with a ANC of 0 on admission.
On the ___ floor, her cough improved and her fevers resolved,
and her antibiotics were weaned to levofloxacin.
While she was here, she underwent a bone marrow biopsy to
evaluate her marrow prior to her transplant.
She was discharged to follow up with her oncologist the
following day
TRANSITIONAL ISSUES
===================
-Follow up results of bone marrow biopsy
-The patient's aspirin 81 mg should be discontinued when her
platelet counts fall
-The patient was discharged with a script for levofloxacin, to
complete a 10-day total course of antibiotics (day 1 ___
-Consider repeating a CXR prior to transplant to assess for
resolution of her pneumonia
-The patient's metoprolol was increased to 100 mg daily for
atrial fibrillation
-Consider adjusting insulin as necessary for hyperglycemia
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Magnesium Oxide 400 mg PO BID
2. Fluconazole 400 mg PO Q24H
3. Metoprolol Succinate XL 50 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. LaMIVudine 100 mg PO DAILY
6. Acyclovir 400 mg PO Q8H
7. Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acyclovir 400 mg PO TID
2. Fluconazole 400 mg PO Q24H
3. LaMIVudine 100 mg PO DAILY
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Levofloxacin 750 mg PO DAILY
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*5 Tablet Refills:*0
6. Magnesium Oxide 400 mg PO BID
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
10. Benzonatate 200 mg PO TID cough
RX *benzonatate 200 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Febrile neutropenia
Acute bacterial pneumonia
Sepsis
Syncope
Atrial fibrillation with rapid ventricular rate
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital after you experienced a
syncopal event (passing out) at home and were found to have a
high fever. We performed a chest X-ray which showed a pneumonia,
for which we treated you with strong antibiotics. You are being
discharged on an antibiotic called Levaquin, and should take all
of this medication.
While you were here, you experienced rapid heart rates, and were
diagnosed with a condition called atrial fibrillation. This
required IV medications to control, however your heart rates
normalized and we increased your metoprolol to 100 mg daily.
Because atrial fibrillation increases your risk of stroke, we
put you on aspirin 81 mg daily, which helps thin the blood. It
is important that you discontinue this medication when your
platelet counts start to fall.
Before you were discharged, you underwent a bone marrow biopsy
and should follow up with Dr. ___ in her clinic tomorrow
(___).
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
19880967-DS-29
| 19,880,967 | 22,946,682 |
DS
| 29 |
2175-11-25 00:00:00
|
2175-11-26 15:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
bone marrow biopsy on ___
History of Present Illness:
Conditioning/chemotherapy Regimen: s/p 7+3 and 2 cycles of HiDAC
consolidation, alloSCT with Flu/Bu/ATG (Day 0: ___,
sorafenib
maintenance
Regimen day: now off sorafenib
Primary Disease: AML
Chief Complaint: fever
HPI:
___ yo F with AML s/p allo-SCT (day 0: ___ with URD, now with
recent relapse confirmed on bone marrow biopsy (___), a
fib,
T2DM, HTN, HBV who presented with fever.
She reports that yesterday she suddenly felt unwell, had chills,
took her temperature which peaked to ___ at home. She reported
a
mild dry cough that was fleeting yesterday and has since
resolved. No diarrhea, rhinorrhea, sore throat, dysuria. No sick
contacts.
She presented to ___ yesterday where she
reportedly received zosyn and fluids, from which she was then
referred to ___. In the ___ ED, she was afebrile, VSS. CBC
notable for WBC 4, 45% blasts, ANC 40. She received vanc/zosyn.
This morning, she feels much better, pretty close to her usual
baseline. No complaints. No more fevers, chills, or coughing.
Of note, since her recent discharge from ___ on ___ when
her PICC was placed, she has been following at ___ for
labs and has received 2 platelet transfusions. She did have per
patient 2 hives with the first infusion, so received steroids
prior to the second infusion.
Review of Systems:
10-point ROS was negative except as in HPI above.
Past Medical History:
___ with obesity, T2DM, HTN, current smoker, presented with 3
weeks of malaise and shortness of breath, to the ED and found to
have leukocytosis to 84.5K with 50% blasts, Hgb of 7.3 and plt
count of 115K. BM biopsy demonstrated 100% cellularity with
blasts accounting for 80-90% c.w acute myeloid leukemia on the
core biopsy. The rapid heme panel identified NPM1 mutation and
FLT-3 ITD positivity. Cytogenetics revealed normal female
karyotype.
Echo demonstrated mod pulmonary HTN, normal EF and mild MR.
___: Started on ___ plus 3 for AML treatment. Daunorubicin
administered at 60mg/m2.
Day 14 BM was ablated
Inpatient course c.b febrile neutropenia and cellulitis from
obesity, DM and poor venous return. Discharged on po augmentin
on
___ upon recovery of counts.
___: Day 28 BM biopsy performed after recovery of counts
demonstrated remission.
Cytogenetics was again normal
FLT3 ITD mutation was not detected suggestive of molecular
remission.
___: Admitted for HiDAC cycle 1.
___: Admitted for febrile neutropenia and sepsis from PNA.
Treated with Levaquin and improved.
___: BM biopsy performed after recovery of counts s.p cycle 1
of
consolidation demonstrated molecular remission as FLT3 ITD
mutation was not detected in the BM aspirate.
Overall plan was to move forward with MRD transplant in ___ CR.
Pretransplant Eligibility:
Echo : normal
PFT's: normal
Seen by transplant ID who suggested extended course of Levaquin
for continued cough and treatment of PNA.
___: It was found out that the brother the pt's sibling and
presumed donor needed extensive evaluation for clearance to be
the donor.
___: URD search was promising and several URD were activated.
___: Underwent removal of several teeth (almost 8) in
preparation for transplant.
Delay in availability of URD's hence after discussion of case at
___ meeting, plan made to proceed with another cycle of
consolidation while awaiting donor availability and collection.
___: Rcd cycle 2 of HIDAC in house. Tolerated well with no
complications. Pt had recent several teeth extractions and one
open healing wound in right upper molars. Evaluated by ___ who
felt that there was no e.o of infection.
Discharged on Cipro/Flagyl for prophylaxis.
___: Admitted for sepsis and febrile neutropenia. No focus
of infection was found. Discharged after treatment with broad
spectrum antibiotics and recovery of counts.
___: BM biopsy upon recovery of counts demonstrated no e.o
leukemia. FLT 3ITD was neg suggestive of molecular remission.
___ Admitted for myeloablative Flu/Bu/ATG with URD
Day 0: ___
GVHD prophylaxis: ATG plus Tacrolimus
Donor; CMV pos, A pos. ___ permissive mismatch at DP1 and both
patient and donor are CMV pos and A pos.
Hospital Course complicated by febrile neutropenia and
mucositis.
Discharged on ___.
___: Bactrim stopped due to drop in Plt count. Switched to
Atovaquone.
___: Found to have transaminitis and low grade fevers.
fluconazole stopped. Also found to have CMV titers of >1500.
Infectious work up neg.
___: Switched to Micafungin and started on Valganciclovir per
renal adjustment
___: Valgan increased to 900mg po bid with improvement in renal
function.
___: Micafungin stopped with stabilization of LFT's and
switched
to po Fluconazole
___: Found to have sudden increase in wt by >30 lbs with b/l ___
venous congestion. Started on diuresis with Lasix. Echo showed
normal LVEF and no e.o diastolic failure. Normal LFT's and
albumin.
___: 2 CMV PCR'S undetectable 1 week apart hence switched to
Valgan Maintenance per renal clearance.
___: Increase in creatinine likely medication effect (Lasix
plus Valgan plus Tac). Hence Lasix stopped as weight down by
10lbs. No cellulitis noted. Doses of medications renally
adjusted. CMV PCR undetectable.
___: CMV PCR undetectable. Doing well off Lasix.
___: Diagnosed with Klebsiella UTI.Started on 10 day course of
Cefpodoxime.
___: ___ stopped and switched back to acyclovir.
___: Day 90 staging performed with repeat BM biopsy.
Suggestive
of morphologic remission. FLT3 ITD neg on BM aspirate by PCR.
FISH for chimerism demonstrated >95% donor cells.
___: ___ removed.
___: Started Sorafenib at 200mg/day.
___: Started on HCTZ by PCP for ___ control from Sorafenib.
___: Asked to increase dose of Sorafenib but pt reluctant. Tac
taper started.
___: Sorafenib increased to 400 mg po daily. Tac taper
continued.
___: Has been on sorafenib 400 mg/day. Continued taper of tac.
No e.o GVHD or infections.
___: Tac further tapered. Doing well on Sorafenib maintenance
at 400 mg/day. Reluctant in increasing the dose.
___: Presented with cough. NP swab negative. IgG levels
adequate.
CXR neg for PNA and effusion. CT chest neg for PNA or pleural
effusion or any obstructive pattern.
PAST MEDICAL HISTORY (per OMR and patient):
T2DM
HTN
pAF
hepatitis B ___ transfusion)
s/p MVA age ___ with maxillary, mandibular, arm fractures
ectopic pregnancy
s/p 2 C-sections
s/p TAH
Social History:
___
Family History:
Mother alive, lives with them
Father died in his late ___, lung cancer. Psych history.
Not much contact with paternal relatives
Cousin with leukemia Dx age ___, died age ___.
No other known cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==============================
Vitals: 98.7PO102 / ___
Gen: Pleasant, calm, WD WN obese woman in NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear. poor
dentition. Molar on R lower mandible with darkening at
midsection, patient says is a crown, nontender.
NECK: supple
LYMPH: No cervical or supraclav LAD
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. trace ___ edema.
SKIN: petechiae on backs of palms, no other rashes noted.
NEURO: A&Ox3.
LINES: R PICC, dressing c/d/i, skin without erythema, nontender
DISCHARGE PHYSICAL EXAM:
===============================
Vitals: 98.4PO 140 / 82L Sitting 91 18 97 RA
Gen: Pleasant, calm, WD WN obese woman in NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear. poor
dentition. Molar on R lower mandible with darkening at
midsection, patient says is a crown, nontender.
NECK: supple
LYMPH: No cervical or supraclav LAD
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. trace to 1+ ___ edema, chronic venous stasis changes
SKIN: petechiae on backs of palms, no other rashes noted.
NEURO: A&Ox3.
LINES: R PICC, dressing c/d/i, skin without erythema, nontender
Pertinent Results:
ADMISSION LABS:
===========================
___ 01:25AM BLOOD WBC-4.0# RBC-2.47*# Hgb-8.5*# Hct-25.0*#
MCV-101* MCH-34.4* MCHC-34.0 RDW-14.7 RDWSD-53.8* Plt Ct-38*
___ 01:25AM BLOOD Neuts-1* Bands-0 ___ Monos-0 Eos-1
Baso-0 ___ Myelos-0 Blasts-45* AbsNeut-0.04*
AbsLymp-2.12 AbsMono-0.00* AbsEos-0.04 AbsBaso-0.00*
___ 01:25AM BLOOD Hypochr-NORMAL Anisocy-1+* Poiklo-NORMAL
Macrocy-2+* Microcy-NORMAL Polychr-NORMAL
___ 12:30PM BLOOD ___ PTT-28.5 ___
___ 01:25AM BLOOD Glucose-142* UreaN-23* Creat-0.9 Na-140
K-3.3 Cl-100 HCO3-26 AnGap-14
___ 01:25AM BLOOD ALT-23 AST-16 LD(LDH)-214 AlkPhos-57
TotBili-0.6
___ 12:30PM BLOOD Calcium-7.7* Phos-3.2 Mg-1.8 UricAcd-2.1*
___ 01:29AM BLOOD Lactate-1.3
RELEVANT LABS:
==============================
___ 12:30PM BLOOD WBC-2.9* Lymph-64* Abs ___ CD3%-63
Abs CD3-1170 CD4%-11 Abs CD4-200* CD8%-52 Abs CD8-967*
CD4/CD8-0.21*
___ 12:00AM BLOOD D-Dimer-2509*
___ 12:00AM BLOOD TSH-0.85
___ 12:00AM BLOOD T4-6.2 T3-90
___ 12:30PM BLOOD CMV VL-NOT DETECT
___ 12:30PM BLOOD HBV VL-NOT DETECT
___ 01:29AM BLOOD Lactate-1.3
DISCHARGE LABS:
================================
___ 12:00AM BLOOD WBC-1.3* RBC-2.20* Hgb-7.3* Hct-21.0*
MCV-96 MCH-33.2* MCHC-34.8 RDW-14.4 RDWSD-49.7* Plt Ct-12*
___ 12:00AM BLOOD Neuts-6.2* Lymphs-88.5* Monos-5.3
Eos-0.0* Baso-0.0 AbsNeut-0.08*# AbsLymp-1.16* AbsMono-0.07*
AbsEos-0.00* AbsBaso-0.00*
___ 09:27AM BLOOD Plt Ct-39*#
___ 12:00AM BLOOD Glucose-113* UreaN-16 Creat-0.8 Na-146
K-4.2 Cl-108 HCO3-26 AnGap-12
___ 12:00AM BLOOD ALT-23 AST-16 LD(LDH)-153 AlkPhos-77
TotBili-0.4
___ 12:00AM BLOOD Albumin-3.1* Calcium-8.1* Phos-3.7 Mg-1.9
UricAcd-1.9*
IMAGING:
====================================
CXR
___
IMPRESSION:
Comparison to ___. The patient carries a
right-sided PICC line.
The course of the line is unremarkable, the tip of the line
projects over the
cavoatrial junction. No pneumothorax or other complications.
Borderline size
of the heart. No pleural effusions. No pneumonia. Minimal
left basal
atelectasis.
CT ABD & PELVIS W/O CONTRAST
___
FINDINGS:
LOWER CHEST: Heart size is normal without significant
pericardial effusion.
Coronary artery calcifications are seen. There is
hypoattenuation of the
blood pool relative to the cardiac musculature suggestive of
anemia. There is
mild linear scarring or atelectasis in the left lung base. The
imaged lung
bases are otherwise grossly clear.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation
throughout.
There is no evidence of focal lesions within the limitations of
an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic
biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions within the limitations of an unenhanced scan.
There is no
pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size. There is
no evidence
of focal renal lesions within the limitations of an unenhanced
scan. There is
no hydroureteronephrosis or nephroureterolithiasis. There is no
perinephric
abnormality.
GASTROINTESTINAL: There is a tiny hiatal hernia. The stomach is
otherwise
grossly unremarkable. Small bowel loops demonstrate normal
caliber and wall
thickness throughout. Very few scattered colonic diverticula
are seen. The
colon and rectum are otherwise within normal limits. The
appendix is normal.
There is no obstruction. Ingested oral contrast reaches the
level of the
cecum.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and ovaries are not seen. There
is no gross
adnexal abnormality.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate
atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
There are mild lumbar degenerative changes. There is a
Schmorl's node at the
superior endplate of L4.
SOFT TISSUES: There is paraumbilical rectus diastasis along with
a tiny
paraumbilical fat containing hernia to the left of midline
(02:53).
IMPRESSION:
1. No acute findings or infectious source in the abdomen or
pelvis. No fluid
collection.
2. Tiny fat containing paraumbilical hernia to the left of
midline.
3. Tiny hiatal hernia.
4. Findings suggesting anemia.
PATHOLOGY
===============================
Bone marrow biopsy
___
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
INTERPRETATION
Immunophenotypic findings consistent with involvement by acute
myeloid leukemia. Correlation with clinical, morphologic (see
separate pathology report ___ and other ancillary
findings is recommended. Flow cytometry immunophenotyping may
not detect all abnormal populations due to topography, sampling
or artifacts of sample preparation.
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY
DIAGNOSIS:
HYPERCELLULAR MYELOID PREDOMINANT BONE MARROW WITH LEFT-SHIFTED
MATURATION AND EXTENSIVE INFILTRATION WITH ACUTE MYELOID
LEUKEMIA.
MICROSCOPIC DESCRIPTION
Peripheral blood smear:
The smears are adequate for evaluation. Erythrocyte are markedly
decreased in number;
normochromic, macrocytic and have slight anisopoikilocytosis.
Frequent echinocytes are seen. The
white blood cell count is moderately decreased. The platelet
count is markedly decreased. Large
and giant platelets are not seen. A100 cell differential shows
0% neutrophils, 1% bands, 63%
lymphocytes, 0% monocytes, 0% eosinophils, 0% basophils, 0%
metamyelocytes, 0% myelocytes,
0% promyelocytes, and 36% blasts.
Bone marrow aspirate:
The aspirate material is inadequate due to a lack of spicules
and hemodilution.
Clot section and biopsy slides:
The core biopsy material consists of a 0.8 cm long tangential
core biopsy composed of periosteum
and trabecular marrow with a cellularity of 90%. The M:E ratio
estimate is increased. There is an
interstitial infiltrate of immature mononuclear cells consistent
with blasts occupying 50% of the
overall cellularity. In the remaining cellularity, the M:E ratio
estimate is increased. Erythroid
precursors are decreased in number. Myeloid precursors are
increased in number with left-shifted
maturation. Megakaryocytes are decreased in number and include
occasional small hypolobated
forms.
CYTOGENETICS REPORT - Final
CYTOGENETIC DIAGNOSIS: 46,XX[15]
//46,XY[1]
INTERPRETATION/COMMENT: Fifteen of the 16 metaphase bone marrow
cells available for
examination had the apparently normal female karyotype of the
patient and one cell had the
apparently normal male karyotype of the bone marrow donor.
FISH: XX 49%, XY 51%. 102 of 200 (51%) interphase bone marrow
cells examined had the male
probe signal pattern of the bone marrow donor. 98 of 200 (49%)
had the female probe signal pattern
of the recipient.
MICROBIOLOGY:
============================
___ blood culture x2: neg
___ urine culture: neg
Blood culture from ___ (from ___ sent to ___ lab:
___ 3:14 pm Isolate Source: blood isolate.
ISOLATE FOR MIC (Preliminary):
SENT TO ___ FOR ID AND SUSCEPTIBILITY ON ___.
___ ___
___: ___
BLOOD CULTURE 1 Final
ANAEROBIC BOTTLE POSITIVE FOR OLIGELLA URETHRALIS
UNABLE TO PERFORM SENSITIVITY TESTING ON THIS ORGANISM
AEROBIC BOTTLE NO GROWTH FIVE DAYS
Blood culture 2 no growth
Brief Hospital Course:
___ year old woman with AML s/p allo-SCT (day 0: ___, now
with recent relapse confirmed on bone marrow biopsy (___),
a fib, T2DM, HTN, HBV who presented with neutropenic fever.
ACTIVE PROBLEMS:
# Neutropenic fever
# Blood culture positive for oligella urethralis
She reported being febrile to 102 at home prior to presentation,
with chills. She also reported that she had foul smelling and
cloudy urine prior at that time. She presented initially to ___
___, where she was started on zosyn (first dose ___ ___.
One blood culture bottle drawn on ___ at ___ grew
oligella urethralis; ID was consulted and the specimen was sent
to the ___ lab for further analysis and sensitivities.
Infectious workup including blood cultures at ___ have been
negative. She was continued on zosyn, and she was stable,
afebrile, and asymptomatic during her admission. CT A/P without
contrast (patient refused contrast) was negative. Preliminary
planned 2-week course of zosyn (projected last day on ___.
# AML
AML s/p allo-SCT (day 0: ___ with URD, now with confirmed
relapsed disease. Bone marrow biopsy prior to presentation on
___ showed AML, 10% donor and 90% recipient. Rapid heme panel
showed FLT3-ITD positive disease. This admission, she was
enrolled in a phase III clinical trial for a FLT3 inhibitor:
___: A Phase 3 Open-label, Multicenter, Randomized Study of
ASP2215 versus Salvage Chemotherapy in Patients with Relapsed or
Refractory Acute Myeloid Leukemia (AML) with FLT3 Mutation". She
was started on the study drug on ___. She did receive another
bone marrow biopsy on ___ per study protocol. Her hydroxyurea
was held early this admission given her falling counts. She was
continued on allopurinol, acyclovir, and atovaquone (CD4 count
was 200). Her fluconazole was discontinued, per study protocol.
CHRONIC PROBLEMS:
# Hep B: continued home lamivudine. Hep B viral load
undetectable this admission.
# T2DM: continued home glargine 20 qhs, ISS
# Afib: continued home metoprolol
# HTN: held home nifedipine; she was normotensive off this.
# ___: noncardiogenic, continued home furosemide 10 PO prn
# Anxiety: continued home at___ prn
TRANSITIONAL ISSUES:
- will have follow up tomorrow, locally for lab check and
possible transfusion as well as on ___ for lab check,
possible transfusion, possible readmission
- f/u sensitivities of oligella urethralis from ___ lab, to
guide antibiotic therapy
- preliminary planned 2-week course of zosyn (full ___,
projected last day ___
- PLEASE NOTE her fluconazole ppx has been stopped (due to study
restrictions)
- she received 1U pRBC and 1U PLT on day of discharge
- new meds: study drug ASP2215, zosyn
- changed meds: none
- stopped meds: fluconazole, nifedipine, hydroxyurea
# CODE: Presumed Full
# EMERGENCY CONTACT: ___
Relationship: Spouse
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Acyclovir 400 mg PO Q12H
3. Atovaquone Suspension 1500 mg PO DAILY
4. Fluconazole 400 mg PO Q24H
5. Furosemide 10 mg PO DAILY:PRN ___ edema
6. Hydroxyurea 500 mg PO BID
7. LaMIVudine 100 mg PO DAILY
8. Glargine 20 Units Bedtime
9. LORazepam 0.5-1 mg PO Q6H:PRN anxiety, nausea, vomiting
10. Magnesium Oxide 400 mg PO BID
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. NIFEdipine (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. ASP2215 Study Med 120 mg Oral DAILY
2. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam 4.5 gram 4.5 g IV every 8 hours Disp
#*12 Vial Refills:*0
3. Acyclovir 400 mg PO Q12H
4. Allopurinol ___ mg PO DAILY
5. Atovaquone Suspension 1500 mg PO DAILY
6. Furosemide 10 mg PO DAILY:PRN ___ edema
7. Glargine 20 Units Bedtime
8. LaMIVudine 100 mg PO DAILY
9. LORazepam 0.5-1 mg PO Q6H:PRN anxiety, nausea, vomiting
10. Magnesium Oxide 400 mg PO BID
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. HELD- NIFEdipine (Extended Release) 30 mg PO DAILY This
medication was held. Do not restart NIFEdipine (Extended
Release) until you discuss with your outpatient doctor.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
neutropenic fever
AML
oligella urethralis bacteremia
SECONDARY DIAGNOSIS:
type 2 diabetes
hepatitis B
hypertension
atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at ___
___.
WHY WERE YOU ADMITTED?
- You had fevers.
WHAT HAPPENED IN THE HOSPITAL?
- You received IV antibiotics.
- One of your blood cultures from ___ grew a bacteria
called "oligella urethralis".
- The blood culture specimen was sent to ___ so our lab could
further analyze it.
- You were enrolled in a clinical trial for your relapsed AML.
WHAT SHOULD YOU DO ON DISCHARGE?
- Please take your medications as prescribed.
- You will need to stay on the IV antibiotic until our lab has
more information about the bacteria.
- Please follow up with your heme/onc appointment on ___
___. At that point, we will check your labs, see if you need
transfusions, and see if you need to be readmitted.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
19881062-DS-12
| 19,881,062 | 20,167,909 |
DS
| 12 |
2143-11-10 00:00:00
|
2143-11-10 22:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
motor vehicle collision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ transfer from ___ s/p head-on MVC car vs.
tree; intoxicated; unrestrained driver -initially a/o GCS
15-intubated due to agitation at OSH (O2 sat 100% prior) and for
transport. Trauma activation in ___. Admitted to ___ for
extubation and further management.
Past Medical History:
PMH: ?urethral stricture
PSH: ?posterior spinal fusion
MEDS: none
Social History:
___
Family History:
N/C
Physical Exam:
On D/C from TSICU:
VS: AVSS
GEN: WD, WN M in NAD
HEENT: severe R periorbital ecchymosis, R periorbital
lacerations w suture repair x 2, EOMI, PERRLA
CV: RRR
PULM: CTA
ABD: S/NT/ND
EXT: WWP
Pertinent Results:
LABS:
___ 02:52AM BLOOD WBC-10.2 RBC-3.78* Hgb-11.8* Hct-34.0*
MCV-90 MCH-31.2 MCHC-34.7 RDW-13.2 Plt ___
___ 04:00AM BLOOD ___ PTT-30.0 ___
___ 02:52AM BLOOD Glucose-107* UreaN-16 Creat-0.9 Na-138
K-3.6 Cl-104 HCO3-24 AnGap-14
___ 04:00AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
CT Torso ___ - No acute process in the chest, abdomen, or
pelvis.
CT Face ___ - Right orbital floor blowout fracture without
evidence of extraocular muscle entrapment. Fracture throughout
the bony nasal septum. Likely b/l nasal bone fractures.
Extensive paranasal sinus disease.
CT Head ___ - No significant interval change in size of small
left frontotemporal subdural hematoma.
MICRO: n/a
PATH: n/a
Brief Hospital Course:
___ xfer from OSH s/p MVC car vs tree. Intubated for agitation
___ EtOH intoxication for obtaining radiology/transport.
Transferred to ___ ED for further management. Trauma
activation on arrival to ___ ED. Imaging obtained as above.
Admitted TSICU for extubation and further management.
INJURIES:
2cm R. eyebrow laceration
R. ___ ecchymoses
<1cm laceration inferior to R. orbit
R. orbit fx (likely nonoperative)
Temporal laceration
R. 5mm extra-axial hematoma per OSH CT
likely nasal tip fracture
small frontotemporal SDH
COURSE:
Neurologic: Injuries as above. Followed commands while
intubated. Imaging results as above. Neurosurgical
consultation obtained. Recommended dilantin x 10d and f/u in 8
weeks w I(-) head CT. This was arranged.
Patient mildly confused on initial interactions following
extubation. This improved and patient deemed safe for d/c to
home.
Initially sedated for intubation. Oral analgesics well
tolerated s/p extubation. No narcotic requirement.
HEENT/OPHTHO: Patient w blow-out" R fx of orbital floor w no
evidence of
extraocular muscle entrapment. Consultations obtained by
plastics and ophtho. Plastics rec sinus precautions and HOB >
30 degrees which were enacted. Will f/u in plastics clinic. No
entrapment on ophtho eval. Did demonstrate dyschromatopsia
which likely represents baseline. Will f/u as OP for further
eval.
CV: Had no active issues. Monitored per ICU protocol.
PULM: Presented intubated. Met criteria for extubation and was
extubated without incident. Recommended pulmonary toilet/IS.
Monitored per ICU protocol.
GI: NPO w IVF initially ___ intubation. OGT removed w
extubation. Advanced from clears to regular diet well
tolerated. Bowel regimen started and will continue as
outpatient. Normal bowel function on this admission.
___: Foley placed at OSH. Removed w extubation and voided
appropriately.
Hematology: Hct checked per ICU protocol and no irregularities
noted.
Endocrine: Blood sugar maintained w ISS per ICU protocol.
ID: No issues. Temperature closely monitored.
PPx: SCDs were applied at time of admission and HSQ initiated
___.
DISPO: Pt and family met w SW on multiple occasions to discuss
coping w accident/recovery. Met criteria for d/c to home and
was discharged ___.
___ patient was mentating well, A&Ox3, tolerating diet, pain
well controlled, and ambulatory. Discharged to home.
Medications on Admission:
None
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO four times
a day as needed for pain.
3. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 9 days.
Disp:*27 Capsule(s)* Refills:*0*
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain: Take with food. .
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Right orbital fracture
2. Right 5mm extra-axial hematoma
3. Facial lacerations
4. Small frontotemporal subdural hematoma
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
management of injuries sustained in a motor vehicle collision.
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 10
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.
WOUND CARE:
Please apply bacitracin to facial lacerations three times daily.
Sutures will be removed in ___ clinic per follow up
instructions.
SINUS PRECAUTIONS:
During your accident you sustained facial fractures that
communicated with your sinuses. As a result you should maintain
sinus precautions for your safety. These should be maintained
until your follow up appointment with plastic surgery at which
time they can advise you whether to continue these. These
include:
- no drinking through a straw
- no nose blowing
- sleep with head elevated at least 30 degrees (i.e. sleep on
___ pillows or in a recliner)
Followup Instructions:
___
|
19881159-DS-9
| 19,881,159 | 20,912,393 |
DS
| 9 |
2153-11-12 00:00:00
|
2153-11-14 15:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
oxybutynin
Attending: ___.
Chief Complaint:
Back pain, vertebral compression fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with h/o HLD, GERD, osteoporosis, and Afib on
Eliquis, R thigh pseudotumor who presents with R thigh pain.
Patient was in her USOH until ___ when she woke up with R thigh
pain and back pain radiating down her lower back into her R
thigh. She has had chronic R thigh pain (see below) but the
lower back pain is new. She denies falls but does recall a
twisting injury that may have incited back pain. She denies ___
weakness, bowel/bladder incontinence (reports constipation in
setting of opioid use for pain), denies groin numbness. Patient
initially presented to ___ for this on ___ but was
transferred to ___ given pt preference and surgeries
previously done here (she underwent XR and CT at OSH -
imaging reports below).
Patient has a long history with regard to her R thigh
pseudotumor. In brief, she has a long history of R hip
procedures dating back to ___ starting with R hip replacement.
Since then, she has required subsequent revisions and ultimately
developed a pseudotumor felt to be ___ metallic debris. She was
admitted ___ for after she had imaging suggesting
extensive osteolysis surrounding and causing failure of right
total hip arthroplasty and very extensive and large hematoma
cavity of the R thigh in setting of anticoagulation for Afib.
She underwent revision of hip replacement and placement of a
fascia iliaca catheter for hematoma drainage/evacuation. Her
hospital course at that time was concerning for hypotension due
to hemorrhagic shock for which she was admitted to the MICU. She
was ultimately stabilized and discharged to rehab on ___. She
remained essentially wheelchair bound at rehab but progressed
such that she was discharged from rehab to home with ___
services approx. 2 weeks ago. She was doing fairly ok per pt at
home although continued to have R thigh pain limiting daily
activities.
In the ___, initial vitals were: T 98 HR 94 BP 145/81 18 RR 18
94% RA
Exam notable for ___ edema
Labs notable for +UA, BNP 3000, CRP 18, INR 1.3
Imaging notable for:
--MRI sacrum/ SI joints - 8 discrete heterogeneously enhancing
presacral mass 3.6x2.6 cm, grossly unchanged; this may represent
extramedullary hematopoiesis.
--MR ___ spine with loss of normal bone marrow signal at L3, L4.
Complete loss of vertebral body height at L3, unlikely to be
infectious. 5 mm retropulson of the vertebral body at L3 mildly
contacts the thecal sac w/o significant deformity. Partially
visualized presacral mass may represent extramedullary
hematopoeissis. >50% vertebral body height loss at L2. Mod to
severe canal narrowing at L2-3 and L3-4 due to disc bulge, and
ligamentum flavum infolding
--CT R ___: thick rimmed fluid collection containing air-fluid
levels, with h/o chronic hematoma s/op debridgement. cannot
exclude superimposed infxn. Fluid collection deep to the skin
staples measuring up to 2.9 cm, diffuse SubC stranding and skin
thickening, may represent postop changes and seroma, though
underlying infxn cannot be excluded
Consults:
--Ortho: per comments to ___, imaging most c/w seroma
--___: recommended rehab; pt unable to bear weight on LLE,
unable to tolerate standing
--Spine: pt seen and examined and images reviewed including MRI
L spine. Felt that there was no urgent or emergent NSGY
intervention required and that pt should wear LSO brace at all
times when OOB
Patient was given: oxycodone 5 mg, ceftriaxone 1g IV,
acetaminophen 650 po
Decision was made to admit for bed placement while awaiting
rehab
Vitals prior to transfer: T 97.9 HR 92 BP 127/69 RR 18 97% RA
On the floor, pt reports pain is improved. Back pain is only
exacerbated with movement.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
Hypercholesterolemia
Osteoporosis
GERD
Overactive bladder
Atrial fibrillation on anticoagulation
Social History:
___
Family History:
Father - ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
Vital Signs: T 98 BP 122/62 HR 90 RR 18 97% RA
General: Very pleasant older female, alert, oriented, mildly
uncomfortable
HEENT: Sclera anicteric, MMM
CV: RRR, no m/r/g
Lungs: coarse rales in bases bilaterally, no wheeze or rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
abd scars noted
GU: No foley
Ext: R > L edema with 2+ on R, trace on L. R hip and upper
lateral thigh with TTP
Neuro: CNII-XII intact, RLE with ___ ___ and distal strength
limited by pain, LLE w ___ strength. TTP over lumbar and sacral
spine
DISCHARGE PHYSICAL EXAM:
===========================
VITALS: 98.4 128/53 88 18 98% RA
General: AAOx3
HEENT: NC/AT, Sclera anicteric, MMM , v waves noted
CV: RRR, ___ systolic ejection murmur without radiation to R
axilla, no delay nor diminuation in carotid upstroke
Lungs: scattered rhonchi LLL clear with coughing, bilateral
late inspiratory crackles, no wheezes
Abdomen: Soft, non-tender, non-distended, bowel sounds
present, abd scars noted
GU: No foley
Ext: R hip staple line c/d/I without prurlence nor discharge;
staples in place; Mild trace R>L LUE edema
Neuro: CNII-XII intact, RLE ___, LLE ___. TTP over left
ishcial tuberosity, mild TTP over lumbar and sacral spine
Pertinent Results:
ADMISSION LABS
===============
___ 08:47PM WBC-9.9# RBC-3.72*# HGB-10.7*# HCT-36.3#
MCV-98 MCH-28.8 MCHC-29.5* RDW-16.9* RDWSD-60.7*
___ 08:47PM GLUCOSE-82 UREA N-13 CREAT-0.7 SODIUM-136
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-24 ANION GAP-17
___ 08:47PM ___ PTT-32.9 ___
___ 08:47PM CALCIUM-8.5 PHOSPHATE-3.4 MAGNESIUM-1.8
___ 08:47PM proBNP-3252*
___ 08:57PM LACTATE-1.5
___ 06:20AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 06:20AM URINE BLOOD-TR NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 06:20AM URINE RBC-4* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-1
MICROBIOLOGY
===============
URINE CULTURE (___): >100,000 CFU/mL. Proteus and
escherichia coli both susceptible to bactrim, cephalosporins,
nitrofurantoin
PLEURAL FLUID (___): Gram stain 2+ PMNs, no
microorganisms, fluid culture: no growth, anaerobic
(preliminary): no growth
BLOOD CULTURE (___): Negative
BLOOD CULTURE (___): Negative
BLOOD CULTURE (___): Negative
PERTINENT INTERVAL LABORATORY RESULTS
===========================
PLEURAL SERUM
LDH (nl 94-250): 147 379 39% (of 59% UL)
Total protein: 2.5 5.3 47%
IMAGING
===============
CHEST X-RAY (___): Comparison to ___.
Decrease in extent of the known left pleural effusion. Decrease
in extent of the associated atelectasis. No pneumothorax.
Stable appearance of the cardiac silhouette.
CHEST X-RAY (___): Moderate to large left pleural
effusion with overlying atelectasis, not
significantly changed from prior. Age indeterminate thoracic
vertebral body compression deformities.
MRI LUMBAR SPINE W AND W/O CONTRAST (___): 1. Spinal
labeling has been provided on series 5, image 11 based on the
last costal process of the prior CT. Note is made of
sacralization of the L5 vertebral body.
2. Moderate anterior wedge compression deformity of L1, is of
indeterminate chronicity.
3. Severe compression fracture with vertebral plana centrally of
L2 and moderate retropulsed bowing of the posterior cortex in
the central canal,results in moderate canal narrowing. This is
also of indeterminate chronicity, and an underlying neoplastic
or inflammatory process cannot be excluded but appears less
likely. No definite enhancement is seen.
4. Increased STIR hyperintensity of L3, with mild enhancement
and loss of height of the middle column, suggest a subacute
compression deformity.
5. Presacral mass, incompletely visualized on this exam, better
evaluated on the dedicated MRI of the sacrum.
MRI SACRUM SI JOINTS (___): 1. Small effusion at the
right sacroiliac joint, but no bone erosion. Mild bone edema
about the right sacroiliac joint appears similar or slightly
improved compared to prior.
2. Small nonspecific foci of STIR hyperintensity in the left
sacral ala and left iliac bone are likely stable from previous
exam.
3. No acute fracture.
4. Presacral soft tissue mass is nonspecific but could represent
extramedullary hematopoiesis. Alternative neoplastic etiology
is not completely excluded. The lesion however was likely
present on previous exam from ___ without gross change
although direct comparison is limited by difference in scan
technique.
5. Sigmoid colon diverticulosis.
6. Bladder diverticulosis.
7. Lumbar spine compression deformities better evaluated on MRI
sacrum performed same day.
DISCHARGE LABS
===============
___ 10:35AM BLOOD WBC-8.7 RBC-4.19 Hgb-12.2 Hct-41.2 MCV-98
MCH-29.1 MCHC-29.6* RDW-16.8* RDWSD-60.3* Plt ___
___ 10:35AM BLOOD Glucose-105* UreaN-12 Creat-0.7 Na-141
K-4.1 Cl-101 HCO3-27 AnGap-17
___ 09:38AM BLOOD LD(LDH)-147
___ 10:35AM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.7 Mg-1.9
___ 07:40AM BLOOD 25VitD-51
___ 08:03AM PLEURAL WBC-461* RBC-3600* Polys-16* Lymphs-60*
Monos-3* Eos-18* Meso-3*
___ 08:03AM PLEURAL TotProt-2.5 Glucose-103 LD(LDH)-138
Albumin-1.9 Cholest-49 Triglyc-21
Brief Hospital Course:
This is an ___ year old female with past medical history atrial
fibrillation on eliquis, complex surgical history involving a
remote R hip replacement requiring multiple revisions
complicated by R thigh pseudotumor, recent admission
___ for R hip replacement and drainage of R thigh
hematoma, admitted with new L1-L3 fractures, incidentally found
to have a transudative pleural effusion now status post
thoracentesis, able to be discharged home with services.
# L1-3 compression fractures - Patient presented with lower back
pain, and on MRI L-spine was found to have moderate anterior
wedge compression deformity of L1 (of indeterminate chronicity),
severe compression fracture of L2 (also of
indeterminate chronicity), and possible subacute L3 compression
fracture. She was seen by neurosurgery who recommended LSO
brace, which should be worn at all times. She was given vitamin
D and Calcium. Would consider bisphosphonate as an outpatient.
There were no signs to suggest a pathological etiology of this
fracture, but would recommend bringing routine health preventive
screenings up to date.
# Pleural effusion - Admission chest xray showed left moderate
pleural effusion that remained present on follow-up imaging.
Thoracentesis yielded 800cc serous fluid consistent with
transudative etiology by Light's criteria. Unclear etiology of
this effusion--she had a mildly elevated BNP, but no signs of
decompensated heart failure on remainder of exam or on history.
Given splinting in setting of back pain, thought this could
potentially be secondary to atelectasis. Would consider repeat
chest xray in ___ weeks to look for recurrence--if does recur
could consider cardiac workup (e.g. TTE).
# Acute bacterial UTI: Patient presented with several days of
urinary frequency, found to have a UA concerning for UTI.
Urine culture grew e. coli and proteus sensitive to Bactrim.
She initially received IV ceftriaxone and then was transitioned
to PO Bactrim. She will be discharged on Bactrim DS BID for 1
day to finish seven day course of antibiotics.
# R thigh pseudotumor and hematoma: after multiple R hip
replacement revisions, most recently ___. Per ortho,
current imaging most suggestive of seroma. Given asymptomatic,
orthopedics recommeded against any intervention. Patient
reports leg pain is at baseline. Her anticoagulation was
continued.
CHRONIC ISSUES:
=====================================
#HLD: previously was on simvastatin but this was held last
hospital course due to interaction with diltiazem. Did not
restart this hospitalization given questionable benefit in an ___
year old female for primary CAD prevention
# GERD: Continued Omeprazole
#BLADDER SPASMS: Continued trospium 20mg BID; allergic to
oxybutynin
# GALLSTONES s/p CCY: Continue Ursodiol 300mg TID
#ATRIAL FIBRILLATION on Eliquis: CHADS2Vasc 5. Patient was not
in atrial fibrillation during this hospital course although
prior hospital courses have been c/b by afib w RVR requiring
esmolol gtt. Home metoprolol and diltiazem were continued.
Home apixiban was held day of thoracentesis and restarted after.
TRANSITIONAL ISSUES:
- Would recheck chest xray in ___ weeks. If symptoms of heart
failure or recurrence of pleural effusion, consider workup for
cardiac etiology (e.g. TTE)
- Consider initiation of bisphosphonate as an outpatient given
recent compression fractures
- Consider ensuring health preventative screening up to date
- Has follow-up with orthopedics and neurosurgery scheduled
# CODE: DNR/DNI
# CONTACT: ___ (son/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Apixaban 2.5 mg PO BID
3. Ascorbic Acid ___ mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Ursodiol 300 mg PO TID
7. Vitamin D 400 UNIT PO DAILY
8. Diltiazem Extended-Release 120 mg PO DAILY
9. trospium 20 mg oral BID
10. Metoprolol Succinate XL 200 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. Tolterodine 2 mg PO BID
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*2 Tablet Refills:*0
2. Tolterodine 2 mg PO BID
3. Acetaminophen 1000 mg PO Q8H
4. Apixaban 2.5 mg PO BID
5. Ascorbic Acid ___ mg PO DAILY
6. Diltiazem Extended-Release 120 mg PO DAILY
7. Metoprolol Succinate XL 200 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY
11. trospium 20 mg oral BID
12. Ursodiol 300 mg PO TID
13. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Vertebral compression fracture
Pleural effusion
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 back and leg pain. We
found that you have fracture along your spine. The neurosurgeons
saw you and did not recommend surgery. However, they recommended
a brace. You should wear this brace at all times whenever you're
out of bed.
We also found some fluid around your lung. We took a sample of
the fluid and it did not look like you had an infection. If you
have any problems breathing or have a worsening cough, please
call your primary doctor. You may need another Xray to make sure
the fluid has not come back.
It was a pleasure taking care of you, and we are happy that you
are feeling better!
Followup Instructions:
___
|
19881376-DS-27
| 19,881,376 | 23,142,070 |
DS
| 27 |
2171-06-09 00:00:00
|
2171-06-09 17:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Fentanyl / adhesive bandage / surgical tape / cefepime
Attending: ___
Chief Complaint:
confusion & word-finding difficulty
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o male with PMH significant for ESRD on dialysis three
days/week presents to the ED with complaints of confusion and
word-finding difficulties over the past several days. He states
that he has not experienced any recent falls but does state he
fell several weeks ago and struck his head but did not seek
medical attention after this occurred.
He denies any headaches, diplopia, dizziness, blurred vision,
confusion, or word-finding difficulty. He denies any
paresthesias
or weakness of his extremities.
Past Medical History:
- ESRD on HD, MWF, since ___, has right brachiocephalic
fistula
created ___.
- GI bleed in ___, massive GI bleed ___, now off coumadin and
ASA
- CAD s/p CABG x3 in ___ and cath with 1 graft down (SVG to CX)
- Atrial fibrillation, not on coumadin ___ GI bleed
- Anemia - normocytic, normochromic attributed to chronic
disease and mild renal insufficiency; patient gets iron
infusions
- Chronic hematuria -- likely from renal cysts
- CHF: EF 40 - 45 % on ___, ECHO with moderate to severe (3+)
MR
- DM2: Followed at ___
- Hypertension
- Hyperlipidemia
- PVD with venous stasis ulceration
- Chronic back pain from disc disease/spinal stenosis/nerve root
compression on oxycontin and gabapentin
- s/p hip replacements ___
- s/p CCY
- Colonic polyps with adenoma on path on c-scope ___ with neg
EGD in ___
- Gout
- GERD
- BPH
Social History:
___
Family History:
unknown -- family died in ___
Physical Exam:
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5-2mm bilaterally. EOMs intact throughout.
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, 2.5 to 2mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift.
Sensation: Intact to light touch bilaterally.
Handedness: Right
Pertinent Results:
___ 08:35PM PLT SMR-LOW PLT COUNT-104*#
___ 08:35PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 08:35PM NEUTS-74* BANDS-0 LYMPHS-13* MONOS-10 EOS-1
BASOS-0 ATYPS-2* ___ MYELOS-0
___ 08:35PM WBC-7.5# RBC-3.57* HGB-12.7* HCT-39.2*
MCV-110* MCH-35.6* MCHC-32.4 RDW-15.6*
___ 08:35PM estGFR-Using this
___ 08:35PM GLUCOSE-97 UREA N-13 CREAT-2.6* SODIUM-138
POTASSIUM-5.1 CHLORIDE-99 TOTAL CO2-27 ANION GAP-17
___ 10:10PM ___ PTT-40.8* ___
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
8:15 ___
IMPRESSION: 8-mm left-sided acute on chronic subdural hematoma
with local
mass effect and 3 mm rightward shift.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
2:47 ___
IMPRESSION: Stable mixed density subdural hemorrhage along the
left
Preliminary Reportconvexity.
___ CT Cervical Spine
Brief Hospital Course:
This is a ___ year old male with PMH significant for ESRD on
dialysis three
days/week presented to the emergency department on ___
with complaints of confusion and word-finding difficulties over
the past several days. He stated
that he has not experienced any recent falls but does state that
he
fell several weeks ago and struck his head but did not seek
medical attention after this occurred. Upon arrival to the
emergency department that patient had a head CT performed which
was consistent with -mm left-sided acute on chronic subdural
hematoma with local mass effect and 3 mm rightward shift. The
patient was admitted to the neuro ICU for further evaluation and
assessment. The patient was neurologically intact and started
on a regular diet. The patient was mobilized out of bed to the
chair and a repeat NCHCT was performed which was consistent with
stable NCHCT. The patient was deemed appropriate for floor
status and was awaiting transfer to the floor.
On ___, he was transferred to the floor. He was seen in the
morning by the nephrology fellow. His K was elevated to 5.4 and
his SBP range remained in the ___. No intervention was
recommended by Nephrology. He went to dialysis. The patient
tolerated dialysis without any complications.
On ___, the patient remained stabled on the floor without
any complaints. A CT of his C-spine was within normal limits
though it did reveal a lung nodule that has increased in size
since ___. He was then discharged to home with teaching and was
instructed to complete a 7 day course of Phenytoin. He will
follow up in our clinic in 4 weeks with a repeat head CT. He wil
also follow up with his primary care physician and will need a
repeat chest CT in 6 months to track his pulmonary nodule.
Medications on Admission:
NephroCaps 1mg daily PRN; Folic Acid 1mg PO daily; Gabapentin
100mg PO BID; Oxycodone 5mg PO BID prn; Oxyconein 10mg PO QID;
Januvia 50mg PO daily; ___ 500mg PO daily; Metoprolol 12.5mg
daily (6.25 on HD days); Simvastatin 20mg daily Allopurinol
___ daily; Atenolol 25mg daily (hold on M, W, F for dialysis),
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Nephrocaps 1 CAP PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 100 mg PO BID
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
7. OxyCODONE SR (OxyconTIN) 10 mg PO Q8H
8. Simvastatin 20 mg PO DAILY
9. Phenytoin Sodium Extended 100 mg PO BID Duration: 5 Days
RX *phenytoin sodium extended 100 mg 1 capsule(s) by mouth Three
times daily (every 8 hours) Disp #*15 Capsule Refills:*0
10. Senna 1 TAB PO BID:PRN constipation
11. Docusate Sodium 100 mg PO BID:PRN constipation
You may stop this medication if you are having regular bowel
movements
12. Januvia *NF* (sitaGLIPtin) 50 mg Oral Daily
13. Metoprolol Succinate XL 12.5 mg PO DAILY
6.25mg on HD days
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ for an
acute on chronic subdural hematoma. You have recovered from this
injury and are now ready for discharge home from the hospital.
For your heart health, make sure to weigh yourself every morning
and call your PCP if weight goes up more than 3 lbs. It may
mean that your heart is not pumping efficiently and can lead to
heart failure.
Nonsurgical Brain Hemorrhage
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
safely resume taking this on XXXXXXXXXXX.
**You have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
**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, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
19881376-DS-28
| 19,881,376 | 20,585,454 |
DS
| 28 |
2171-09-25 00:00:00
|
2171-09-28 12:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Fentanyl / adhesive bandage / surgical tape / cefepime
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Occipital nerve block.
History of Present Illness:
This is an ___ year old man with history of ESRD on HD, CAD s/p
CABG, atrial fibrillation (not anticoagulated due to prior GIB
and chronic SDH), diabetes, PVD, and BPH, chronic subdural
hematoma (resolved) who presented on ___ with two days of
severe headache and neck pain.
The patient complained of paroxsymal, superficial, sharp pain in
the back of his head and left side of his head. It worsened when
touching the skin, or with pressure on his posterior neck or
shoulders. He denied recent falls or trauma to the head or
neck. He denied change in his baseline strength in the arms and
legs, paraesthesias, extremity pain, incontinence of bladder or
bowel, or difficulty speaking. He denied visual changes and
nausea.
Of note, the patient had a recent hospitalization with
neurosurgical ICU stay at ___ ___ for acute worsening of a
chronic subdural hematoma. He initially presented to the ED w
intermittent left frontotemporal headaches and speech
difficulty. During this admission, he denied similar symptoms.
Past Medical History:
- ESRD on HD, MWF, since ___, has right brachiocephalic
fistula
created ___.
- GI bleed in ___, massive GI bleed ___, now off coumadin and
ASA
- CAD s/p CABG x3 in ___ and cath with 1 graft down (SVG to CX)
- Atrial fibrillation, not on coumadin ___ GI bleed
- Anemia - normocytic, normochromic attributed to chronic
disease and mild renal insufficiency; patient gets iron
infusions
- Chronic hematuria -- likely from renal cysts
- CHF: EF 40 - 45 % on ___, ECHO with moderate to severe (3+)
MR
- DM2: Followed at ___
- Hypertension
- Hyperlipidemia
- PVD with venous stasis ulceration
- Chronic back pain from disc disease/spinal stenosis/nerve root
compression on oxycontin and gabapentin
- s/p hip replacements ___
- s/p CCY
- Colonic polyps with adenoma on path on c-scope ___ with neg
EGD in ___
- Gout
- GERD
- BPH
Social History:
___
Family History:
unknown -- family died in ___
Physical Exam:
Vitals- 98.0 97.9 89 88/51 18 100% RA
General- NAD, laying in bed
HEENT- NCAT, ___ clear, dentures. palpation refused by patient
Neck- JVP not elevated, refused by patient.
Lungs- CTAB, though exam limited by patient's supine position
and inability to move on HD
CV- Irregularly irregular, no murmurs appreciated
Abdomen- Soft, non-tender, non-distended
GU- no foley
Ext- Warm, 2+ DP, no edema, brawny skin changes and dry skin in
lower extremities bilaterally.
Neuro- AOX2, thought he was not in hospital, unaware that he did
not have a roommate
Pertinent Results:
___ 07:25AM BLOOD WBC-7.0 RBC-3.23* Hgb-11.8* Hct-35.7*
MCV-110* MCH-36.6* MCHC-33.1 RDW-15.3 Plt Ct-91*
___ 09:30PM BLOOD WBC-6.1 RBC-3.26* Hgb-11.8* Hct-35.2*
MCV-108* MCH-36.1* MCHC-33.4 RDW-15.2 Plt Ct-94*
___ 07:25AM BLOOD Glucose-131* UreaN-32* Creat-4.1*#
Na-129* K-8.2* Cl-91* HCO3-23 AnGap-23*
___ 08:15AM BLOOD Glucose-97 UreaN-55* Creat-4.4* Na-133
K-4.8 Cl-89* HCO___ AnGap-23*
___ 08:15AM BLOOD Calcium-8.8 Phos-5.1* Mg-2.___
IMPRESSION: No acute intracranial abnormality. Complete
interval resolution of left lateral convexity subdural hematoma.
C-spine non trauma XR ___
IMPRESSION: Mild anterolisthesis of C4 on C5 and C5 on C6 with
no instability with flexion or extension.
CT chest w/ contrast ___:
IMPRESSION:
1. The right upper lobe ground-glass nodule is stable over a
period of ___ years. However, a third followup in one year is
recommended to rule out minimally invasive adenocarcinoma. All
the other nodules are not concerning for malignancy. A new
ground-glass nodule was not visible on prior examination due to
different technique. Minimal atelectases are in the right
middle lobe and right lower lobe. A small scarring is at the
left lung base.
2. There is no central lymphadenopathy.
3. Heart size is moderately-to-severe enlarged with moderate
aortic valve, coronary artery and aortic calcification.
4. Mild ascites and multiple left kidney cysts are
redemonstrated.
CT spine w/ contrast ___:
IMPRESSION: No acute cervical spine fracture or traumatic
malalignment. MRI is more sensitive for ligamentous injury.
Ct heat ___:
FINDINGS:
There is no evidence of intracranial hemorrhage, vascular
territorial infarction, shift of the normally midline
structures, or mass, mass effect or edema. The ventricles and
sulci are prominent, in keeping with age-related involutional
changes or atrophy. The basal cisterns appear patent. The
gray-white matter differentiation is preserved. No fractures
identified. The cranial and facial soft tissues are
unremarkable. The globes are intact bilaterally. The paranasal
sinuses, mastoid air cells and middle ear cavities are clear.
IMPRESSION: No acute intracranial process.
Brief Hospital Course:
___ with history of ESRD on HD, CAD s/p CABG, atrial
fibrillation (not anticoagulated due to prior GIB and chronic
SDH), diabetes, PVD, and BPH, chronic subdural hematoma presents
with severe headache x 2 days.
ACTIVE ISSUE
# OCCIPITAL NEURALGIA / HEADACHE: Initial head CT ruled out
acute intracranial process and confirmed resolved SDH. Spine CT
ruled out an acute process as well as fracture or infection.
Throughout the hospitalization his neuro exam was grossly
normal. He had partial response with Possible occipital
neuralgia given some response to occipital block and location of
pain. However, the patient is complaining of severe pain on the
floor. This may be a tension headache from musculoskeletal
rigidity. CT C-spine negative for fracture. Pain treated with
Oxycontin 20mg q12, Oxycodone 5mg q4PRN. Gabapentin,
acetaminophen, lidocaine patches. Started on flexeril which
improved neck discomfort, but caused overnight delirium.
Subsequently started on baclofen with good effect before
discharge. Pt recieved a trigger point injection day before
discharge.
INACTIVE ISSUES
#ESRD: Secondary to longstanding DMII, on HD. Continued on ___
dialysis.
#DM2: Followed at ___. Held sitagliptin in house. QID ___ and
SS while in house. restarrted on discharge.
# Afib: Patient normally lives in ___ fibrillation. Notes
palpitations at baseline. Denies SOB or chest pain. Off
coumadin due to past GIB and SDH. Cont home metoprolol.
# Chronic low back pain: ___ nerve root compression,
degenerative disc disease, and spinal stenosis. Pain did not
flare this admission.
#Anemia: Likely ___ to CKD. Hct 35.7 on admission, baseline
35-39. Continued procrit HD as before.
# Hx Gout: stable. cont allopurinol
TRANSITIONAL ISSUES
# Workup of macrocytic anemia, low platelets: B12/Fol, Liver
disease
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Nephrocaps 1 CAP PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 100 mg PO BID
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
6. OxyCODONE SR (OxyconTIN) 10 mg PO Q8H
7. Simvastatin 20 mg PO DAILY
8. Phenytoin Sodium Extended 100 mg PO BID
9. Senna 1 TAB PO BID:PRN constipation
10. Docusate Sodium 100 mg PO BID:PRN constipation
11. Januvia (sitaGLIPtin) 50 mg Oral Daily
12. Metoprolol Succinate XL 12.5 mg PO DAILY
13. Ascorbic Acid ___ mg PO DAILY
14. Glucosamine (glucosamine sulfate) 500 mg Oral daily
15. Lidocaine-Prilocaine 1 Appl TP BEFORE DIALYSIS
16. sevelamer CARBONATE 800 mg PO 2 TABLETS WITH EACH MEAL AND 1
TABLET WITH EACH SNACK
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Gabapentin 100 mg PO BID
4. Lidocaine-Prilocaine 1 Appl TP BEFORE DIALYSIS
5. Nephrocaps 1 CAP PO DAILY
6. Phenytoin Sodium Extended 100 mg PO BID
7. sevelamer CARBONATE 800 mg PO 2 TABLETS WITH EACH MEAL AND 1
TABLET WITH EACH SNACK
8. Simvastatin 20 mg PO DAILY
9. Acetaminophen 1000 mg PO Q8H pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth Every 8 hours Disp
#*42 Tablet Refills:*0
10. Lidocaine 5% Patch 1 PTCH TD DAILY
RX *lidocaine 5 % (700 mg/patch) Apply 1 patch to affected area
Once a day Disp #*7 Transdermal Patch Refills:*0
11. Glucosamine (glucosamine sulfate) 500 mg Oral daily
12. Januvia (sitaGLIPtin) 50 mg Oral Daily
13. Metoprolol Succinate XL 12.5 mg PO DAILY
14. Metoprolol Succinate XL 6.25 mg PO DAILY on HD days
TO REPLACE 12.5MG DOSE ON HD DAYS, DO NOT GIVE IN ADDITION.
15. Baclofen 10 mg PO HS:PRN pain
RX *baclofen 10 mg 1 tablet(s) by mouth HS Disp #*30 Tablet
Refills:*2
16. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
17. FoLIC Acid 1 mg PO DAILY
18. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
19. OxyCODONE SR (OxyconTIN) 10 mg PO Q8H
20. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
# Occipital neuralgia vs. muscle spasm
Secondary Diagnoses:
# Right upper lobe ground glass nodule - stable over ___ years,
___ year follow-up recommended
# Mild hyponatremia, asymptomatic
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted with severe headache and neck pain.
Head and neck CT scans ruled out an acute process as well as
infection, cancer, or bony abnormalities. Your pain was likely
due to both severe muscle spasm and a condition called occipital
neuralgia. A nerve block, oral medications and increases in your
other pain meds were used to relax the muscles of your neck.
This seemed to improve your pain.
You can call the pain clinic at ___ for outpatient follow up
of chronic pain issues. The number is ___.
Followup Instructions:
___
|
19881376-DS-30
| 19,881,376 | 26,006,446 |
DS
| 30 |
2172-07-24 00:00:00
|
2172-07-31 18:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Fentanyl / adhesive bandage / surgical tape / cefepime /
baclofen
Attending: ___.
Chief Complaint:
s/p fall
acute on chronic left lower extremity pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with ESRD on HD, CAD s/p CABG, atrial
fibrillation (not anticoagulated due to prior GIB and chronic
SDH), diabetes, PVD, lumbar spinal stenosis and BPH presents
after fall with back pain. Patient was in his apartment. He
normally walks with a walker. He was standing up and started to
fall backwards and he landed on his back and his hip. Did not
hit his head. No LOC. Complaining of right wrist pain and left
index finger pain. At baseline he has severe back pain and L leg
pain.
In the ED, initial VS: 98.4 97 99/48 18 100% room air. No labs
were drawn. CT chest/lumbar back negative for fractures. L index
finger fracture splinted. Hip/femur prosthesis stable but
incidentally found to have mid-shaft femoral lucency. Attempted
___ in the ED, but limited due to L thigh pain and unsafe to d/c
home. Given 500cc NS for BP in 80's, but patient asymptomatic
and appears that baseline BPs are 80-100's. Given Tramadol,
Oxycodone ___ x4, APAP 500mg, and gabapentin for pain
control. Being admitted for pain control and workup of femoral
lucency. Due for HD today.
Upon arrival to the floor, the patient was in NAD but c/o L leg
pain.
Past Medical History:
- ESRD on HD, MWF, since ___, has right brachiocephalic
fistula
created ___.
- GI bleed in ___, massive GI bleed ___, now off coumadin and
ASA
- CAD s/p CABG x3 in ___ and cath with 1 graft down (SVG to CX)
- Atrial fibrillation, not on coumadin ___ GI bleed
- Anemia - normocytic, normochromic attributed to chronic
disease and mild renal insufficiency; patient gets iron
infusions
- Chronic hematuria -- likely from renal cysts
- CHF: EF 40 - 45 % on ___, ECHO with moderate to severe (3+)
MR
- DM2: Followed at ___
- Hypertension
- Hyperlipidemia
- PVD with venous stasis ulceration
- Chronic back pain from disc disease/spinal stenosis/nerve root
compression on oxycontin and gabapentin
- s/p hip replacements ___
- s/p CCY
- Colonic polyps with adenoma on path on c-scope ___ with neg
EGD in ___
- Gout
- GERD
- BPH
Social History:
___
Family History:
Unknown -- family died in ___
Physical Exam:
Admission Physical Exam:
Vitals- T 98 BP 137/76 HR 69 RR 18 O2 98RA
GENERAL: Lying in bed in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pale conjunctiva,
MMM, NECK: nontender supple neck, no LAD
CARDIAC: RRR, nl S1/S2, no murmurs, gallops, rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, non-tender, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: decreased sensation b/l in the lower extremities
upto mid-shin, tenderness to palpation over the lumbar spinous
process, pain on L leg movt
PULSES: unable to feel pulses bilaterally
NEURO: CN II-XII intact
SKIN: Venous stasis changes b/l in L extremities
Discharge Physical Exam:
Vitals- T 98.6 Tc:97.7 BP 99/62 99 20 98%RA
GENERAL: Lying in bed, NAD
HEENT: NCAT, EOMI, red lesion on R upper eyelid (stye-like
appearance) that patient reports preceeded admission, MMM
NECK: supple, non-tender, no LAD
CARDIAC: irregularly irregular S1/S2 No M/R/G
LUNG: CTAB
ABDOMEN: +BS soft NT/ND
EXTREMITIES: decreased sensation b/l in the lower extremities
upto mid-shin, tenderness to palpation over the lumbar spinous
process, limited ROM R hip flexion. ___ strength throughout.
NEURO: AAOx3, no focal neuro deficits noted
SKIN: Venous stasis changes b/l in L extremities
Pertinent Results:
ADMISSION LABS:
___ 07:20PM BLOOD WBC-8.7 RBC-3.41* Hgb-12.0* Hct-38.7*
MCV-114* MCH-35.2* MCHC-31.0 RDW-14.9 Plt Ct-87*
___ 07:20PM BLOOD Glucose-94 UreaN-34* Creat-4.9*# Na-130*
K-7.0* Cl-93* HCO3-27 AnGap-17
___ 07:20PM BLOOD Calcium-9.1 Phos-4.7* Mg-2.1
INTERIM RESULTS:
CBC:
___ 06:05AM BLOOD WBC-5.9 RBC-3.23* Hgb-11.3* Hct-36.4*
MCV-113* MCH-35.0* MCHC-31.1 RDW-14.3 Plt ___
___ 06:30AM BLOOD WBC-6.2 RBC-3.23* Hgb-11.1* Hct-36.8*
MCV-114* MCH-34.4* MCHC-30.3* RDW-14.5 Plt ___
.
CHEMISTRY:
___ 06:42AM BLOOD Glucose-111* UreaN-37* Creat-5.5* Na-133
K-5.3* Cl-93* HCO3-28 AnGap-17
___ 06:05AM BLOOD Glucose-98 UreaN-13 Creat-2.6* Na-137
K-3.7 Cl-97 HCO3-29 AnGap-15
___ 06:30AM BLOOD Glucose-99 UreaN-16 Creat-3.2*# Na-136
K-4.0 Cl-97 HCO3-32 AnGap-11
___ 06:42AM BLOOD Calcium-9.1 Phos-5.4* Mg-2.1
___ 07:02AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.8
___ 06:30AM BLOOD Calcium-9.0 Phos-3.7# Mg-1.9
.
Other:
SPEP Negative
Imaging:
CT Thigh:
WET READ: ___ SUN ___ 5:59 ___
Status post bilateral total hip arthroplasties. Within the mid
to distal left femur there is a combination of osteopenia and
endosteal sclerosis which are likely secondary to altered stress
mechanics secondary to the patient's prosthesis. No mass is
seen.
___
PELVIS (AP ONLY); FEMUR (AP & LAT) LEFT
IMPRESSION:
1. No fracture hardware failure.
2. Incidental enlarging lesion mid shaft of left femur.
Correlation with
history of malignancy is recommended.
___ MRI THIGH LEFT
Preliminary Report
Limited exam. No gross mass is seen within the region of
abnormality visualized on previous radiographs.
Brief Hospital Course:
___ year old man with ESRD on HD, CAD s/p CABG, atrial
fibrillation (not anticoagulated due to prior GI bleeding and
chronic SDH), diabetes, PVD, lumbar spinal stenosis and BPH
presented after fall with acute on chronic L leg pain and back
pain, and admitted for pain management.
ACTIVE ISSUES:
# Acute on chronic pain: Patient presented with acute on chronic
L leg pain and back pain after his fall. Pt did not hit his head
and was A&OX3. Lumbar CT-spine did not show acute findings. No
thoracic vertebral body fractures on CT. L femur/hip xray didnot
show any fractures or contusion. Pt sustained a left index
finger fracture which was splinted. Pt's overall pain was
managed with increased dose and frequency of home oxycodone. Pt
was evaluated by physical therapy who recommended rehabilitation
at a facility and pt was subsequently discharged to rehab.
# L femur lucency: An irregular mixed lucent and sclerotic
lesion was noted in the shaft of the left femur on femur x-ray,
increased in size compared to a ___ study. Follow up MRI was
severly limited by pt's inability to complete exam due to pain.
However, no gross mass was seen. Follow up CT showed a
combination of osteopenia and endosteal sclerosis which were
thought to be due to altered stress mechanics secondary to the
patient's prosthesis. No mass was seen. There was initially a
concern for a malignant lytic lesion.
CHRONIC ISSUES:
# ESRD: On HD, MWF, has right brachiocephalic fistula, had HD in
hospital. Continued on Nephrocaps 1 CAP PO DAILY and sevelamer
CARBONATE 1600 mg PO 3x/DAY w/meals.
# CAD: s/p CABG x3 in ___ and cath with 1 graft down (SVG to
CX), continued on home metoprolol and simvastatin.
# Atrial fibrillation: not on coumadin ___ GI bleed, rate well
controlled while in hospital.
# Hx of Anemia: normocytic, normochromic attributed to chronic
disease and mild renal insufficiency
# CHF: LVEF 55 % on ___, ECHO, euvolemic during
hospitalization.
# DM2: Followed at ___, continued home januvia and ISS, BG
well controlled during hospitalization.
# Hypertension: continued home metoprolol
# Gout: Continued home allopurinol
=======================================
Transitional Issues
=======================================
- Continued titration of narcotic regimen to allow for full
participation in ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE SR (OxyconTIN) 10 mg PO Q6H:PRN pain
2. OxycoDONE (Immediate Release) 5 mg PO Q12H:PRN pain
3. Allopurinol ___ mg PO BID
4. Metoprolol Succinate XL 12.5 mg PO QMOWEFR
5. Metoprolol Succinate XL 12.5 mg PO BID ON NON DIALYSIS DAYS
6. Gabapentin 100 mg PO BID
7. Januvia (sitaGLIPtin) 50 mg oral as needed if BG>120
8. Simvastatin 20 mg PO DAILY
9. Nephrocaps 1 CAP PO DAILY
10. Glucosamine (glucosamine sulfate) 500 mg oral DAILY
11. sevelamer CARBONATE 1600 mg PO TID W/MEALS
12. FoLIC Acid 1 mg PO DAILY
13. Ascorbic Acid ___ mg PO DAILY
14. Cyanocobalamin ___ mcg PO DAILY
15. Midodrine 5 mg PO 3X/WEEK ON DIAYLSIS DAYS
Discharge Medications:
1. Allopurinol ___ mg PO BID
2. Ascorbic Acid ___ mg PO DAILY
3. Cyanocobalamin ___ mcg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO QMOWEFR
5. Metoprolol Succinate XL 12.5 mg PO BID ON NON DIALYSIS DAYS
6. Midodrine 5 mg PO 3X/WEEK ON DIAYLSIS DAYS
7. Nephrocaps 1 CAP PO DAILY
8. OxyCODONE SR (OxyconTIN) 10 mg PO Q6H:PRN pain
RX *oxycodone [OxyContin] 15 mg 1 tablet(s) by mouth every six
(6) hours Disp #*20 Tablet Refills:*0
9. sevelamer CARBONATE 1600 mg PO TID W/MEALS
10. Simvastatin 20 mg PO DAILY
11. Acetaminophen 1000 mg PO Q8H
12. Docusate Sodium 100 mg PO BID
13. Senna 8.6 mg PO BID:PRN constipation
14. Vitamin D 1000 UNIT PO DAILY
15. FoLIC Acid 1 mg PO DAILY
16. Glucosamine (glucosamine sulfate) 500 mg oral DAILY
17. Januvia (sitaGLIPtin) 50 mg oral as needed if BG>120
18. Gabapentin 200 mg PO DAILY
19. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Mechanical fall
Acute on chronic left lower extremity pain
Osteopenia
Spinal stenosis
End stage renal 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 Mr. ___,
You were admitted to ___
for the management of acute on chronic left lower leg pain after
your recent fall. You had a CT scan to evaluate a concerning
lesion on your xray. This showed some changes in the bone
related to your prosthesis, but you did not have any fracture,
dislocation or problems with your prosthetic. It does appear
that the area of bone below the prosthesis is weakened and thin,
which may be the cause of your pain. While in the hospital, we
increased the frequency of your pain medications to manage your
acute on chronic pain. You were seen by the physical therapy
team and they recommended that you should go to a rehabilitation
center after hospitalization to regain your strength and improve
your functioning. Please take medications as prescribed and
attend follow up appointments as indicated below.
Sincerely,
___ medical team
Followup Instructions:
___
|
19881376-DS-31
| 19,881,376 | 28,229,589 |
DS
| 31 |
2173-07-04 00:00:00
|
2173-07-04 15:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Fentanyl / adhesive bandage / surgical tape / cefepime /
baclofen
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ M PMHx CAD s/p CABG, CHF, AF not on anticoagulation ___
previous GIB, hx stable SDH), ESRD on HD MWF (anuric), back
pain, b/l hip replacements c/b aseptic loosening presented to ED
after mechanical fall from standing.
Patient reports that he has chronic pain which has been
difficult to control (leg and back pain) for which they have
been making changes to his medication regimen. He reports that
he was recently transitioned from oxycontin to methadone 2.5mg
TID and this was changed today to 5mg TID. He says he took this
dose around 3pm. THis evening, was making dinner (heating up
soup) and felt "funny" or "woozy". He turned to reach for
something and fell. He ___ LOC, CP, dyspnea or palpitations.
Due to the fall and severe pain in the left leg following the
fall, he was brought to the ED. He denies confusion, dizziness
or lightheadedness prior to or after the fall.
At baseline, patient reports he occasionally ambulates with a
walker; he uses a wheelchair outside of his house. Patient
reports a history of bilateral total hip replacements ___ &
___ complicated by aseptic loosening causing pain with
ambulation.
In the ED, initial vitals were: HR 116, BP 106/67, RR 18, 98%
RA, pain ___.
- Labs were significant for INR = 1.2, stable Hgb/Hct
(11.5/36.3), trop 0.08, lactate of 1.7
- Imaging revealed:
- CT head w/o contrast: 1. No acute intracranial process (wet
read)
- CT c-spine w/o contrast: 1. No evidence of fracture or
traumatic malalignment. (wet read)
-Xrays LLE: minimally displaced proximal tib fib fxs
-Xrays hip: evidence of varus malalignment of left femoral
prosthesis, proximal femoral osteolysis
- The patient was given a total of 2mg IV dilaudid with minimal
effect.
- Mr. ___ was evaluated in the ED by ortho, who, in
light of the tib/fib fractures, recommended preparing the
patient for OR tomorrow. He was admitted to the medicine service
due to his complicated medical history and management of his
multiple comorbidities.
Vitals prior to transfer were: 10 97.9 108 105/68 14 93% RA
Upon arrival to the floor, vitals 98.2 110/68 107 21 93%RA.
Patient reports significant pain in the left leg, worse with any
movement, and baseline low back pain.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria.
Past Medical History:
- ESRD on HD, MWF, since ___, has right brachiocephalic
fistula
created ___.
- GI bleed in ___, massive GI bleed ___, now off coumadin and
ASA
- CAD s/p CABG x3 in ___ and cath with 1 graft down (SVG to CX)
- Atrial fibrillation, not on coumadin ___ GI bleed
- Anemia - normocytic, normochromic attributed to chronic
disease and mild renal insufficiency; patient gets iron
infusions
- Chronic hematuria -- likely from renal cysts
- CHF: EF 40 - 45 % on ___, ECHO with moderate to severe (3+)
MR
- DM2: Followed at ___
- Hypertension
- Hyperlipidemia
- PVD with venous stasis ulceration
- Chronic back pain from disc disease/spinal stenosis/nerve root
compression on oxycontin and gabapentin
- s/p hip replacements ___
- s/p CCY
- Colonic polyps with adenoma on path on c-scope ___ with neg
EGD in ___
- Gout
- GERD
- BPH
Social History:
___
Family History:
Unknown -- family died in ___
Physical Exam:
ADMISSION
Vitals: 98.2 110/68 107 21 93%RA
General: Alert, oriented, intermittent significant pain in left
leg
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: Supple, JVP not elevated
CV: Irregularly irregular, 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,
GU: No foley
Ext: Cool bilaterally, left leg wrapped in brace from ortho in
ED, toes cool but not cold, ttp, right leg with chronic venous
stasis changes below knee, dimished pulse, no significant edema
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro: Oriented x2-3
DISCHARGE
Vitals- 98.6 98.1 ___ 89-113 20 95-100% on RA
Wt: 73.8 (from 77.4 on ___
General- Alert, oriented
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP at 10-12cm , no LAD
Lungs- Poor exam given limited mobility, crackles at L lung
base, clear to auscultation otherwise.
CV- Irregularly irregular rhythm, normal S1 + S2, holosystolic
murmur best heard at cardiac apex.
Abdomen- soft, non-tender, non-distended, active bowel sounds
GU- No foley
Ext- Toes cool to touch bilaterally, RLE cool to touch, LLE warm
to touch. Sensation grossly intact to light touch in distal ___,
with decreased sensation on L than R. Skin thickening and
pigmentation of RLE c/w chronic venous stasis changes. LLE
splinted and wrapped. No edema. Eschar on R ___ toe, unstageable
ulcer (which may be old) and skin tear with slight bleeding on L
dorsum when ACE unwrapped.
Pertinent Results:
Relevant Imaging this Admission:
-CT head w/o contrast: 1. No acute intracranial process (wet
read)
-CT c-spine w/o contrast: 1. No evidence of fracture or
traumatic malalignment. (wet read)
-Xrays LLE: minimally displaced proximal tib fib fxs
-Xrays hip: evidence of varus malalignment of left femoral
prosthesis, proximal femoral osteolysis
Labs on Admission:
--------------------
___ 10:55PM WBC-8.0 RBC-3.37* HGB-11.5* HCT-36.3*
MCV-108* MCH-34.1* MCHC-31.7* RDW-14.9 RDWSD-58.8*
___ 10:55PM PLT SMR-LOW PLT COUNT-90*
___ 10:55PM NEUTS-67.0 LYMPHS-18.7* MONOS-11.3 EOS-1.9
BASOS-0.5 IM ___ AbsNeut-5.34 AbsLymp-1.49 AbsMono-0.90*
AbsEos-0.15 AbsBaso-0.04
___ 10:55PM GLUCOSE-112* UREA N-26* CREAT-3.8* SODIUM-135
POTASSIUM-4.9 CHLORIDE-92* TOTAL CO2-33* ANION GAP-15
___ 10:59PM LACTATE-1.7
___ 10:55PM CK(CPK)-40*
___ 10:55PM cTropnT-0.08*
___ 10:55PM CK-MB-2
Labs on Discharge:
--------------------
___ 08:29AM BLOOD WBC-7.2 RBC-3.07* Hgb-10.3* Hct-33.6*
MCV-109* MCH-33.6* MCHC-30.7* RDW-15.8* RDWSD-62.0* Plt ___
___ 08:29AM BLOOD Plt ___
___ 08:29AM BLOOD Glucose-105* UreaN-20 Creat-2.7*# Na-138
K-4.1 Cl-98 HCO3-29 AnGap-15
___ 08:29AM BLOOD Calcium-9.2 Phos-2.7 Mg-2.2
Brief Hospital Course:
This is an ___ year old male with past medical history of CAD s/p
CABG, chronic systolic CHF, diabetes type 2 controlled with
complications including diabetic kidney, CKD V / ESRD on HD,
atrial fibrillation not on anticoagulation, chronic back, hip
and bilateral leg pain on methadone admitted ___nd proximal left tibia and fibula fractures,
course notable for continuation of his baseline hypotension,
stable without signs of sepsis, complicated by acute bacterial
pneumonia, on IV antibiotics with notable improvement, PICC in
place and discharged to rehab to complete course, with plan for
PICC removal as soon as he completes antibiotics course (to
preserve additional possible future dialysis access sites).
# Fall / Acute Leg Pain / L comminuted fractures of proximal L
tibia and fibula - patient admitted with mechanical fall from
standing, without loss of consciousness; given history and
clinical setting this was felt to represent deconditioning and
instability due chronic aseptic loosening of hip implants; no
signs of cardiac or neurologic causes on workup including
telemetry and head CT. Plain film of the left lower extremity
showed minimally displaced proximal tib fib fractures. Plain
films of the left hip showed evidence of varus malalignment of
left femoral prosthesis, proximal femoral osteolysis department.
Concern was raised regarding potential effect that medications
may have played (he is on methadone and Percocet at home), in
setting of acute pain episode from fracture, pain medications
were unable to be down-titrated, but should be considered for
downtitration in the future, given his fall risk. Regarding L
Tib/fib fracture, orthopedics determined that given the
patient's multiple comorbidities and the minimal displacement of
these fractures, this would be best managed cnservatively
without surgical intervention. A locked brace was placed by
orthopedic surgery, with ___ rehab and planned outpatient
___ clinic follow-up after discharge. Regarding acute on
chronic leg pain, given difficult to control symptoms, pain
service was consulted---he was continued on his home methadone
5mg TID, standing acetaminophen, and was initially on a dilaudid
PCA before being downtitrated to oral dilaudid ___ PO q3h PRN
pain. Continued home home gabapentin (dosed for HD). As above,
believe that once acute pain episode is over, he may benefit
from additional weaning of narcotics regimen.
# Sepsis / Acute Bacterial Pneumonia - course was complicated by
tachycardia, leukocytosis, hypoxia, increased cough and sputum
production on ___. Initial CXR showed no pneumonia, but CT angio
chest showed possible developing pneumonia (no pulmonary
embolism); given occurrence > 48 hours after admission, concern
was for resistant gram negatives and positives--he was started
on vancomycin/meropenem on ___ after failed improvement on a
floroquinolone. Leukocytosis and hypoxia resolved. Given high
concern for failure of an oral regimen, he was discharged with a
PICC in placed to complete antibiotic course; PICC to be removed
as soon as antibiotics complete, so as to preserve potential
future HD access.
# Acute Metabolic Encephalopathy - course was notable for
episodes of encephalopathy, including confusion, myoclonic jerks
and asterixis; that occured on mornings prior to dialysis and
resolved with dialysis; they did not recur further; they were
felt to related to
# Hypotension - patient with chronic hypotension to SBP ___,
documented in his outpatient records; blood pressure ranged
between SBP high ___ - low ___ during this admission while at
dry weight and without signs of volume depletion on exam;
patient asymptomatic, continued on home midodrine;
# Diabetic Nephropathy / ESRD on HD - Continued HD ___,
___, and ___. Continued home midrodrine, nephrocaps
and sevalamer.
# Diabetes type 2, controlled with complications - continued
home januvia and metformin
# GERD: The patient was continued on pantoprazole. Sucrafate
was discontinued per patients report that he no longer uses it.
# Afib: Not on anticoagulation due to history of GI bleed;
# HLD: Contniued home simvastatin.
# Gout: Continued home allopurinol.
***TRANSITIONAL ISSUES***
- Unclear if patient's opiates (recent increase in methadone to
5mg TID prior to admission) contributed to his initial fall;
given acute pain issues related to fracture, his pain regimen
was augmented; once healing, would consider down-titration of
pain medications
- Abx start date is ___ (vancomycin/cefepime). End date:
___. Please remove PICC promptly after last abx dose on
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Cyanocobalamin ___ mcg PO DAILY
3. Metoprolol Succinate XL 12.5 mg PO QMOWEFR
4. Metoprolol Succinate XL 12.5 mg PO BID ON NON DIALYSIS DAYS
5. Midodrine 5 mg PO 3X/WEEK ON DIAYLSIS DAYS
6. Nephrocaps 1 CAP PO DAILY
7. sevelamer CARBONATE 1600 mg PO TID W/MEALS
8. Simvastatin 20 mg PO DAILY
9. Acetaminophen 1000 mg PO Q8H
10. Docusate Sodium 200 mg PO QHS
11. Vitamin D 1000 UNIT PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Glucosamine (glucosamine sulfate) 500 mg oral BID
14. Januvia (sitaGLIPtin) 50 mg oral as needed if BG>120
15. Gabapentin 100 mg PO Q6H
16. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
17. Methadone 2.5 mg PO TID
18. Allopurinol ___ mg PO BID
19. Lidocaine-Prilocaine 1 Appl TP 1 APPLICATION BEFORE DIALYSIS
20. OxyCODONE SR (OxyconTIN) 15 mg PO Q6H
21. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Cyanocobalamin ___ mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Glucosamine (glucosamine sulfate) 500 mg oral BID
4. Januvia (sitaGLIPtin) 50 mg oral as needed if BG>120
5. Lidocaine-Prilocaine 1 Appl TP 1 APPLICATION BEFORE DIALYSIS
6. Pantoprazole 40 mg PO Q12H
7. Docusate Sodium 200 mg PO QHS
8. Gabapentin 100 mg PO Q6H
9. Metoprolol Succinate XL 12.5 mg PO QMOWEFR
10. Metoprolol Succinate XL 12.5 mg PO BID ON NON DIALYSIS DAYS
11. Midodrine 5 mg PO 3X/WEEK ON DIAYLSIS DAYS
12. Nephrocaps 1 CAP PO DAILY
13. sevelamer CARBONATE 1600 mg PO TID W/MEALS
14. Simvastatin 20 mg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. Acetaminophen 1000 mg PO Q8H
17. Allopurinol ___ mg PO BID
18. Ascorbic Acid ___ mg PO DAILY
19. Methadone 5 mg PO TID
RX *methadone 5 mg 5 mg by mouth three times a day Disp #*90
Tablet Refills:*0
20. Meropenem 500 mg IV Q24H
21. Vancomycin 1000 mg IV HD PROTOCOL
22. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every three hours
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
fracture of the left proximal tibia and fibula
pneumonia
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ___
for left tibia and fibula fracture after sustaining a fall at
home. You were evaluated by the orthopedic surgeons in the
Emergency Department; they determined that your injury would be
best managed conservatively without surgery. They applied a
locked brace to your left leg to stabilize the fractures. While
you were in the hospital, you described significant pain in your
left foot, therefore X-rays of your foot and ankle were obtained
which did not show any additional fractures. We treated your
pain.
While you were in the hospital, you developed pneumonia, an
infection of your lungs. You were started on antibiotics. These
antibiotics must be given intravenously (through an IV),
therefore a special IV called a PICC was placed, and you will
receive the rest of your antibiotics through this PICC at your
rehabilitation facility.
Please take all of your medications as prescribed. Please attend
all of your doctors' appointments and call if you will be unable
to attend. It is important that you weigh yourself every
morning, and call your doctor if your weight goes up more than 3
lbs. It has been a pleasure taking part in your care and we wish
you the best in your recovery.
Sincerely,
The ___ Team
Followup Instructions:
___
|
19881395-DS-20
| 19,881,395 | 26,515,341 |
DS
| 20 |
2184-11-22 00:00:00
|
2184-11-28 08:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
trauma s/p fall
Major Surgical or Invasive Procedure:
___: Open reduction, internal fixation of left
proximal femur fracture.
History of Present Illness:
___ staying in assisted living accommodation, normally
mobilizing with walker. Found on bathroom floor without walker,
questionable syncopal event.Unknown duration of being left on
floor, unknown LOC or
headstrike. She was completely unable to weight bear and her
left
hip was kept in flexion. At OSH, it was noted that she had a C2
vertebral body fracture which was undisplaced. She also had
multiple fractures in her right ribs, a left neck of femur
fracture as well as superior and inferior pubic rami fractures.
There was no acute head injury demonstrable on head CT. Repeat
CT
chest, ___ done on arrival at ___ confirmed the above
findings.
Past Medical History:
Dementia
Anemia
Falls
OA
Spondylothesis
HTN
___
Chronic steroid use for myeloma
CHF
Social History:
___
Family History:
non-contributory
Physical Exam:
On admission:
Patient very agitated, not following commands
HEENT: No visible head injury. Patient not complaining of
visual/auditory symptoms
___: Loud pansystolic murmur radiating all over prechordium.
Chest: Lungs clear, no crackle/wheeze, tenderness on palpation
over right lower ribs
___: Abdomen soft, non-tender, normal bowel sounds
MSK: Very tender to palpate across L hip join. Limited mobility/
range of movment in left leg. Palpable pedal pulses in both
lower
extremities. Feet warm to touch. Good capillary refill
bilaterally.
On discharge:
PHYSICAL EXAM:
Vitals: T:98 BP: 131/74 P:61 R:18 O2: 96%RA
General: elderly female, A+Ox1, self. She is aware she is in a
hospital, but thinks its in ___. obeys partial commands, and
cooperative upon exam. More oriented today.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: ___ Collar in place.
Lungs:B/L diffuse crackles noted
CV: pansystolic murmor ___. sharp S1, S2. RRR
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, distal pulses intact, no clubbing,
cyanosis or edema
Skin: Multiple ecchymosis with edematous upper extremities. No
lower extremity edema noted. Dressing C/D/I to left thigh. Skin
tear to left arm covered with mepilex.
Neuro: Able to move all extremities. Decrease ability to move
left lower extremity, but able to flex and extend righ hip.
Able to raise eyebrows and close eyes tight and stick out tongue
and squeeze fingers.
Pertinent Results:
on admission:
___ 04:25PM CK(CPK)-229*
___ 04:25PM HCT-29.2*
___ 01:00PM URINE HOURS-RANDOM
___ 01:00PM URINE UHOLD-HOLD
___ 01:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 01:00PM URINE RBC-<1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 12:30PM GLUCOSE-108* UREA N-36* CREAT-1.2* SODIUM-143
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-30 ANION GAP-16
___ 12:30PM estGFR-Using this
___ 12:30PM CALCIUM-9.1 PHOSPHATE-4.0 MAGNESIUM-2.1
___ 12:30PM WBC-10.0 RBC-2.64* HGB-8.5* HCT-27.0*
MCV-103* MCH-32.2* MCHC-31.4 RDW-17.6*
___ 12:30PM NEUTS-77.9* LYMPHS-15.2* MONOS-4.2 EOS-2.3
BASOS-0.5
___ 12:30PM PLT COUNT-275
___ 12:30PM ___ PTT-22.5* ___
On discharge:
___ 09:10AM BLOOD WBC-6.4 RBC-2.96* Hgb-9.2* Hct-29.1*
MCV-98 MCH-31.2 MCHC-31.7 RDW-18.4* Plt ___
___ 09:10AM BLOOD Plt ___
___ 09:10AM BLOOD Glucose-95 UreaN-36* Creat-1.3* Na-140
K-3.8 Cl-102 HCO3-30 AnGap-12
___ 06:45AM BLOOD ___
___ 06:45AM BLOOD ALT-8 AST-23 LD(LDH)-255* AlkPhos-66
TotBili-1.3
___ 06:45AM BLOOD Ammonia-25
Imaging:
CT Scan Chest/Abdomen/Pelvis (___)
1. Bony injuries: Impacted left subcapital fracture. Left
inferior and
superior pubic rami fractures at junction with left pubic bone.
Chronic
anterior dislocation and degenerative changes the right
glenohumeral joint, with probable small focal area of posterior
humeral head acute fracture with flake like posterior humeral
head cortical fragmentation. Predominantly chronic right-sided
rib fractures, with equivocal superimposed injury for example
right second rib.
2. Nodule in the right lobe of the thyroid. Recommend
nonemergent thyroid
ultrasound for additional evaluation of this is not already been
performed.
3. Bilateral hyperdense lesions in the kidneys which likely
represent cysts with hemorrhage, or less likely solid masses.
Recommend nonemergent ultrasound for additional evaluation.
4. Cholelithiasis
Glenohumeral ___ Chronic appearing anterior
dislocation of the right glenohumeral joint. ___
deformity and deformity of the glenoid. Please note that
superimposed acute fracture would be difficult to exclude
Intraop Flouro (___) Percutaneous pinning of the left femoral
neck.
Chest XRay (___): In comparison with the study of ___ from
an outside facility, there is again enlargement of the cardiac
silhouette with suggestion of some central pulmonary vascular
congestion. The hemidiaphragms are not well seen, raising the
possibility of a small pleural effusion and compressive
atelectasis. In the left mid to lower zone, there is a
suggestion of a somewhat ill-defined
area of increased opacification. This could possibly represent a
pulmonary nodule. Extensive posttraumatic changes are seen in
the right ribs as well as dislocation about the right shoulder
joint.
Brief Hospital Course:
Ms. ___ is a ___ year old female, s/p fall during which she
incurred multiple injuries including C2 vertebral fracture, left
NOF fracture, left superior and inferior pubic rami fracture,
right lower rib fractures ___ and and right humeral head
dislocation.
# Non-displaced C2 fracture. Evaluated by Neurosurgery and they
recommended no neurosurgical intervention and a ___ J collar
at all times
[] Follow up with Neurosurg in 1 month. Patient needs to have a
follow up CT scan prior to this date and can present to
radiology at ___ prior to her neurosurgery appt.
# Left proximal femur fracture. On HD2 patient was taken to the
OR with orthopedic surgery for an uncomplicated open reduction,
internal fixation of left
proximal femur fracture. Per ortho, anticoagulation with aspirin
325 mg PO
[] Return in 2 weeks for removal of staples
[] WBAT to left lower extremity
# Delirum. Post-opertivately patient became very agitated,
pulling out her IV and attempting to pull out her foley, she had
to placed on restraints and a geriatrics consult was requested
to better control her agitation. Delirium thought
multifactorial: prolonged hospitalization, major surgery,
anesthesia, pain and need for narcotics, multiple lines and
catheters, disturbances of sleep wake cycle. UA negative for
infection. Patient was placed on haldol and aggressive pain
control (with limited narcotics) was continued: tylenol ___
TID standing, lidocaine patch 5% topical, home dose of
methadone, oxycodone 2.5mg q4 hours prn.
# Anemia: Patient with decreasing hematocrit in house likely
secondary to loss +/- component of underproduction in
pro-inflammatory state. She was transfused 2u of pRBCs with
improvement of HCT. HCT remained stable in house.
# R comminuted humeral fx-C-collar. Per ACS/Ortho fracture
stable. ROMAT to Right arm.
# Multiple Myeloma. Patient with history of multiple myeloma and
per documentation on standing prednisone for treatment and
methadone for pain control. These medications were continued in
house.
[] Continue home methadone 2.5 mg PO QHS, Methadone 5 mg PO BID,
[] Consider initiation of H2/PCP ppx blocker as well as PCP ppx
as she is on long-term steroids.
# Discharge: Patient will be discharge to ___ in ___,
a rehab facility.
Estimated length of stay at rehab facility is less than thirty
days
# Medication Rec
[] Started aspirin 325mg PO qd
[] Lasix and Ibuprofen discontinued in setting of chronic renal
insuffiencyand due to decreased PO intake was not continued at
time of discharge
# Imaging Findings: Thyroid Nodule, Kidney Cystic Structure
[] outpatient US for eval thyroid nodule and kidney cystic
structure
#Code Status: DNR/DNI
#Contact: ___, niece ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Acetaminophen 1000 mg PO Q6H
4. Atenolol 50 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Duloxetine 20 mg PO DAILY
7. Furosemide 60 mg PO DAILY
8. Guaifenesin ER 600 mg PO Q12H:PRN congestion
9. Furosemide 20 mg PO DAILY
10. Methadone 2.5 mg PO TID:PRN pain
11. PredniSONE 10 mg PO DAILY
12. Ibuprofen 400 mg PO ONCE
13. Senna 8.6 mg PO DAILY
14. Potassium Chloride 20 mEq PO DAILY
15. Mirtazapine 7.5 mg PO HS
16. Polyethylene Glycol 17 g PO EVERY OTHER DAY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 2.5 mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Duloxetine 20 mg PO DAILY
7. PredniSONE 10 mg PO DAILY
8. Senna 8.6 mg PO DAILY
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*30
Tablet Refills:*0
11. Mirtazapine 7.5 mg PO HS
12. Polyethylene Glycol 17 g PO EVERY OTHER DAY
13. Potassium Chloride 20 mEq PO DAILY
14. Guaifenesin ER 600 mg PO Q12H:PRN congestion
15. Haloperidol 0.5 mg PO HS
Please give at 5pm
16. TraZODone 50 mg PO HS
Please give at 8pm
17. Methadone 2.5 mg PO TID:PRN pain
Patient takes 5 mg in the morning and 7.5 mg at night
RX *methadone 5 mg 1 tablet by mouth as directed Disp #*20
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: S/P Open Reduction Internal Fixation Left femoral neck
Secondary: left sup and inf pubic fami fractures, right proximal
comminuted humerus fracture, C2 vertebral body fracture and
right sided rib fractures, ___, delirium,
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:
Mrs. ___ was a pleasure taking care of you during your stay at ___.
You were transferred from ___ following a fall in
your assisted living facility where you obtained multiple
fractures that were diagnosed with a CT scan. These fractures
include a cervical spine fracture located at C2 vertebrae,
fracture at neck of left femur, left superior and inferior pubic
rami fracture, Right lower rib fractures ___ and chronic
bilateral humeral fractures and right humeral head dislocation.
While in the hospital, an orthopedic surgeon performed surgery
to fix a left leg fracture. Please follow these instructions:
-Remain weight bearing as tolerated to left lower extremity
-Remain on Aspirin 325 mg once daily
-follow up appointment in 2 weeks for removal of staples
Neurosurgery saw you for non-displaced C2 fracture and requested
you remain in C-collar until a follow up appointment with Dr.
___. Patient needs to have a follow up CT scan prior
to this date, which will be scheduled by the rehab facility.
Your hospital course was complicated by episodes of delirium and
severe agitation. This was controlled with medications and at
the time of discharge you had returned to your baseline. Your
pain was adequately controlled with your home methadone, a
lidocaine patch and oxycodone.
You were seen by a physical therapist who recommended you be
discharged to a rehab facility, ___ in ___.
Appointments have been made for you in 1 month with a
neurosurgeon, and 2 weeks with an Orthopedic Surgeon to remove
your staples.
We wish you the best of luck in the future,
Your team at ___
Followup Instructions:
___
|
19881444-DS-11
| 19,881,444 | 29,133,463 |
DS
| 11 |
2162-02-14 00:00:00
|
2162-02-14 11:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / benzocaine
Attending: ___.
Chief Complaint:
sob
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year-old female with the history below who
presented to the ED today complaining of dyspnea. She reported
3
dd of cough, increased sputum production, URI symptoms, and her
sob became worse last night. In the ED she was found to have
hypoxemia (ra sat high ___. CXR had some ? atypical
infiltrate. She was given azith, pred, neb, and improved. She
was admitted.
Past Medical History:
PAST ONCOLOGIC HISTORY:
1. Patient had a protracted course of pneumonia starting in
___ required two months of antibiotics.
2. Presented to PCP in early ___ with symptoms of
headache,
chest discomfort, right shoulder pain, right arm
weakness/tingling, and difficulty swallowing. A CT scan was
performed on ___ and showed extensive adenopathy,
paratracheal, posterior to the SVC, compressing the SVC, and
enveloping the right main pulmonary artery. There was also
extensive hilar adenopathy, precarinal adenopathy, and
azygoesophageal adenopathy.
3. Patient was subsequently admitted to ___ from ___ to
___. Bronchoscopy with biopsy of level 7 and 4L lymph
nodes
was performed. Note that stenting of right bronchus intermedius
was also performed. Pathology was notable for malignant cells,
consistent with small cell carcinoma. Completion of staging
evaluation revealed no brain or osseous metastases; patient was
considered to have limited stage disease.
4. Cycle 1 of chemotherapy was started on ___ cisplatin 75
mg/m2 on day 1 and etoposide 100 mg/m2 on days ___.
5. Initial visit with radiation oncology on ___. Radiation
was initiated on ___ (31 treatments planned).
6. Patient reported increased tinnitus and hearing loss at visit
on ___. She was evaluated by audiologist (Dr. ___ with
findings notable for high frequency sensorineural hearing loss.
Cycle 2 of cisplatin and etoposide administered on ___
without modification (note that cisplatin administered on day 3
of cycle).
7. Patient subsequently developed chest and upper abdominal
discomfort associated with odynophagia. This was attributed to
GERD with possible contribution from mucositis and she was
started on omeprazole 20 mg QD and magic mouthwash as needed.
8. Patient noted to have new onset right calf swelling on
___. A lower extremity ultrasound was negative for DVT.
9. Bronchial stent was removed on ___.
10. Patient presented to clinic on ___ with chills, sore
throat, shortness of breath, and cough. Patient was admitted to
the hospital for further evaluation and care. CXR was negative
for pneumonia. Blood and urine cultures were negative. Patient
was treated with IVF and sucralfate was added to regimen. She
was discharged home the following day.
11. Cultures from bronchial stent removal returned positive for
stenotrophomonas maltophilia. Patient completed a two week
course of Bactrim (15 mg/kg/day).
12. Cycle 3 of cisplatin and etoposide initiated on ___.
Cycle was complicated by poor PO intake, hypovolemia, and
orthostasis requiring multiple visits to ___
IVF.
13. Follow up audiology evaluation revealed progressive hearing
loss. Carboplatin AUC 6 was substituted for cisplatin in cycle
4
of therapy (administered with etoposide on ___.
14. Radiation therapy end date was ___. Patient received a
total dose of 5580 cGy.
15. Prophylactic cranial irradiation initiated on ___.
PAST MEDICAL HISTORY:
Small cell lung carcinoma
Stage II IDC of breast
Chronic obstructive pulmonary disease
Tobacco abuse
Vertebral degenerative disc disease
Chronic back pain
Scoliosis
Left shoulder bursitis
Osteoporosis
History of pneumonia
Social History:
___
Family History:
2 cousins (1 maternal, 1 paternal) both diagnosed with BC in
___. Mom with Lung ca, Dad throat ___
Physical Exam:
Afebrile and vital signs stable (reviewed - see according
flowsheets and or bedside record); specific comments regarding
VSS
FSBG (if recorded):
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERRL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions, no supraclavicular or cervical lymphadenopathy, no JVD,
no carotid bruits, no thyromegaly or palpable thyroid nodules
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Cn II-XII intact. ___ strength throughout all
extremities and symmetric. No sensory deficits to light touch
appreciated. No pass-pointing on finger to nose.
2+DTR's-patellar and biceps. No asterixis, no pronator drift,
fluent speech.
Psychiatric: pleasant, appropriate affect
GU: no urinary catheter in place
Brief Hospital Course:
AECOPD, likely due to viral URI. Flu neg. Stable. Improved
rapidly with nebs, abx, and prednisone. Ambulatory sats normal
on room air, felt much better by HD 3, evaluated by ___ and felt
safe for home no services from a mobility standpoint.
Encouraged smoking cessation repeatedly to pt. Gave nicoderm
patch
Hx mult cancers, ? in remission, due for surveillance in onc f/u
___. No acute issues on this front evident during this
hospitalization
Chronic back pain on high dose opiates: cont ms contin. We do
not have fentora. Discussed with pharmacy, who recommended
dilaudid po ___ mg q 3 h prn pain while hospitalized, which
worked well for pain control without sedation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Headache
3. Fentora (fentaNYL citrate) 400 mcg buccal Q6H:PRN
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. FoLIC Acid 1 mg PO DAILY
6. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN osb
7. Mirtazapine 7.5 mg PO QHS
8. Morphine SR (MS ___ 60 mg PO Q12H
9. Omeprazole 20 mg PO DAILY
10. Bisacodyl 10 mg PO DAILY:PRN c
11. Multivitamins 1 TAB PO DAILY
12. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 3 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H sob
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 neb
neb q 6 H Disp #*60 Ampule Refills:*0
3. Nicotine Patch 21 mg TD DAILY
RX *nicotine [Nicoderm CQ] 21 mg/24 hour 1 patch daily Disp #*30
Patch Refills:*0
4. PredniSONE 40 mg PO DAILY Duration: 3 Days
RX *prednisone 10 mg 4 tablets(s) by mouth daily Disp #*12 Dose
Pack Refills:*0
5. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Headache
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
7. Bisacodyl 10 mg PO DAILY:PRN c
8. Fentora (fentaNYL citrate) 400 mcg buccal Q6H:PRN
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. FoLIC Acid 1 mg PO DAILY
11. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN osb
12. Mirtazapine 7.5 mg PO QHS
13. Morphine SR (MS ___ 60 mg PO Q12H
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 20 mg PO DAILY
16. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
AECOPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
stop smoking as we discussed.
Keep your follow up appointments
take medications as prescribed
Followup Instructions:
___
|
19881444-DS-14
| 19,881,444 | 22,089,593 |
DS
| 14 |
2163-03-17 00:00:00
|
2163-03-17 13:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
Left bimalleolar ankle fracture dislocation
Major Surgical or Invasive Procedure:
ORIF Left ankle fracture ___ ___
History of Present Illness:
___ female with left ankle pain after a fall. Patient
had multiple falls in the setting of dizziness/presyncope at
home over the course of the day, culminating in a fall in her
bedroom with inversion of the left foot, landing on the ground,
she cannot remember details beyond this. Unable to walk
afterwards. Severe pain left ankle. Denies numbness weakness
or tingling.
Review of systems:
No headache, double vision, chest pain, shortness of breath,
nausea. vomiting, rash, fever, chills except as noted in HPI.
Past Medical History:
-Small call lung cancer, limited stage - s/p definitive
concurrent chemoradiation in ___ and prophylactic cranial
radiation ___, no disease recurrence on recent scan ___
cognitive effects of cranial radiation reportedly improving
-Invasive ductal/lobular carcinoma of L breast, stage II -
completed all therapy as of ___, no known disease recurrence
-smoking
-Chronic obstructive pulmonary disease
-Tobacco abuse
-Vertebral degenerative disc disease
-Chronic back pain
-Scoliosis
-Left shoulder bursitis
-Osteoporosis
-History of pneumonia
-History of c diff
-History of catheter associated DVT in setting of active
maligancy
Social History:
___
Family History:
2 cousins (1 maternal, 1 paternal) both diagnosed with BC in
___. Mom with Lung ca, Dad throat ___
Physical Exam:
On discharge:
General: alert, oriented, interactive, no acute distress
Chest/Resp: non-labored, no respiratory distress
Abd: grossly non-distended
LLE: splint in place, clean and intact without staining; SILT at
toes; fires FHL/FDL, ___ toes pink, well-perfused
Pertinent Results:
___ 02:00PM BLOOD WBC-6.7 RBC-3.56* Hgb-11.5 Hct-35.4
MCV-99* MCH-32.3* MCHC-32.5 RDW-14.9 RDWSD-54.5* Plt ___
___ 02:00PM BLOOD Neuts-84.2* Lymphs-5.7* Monos-8.7
Eos-0.9* Baso-0.1 Im ___ AbsNeut-5.64 AbsLymp-0.38*
AbsMono-0.58 AbsEos-0.06 AbsBaso-0.01
___ 02:00PM BLOOD Plt ___
___ 02:00PM BLOOD ___
___ 02:00PM BLOOD Glucose-104* UreaN-8 Creat-0.5 Na-136
K-8.0* Cl-102 HCO3-26 AnGap-8*
___ 04:19PM BLOOD K-4.2
___ 03:54PM BLOOD K-7.8*
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left bimalleolar ankle fracture dislocation and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for ORIF Left ankle
fracture, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the Left lower extremity, and will be discharged on
Lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
Advair, correctol, Fentora, Fioricet, MS ___, albuterol,
mirtazapine
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
Use daily as needed for constipation. Hold for diarrhea or loose
stools.
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily as needed Disp
#*20 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
Take as directed. Hold for diarrhea or loose stools.
RX *docusate sodium [Colace] 100 mg 2 capsule(s) by mouth daily
Disp #*20 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC QHS
Use as directed for 4 weeks post-operatively to prevent blood
clots.
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneously every
evening Disp #*26 Syringe Refills:*0
4. Nicotine Patch 14 mg TD DAILY
Use as directed to help with tobacco/smoking cessation.
RX *nicotine [Nicoderm CQ] 14 mg/24 hour use to help with
tobacco/smoking cessation daily as needed Disp #*30 Patch
Refills:*0
5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
Use as needed for severe pain not relieved by home regimen.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*40 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
Take as directed. Hold for diarrhea or loose stools.
RX *sennosides [senna] 8.6 mg 2 tablets by mouth every evening
Disp #*20 Tablet Refills:*0
7. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Headache
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
11. Mirtazapine 7.5 mg PO QHS
12. Morphine SR (MS ___ 60 mg PO Q12H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left bimalleolar ankle fracture dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Nonweightbearing to left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks post-operatively 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 remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Please remain in the splint until follow-up appointment. Please
keep your splint dry. If you have concerns regarding your
splint, please call the clinic at the number provided.
Followup Instructions:
___
|
19881444-DS-16
| 19,881,444 | 21,220,346 |
DS
| 16 |
2164-01-31 00:00:00
|
2164-01-31 20:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
Ms. ___ is a ___ woman with history of COPD, SCLC
c/b right mainstem obstruction s/p stenting and chemo/radiation,
left breast cancer s/p lumpectomy/radiation, chronic back pain
on
opiates, who presents with shortness of breath.
The patient reports that she began to develop worsening
shortness
of breath starting one week prior to admission. Her shortness of
breath progressed over the week, from feeling dyspneic only with
exertion to experiencing shortness of breath at rest. She also
reports a cough productive of yellow sputum. She denies fevers
but notes chills. No chest pain or palpitations. No sick
contacts. No nausea, vomiting, diarrhea, abdominal pain. No
headache, vision changes, confusion, numbness, tingling,
weakness. Given her worsening shortness of breath, she presented
to the ED for further evaluation.
In the ED, initial vitals: 97.8 99 155/86 18 98% 2L NC
Exam notable for: Resp: On oxygen nasal cannula, normal work of
breathing, left-sided rales, decreased breath sounds right side
Labs notable for: WBC 5.2, plt 439; flu negative
Imaging notable for: CXR with right-sided pleural effusion
Patient given:
___ 16:00 IH Ipratropium-Albuterol Neb 1 NEB
___ 17:30 PO/NG Morphine Sulfate ___ 15 mg
___ 17:30 TD Nicotine Patch 21 mg/day
___ 21:22 PO Morphine SR (MS ___ 30 mg
___ 21:23 IV Levofloxacin 750 mg
___ 23:01 PO/NG Mirtazapine 45 mg
___ 23:04 PO DULoxetine 20 mg
___ 23:04 PO CloNIDine .2 mg
___ 23:10 PO/NG Morphine Sulfate ___ 15 mg
On arrival to the floor, she reports that she feels mildly short
of breath. She reports some anxiety regarding possible
recurrence
of her cancer. She also reports a headache. She denies any other
complaints at present.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
-Small call lung cancer, limited stage - s/p definitive
concurrent chemoradiation in ___ and prophylactic cranial
radiation ___, no disease recurrence on recent scan ___
cognitive effects of cranial radiation reportedly improving
-Invasive ductal/lobular carcinoma of L breast, stage II -
completed all therapy as of ___, no known disease recurrence
-smoking
-Chronic obstructive pulmonary disease
-Tobacco abuse
-Vertebral degenerative disc disease
-Chronic back pain
-Scoliosis
-Left shoulder bursitis
-Osteoporosis
-History of pneumonia
-History of c diff
-History of catheter associated DVT in setting of active
maligancy
Social History:
___
Family History:
2 cousins (1 maternal, 1 paternal) both diagnosed with BC in
___. Mom with Lung ca, Dad throat ___
Physical Exam:
VITALS: 97.7 105/71 88 28 97 3.5L NC
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Breathing is non-labored; decreased breath sounds over
right lung; no wheezing
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Very pleasant, appropriate affect
Pertinent Results:
___ 06:58AM BLOOD WBC-6.4 RBC-3.53* Hgb-11.1* Hct-34.5
MCV-98 MCH-31.4 MCHC-32.2 RDW-13.4 RDWSD-48.0* Plt ___
___ 07:30AM BLOOD Glucose-101* UreaN-7 Creat-0.6 Na-138
K-4.1 Cl-99 HCO3-28 AnGap-11
___ 07:30AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.8
___ 07:24AM BLOOD ALT-6 AST-13 AlkPhos-98 TotBili-<0.2
MRI BRAI:
IMPRESSION:
1. No acute intracranial abnormality. No evidence of
intracranial metastases.
2. Moderate to severe changes of chronic white matter
microangiopathy.
CT CHEST:
IMPRESSION:
1. Interval opacification of the entire right lower, right
middle and much of
the right upper lobe, with nodular opacification, irregular
intra and
interlobular septal thickening and ground-glass throughout the
remaining
aerated right upper lobe is concerning for lymphangitic spread
of the known
malignancy with mass effect on the right-sided airway.
Enhancement in a
central distribution throughout the lung and along the pleura
inferiorly are
concerning for possible underlying mass.
2. New soft tissue nodule along the right epicardium.
3. Atelectatic collapse of right middle lobe, with mild collapse
of the right
lower lobe.
CT ABD:
IMPRESSION:
1. New mesenteric and retroperitoneal lymphadenopathy are
concerning for nodal
metastasis.
2. New numerous subcentimeter hypodense lesions throughout the
liver
suspicious for liver metastasis.
PATHOLOGIC DIAGNOSIS:
- SMALL CELL CARCINOMA. See note.
2. Lung, right lower lobe, endobronchial biopsy:
- Rare poorly preserved cells, consistent with SMALL CELL
CARCINOMA.
Note: By immunohistochemistry, tumor cells are positive for
TTF-1 and synaptophysin.
Brief Hospital Course:
Ms. ___ is a ___ woman with history of COPD, SCLC c/b
right mainstem obstruction s/p stenting and chemo/radiation,
left breast cancer s/p lumpectomy/radiation, chronic back pain
on opiates, who presented with shortness of breath found to have
bronchial obstruction and likely worsening metastatic disease.
s/p Bronchoscopy with bx.
# Acute hypoxic respiratory failure
# Chronic obstructive pulmonary disease with possible
exacerbation (increased cough, sputum and wheezy today)
# Small cell lung cancer
# Right pleural effusion
# Possible post-obstructive pneumonia:
Patient with history of SCLC presenting with progressive
dyspnea, initially suspected to have large R pleural effusion.
CT chest performed and was more concerning now for bronchial
obstruction and recurrent malignancy with lymphangitic spread
with possible PNA. She underwent bronchoscopy with bx
confirming small cell lung cancer. MRI brain was performed
which was negative for brain mets. She was suspected to have a
COPD flare and possible PNA as well and was treated with 5 days
of steroids and Levo/Flagyl. She also required supplemental 02
and desaturated on ambulation. Home 02 was arranged for DC.
She was discharged to follow up with her oncologist. She should
follow up with Pulm as well.
# Liver metastasis:
# Metastasis to LN:
CT abd notable for findings concerning for metastatic disease.
She has a h/o lung and breast cancers. I reviewed this with the
patient . LFTs normal. Brain MRI normal. Onc follow up
arranged.
# Nicotine dependence:
- Nicotine patch
CHRONIC/STABLE PROBLEMS:
# Chronic pain:
- Continued MS contin, morphine ___
- Continued bowel regimen
# Migraines:
- Continued Fioricet as needed
# ?Depression/Anxiety:
- Continued duloxetine, mirtazapine, clonidine
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Pain - Mild
2. Mirtazapine 45 mg PO QHS
3. Morphine SR (MS ___ 30 mg PO Q12H
4. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
5. diclofenac sodium 1 % topical QID
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Prochlorperazine 10 mg PO TID
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
9. fentaNYL citrate 400 mcg sublingual Q6H:PRN
10. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
Shortness of breath
11. DULoxetine 20 mg PO QHS
12. Morphine Sulfate ___ 15 mg PO Q8H:PRN Pain - Moderate
13. CloNIDine 0.2 mg PO QHS
Discharge Medications:
1. Nicotine Patch 21 mg/day TD DAILY
RX *nicotine 21 mg/24 hour apply 1 patch to shoulder Daily Disp
#*28 Patch Refills:*0
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Pain - Mild
3. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
4. CloNIDine 0.2 mg PO QHS
5. diclofenac sodium 1 % topical QID
6. DULoxetine 20 mg PO QHS
7. Fentanyl Citrate 400 mcg sublingual Q6H:PRN pain
8. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
Shortness of breath
9. Mirtazapine 45 mg PO QHS
10. Morphine SR (MS ___ 30 mg PO Q12H
11. Morphine Sulfate ___ 15 mg PO Q8H:PRN Pain - Moderate
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Prochlorperazine 10 mg PO TID
14. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
Right bronchial obstruction
history of lung cancer
COPD with exacerbation
Post obstructive pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation of shortness of breath and
obstruction in your right lung tree. You underwent a
bronchoscopy and biopsies were taken, these are PENDING. We are
concerned about a recurrence of your cancer. We have scheduled
close follow up with your oncologist next week.
Please resume your home medications as instructed. We have also
arranged for home oxygen given your low oxygen levels. it is
very important that you DO NOT smoke around your oxygen.
Followup Instructions:
___
|
19881444-DS-17
| 19,881,444 | 28,475,591 |
DS
| 17 |
2164-02-27 00:00:00
|
2164-02-28 16:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
PICC placement and removal
History of Present Illness:
___ PMH of SCLC s/p chemoradiation, recently found to have
recurrent metastatic small cell carcinoma (s/p C1
___/ Atezolizumab), Tobacco abuse, Chronic back pain
(on opiates), presented with shortness of breath
Patient noted that since recent discharge she has had a steady
worsening of her shortness of breath. She noted that she has
dyspnea both at rest and with exertion. She noted that she is
on 3 L of nasal cannula at home and has not increased her O2.
She denied any cough, chest discomfort, fevers or chills, leg
swelling. She noted that shortness of breath is limiting her
activities of daily living. She denied any excessive wheezing
at
home and noted that she is taking duo nebs with little effect.
She noted that she continues to smoke 1 pack/day
Also describes some suprapubic tenderness, but no dysuria or
difficulties with urinating.
In the ED, initial vitals: 36.2 110 140/90 24 94. Na 134, CL 90,
HCO# 35, BNP 1716, Trop 0.08, CK 93, MB 3, lactate 1.5, UA
negative for infection. Flu swab negative
CTA:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Re-demonstrated ill-defined right hilar mass producing mass
effect upon the right middle and lower lobes, with complete
opacification of both of these lobes. Re-demonstrated nodular
interlobular septal thickening in the right upper lobe
concerning
for lymphangitic tumor spread, as before. Moderate right pleural
effusion. It is difficult to exclude superimposed
postobstructive
infection.
3. Increasing hepatic metastases. Re-demonstrated
retroperitoneal
bulky lymphadenopathy and left adrenal nodule.
EKG:
Sinus tachycardia, wavering baseline so difficult to assess ST
segments but has new qwaves in V2/V3 and TWI in aVL.
CXR Post PICC:
1. Precise location of the PICC is very difficult to evaluate
given complete opacification of the right hemithorax. Given this
limitation, the PICC likely lies within the right atrium and
retraction by approximately 4 cm should put it near the superior
cavoatrial junction or in the low SVC.
2. Opacification of the majority of the right hemithorax as well
as a right pleural effusion is better assessed on same day CT.
IP evaluated patient and felt that pleural effusion was roughly
stable. They also found that she had paradoxical motion of right
hemidiaphragm likely ___ malignant involvement. They noted that
her respiratory status is extremely tenuous given multiple
insults to her lung and noted that IP intervention was not
possible. ___ team pulled catheter back 4cm after CXR read. She
was then given duonebs and Ativan and admitted for further care.
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per last ___ clinic note:
"1. Patient had a protracted course of pneumonia starting in
___ required two months of antibiotics.
2. Presented to PCP in early ___ with symptoms of
headache, chest discomfort, right shoulder pain, right arm
weakness/tingling, and difficulty swallowing. A CT scan ___
and showed extensive adenopathy, paratracheal, posterior to the
SVC, compressing the SVC, and enveloping the right main
pulmonary
artery. There was also extensive hilar adenopathy, precarinal
adenopathy, and azygoesophageal adenopathy.
3. Patient was subsequently admitted to ___ from ___ to
___. Bronchoscopy with biopsy of level 7 and 4L lymph
nodes was performed and stenting of right bronchus intermedius
was also performed. Pathology was notable for malignant cells,
consistent with small cell carcinoma. Completion of staging
evaluation revealed no brain or osseous metastases; patient was
considered to have limited stage disease.
4. She started cisplatin 75mg/m2 D1/etoposide 100mg/m2 D1-3,
C1D1
___
5. Radiation was initiated on ___
6. Bronchial stent was removed on ___.
7. admitted ___ w/ chills, sore throat, SOB, cough.
8. Carboplatin AUC 6 was substituted for cisplatin (due to
ototoxicity)for cycle
9. Radiation therapy end date was ___. Patient received a
total dose of 5580 cGy.
10. Prophylactic cranial irradiation initiated on ___.
-___: Admitted for SOB, found to have post obstructive
PNA. Imaging showed opacification of the entire R lower, R
middle
and much of the R upper lobe, mesenteric and retroperitoneal LAD
and hypodense lesions throughout liver, concerning for
recurrence
of SCLC. Endobronchial biopsy confirmed recurrent disease
___ C1 D1 ___/ Atezolizumab "
PAST MEDICAL HISTORY:
-Small call lung cancer, limited stage initially - s/p
definitive
concurrent chemoradiation in ___ and prophylactic cranial
radiation ___, recent metastatic recurrence ___
-Invasive ductal/lobular carcinoma of L breast, stage II -
completed all therapy as of ___, no known disease recurrence
-Chronic obstructive pulmonary disease
-Tobacco abuse
-Vertebral degenerative disc disease
-Chronic back pain
-Scoliosis
-Left shoulder bursitis
-Osteoporosis
-History of pneumonia
-History of c diff
-History of catheter associated DVT in setting of active
malignancy
Social History:
___
Family History:
2 cousins (1 maternal, 1 paternal) both diagnosed with BC in
___. Mom with Lung ca, Dad throat ___
Physical Exam:
Admit:
GENERAL: chronically ill-appearing, fatigued, easily falls
asleep during interview, tachypneic
EYES: PERLA anicteric
ENT: Oropharynx clear without lesion, MMM, dentures in place
NECK: supple, normal ROM
LUNGS: patient is tachypneic with increased work of breathing,
though does not appear in distress, has decreased breath sounds
in right upper lobe and absent breath sounds in the right middle
and lower lobe, left lung sounds clear patient able to speak in
short sentences without difficulty.
CV: Regular rate and rhythm, normal distal perfusion without
significant edema
ABD: Slight suprapubic tenderness, soft, nondistended, no
rebound
or guarding
GENITOURINARY: Slight suprapubic tenderness, no foley
EXT: decreased muscle bulk, no edema
SKIN: warm, dry, no rash
NEURO: AOx2 ___, falls asleep when asking her other
questions), is able to state husbands phone number, easily
arousable to voice/name. Moving all extremities.
ACCESS: PICC in RUE with dressing c/d/I
Discharge:
GENERAL: AOx3, breathing comfortably, sitting in bed, children
at bedside
EYES: PERLA anicteric
ENT: Oropharynx clear without lesion, MMM, dentures in place
NECK: supple, normal ROM
LUNGS: slightly tachypneic but no increased WOB, has decreased
breath sounds in right upper lobe and absent breath sounds in
the
right middle and lower lobe, left lung sounds clear (unchanged
since admit)
CV: Regular rate and rhythm, normal distal perfusion without
significant edema
ABD: no suprapubic tenderness, soft, nondistended, no rebound
or guarding
GENITOURINARY: no suprapubic tenderness, foley removed
EXT: decreased muscle bulk, no edema
SKIN: warm, dry, no rash
NEURO: AOx3, cranial nerves/strength/sensory grossly intact
Pertinent Results:
Admit:
___ 08:40PM BLOOD WBC-4.5 RBC-3.40* Hgb-10.4* Hct-32.4*
MCV-95 MCH-30.6 MCHC-32.1 RDW-13.2 RDWSD-46.7* Plt ___
___ 12:50PM BLOOD Glucose-116* UreaN-10 Creat-0.5 Na-134*
K-5.3 Cl-90* HCO3-35* AnGap-9*
___ 10:25PM BLOOD ALT-8 AST-23 CK(CPK)-65 AlkPhos-98
TotBili-0.3
___ 10:25PM BLOOD Calcium-8.7 Phos-3.1 Mg-1.8
Discharge:
___ 04:33AM BLOOD WBC-2.9* RBC-2.84* Hgb-8.7* Hct-26.7*
MCV-94 MCH-30.6 MCHC-32.6 RDW-13.1 RDWSD-45.1 Plt ___
___ 04:33AM BLOOD ___ PTT-28.6 ___
___ 04:33AM BLOOD Glucose-96 UreaN-10 Creat-0.6 Na-144
K-3.7 Cl-99 HCO3-31 AnGap-14
___ 05:33AM BLOOD ALT-8 AST-23 AlkPhos-88 TotBili-0.3
___ 10:25PM BLOOD TSH-1.2
___ 10:25PM BLOOD VitB12-429
___ 10:04AM BLOOD Type-MIX pO2-49* pCO2-44 pH-7.46*
calTCO2-32* Base XS-6
Micro:
___ 8:00 am URINE Source: Catheter.
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 CFU/mL.
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
CFU/mL.
STUDIES:
CTH ___:
No acute intracranial abnormality.
MRI Brain ___:
1. No evidence of metastatic disease.
2. No acute infarct or intracranial hemorrhage.
3. Chronic microvascular angiopathy changes.
CTA:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Re-demonstrated ill-defined right hilar mass producing mass
effect upon the right middle and lower lobes, with complete
opacification of both of these lobes. Re-demonstrated nodular
interlobular septal thickening in the right upper lobe
concerning
for lymphangitic tumor spread, as before. Moderate right pleural
effusion. It is difficult to exclude superimposed
postobstructive
infection.
3. Increasing hepatic metastases. Re-demonstrated
retroperitoneal
bulky lymphadenopathy and left adrenal nodule.
EKG:
Sinus, 1mm STE in V3, <1mm STE in V4, TWI in multiple precordial
leads
CXR Post PICC:
1. Precise location of the PICC is very difficult to evaluate
given complete opacification of the right hemithorax. Given this
limitation, the PICC likely lies within the right atrium and
retraction by approximately 4 cm should put it near the superior
cavoatrial junction or in the low SVC.
2. Opacification of the majority of the right hemithorax as well
as a right pleural effusion is better assessed on same day CT.
Micro:
___ 8:00 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ PMH of SCLC s/p chemoradiation, recently found to have
recurrent metastatic small cell carcinoma (s/p C1
___/ Atezolizumab), Tobacco abuse, Chronic back pain
(on opiates), presented with shortness of breath, and
encephalopathy, both of which resolved prior to discharge.
#Encephalopathy
Unclear etiology. On admission, patient was sedated which may
have been ___ Ativan given in ED. On hospital day 2 she was much
more alert, but very disoriented (AOx1, paucity of speech,
unable to name objects) with non-focal neuro exam. ___ have been
___ delirium or toxic metabolic encephalopathy as she returned
to baseline in 48 hrs without intervention. CTH/MRI brain
revealed only chronic findings. Neurology evaluated patient,
considered seizure, and EEG was performed (though was when
patient was improved), and was negative. While EEG did not
definitively r/o seizure as it was done when her mental status
had returned to baseline, it had no suspicious findings so AED
was not started.
As per discussion with patient's oncologist, she has had similar
encephalopathic episodes with prior admits, so may be more
sensitive to stressors (dehydration, pain, SOB, hypoxia) as a
result of prior prophylactic cranial irradiation or other CNS
insult in the past.
#SOB
#Acute Hypoxic Respiratory Distress
Shortness of breath likely multifactorial including known mass
(recurrent SCLC) causing atelectasis/compression RML/RLL as well
as lymphangitic spread in RUL, and growing effusion, now
moderate causing further mass effect. Patient remained afebrile
without clear infectious symptomatology. No e/o COPD
exacerbation. IP evaluated patient and felt that pleural
effusion was roughly stable on U/S evaluation by their team and
therefore did not warrant
intervention. They also found that she had paradoxical motion of
right hemidiaphragm likely ___ malignant involvement. They noted
that her respiratory status is extremely tenuous given multiple
insults to her lung and noted that IP intervention was not
possible.
Once mental status resolved and patient was returned to normal
opiate regimen, her dyspnea was well controlled. I strongly
encouraged patient to quit smoking and asked that she avoid
Ativan as it made her very sedated on admission.
#Elevated Troponin
Patient with elevated troponin, possibly ___ increased demand
during acute hypoxic resp distress as above. EKG with changes in
V2-V3 but troponin downtrended and without chest pain so
unlikely ACS.
#Receurrent Metastatic SCLC
CT with interval increase in hepatic metastases which was not
necessarily surprising in that she only started chemotherapy
several days ago. However, disease burden in chest is causing
significant respiratory compromise. As per Dr ___,
patient to f/u in clinic for next cycle on ___ with imaging
after next cycle to assess response. Pt noted to have declining
counts (WBC/Hgb) which outpatient team was aware of and will
trend at next f/u appt.
#Urinary Retention
#CAUTI
Unclear etiology, occurred on admission. Foley in place for 48
hrs while patient altered, removed afterward and patient passed
voiding trial. After foley removed patient c/o dysuria and had
new pyuria on UA, so treated with Cipro x3 days (ending ___.
UCx resulted klebsiella sensitive to cipro.
# Nicotine dependence:
Pt counseled extensively that tobacco use will cause PNA or COPD
flare which may be life threatening as she only has 1
functioning lung. Patient was prescribed nicotine patch on
discharge
# Neoplasm related pain:
Once encephalopathy resolved, patient with significant chronic
low back pain which required stepwise re-introduction of opiates
Transitional Issues:
1. I strongly encouraged patient to quit smoking and asked that
she avoid Ativan as it made her very sedated on admission.
2. As per Dr ___, patient to f/u in clinic for next cycle
on ___ with imaging after next cycle to assess response. Pt
noted to have declining counts (WBC/Hgb) which outpatient team
was aware of and will trend.
3. After foley removed patient c/o dysuria and had new pyuria on
UA, so treated with Cipro x3 days (ending ___.
I personally spent 57 minutes preparing discharge paperwork,
coordinating care with outpatient providers, educating patient,
and answering questions.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Pain - Mild
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
3. CloNIDine 0.2 mg PO QHS
4. DULoxetine 20 mg PO QHS
5. Mirtazapine 45 mg PO QHS
6. Morphine SR (MS ___ 30 mg PO Q12H
7. Morphine Sulfate ___ 15 mg PO Q8H:PRN Pain - Moderate
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Prochlorperazine 10 mg PO TID
10. Senna 8.6 mg PO BID:PRN Constipation - First Line
11. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
Shortness of breath
12. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*3 Tablet Refills:*0
2. Nicotine Patch 21 mg/day TD DAILY
RX *nicotine 21 mg/24 hour (28)-14 mg/24 hour (14)-7 mg/24 hour
(14) Apply 1 patch daily Disp #*56 Patch Refills:*0
3. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Pain - Mild
4. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
5. CloNIDine 0.2 mg PO QHS
6. DULoxetine 20 mg PO QHS
7. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
Shortness of breath
8. Mirtazapine 45 mg PO QHS
9. Morphine SR (MS ___ 30 mg PO Q12H
10. Morphine Sulfate ___ 15 mg PO Q8H:PRN Pain - Moderate
11. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First
Line
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Prochlorperazine 10 mg PO TID
14. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute Hypoxic Resp Distress ___ collapsed lung due to malignancy
Toxic Metabolic Encephalopathy
CAUTI
Elevated Troponin
Receurrent Metastatic SCLC
Tobacco Abuse
Chronic Neoplasm related pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs ___
___ was a pleasure taking care of you while you were
hospitalized. You were admitted because you were confused, which
resolved on its own. However, it remains unclear why it
happened.
You were also admitted for shortness of breath due to your
limited remaining lung function as a result of your cancer. You
should continue taking morphine for dyspnea. Remember, it is
crucial that you stop smoking as it increases the risk for COPD
flare, or pneumonia that could kill you.
You have followup already scheduled with Dr ___ your
next chemo session.
Followup Instructions:
___
|
19881444-DS-7
| 19,881,444 | 20,158,003 |
DS
| 7 |
2160-08-30 00:00:00
|
2160-09-14 11:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / benzocaine
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
bronchoscopy w/ bronchial stent placed ___
History of Present Illness:
___ hx stage II breast cancer ER/PR pos, HER2 neg ___ s/p
left
modified mastectomy, treated with Adriamycin/Cytoxan followed by
taxol, COPD who was sent to the ED after CT scan ordered by PCP
showed ___ right 3.3 x 2.7 x 2.1 supraclavicular LN. For the past
week she has had headache for three days, worse w/lying down,
feeling like her chest is "barking like a dog" with burning when
she lies down, intermittent R shoulder pain w/associated arm
weakness and tingling, and difficulty swallowing. She had a
protracted course of PNA in ___, requiring 2 months of
levoquin.
In the ED, initial VS were: T98.6 P93 BP126/71 RR18 O2 sat 99%
Labs were notable for: WBC 4.5 (normal diff), HCT 38.6, PLT 255,
Cr 0.6, LDH 269, urinalysis was unremarkable.
Imaging included: CT head unremarkable.
Consults called: None
Treatments received: Fioricet, Morphine
Vitals prior to transfer: P81 BP156/88 RR14 O2 sat 98% RA
On arrival to the floor, patient reports that she had PNA in
___ was took ~2 months to recover. She went to ___ on
vacation in ___ and continued to have DOE and fatigue. For
the last two months she has had increased SOB requiring daily
use
of her albuterol rescue inhaler. In addition to the symptoms
described above she reports ~10lb weight loss over the last 2
months, dry cough, nausea, intermittent sensation of "room
spinning" when she gets up at night. She has chronic night
sweats which she attributes to being post-menopausal,
intermittent constipatin/diarrhea from her opioid/laxative use.
REVIEW OF SYSTEMS:
Denies vision changes, rhinorrhea, congestion, sore throat,
cough, chest pain, abdominal pain, vomiting, BRBPR, melena,
hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
PAST ONCOLOGIC HISTORY
Ms. ___ was diagnosed in ___ with a stage II (T1cN1)
grade
2, multifocal IDC, 1.5 cm at largest extent, ER/PR pos, HER2
neg,
node pos ___. She underwent a left modified radical mastectomy
with reconstruction and then received four cycles of Adriamycin
and Cytoxan followed by four cycles of every three-week Taxol.
She was on tamoxifen for ___ years, and then switched to ___
followed by ___, completed adjuvant endocrine therapy in ___.
PAST MEDICAL HISTORY:
- COPD
- Chronic back pain
- Scoliosis
- Vertebral DJD
- Left shoulder bursitis
- Osteoporosis
- PNA ___
- Tobacco
- s/p cholecystectomy
- s/p herniated disc repair (L-spine) ___
Social History:
___
Family History:
2 cousins (1 maternal, 1 paternal) both diagnosed with BC in
___. Mom with Lung ca, Dad throat ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T97.9 P88 BP 106/62 RR20 O2 sat 94%RA
GENERAL: NAD, sitting up in bed breathing comfortably
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: RRR, normal S1 & S2, ___ SEM RSB
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema, mild clubbing on b/l
hands
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in UE and ___, sensation
intact throughout, ROM wnl, gait slightly ataxic
SKIN: Warm and dry, without rashes
Pertinent Results:
IMAGING:
CT Head ___:
1. No acute intracranial abnormality. No large intracranial
mass.
Of note MR is more sensitive in detection of subtle mass
lesions.
2. 1 cm hypodensity within the left putamen is most consistent
with a
prominent Virchow ___ space or chronic lacune.
CTA chest ___ ___):
FINDINGS: There are no filing defects in the pulmonary arteries
to suggest pulmonary emboli. The lung parenchyma shows
confluent
parenchymal opacities with air bronchograms involving the right
lower lobe and anterior left upper lobe with other patchy
opacities in the anterior right upper lobe and a 5mm somewhat
nodular opacity in the left upper lobe. The major airways, and
the pleura are unremarkable. Mediastinal and bilateral hilar
lymphadenopathy may be reactive. This includes a 1.5 x 2.1 cm
subacrinal node and a 1.7 x 1.1 cm right hilar node/node
conglomerate. The heart is normal in size, and there is no
pericardial effusion. There is no atherosclerosis, aortic
aneurysms, or aortic dissection. There is no axillary
lymphadenopathy. The included upper abdomen is unremarkable.
There is dextroscoliosis of the lower thoracic spine as well as
multilevel degenerative changes.
IMPRESSION:
1. No CT evidence for pulmonary thromboembolism.
2. Multifocal airspace disease likely representing pneumonia.
3. Mediastinal and hilar lymphadenopathy is likely reactive.
Follow-up examination to evaluate for resolution and exclude the
possiblity of an underlying neoplastic process is recommended.
CT neck (___) ___:
Impression:
1. Large right supraclavicular mass measuring approximately 3.3
x
2.7
x 2.1 cm consistent with pathologic adenopathy or line
2. Abnormal anterior mediastinal adenopathy please see chest CT
report
CT chest (___) ___:
Impression:
1. Extensive adenopathy paratracheal, posterior to the SVC
compressing
the SVC, enveloping the right main pulmonary artery extensive
hilar
adenopathy, precarinal adenopathy, and azgoesophageal adenopathy
Differential would include primary lung carcinoma, or possible
lymphoma. This would be unusual for for metastatic breast CA
without
any other metastatic lesions and given the fact it appears as if
the
surgical clips on the left side of the chest and there is no
left
hilar adenopathy.
CT abdomen/pelvis (___) ___:
Impression:
1. No evidence of metastatic disease.
C-scope ___: diverticulosis, 3 polyps (path showed 2 tubular
adenomas, 1 hyperplastic polyp)
Brief Hospital Course:
___ smoker with history of of stage II breast cancer in ___,
now presenting with SVC syndrome and mediastinal/supraclavicular
LAD and mass.
# Small cell lung cancer - pathology from biopsies done during
bronch ___ c/w small cell lung cancer. Brain MRI showed no
evidence of metastatic disease. Chemotherapy was started with
cisplatin/etoposide on ___ after bone scan showed no evidence
of osseous metastases.
She will follow up with medical oncology and radiation oncology
at ___. At this point considered limited stage disease. s/p
right bronchus intermedius stenting ___ and IP notes need to
continue following her post stent placement as SCLC is expected
to shrink in response to therapy and stent placement will need
to be monitored as this occurs. The patient was counseled about
Zofran and Compazine PO to be used PRN for nausea which are new
medications for her at home.
# Possible SVC syndrome: Pt reported positional headaches along
with dyspnea and there was concern for SVC syndrome given CT
imaging with mass compressing the SVC. However clinically, she
had no plethora or facial swelling or IJ distention. She did
have some reddish color to the upper chest and possibly small
dilated collateral veins but nothing marked. Dyspnea improved
after bronchial stent placement. She had no stridor, and
laryngospasm after the bronchoscopy was felt to be unrelated.
Given that her symptoms of headache and dyspnea were not clearly
___ SVC compression, ___ was consulted but the consensus was to
defer SVC stent placement in favor of chemotherapy/radiation. At
the time of discharge, her headaches were significantly improved
and no longer woke her from sleep.
# Dyspnea, Cough - Pt comfortable on RA during the day but on O2
to sleep.
No WBC or fever to suggest pneumonia. Dyspnea and cough likely
secondary to intrathoracic mass and acute COPD exacerbation with
the latter being suggested by increased cough and wheezing noted
in the days prior to discharge.
- standing duonebs q6, and hypertonic saline nebs q12
- mucinex BID
- patient had not been using inhaled corticosteroid at home and
was prescribed Advair on discharge
- she was also started on a prednisone taper prior to discharge
after discussing likely copd exacerbation with IP; they will
monitor her progress on her f/u visit and adjust her taper as
needed.
# Chronic back pain: from DJD w/prior disc herniations. No
worsening
of her chronic pain and bone scan negative for osseous
metastases. However, if she does develop worsening pain in the
future, may need further imaging of spine to r/o metastatic
disease.
- continue home morphine SR and fentora (on discharge)
- dilaudid ___ mg PO q3hrs PRN pain was added to pain regimen
- bowel regimen was started with colace standing and dulcolax as
needed
# Tobacco use:
- discharged on nicotine patch
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
2. Fentora (fentaNYL citrate) 400 mcg buccal QID pain
3. Morphine SR (MS ___ 30 mg PO Q8H
4. TraZODone 150 mg PO QHS
5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN wheezing, sob
6. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
Discharge Medications:
1. oxygen
Portable oxygen. Pt needs 2L via NC. Intermittently desats to
<88% when walking. Diagnosis: Lung cancer.
Length of need: 13 months
2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H wheeze
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 neb
inhaled q6 Disp #*100 Ampule Refills:*0
3. Sodium Chloride 3% Inhalation Soln 15 mL NEB BID
RX *sodium chloride [Hyper-Sal] 3.5 % 1 neb inhaled twice daily
Disp #*60 Vial Refills:*0
4. nebulizer machine
nebulizer machine
diagnosis: lung cancer length of need: 13 months
5. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
6. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
7. Morphine SR (MS ___ 45 mg PO Q8H
RX *morphine 45 mg 1 capsule(s) by mouth three times a day Disp
#*90 Capsule Refills:*0
8. TraZODone 150 mg PO QHS
9. Albuterol Inhaler ___ PUFF IH Q2H:PRN sob or wheezing
10. Bisacodyl 10 mg PO DAILY:PRN constipation
11. Docusate Sodium 100 mg PO BID constipation
12. Guaifenesin ER 1200 mg PO Q12H
RX *guaifenesin 600 mg 2 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*4
13. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 4 mg 2 - 2.5 tablet(s) by mouth every 3 hours
as needed Disp #*160 Tablet Refills:*0
14. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour one patch daily apply to skin daily
Disp #*30 Patch Refills:*5
15. Nicotine Polacrilex 2 mg PO Q1H:PRN craving
RX *nicotine (polacrilex) 2 mg use one every hour as needed
every hour as needed Disp #*100 Gum Refills:*0
16. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron [Zofran ODT] 8 mg 1 tablet(s) by mouth every 8
hours as needed Disp #*60 Tablet Refills:*0
17. Senna 8.6 mg PO BID constipation
18. Fentora (fentaNYL citrate) 400 mcg buccal QID pain
19. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
Q4H:PRN wheezing, sob
20. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every 6
hours as needed Disp #*60 Tablet Refills:*0
21. PredniSONE 10 mg PO DAILY
Please follow your doctor's instructions- start by taking 40 mg
daily for 7 days.
Tapered dose - DOWN
RX *prednisone 10 mg 4 tablet(s) by mouth daily. Disp #*38
Tablet Refills:*0
22. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
inhalation by mouth in the morning and in the evening Disp #*1
Disk Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
small cell lung cancer
COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
1. You have a new diagnosis of small cell lung cancer. You
started chemotherapy when in the hospital. You will continue
this every three weeks. You were given a prescription for
Ondansetron and Prochlorperazine which are to be taken as needed
for nausea.
You will have your next chemo ___. You will have radiation set
up also in the meantime.
2. You had a stent placed in your lung on the right side. Please
use the saline nebulizer solution twice a day. The
interventional pulmonary team place that stent (Dr. ___ and
need to see you in their clinic; they will call you with an
appointment.
3. You had wheezing during your stay here and the interventional
pulmonary team recommended that you have a course of steroids
for a likely COPD exacerbation. Please take prednisone 40 mg by
mouth daily for 7 days and then decrease your dose by 10 mg
every two days:
___ 40 mg
___ 30 mg
___ 20 mg
___ 10 mg
___ompleted
You are also being started on a steroid inhaler (Advair) for
your COPD. Please also continue using Ipratropium/Albuterol
nebulizer treatments every 6 hours as needed for wheezing.
Followup Instructions:
___
|
19881444-DS-8
| 19,881,444 | 20,672,000 |
DS
| 8 |
2160-10-09 00:00:00
|
2160-10-10 09:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / benzocaine
Attending: ___.
Chief Complaint:
Fatigue, odynophagia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old female with a history of stage II
breast cancer and recent diagnosis of small cell lung cancer
currently being treated with combined chemotherapy and
radiation. Received C2 chemo ___ and started XRT on ___.
Pt was seen in clinic today and reporting worsening pain in
throat and uppper chest, esp w/ swallowing. Is taking only soft
foods like yogurt, drinking liquids fine. No sensation of food
getting stuck just painful to swallow. She had bronchial stent
removed on ___ and states that pain is better, no longer
having sharp pains radiating down her chest but still has the
throat pain.
She was recently started on omeprazole and magic mouthwash for
GERD and possible mucositis. Denies any mouth sores but does
have some epigastric pain and heartburn. She did get a little
relief from throat pain w/ MM. She is not losing weight.
She also reports feeling very fatigued and chilled but no
fevers. Was able to do some activities, can get around house ok
but sleeping alot more. She does note intermittent SOB but not
worse w/ activity. Uses her inhaler several times day and use
has not increased. Uses O2 at home at night but not during day
or w/ activity. She denies cough, hemoptysis, rhinorrhea.
SHe has chronic pain in lower back for which she takes MS contin
and fentora, when she is admitted here she substitutes for oral
dilaudid.
BM are regular, she is dependent on bowel regimen and
occasionally get loose stools due to meds but no recent
diarrhea. No abdominal pain, nausea, or emesis.
Pt was referred to ED w/ concern for pneumonia or other
infection. CXR was clear. She was given dil 0.5mg x 2 for pain
while in ED and on arrival to floor reporting ___ pain in
throat.
ROS: No HA, vision changes, numbness, focal weakness. No skin
rash. No dysuria, hematuria, or increased urinary frequency. No
dizziness, lightheadedness, or syncope.
No bleeding or clotting
Remainder 10 pt ROS negative other than HPI above.
Past Medical History:
PAST ONCOLOGIC HISTORY: per OMR
ONCOLOGIC HISTORY:
1. Patient had a protracted course of pneumonia starting in
___ required two months of antibiotics.
2. Presented to PCP in early ___ with symptoms of
headache,
chest discomfort, right shoulder pain, right arm
weakness/tingling, and difficulty swallowing. A CT scan was
performed on ___ and showed extensive adenopathy,
paratracheal, posterior to the SVC, compressing the SVC, and
enveloping the right main pulmonary artery. There was also
extensive hilar adenopathy, precarinal adenopathy, and
azygoesophageal adenopathy.
3. Patient was subsequently admitted to ___ from ___ to
___. Bronchoscopy with biopsy of level 7 and 4L lymph nodes
was performed. Note that stenting of right bronchus intermedius
was also performed. Pathology was notable for malignant cells,
consistent with small cell carcinoma. Completion of staging
evaluation revealed no brain or osseous metastases; patient was
considered to have limited stage disease.
4. Cycle 1 of chemotherapy was started on ___ cisplatin 75
mg/m2 on day 1 and etoposide 100 mg/m2 on days ___.
5. Initial visit with radiation oncology on ___. Radiation
was initiated on ___ (31 treatments planned).
6. Patient reported increased tinnitus and hearing loss at visit
on ___. She was evaluated by audiologist (Dr. ___ with
findings notable for high frequency sensorineural hearing loss.
Cycle 2 of cisplatin and etoposide administered on ___
without modification (note that cisplatin administered on day 3
of cycle).
7. Patient subsequently developed chest and upper abdominal
discomfort associated with odynophagia. This was attributed to
GERD with possible contribution from mucositis and she was
started on omeprazole 20 mg QD and magic mouthwash as needed.
8. Patient noted to have new onset right calf swelling on
___. A lower extremity ultrasound was negative for DVT.
9. Bronchial stent was removed on ___.
PAST MEDICAL HISTORY:
Small cell lung carcinoma as above
Stage II IDC of breast as above
Chronic obstructive pulmonary disease
Tobacco abuse
Vertebral degenerative disc disease
Chronic back pain
Scoliosis
Left shoulder bursitis
Osteoporosis
History of pneumonia
SURGICAL HISTORY:
Cholecystectomy
Herniated disc repair (L spine, ___
FAMILY HISTORY:
Mother:Lung carcinoma (patient thinks this was also small cell).
Father: ___ cancer, MI age ___.
Paternal grandmother: Cancer, unknown type.
Aunt: ___ cancer.
Aunt: Lung cancer.
Uncle: Lung cancer.
Social History:
___
Family History:
2 cousins (1 maternal, 1 paternal) both diagnosed with BC in
___. Mom with Lung ca, Dad throat ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: 98.3 138/70 71 16 94%RA
ADMIT WT: 130.8lbs
HEENT: MMM, OP erythematous no exudates, no oral ulcers or
thrush
Neck: supple, no JVD
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB, nonlabored no wheeze
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: warm well perfused, no edema, no pain over palpation of
chest
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face
symmetric, no tongue deviation, full hand grip, shoulder shrug
and bicep flexion, full toe dorsiflexion and hip flexion against
resistance bilateral, sensation intact to light touch, no clonus
DISCHARGE EXAM:
VS: 98.1 152/70 92 16 93%RA
GEN: NAD
HEENT: NCAT
Neck: supple, no cervical LAD, nontender, + tender with
swallowing. Nonpalpable thyroid.
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB, nonlabored no wheeze. Coarse breath sounds.
ABD: soft, NTND, no masses or hepatosplenomegaly
EXT: warm well perfused, no edema
SKIN: No rashes or skin breakdown. R side femoral port site
clean/dry/intact without erythema or drainage.
NEURO: AOx3, face symmetric
Pertinent Results:
ADMISSION LABS:
___ 11:00AM BLOOD WBC-2.1* RBC-2.94* Hgb-9.6* Hct-27.8*
MCV-95 MCH-32.7* MCHC-34.5 RDW-14.3 RDWSD-47.4* Plt ___
___ 02:30PM BLOOD Neuts-74* Bands-1 Lymphs-15* Monos-10
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-1.50*
AbsLymp-0.30* AbsMono-0.20 AbsEos-0.00* AbsBaso-0.00*
___ 11:00AM BLOOD Glucose-109* UreaN-4* Creat-0.6 Na-135
K-4.1 Cl-99
___ 11:00AM BLOOD ALT-9 AST-16 AlkPhos-80 TotBili-0.4
___ 11:00AM BLOOD TotProt-6.5 Albumin-3.9 Globuln-2.6
Calcium-8.8 Mg-1.9
___ 02:40PM BLOOD Lactate-0.7
DISCHARGE LABS:
___ 06:01AM BLOOD WBC-1.9* RBC-2.76* Hgb-8.9* Hct-25.7*
MCV-93 MCH-32.2* MCHC-34.6 RDW-14.2 RDWSD-45.8 Plt ___
___ 06:01AM BLOOD Neuts-67 Bands-0 ___ Monos-11 Eos-1
Baso-0 ___ Myelos-0 AbsNeut-1.27* AbsLymp-0.40*
AbsMono-0.21 AbsEos-0.02* AbsBaso-0.00*
___ 06:01AM BLOOD Glucose-90 UreaN-5* Creat-0.6 Na-138
K-3.5 Cl-105 HCO3-25 AnGap-12
___ 06:01AM BLOOD Calcium-8.2* Phos-4.0 Mg-1.9
IMAGING:
CXR ___:
IMPRESSION:
Marked interval reduction in size of right hilar mass and
apparent resolution of the right paratracheal lymphadenopathy
compared to the previous chest radiograph from ___. No
acute cardiopulmonary abnormality.
MICRO:
___ 2:03 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
Brief Hospital Course:
Ms ___ is a ___ year old female with a history of stage II
breast cancer and recent diagnosis of small cell lung cancer
currently being treated with combined chemotherapy and radiation
who was admitted from clinic w/ worsening odynophagia and
chills.
#Odynophagia w/ PO intolerance - likely related to radiation
?esophagitis and mild mucositis, pt is receiving
hilar/medistinnal XRT and chemo. Radiation therapy scheduled
for ___ was held with plan to resume on ___ per radiation
oncology note. Patient was given magic mouthwash and carafate.
Patient felt better clinically on hospital day 2 and was
tolerating POs without difficulty.
#Chills - concern for pneumonia or other infection in clinic.
Infectious workup including labs, CXR and u/a were unrevealing.
Femoral port site appeared clean, was without visible drainage,
erythema or tenderness. There were no localizing symptoms
suggestive of infection. Patient remained afebrile during
hospitalization. Patient felt well and back to baseline by day
2 hospitalization.
#Orthostasis - noted in clinic on day of admission. Was likely
___ poor PO intake. Was given IVF hydration. BPs were stable on
day 2.
#Small cell lung carcinoma: limited stage disease, receiving
concurrent chemoradiation, completed C2 chemo ___. Plan for
radiation ___ (total ___ Fr) Her most recent CT scan is
consistent with treatment response.
- due for next chemo ___. As noted above XRT was held on
___ due to ongoing esophagitis, next treatment on ___.
Further chemorads plan per outpatient providers.
#Pain: Chronic and related to lumbar spinal disease/scoliosis.
Patient's pain management physician continues to serve as her
sole prescriber. Was continued on home regimen of MS contin, is
on short acting fentanyl at home, uses PO dilaudid when admitted
as fentora not available ___ hospital pharmacy.
#COPD: Stable; continued Advair and nebulizers
#Hx RLE swelling - recent right lower extremity ultrasound was
negative for DVT.
Transitional Issues:
=================================
[ ] f/u with outpatient oncologist (Dr. ___ for
continued management of small cell lung cancer
[ ] f/u BCx and Urine Cultures drawn during hospitalization
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ipratropium-Albuterol Neb 1 NEB NEB Q6H wheeze
2. Sodium Chloride 3% Inhalation Soln 15 mL NEB BID
3. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
4. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
5. Morphine SR (MS ___ 45 mg PO Q8H
6. TraZODone 150 mg PO QHS
7. Bisacodyl 10 mg PO DAILY:PRN constipation
8. Docusate Sodium 100 mg PO BID constipation
9. Guaifenesin ER 1200 mg PO Q12H
10. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
11. Nicotine Patch 21 mg TD DAILY
12. Nicotine Polacrilex 2 mg PO Q1H:PRN craving
13. Ondansetron 8 mg PO Q8H:PRN nausea
14. Senna 8.6 mg PO BID constipation
15. Fentora (fentaNYL citrate) 400 mcg buccal QID pain
16. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
Q4H:PRN wheezing, sob
17. Prochlorperazine 10 mg PO Q6H:PRN nausea
18. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
19. Dexamethasone 4 mg PO DAILY
20. Omeprazole 20 mg PO DAILY
21. Lidocaine Viscous 2% 15 mL PO TID:PRN sore throat
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Docusate Sodium 100 mg PO BID constipation
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Guaifenesin ER 1200 mg PO Q12H
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H wheeze
7. Morphine SR (MS ___ 45 mg PO Q8H
8. Nicotine Patch 21 mg TD DAILY
9. Senna 8.6 mg PO BID constipation
10. TraZODone 150 mg PO QHS
11. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
12. Dexamethasone 4 mg PO DAILY
13. Fentora (fentaNYL citrate) 400 mcg buccal QID pain
14. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
15. Lidocaine Viscous 2% 15 mL PO TID:PRN sore throat
16. Nicotine Polacrilex 2 mg PO Q1H:PRN craving
17. Omeprazole 20 mg PO DAILY
18. Ondansetron 8 mg PO Q8H:PRN nausea
19. Prochlorperazine 10 mg PO Q6H:PRN nausea
20. Sodium Chloride 3% Inhalation Soln 15 mL NEB BID
21. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
Q4H:PRN wheezing, sob
22. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 10 ml by mouth four times a day
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Odynophagia
2. Fatigue
Secondary Diagnosis:
1. Small Cell Lung Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure caring for you during your admission to ___
___. You were admitted for
evaluation of fatigue and difficulty swallowing. An infectious
workup including a chest xray and urinalysis were done which did
not show any signs of infection. Your pain with swallowing is
likely due to the radiation treatment you are receiving. Your
radation treatment was held for one day, but is scheduled to
resume on ___. You improved clinically and it
was determined you were safe to be discharged to home. You are
scheduled to resume treatment for your lung malignancy next
week. Please take your medications as prescribed and keep your
follow up appointments as scheduled. Should you develop fevers
or worsening shortness of breath please seek medical attention
at your nearest emergency department.
We wish you all the best.
- Your ___ Team
Followup Instructions:
___
|
19881444-DS-9
| 19,881,444 | 28,510,941 |
DS
| 9 |
2161-03-28 00:00:00
|
2161-03-28 16:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / benzocaine
Attending: ___.
Chief Complaint:
Weakness, dehydration
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with stage II breast cancer and limited stage small cell
lung
carcinoma status post chemotherapy and prophylactic brain
radiation presents with generalized weakness and failure to
thrive.
The patient's primary oncologist Dr. ___ an
urgent call from patient's husband and son yesterday. Patient
states she has been unwell for past 1 week with generalized
fatigue, anorexia, some orthostatic symptoms. She declined to
come in for evaluation and plan was for clinic visit today. This
morning, oncologist was contacted again by family. Patient was
too weak to come to clinic. She was not eating or drinking and
too weak to get into the car. EMS was called and she was
transported to ___.
In the ED, initial VS were: T 100.1->98.1 without intervention,
___ 22 100% RA
Labs were notable for: CBC nl, K 3.0, LFTs nl, Ca ___ with
albumin 4.6, lactate nl, VBG nl, flu swab PCR negative
Imaging included: CXR and CT head negative
Treatments received:
___ 11:02 IV Ondansetron 4 mg
___ 11:02 IVF 1000 mL NS 1000 mL
___ 13:01 IVF 1000 mL NS 1000 mL
___ 13:01 IV HYDROmorphone (Dilaudid) 2 mg
___ 15:35 PO Potassium Chloride 40 mEq
___ 15:35 IV Magnesium Sulfate 2 gm
___ 15:35 IV Fentanyl Citrate 25 mcg
___ 15:35 IVF 1000 mL NS 1000 mL
On arrival to the floor, patient had no acute complaints.
Past Medical History:
PAST ONCOLOGIC HISTORY:
1. Patient had a protracted course of pneumonia starting in
___ required two months of antibiotics.
2. Presented to PCP in early ___ with symptoms of
headache,
chest discomfort, right shoulder pain, right arm
weakness/tingling, and difficulty swallowing. A CT scan was
performed on ___ and showed extensive adenopathy,
paratracheal, posterior to the SVC, compressing the SVC, and
enveloping the right main pulmonary artery. There was also
extensive hilar adenopathy, precarinal adenopathy, and
azygoesophageal adenopathy.
3. Patient was subsequently admitted to ___ from ___ to
___. Bronchoscopy with biopsy of level 7 and 4L lymph
nodes
was performed. Note that stenting of right bronchus intermedius
was also performed. Pathology was notable for malignant cells,
consistent with small cell carcinoma. Completion of staging
evaluation revealed no brain or osseous metastases; patient was
considered to have limited stage disease.
4. Cycle 1 of chemotherapy was started on ___ cisplatin 75
mg/m2 on day 1 and etoposide 100 mg/m2 on days ___.
5. Initial visit with radiation oncology on ___. Radiation
was initiated on ___ (31 treatments planned).
6. Patient reported increased tinnitus and hearing loss at visit
on ___. She was evaluated by audiologist (Dr. ___ with
findings notable for high frequency sensorineural hearing loss.
Cycle 2 of cisplatin and etoposide administered on ___
without modification (note that cisplatin administered on day 3
of cycle).
7. Patient subsequently developed chest and upper abdominal
discomfort associated with odynophagia. This was attributed to
GERD with possible contribution from mucositis and she was
started on omeprazole 20 mg QD and magic mouthwash as needed.
8. Patient noted to have new onset right calf swelling on
___. A lower extremity ultrasound was negative for DVT.
9. Bronchial stent was removed on ___.
10. Patient presented to clinic on ___ with chills, sore
throat, shortness of breath, and cough. Patient was admitted to
the hospital for further evaluation and care. CXR was negative
for pneumonia. Blood and urine cultures were negative. Patient
was treated with IVF and sucralfate was added to regimen. She
was discharged home the following day.
11. Cultures from bronchial stent removal returned positive for
stenotrophomonas maltophilia. Patient completed a two week
course of Bactrim (15 mg/kg/day).
12. Cycle 3 of cisplatin and etoposide initiated on ___.
Cycle was complicated by poor PO intake, hypovolemia, and
orthostasis requiring multiple visits to ___
IVF.
13. Follow up audiology evaluation revealed progressive hearing
loss. Carboplatin AUC 6 was substituted for cisplatin in cycle
4
of therapy (administered with etoposide on ___.
14. Radiation therapy end date was ___. Patient received a
total dose of 5580 cGy.
15. Prophylactic cranial irradiation initiated on ___.
PAST MEDICAL HISTORY:
Small cell lung carcinoma
Stage II IDC of breast
Chronic obstructive pulmonary disease
Tobacco abuse
Vertebral degenerative disc disease
Chronic back pain
Scoliosis
Left shoulder bursitis
Osteoporosis
History of pneumonia
Social History:
___
Family History:
Unclear if family history of cancer.
Physical Exam:
VS: T 98.4 BP 126/56 HR 78 RR 18 O2 100%RA
GENERAL: NAD
HEENT: No scleral icterus, OP clear without lesions
HEART: RRR, normal S1 S2, no murmurs
LUNG: Clear, good effort, no wheezes or rales
ABD: Soft, NT ND.
EXT: No ___ edema.
NEURO: Alert and oriented, no focal deficits.
Pertinent Results:
___ 10:50AM BLOOD WBC-8.8# RBC-4.11 Hgb-14.1 Hct-41.2
MCV-100* MCH-34.3* MCHC-34.2 RDW-14.0 RDWSD-50.4* Plt ___
___ 07:01AM BLOOD WBC-2.8* RBC-3.20* Hgb-10.9* Hct-32.9*
MCV-103* MCH-34.1* MCHC-33.1 RDW-14.0 RDWSD-53.1* Plt ___
___ 07:01AM BLOOD Glucose-85 UreaN-5* Creat-0.7 Na-142
K-4.0 Cl-108 HCO3-26 AnGap-12
___ 10:50AM BLOOD ALT-26 AST-29 AlkPhos-104 TotBili-0.8
___ 07:01AM BLOOD Mg-2.0
___ 07:52AM BLOOD VitB12-1271*
___ 07:52AM BLOOD TSH-3.7
CT Head: No acute intracranial process.
CXR: No acute intrathoracic process.
CT Chest: Unchanged pulmonary nodules.
Stable appearance of paratracheal mediastinal and right hilar
lymph nodes with no interval increase.
Unchanged bronchiectasis.
Image portion of the upper abdomen will be reviewed separately
in
corresponding report will be issued.
Previously seen pericardial effusion has resolved with currently
no
pericardial effusion seen and no pleural effusion demonstrated.
CT Abd:
1. No evidence of metastatic disease in the abdomen or pelvis.
2. Thrombus in the infrarenal inferior vena cava appears
increased compared to the prior study and appears to extend into
the right common iliac vein.
3. Nonobstructing right nephrolithiasis.
Brief Hospital Course:
___ with stage II breast cancer and limited stage small cell
lung carcinoma status post chemotherapy and prophylactic brain
radiation who presented with weakness, failure to thrive.
Depression
- Like the cause of the patient's ongoing fatigue, poor
appetite, and failure to thrive. She was started on mirtazapine.
She declined to be started on an SSRI however would likely
benefit from this if started as an outpatient. Would also likely
benefit from seeing a social worker or psychologist as an
outpatient. Patient feeling better prior to discharge with
hydration.
IVC thrombus
- This was seen on previous imaging but she was not started on
anticoagulation. Per the patient's primary oncologist no
anticoagulation at this time as femoral line now removed and no
active cancer.
Small cell lung carcinoma
- Patient had limited stage disease at time of diagnosis and is
now status post definitive concurrent chemoradiation and
prophylactic cranial irradiation. CT scans done did not so any
sign of recurrence. The patient's primary oncologist was aware
of the admission and will follow up with the patient as an
outpatient.
Anemia
- Unclear cause. No bleeding. Minor drop while inpatient likely
dilutional. Needs to be further investigated as an outpatient.
Also with borderline leukopenia which may be due to infection
and needs to be follow up to ensure resolution.
C.Diff
- Diagnosed this admission after the patient had diarrhea. She
was started on flagyl which she will complete a 14 day course of
as an outpatient. This may have been contributing to her fatigue
and dehydration.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze
3. Morphine SR (MS ___ 60 mg PO Q12H
4. TraZODone 150 mg PO QHS
5. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
6. Fentora (fentaNYL citrate) 400 mcg buccal QID:PRN pain
7. Omeprazole 20 mg PO DAILY
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Sodium Chloride 3% Inhalation Soln 15 mL NEB BID:PRN
wheezing
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
Q4H:PRN wheezing, sob
12. Correctol (bisacodyl) 5 mg oral DAILY:PRN constipation
13. Sarna Lotion 1 Appl TP TID:PRN itching
14. Benzonatate 100 mg PO BID:PRN cough
15. Docusate Sodium 100 mg PO BID:PRN constipation
16. Memantine 10 mg PO BID
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Morphine SR (MS ___ 60 mg PO Q12H
5. Omeprazole 20 mg PO DAILY
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Mirtazapine 7.5 mg PO QHS
RX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
9. Correctol (bisacodyl) 5 mg oral DAILY:PRN constipation
10. Fentora (fentaNYL citrate) 400 mcg BUCCAL QID:PRN pain
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
Q4H:PRN wheezing, sob
12. TraZODone 100 mg PO QHS:PRN insomnia
13. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*39 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Dehydration
Small Cell Lung Cancer
C.diff
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with weakness and dehydration. We gave you
fluids and you improved. We also stopped your memantine, this
may make you feel better, and started a medication called
mirtazapine for depression which also stimulates appetite.
Your CT did not show any evidence of your cancer progressing
which is good news.
We did find you have a bowel infection called c.diff which we
started a medication called flagyl for. You will take this for
14 days.
Followup Instructions:
___
|
19881466-DS-19
| 19,881,466 | 22,620,062 |
DS
| 19 |
2168-06-02 00:00:00
|
2168-06-16 23:45:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
___: NEUROLOGY
Allergies:
Aspirin / Nsaids / doxycycline
Attending: ___.
Chief Complaint:
bilateral lower extremity numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year old right handed female with
___'s hypothyroidism, degenerative lumbar disease and
history of right eye retinal detachment presenting with 1 week
of progressive ascending sensory changes and subjective
fatigue/weakness in the bilateral lower extremities.
Briefly, Mrs. ___ reports that she was in her usual state of
health until ___ when first noted tingling in the
bilateral soles of her feet while she was driving to visit her
son in ___. By the end of the day, sensory symptoms
("feeling of numb and cold") progressed to the ankles
bilaterally but there was no weakness. She was able to walk
normally and had no other complaints. ___, she first
noted reduced sensation in her buttocks and pelvis (unable to
feel herself wiping when going to bathroom, though denied
urinary/bowel incontinence). She came to the ED ___ for these
complaints and on Neuro Consult exam (___) had preserved
strength and subjectively decreased sensation in the bilateral
legs to midshin with light touch only. Refelxes were normal
aside from dropped achilles. MRI L-spine in
ED showed stable multilevel degenerative disease of the lumbar
spine, worst at L4-L5. Inflammatory labs (ESR, CRP, RF, SSA,
SSB, HgA1c, B12, Lyme) were sent and she was discharged with
Neuro Urgent follow up the next day with Dr. ___. Neuro exam
was unchanged, and though the patient's sensory complaints
persisted, there was no objective loss of pin on exam and no
myelpathic signs. Dr. ___ for outpatient EMG to
assess atypical CIDP/AIDP and ordered MRI Pelvis. The patient
returned to the ED ___ however, after a spell of worsening
weakness/fatigue when she was walking into work (felt "immense
fatigue" all over). ED LP on that visit to further assess for
atypical sensory was bland: 2WBC, 0RBC, 26 protein. Exam was
___ strength with unchanged subjective sensory symptoms
(involving the groin and bilateral legs skipping the thighs),
normal rectal tone, and stable reflex examination. Case
discussed with Dr. ___ she was discharged again.
Unfortunately the patient presented back today with persistent
symptoms, now slightly progressed to involve the thighs
(previously a skipped region). She reports feeling
fatigued/weak when trying to climb a flight of stairs at home
which is new. Location of abnormal groin sensation is stable,
though she says more severe, unable to feel herself
urinating/defecating, and with a sense that she is voiding
incompletely (though no actual incontinence).
Of note, in the past she has had 2 similar (1 in ___ consisting
bilateral arm/legs heaviness, another in ___ with bilateral
feet/pelvic numbness). Workup for MS then with MRI brain and
C/T/L spine with contrast was unremarkable and symptoms
spontaneously resolved both times. She has been well in the
interim years. No blurry vision or weakness.
REVIEW OF SYSTEMS:
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies focal muscle weakness. Denies difficulty with
gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain. No recent change in
bowel or bladder habits. Denies dysuria or hematuria. Denies
myalgias, arthralgias, or rash.
Past Medical History:
-___'s hypothyroidism
-Degenerative disc disease
-Lumbar scoliosis
-Cervical kyphosis
-right eye retinal detachment ___ years ago
-Asthma
-Allergic rhinitis
Social History:
___
Family History:
Paternal family has ulcerative colitis, heart disease and
diabetes. Reports maternal family is healthy. No known
autoimmune disease other than ulcerative colitis in family. No
known stroke history in family. No other known neurologic
problems in the family.
Physical Exam:
Admission Physical Exam:
Vitals: T-97.6 HR-85 BP-122/94 RR-20 SPo2-99% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes. NIF normal.
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
-Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily maintained. Recalls a coherent history. Speech
is fluent with full sentences, intact repetition, and intact
verbal comprehension. Normal prosody. No dysarthria. No apraxia.
No evidence of hemineglect. No left-right agnosia.
-Cranial Nerves - PERRL R4-3 (chronically larger, surgical),
L3->2 brisk. VF full to number counting. EOMI, no nystagmus. No
red desaturation. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
Motor - Normal bulk and tone. No drift. No tremor or asterixis.
Neck ext/flex ___ bilaterally. No fatiguable weakness.
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 - Pinprick is intact throughout. She has intact but
reduced/abnormal sensation to light touch ("dull, heavy, cold")
in the bilateral feet-to-knees (compared to midshin on
___, now mildly involving the thighs, and stable
subjective change the groin (where she DOES feel pin normally).
NO SYMPTOMS above the waist. Proprioception intact, vibration
slightly reduced at the toes (8 seconds bilaterally).
DTRs:
Bi Tri ___ Pat Ach
L ___ 2 1
R ___ 2 0
Plantar response flexor bilaterally. No hyperreflexia.
Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements.
Gait - Normal initiation and base. Normal stride length and arm
swing. Stable without sway. Negative Romberg. Normal stress
gait. Difficulty with tandem.
Discharge Physical Exam:
Vitals: T-98.5 Tm-98.5 ___ ___ RR-18
SPO2-97% RA
General: NAD
HEENT: NCAT
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes.
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema
Skin: No rashes or lesions
Mental Status - Her mental status is unchanged from admission.
On morning of discharge she is alert and attentive, answering
questions appropriately. Her speech is fluent, and she speaks in
full sentences.
Cranial Nerves - Face is symmetrical. Eyes are PERRLA, EOMI, but
she exhibits Right sided ptosis that she states is long-standing
after surgery to fix retinal detachment.
DTRs:
Bi Tri ___ Pat Ach
L ___ 2 1
R ___ 2 1
Her planter reflex is flexor bilaterally.
Sensory - Pinprick and proprioception intact throughout. Light
touch is intact bilaterally, but she complains of "funny"
abnormal feeling in ___ from foot to thigh that she does not
feel in UEs or on abdomen.
Motor -
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4+* 5 4+ 5 5 5
R 5 ___ ___ 4+* 5 4+ 5 5 5
*giveaway
Discharge Exam
RRR, no WOB, no rashes
She continues to have
diminished sensation to light touch from mid-shin distally with
diminished reflexes at the knees and ankles.
Pertinent Results:
___ 12:25PM PLT COUNT-223
___:25PM NEUTS-60.7 ___ MONOS-7.7 EOS-1.1
BASOS-0.5 IM ___ AbsNeut-3.39 AbsLymp-1.65 AbsMono-0.43
AbsEos-0.06 AbsBaso-0.03
___ 12:25PM WBC-5.6 RBC-4.62 HGB-14.1 HCT-42.6 MCV-92
MCH-30.5 MCHC-33.1 RDW-13.1 RDWSD-44.1
___ 12:25PM GLUCOSE-133* UREA N-7 CREAT-0.6 SODIUM-143
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-27 ANION GAP-15
___ 03:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:35PM URINE COLOR-Yellow APPEAR-Clear SP ___
Brief Hospital Course:
___ is a ___ year old right handed female with
___'s hypothyroidism, degenerative lumbar disease, and a
history of right eye retinal detachment presenting with 1 week
of progressive ascending sensory changes in the lower
extremities and pelvis and subjective fatigue/weakness in the
bilateral lower extremities. Initial sensory exam showed intact
pinprick and proprioception. She had abnormal, though not
necessarily reduced sensation to light touch on her lower
extremities that may have represented dysesthesias.
Her work-up included a lumbar spine MRI, which demonstrated
known degenerative disk changes, and a lumbar puncture that was
unremarkable. Thoracic spine MRI performed on the day of
admission was significant for a T2 hyperintense lesion in the T9
area, concerning for a demyelinating lesion. The spinal cord
lesion is concerning, but not definitive for, multiple
sclerosis. Brain MRI did not show any lesions concerning for
demyelination.
Given her symptoms, and the concern for an acute demyelinating
process, the patient was stared on methylprednisolone infusion
the day after admission. On day 3 of infusions, she reported
improved sensation in her lower extremities. She was discharged
after the fourth dose with a plan to complete the fifth dose as
an outpatient. Ms. ___ had issues voiding, with
self-reported increased strain but decreased flow, but was shown
to have a post-void residual of 0 mL.
Labs were normal except for an elevated white count of 15.7 the
day before discharge, associated with infusion of high dose
steroids. Several labs are pending, including MS-profile of CSF,
serum angiotensin 1 converting enzyme, and serum neuromyelitis
optica/squaporin-4-IGG cell binding assay. Gabapentin 300mg BID
was prescribed for ___ pain., and this will be increased to 600mg
BID on ___.
Transitional Issues:
-Fifth dose of MTP
- Several labs are pending, including MS-profile of CSF, serum
angiotensin 1 converting enzyme, and serum neuromyelitis
optica/squaporin-4-IGG cell binding assay.
-MRV pelvis canceled; please reorder if needed
-EMG is scheduled for ___.
Medications on Admission:
levothyroxine 100 mcg daily
omeprazole 20mg daily
bromfenac 0.07% eye drops, 1 gtt in the right eye twice a day
Discharge Medications:
levothyroxine 100 mcg daily
omeprazole 20mg daily
bromfenac 0.07% eye drops, 1 gtt in the right eye twice a day
methylprednisolone sodium succ 1000 mg IV daily
docusate sodium 100 mg PO PRN constipation
senna 8.6 mg PO PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
demyelinating lesion in thoracic spinal cord, concerning for MS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the ___
Neurology ___ for persistent ascending sensory changes in
your lower extremities and pelvic region.
You were found to have a hyperintense lesion in your thoracic
spinal cord, consistent with a demyelinating lesion) which is
the likely cause of your sensory changes. MRI of the head showed
no demyelinating lesions in the brain. The spinal cord lesion is
concerning, but not definitive for, multiple sclerosis. We
therefore sent out several other studies for which the results
are still pending.
You are on a 5 day course of methylprednisolone infusion which
will be completed in the outpatient setting.
Please note that you have several follow up appointments planned
for EMG, and with neurology to further work up the potential
diagnosis.
Thank you for letting us participate in your care.
___ Neurology Team
Followup Instructions:
___
|
19881493-DS-12
| 19,881,493 | 27,120,524 |
DS
| 12 |
2125-06-18 00:00:00
|
2125-06-18 15:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with no PMH who
presents with 10 days of epigastric pain. She reports the onset
of epigastric and RUQ pain starting ten days ago. Since then it
has been constant with periodic flares of her pain intensity.
She states the pain is made worse with eating. She reports
nausea but no emesis with the pain. She also reports an episode
of diarrhea initially which has since resolved. She has lost 6
lbs since the onset of her pain because she is not eating as
much. She denies f/c, CP, SOB, cough, dysuria, bloody or black
stool. She denies significant NSAID use. She went to ___ several times due to the pain. She was prescribed
omeprazole, tramadol, and amoxicillin 5 days ago. She is taking
Tylenol as well. She went back to ___ and
requested xfer to ___ for evaluation. Concern was raised for
cholecystitis and she was evaluated by surgery.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
None
Social History:
___
Family History:
Mother with stomach ulcer.
Physical Exam:
Admission:
GENERAL: Alert and in no apparent distress, thin appearing
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate, MM dry
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, mild epigastric TTP without
reboud or guarding. Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
PSYCH: pleasant, appropriate affect
Discharge:
GENERAL: Alert and in no apparent distress, thin appearing
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate, MM dry
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, very mild epigastric TTP
without
reboud or guarding, improving. 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
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission:
___ 09:28PM URINE HOURS-RANDOM
___ 09:28PM URINE UCG-NEGATIVE
___ 09:28PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:28PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 09:26PM GLUCOSE-94 UREA N-9 CREAT-0.6 SODIUM-136
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-23 ANION GAP-10
___ 09:26PM estGFR-Using this
___ 09:26PM ALT(SGPT)-11 AST(SGOT)-19 ALK PHOS-33* TOT
BILI-0.4
___ 09:26PM LIPASE-30
___ 09:26PM ALBUMIN-4.9
___ 09:26PM WBC-8.6 RBC-4.61 HGB-13.4 HCT-40.6 MCV-88
MCH-29.1 MCHC-33.0 RDW-11.9 RDWSD-37.9
___ 09:26PM NEUTS-50.7 ___ MONOS-4.9* EOS-5.8
BASOS-0.6 IM ___ AbsNeut-4.33 AbsLymp-3.24 AbsMono-0.42
AbsEos-0.50 AbsBaso-0.05
___ 09:26PM PLT COUNT-337
Discharge:
___ 05:48AM BLOOD WBC-7.0 RBC-4.11 Hgb-12.1 Hct-36.1 MCV-88
MCH-29.4 MCHC-33.5 RDW-11.8 RDWSD-37.9 Plt ___
___ 09:26PM BLOOD Neuts-50.7 ___ Monos-4.9* Eos-5.8
Baso-0.6 Im ___ AbsNeut-4.33 AbsLymp-3.24 AbsMono-0.42
AbsEos-0.50 AbsBaso-0.05
___ 05:48AM BLOOD Glucose-73 UreaN-9 Creat-0.7 Na-137 K-4.5
Cl-102 HCO3-22 AnGap-13
___ 05:48AM BLOOD ALT-8 AST-13 AlkPhos-26* TotBili-0.6
___ 05:48AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.1
___ 09:26PM BLOOD Albumin-4.9
Imaging:
RUQUS ___:
IMPRESSION:
Mildly distended gallbladder containing sludge with trace
pericholecystic
fluid without wall thickening or mural edema are not definite
for acute
cholecystitis. If there is a persistent concern for acute
cholecystitis a
HIDA scan can be considered for further evaluation.
HIDA ___:
FINDINGS: Serial images over the abdomen show homogeneous
uptake of tracer into
the hepatic parenchyma.
At 8 minutes, the gallbladder is visualized with tracer activity
noted in the
small bowel at 20 minutes.
IMPRESSION: Normal hepatobiliary scan. No evidence of
cholecystitis.
Brief Hospital Course:
Ms. ___ is a ___ woman with no significant PMH who
presents with 10 days of epigastric pain with unclear etiology,
likely IBS exacerbated by recent viral gastroenteritis.
# Epigastric pain
#Likely IBS
Symptoms are most consistent with IBS vs. post-gastroenteritis
gastritis, although etiology is not entirely clear. RUQUS showed
possible gallbladder dilation and sludge but HIDA was negative.
She was seen by GI here who did not feel that she would benefit
from more inpatient workup including EGD. H. pylori is a
consideration so we sent a stool H. Pylori antigen, pending at
discharge. She had a blood test for H. pylori antibody at ___
___ but this came back within normal range, and also
this does not help diagnose acute illess, just exposure. GI also
felt that there could be an element of IBS so recommended
anti-spasmotic with Bentyl and bowel regimen with senna and
miralax, which she will be discharged with. She has outpatient
GI Follow up and plan for EGD in 3 weeks. Of note, she was
prophylactically started on amoxicillin and a PPI (but not true
triple therapy) but there was not clearly a H. pylori diagnosis.
We will stop the amoxicillin unless H. pylori stool antigen
comes back positive. We will also hold the PPI given no clear
indication and its ability to alter H. pylori results. She was
also given a prescription for Align probiotic.
Transitional Issues:
[] GI follow up on discharge
[] we sent a stool H. Pylori antigen, pending at discharge
>30 minutes were spent preparing this discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. Amoxicillin 875 mg PO Q12H
3. Ranitidine 300 mg PO DAILY
4. TraMADol 50 mg PO TID:PRN Pain - Moderate
Discharge Medications:
1. Align (Bifidobacterium infantis) 10.5 mg (10 million cell)
oral DAILY
RX *Bifidobacterium infantis [Align] 4 mg (1 billion cell) 1
capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
heartburn
3. DICYCLOMine 20 mg PO TID
RX *dicyclomine 20 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by
mouth once a day Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
6. Ranitidine 300 mg PO DAILY
7. TraMADol 50 mg PO TID:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: IBS, viral gastroenteritis
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 of ongoing abdominal pain.
Imaging studies did not identify any issues with your
gallbladder or other organs. GI saw you and they felt that this
was likely IBS, related to a recent gastroenteritis infection.
We will focus on treating your spasms with Bentyl (dicyclomine).
You should also take medications to help you have bowel
movements and see your GI doctor.
We wish you all the best.
Sincerely,
Your care team at ___
Followup Instructions:
___
|
19881566-DS-5
| 19,881,566 | 27,287,770 |
DS
| 5 |
2171-01-17 00:00:00
|
2171-01-19 16:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Vaseline Dermatology Formula / Red Dye /
amiodarone
Attending: ___
Chief Complaint:
Chest heaviness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with history of sick sinus syndrome s/p PPM and
ablation in ___, valvular heart disease (AS/MR), afib,
?interstitial lung disease p/w "chest heaviness" since ___ AM
this morning. She was making breakfast when she began to feel
chest heaviness. Pressure was ___, nonradiating,
non-exertional. She went to her PCP, where she received 324 ASA
and 2 NTG, with improvement in pressure to ___.
She denies pain, radiation, SOB, fever, nausea, abd pain, and
dysuria. The chest heaviness is not related to exertion and has
been happening for the past several months since her ablation.
Her pain is somewhat better sitting up. It is located primarily
substernally diffusely. Her pressure is associated with anxiety.
Today the pressure was worse than her previous episodes, maxing
at ___. It did respond to nitro at PCP's office. EKG shows
ventricularly paced rhythm, with known LBBB and no ST segment
changes (negative Sgarbossa). There was no association with N/V,
diaphoresis, or shortness of breath. She does note some
association with headache.
In the ED initial vitals were: T 98.9, P 70, BP 141/93, RR 18,
O2sat 97% on RA
Labs/studies notable for: CXR without edema.
Patient was given: IV HYDROmorphone (Dilaudid) .125 mg and
Warfarin 2.5 mg
On the floor, patient notes waxing/waning chest pressure as
above. It worsened with anxiety. It resolved with nitroglycerin
SL and patient was able to sleep.
Past Medical History:
- Dyslipidemia,
- Paroxysmal atrial fibrillation
- Aortic stenosis, moderate
- Mitral regurgitation
- Hypertension
- Chronic urinary tract infections
- Hemorrhoids
- History of ___ syndrome
- Lower limb ulcer
- Varicose veins
- Osteopenia
- Glaucoma
Social History:
___
Family History:
Mother with MI in ___, also hx of breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
====================
VS: T 97.9, BP 120/67, P 70, RR 18, O2sat 97% on RA
GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate
but anxious.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Non-elevated JVP at 90 degrees
CARDIAC: RR, mid-peaking III/VI systolic murmur, normal S2.
AS/MR murmurs noted
LUNGS: 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 PHYSICAL EXAM:
=====================
Vitals: Tmax 100.3, BP 118-140/68-84, P 69-70, RR 18, O2sat
98-100% on RA
GENERAL: WDWN F 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: Non-elevated JVP at 90 degrees
CARDIAC: RR, mid-peaking III/VI systolic murmur, normal S2.
AS/MR murmurs noted
LUNGS: Resp were unlabored, no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
===============
___ 05:48PM BLOOD WBC-10.1*# RBC-4.07 Hgb-12.1 Hct-36.7
MCV-90 MCH-29.7 MCHC-33.0 RDW-14.2 RDWSD-46.9* Plt ___
___ 05:48PM BLOOD Neuts-76.4* Lymphs-11.7* Monos-9.8
Eos-0.9* Baso-0.3 Im ___ AbsNeut-7.75*# AbsLymp-1.19*
AbsMono-0.99* AbsEos-0.09 AbsBaso-0.03
___ 05:27PM BLOOD ___ PTT-42.5* ___
___ 05:18PM BLOOD Glucose-125* UreaN-15 Creat-1.0 Na-131*
K-4.5 Cl-95* HCO3-22 AnGap-19
___ 05:18PM BLOOD proBNP-1455*
___ 05:18PM BLOOD cTropnT-<0.01
___ 09:00PM URINE Color-Straw Appear-Clear Sp ___
___ 09:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 09:00PM URINE RBC-3* WBC-136* Bacteri-FEW Yeast-NONE
Epi-2
OTHER RELEVANT LABS:
=================
___ 05:18PM BLOOD cTropnT-<0.01
___ 12:48AM BLOOD cTropnT-<0.01
URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
DISCHARGE LABS:
===============
___ 07:35AM BLOOD WBC-10.9* RBC-4.60 Hgb-13.7 Hct-42.0
MCV-91 MCH-29.8 MCHC-32.6 RDW-14.5 RDWSD-47.9* Plt ___
___ 07:35AM BLOOD ___ PTT-39.1* ___
___ 07:35AM BLOOD Glucose-108* UreaN-16 Creat-1.1 Na-132*
K-3.8 Cl-93* HCO3-24 AnGap-19
CXR (___) IMPRESSION:
1. No pulmonary edema.
2. Possible trace left pleural effusion versus pleural
thickening. No large effusion on the right.
3. Similar mild diffuse interstitial opacities, suggestive of a
chronic interstitial process.
STRESS (!___) IMPRESSION: No anginal type symptoms or
interpretable ST segments.
Nuclear report sent separately.
Cardiac perfusion (___):
1. Normal myocardial perfusion.
2. Normal left ventricular cavity size and systolic function.
Brief Hospital Course:
Ms. ___ is an ___ female with a history of
paroxysmal atrial fibrillation , SSS, with a pacer implanted due
to symptomatic bradycardia, who presented with chest heaviness,
which was subacute in onset with an unchanged EKG and negative
cardiac biomarkers. She had a nuclear stress test done
(sestamibi), which revealed: normal LV cavity, rest and stress
perfusion images revealed uniform uptake through the left
ventricular myocardium. During her course, she was constipated,
which resolved with bisacodyl. Patient had a Tmax of 100.3 on
last day of hospitalization with no evidence of infection or any
suggestion of acute abdomen. Patient had aa negative urine
culture and CXR negative for pneumonia.
Patient was discharged on tylenol ___ mg TID for arthritic knee
pain, docusate and miralax for constipation, and omeprazole for
heartburn/GERD. Aspirin 81 mg daily was held given her
heartburn/GERD symptoms.
Patient was continued on the remainder of her home medications:
diazepam 5 mg prn: anxiety, senna 8.6 mg BID PRN constipation,
timolol for glaucoma, and warfarin for sick sinus
syndrome/atrial fibrillation.
TRANSIIONAL ISSUES:
===================
-Stopped Aspirin 81 mg given heartburn/GERD symptoms, and
without any known CAD, consider resuming for primary prevention
as needed
-New Medications: Tylenol ___ mg TID, Omeprazole 20 mg daily,
docusate 100 mg BID, polyethylene glycol 8.5 g daily
-Discharge WBC 10.9, no infectious symptoms, UA negative and
urine culture contaminated, CXR without acute process and known
prior interstitial changes.
-Discharge INR: 2.3 (Warfarin 2.5 mg daily on discharge), for
atrial fibrillation (goal ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 2.5 mg PO DAILY16
2. Senna 8.6 mg PO BID:PRN constipation
3. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
4. Aspirin 81 mg PO DAILY
5. Diazepam 5 mg PO DAILY:PRN anxiety
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
4. Polyethylene Glycol 8.5 g PO DAILY constipation
RX *polyethylene glycol 3350 [___] 8.5 gram 1 packet by
mouth daily Disp #*15 Packet Refills:*0
5. Diazepam 5 mg PO DAILY:PRN anxiety
6. Senna 8.6 mg PO BID:PRN constipation
7. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
8. Warfarin 2.5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
-Atypical Chest Pain
Secondary:
-Pacemaker ___ (Dual Chamber St ___
-Paroxysmal Atrial Fibrillation
-Moderate aortic stenosis
-Mitral regurgitation
-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 the ___ Cardiology team on ___
because you felt chest heaviness. You had no evidence of a new
heart attack.
You had a nuclear stress test to look for possible disease in
the arteries that supply your heart. This test was normal.
Please follow-up with your PCP and cardiologist.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
19881566-DS-6
| 19,881,566 | 29,352,254 |
DS
| 6 |
2171-09-29 00:00:00
|
2171-09-29 16:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Vaseline Dermatology Formula / Red Dye /
amiodarone
Attending: ___
Chief Complaint:
Dyspnea, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ female with a history of
paroxysmal atrial fibrillation, SSS, with a pacer implanted due
to symptomatic bradycardia (___), recurrent UTIs who
presented by EMS for weakness and dyspnea.
Ms. ___ reports that she developed a bad cold for 4 days
ago with significant coughing. The cough has been dry, without
sputum or hemoptysis. She has gotten progressively worse over
the past few days and this morning had severe lethargy such that
her husband had trouble getting her up. She went to her PCP
yesterday who diagnosed her with bronchitis and prescribed a 5
day course of azithromycin. At that time she noted clear lungs
on examination, but a cxr was not done.
She endorses chills, night sweats, but is not sure if she has
had a fever. She endorses nausea, but denies vomiting or
diarrhea. She has been unable to eat much. She denies SOB and
chest pain, though she does endorse some mild right lower chest
ache a few days ago that resolved. She denies dysuria or
hematuria, but may have had reduced urine output. She endorses
myalgias throughout her body, especially ___ her legs and arms.
She says that her daughter recently had a cold, which she
recovered from, but denies any other infectious contacts. She
recently returned from ___, where she and her husband were
for the last 3 months. At baseline she is ambulatory, walks with
a cane, and exercises on a stationary bike. She denies coughing
while eating or having any trouble swallowing. Of note, the
patient has frequent UTIs. Last took 3d of cipro about 1.5 weeks
ago.
___ the ED, initial VS were T: 100.2 HR: 60 BP:168/68 RR:24
O2sat: 99% Nasal cannula.
Exam notable for severe lethargy, but arousable, following
commands, and A&Ox3. She additionally had weakness ___ the lower
extremities (with intact dorsiflexion and plantarflexion, but
unable to lift legs off of bed). She was wheezy with bilateral
bibasilar crackles and 1+ pitting edema bilaterally.
Labs were remarkable for a negative UA with proteinuria a
positive troponin of 0.04, lactate of 2.9, and proBNP of 15174.
CXR showed new bibasilar opacities concerning for pneumonia, a
small right pleural effusion and central vascular congestion.
She received ceftriaxone, azithromycin, acetaminophen and her
home
medications.
Transfer VS were T:98.9 HR:60 BP:152/74 RR:22 O2sat: 96% Nasal
Cannula
Decision was made to admit to medicine for further management.
Past Medical History:
- Dyslipidemia,
- Paroxysmal atrial fibrillation
- Aortic stenosis, moderate
- Mitral regurgitation
- Hypertension
- Chronic urinary tract infections
- Hemorrhoids
- History of ___ syndrome
- Lower limb ulcer
- Varicose veins
- Osteopenia
- Glaucoma
Social History:
___
Family History:
Mother with MI ___ ___, also hx of breast cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: T: 97.6 BP: 120 / 75 HR: 61 RR: 18 O2sat: 96 2L
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: JVP appears around 8-9 cm
HEART: RRR, S1/S2, with a ___ systolic murmur
LUNGS: CTAB, crackles up to the mid lung bilaterally with
decreased air flow
ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no
rebound/guarding
EXTREMITIES: 1+ pre-tibial pitting edema bilaterally ___ lower
extremities
PULSES: 2+ posterior tibial pulses bilaterally
NEURO: Patient A&Ox3 (though takes very long to answer). Says
that she feels confused. CN grossly II-XII intact. Strength ___
___ lower extremities bilaterally.
SKIN: warm and well perfused, no petechiae or rashes
DISCHARGE PHYSICAL EXAM:
=======================
VS: 98.4 PO 147 / 81 60 17 95 RA
Discharge Weight: 70.4kg
GENERAL: NAD, pleasant, sitting ___ bed
NECK: JVP not elevated
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM
HEART: RRR with a systolic murmur best heard at the RUSB
LUNGS: faint bibasilar crackles
ABDOMEN: nondistended, +BS, no TTP, no rebound/guarding
EXTREMITIES: trace pretibial edema, left knee has decreased
warmth compared to prior. Pain with palpation and movement.
NEURO: CN II-XII grossly intact
SKIN: warm and well perfused, no rashes
Pertinent Results:
ADMISSION LABS
================
___ 01:00PM BLOOD WBC-9.1 RBC-4.43 Hgb-13.6 Hct-40.3 MCV-91
MCH-30.7 MCHC-33.7 RDW-14.2 RDWSD-47.3* Plt Ct-89*
___ 01:00PM BLOOD Neuts-72.0* Lymphs-8.9* Monos-18.1*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-6.54* AbsLymp-0.81*
AbsMono-1.64* AbsEos-0.00* AbsBaso-0.01
___ 05:40AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 01:20PM BLOOD ___ PTT-32.3 ___
___ 01:00PM BLOOD Glucose-120* UreaN-17 Creat-1.0 Na-125*
K-3.8 Cl-89* HCO3-19* AnGap-21*
___ 05:40AM BLOOD ALT-60* AST-70* AlkPhos-79 TotBili-1.0
___ 01:00PM BLOOD ___
___ 05:40AM BLOOD Calcium-8.5 Phos-2.3* Mg-1.9
___ 05:40AM BLOOD Osmolal-266*
___ 06:26AM BLOOD ___ pO2-122* pCO2-35 pH-7.43
calTCO2-24 Base XS-0 Comment-GREEN TOP
___ 01:14PM BLOOD Lactate-2.9*
___ 01:00PM BLOOD cTropnT-0.04*
___ 05:40AM BLOOD CK-MB-3 cTropnT-0.02*
STUDIES
=======
CXR: ___
IMPRESSION:
1. New bibasilar opacities concerning for pneumonia.
2. Small right pleural effusion and central vascular congestion.
2. Background prominent interstitial markings suggestive of
chronic
interstitial disease.
RUQ US: ___
IMPRESSION:
Status post cholecystectomy. No evidence of intrahepatic or
extrahepatic
biliary dilation.
Blood Culture, Routine (Final ___: NO GROWTH
Legionella Urinary Antigen (Final ___: NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
Sputum GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
Sputum RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
DISCHARGE LABS
==============
___ 05:10AM BLOOD WBC-12.0* RBC-4.54 Hgb-13.5 Hct-41.6
MCV-92 MCH-29.7 MCHC-32.5 RDW-14.2 RDWSD-47.9* Plt ___
___ 05:10AM BLOOD Neuts-73.3* Lymphs-11.6* Monos-11.6
Eos-1.1 Baso-0.4 Im ___ AbsNeut-8.61*# AbsLymp-1.37
AbsMono-1.37* AbsEos-0.13 AbsBaso-0.05
___ 06:01AM BLOOD ___ PTT-33.8 ___
Brief Hospital Course:
Ms. ___ is an ___ female with a history of
paroxysmal atrial fibrillation, SSS with a pacer implanted due
to symptomatic bradycardia, and HFpEF who presented by EMS for
weakness and dyspnea ___ the setting of a recent URI and found to
have bibasilar opacities on chest xray concerning for a
pneumonia vs. CHF exacerbation as well as multiple laboratory
abnormalities including hyponatremia, thrombocytopenia, elevated
BNP, and elevated LFTs.
She was treated for a presumed pneumonia with a 5 day course of
ceftriaxone and azithromycin (day 1 ___ - day 5 ___.
On ___ out of concern for a concurrent CHF exacerbation
she was given a single 20 mg dose of furosemide and output 2.3
L. Her thrombocytopenia and LFTs normalized and her hyponatremia
improved. Throughout her hospitalization she remained afebrile
and hemodynamically stable. Her O2 sats remained above 90%,
though she did intermittently require oxygen.
She was maintained on warfarin for her paroxysmal afib, with
titration of the dose to maintain an INR between ___. Her
TImolol eye drops were continued for her glaucoma. For her
chronic knee pain we usedheating/ packs as needed, Tylenol TID
and consulted ___ for a physical evaluation who recommended
discharge to acute reehab.
BY PROBLEM HOSPITAL COURSE:
============================
#Community Acquired Pneumonia:
Patient presented with a 4 day history of cough and fatigue and
a 1 day history of lethargy. ___ the ED was febrile and
tachypnic. CXR showed new bibasilar opacities and sputum sample
shows PMNs and a mixed gram stain, suggesting an infectious
etiology. She treated with a 5 day course of ceftriaxone and
azithromycin for presumed community acquired pneumonia.
Legionella antigen negative. She was given nebulizer treatments
as needed, Guaifenesin twice a day, and her oxygen saturation
was monitored and she was stable on room air prior to discharge.
#HFpEF:
She presented with an abnormal pro-BNP ___ the setting of known
HFpEF suggesting a possible mild CHF exacerbation likely due to
her pneumonia. When she presented she additionally had a mild
troponin elevation of 0.04. EKG showed no signs of ischemia.
Repeat troponin was downtrending and it was presumed to be a
demand ischemia. She received one dose of IV furosemide for
diuresis and was monitored on telemetry. At discharge she
reported symptomatic improvement.
#Hyponatremia:
Her sodium ___ ED was 125. Of note on prior admissions she also
had hyponatremia as low as 126. Most likely etiology is was
considered to be secondary to poor PO intake vs. low
intravascular volume from HFpEF vs. SIADH. Urine electrolytes
were sent and were inconclusive, as was a fluid bolus challenge.
With improved PO intake her hyponatremia improved to 132.
#Thrombocytopenia:
She presented with a platelet count of 80 (normal during prior
hospitalization ___
___. Most likely etiology was infection/sepsis. Platelet
count normalized.
#Chronic Issues:
Her warfarin dose was titrated to maintain an INR of ___. Her
timolol drops were continued.
TRANSITIONAL ISSUES:
====================
CONTACT: Son ___: ___
Proxy name: ___
___: daughter Phone: ___
DISCHARGE WEIGHT: 70.4kg
DISCHARGE INR: 2.1
DISCHARGE WARFARIN: 3MG DAILY
[ ] Please Check INR on ___. Adjust warfarin regimen per
INR. FYI Home regimen is as follows: Warfarin 5 mg PO 2X/WEEK
(MO,TH), Warfarin 3.75 mg PO 5X/WEEK (___). She was
discharged from the hospital on warfarin 3 mg daily.
[ ] Cardiology (___) follow up for moderate Aortic Stenosis,
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 5 mg PO 2X/WEEK (MO,TH)
2. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
4. Warfarin 3.75 mg PO 5X/WEEK (___)
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN cough
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. GuaiFENesin ER 1200 mg PO BID:PRN coughing
4. Multivitamins 1 TAB PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Senna 17.2 mg PO BID:PRN constipation
7. Warfarin 3 mg PO DAILY16
8. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
9. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
- Pneumonia
- Congestive Heart Failure
- Hyponatremia
SECONDARY:
- Osteoarthritis
- Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were recently admitted to ___ for an infection of your
lungs called pneumonia. We also thought you had some extra fluid
___ your body that was making it harder for you to breath. Your
sodium level was low as well.
Here is what we did for you:
- We gave you antibiotics for your pneumonia
- We gave you a pill called Lasix (or furosemide), which made
you pee out some of the extra fluid from your body.
- Your sodium level improved with your improved food intake
We are discharging you to a rehabilitation facility. When you
leave the hospital you should make sure to:
- Be sure to eat regular meals
- Try to walk as much as possible and stay active
- Follow up with your primary care doctor and your cardiologist.
- Look over your medication list below for any changes
It was our pleasure taking care of you,
Your ___ team
Followup Instructions:
___
|
19881575-DS-11
| 19,881,575 | 22,455,619 |
DS
| 11 |
2123-11-25 00:00:00
|
2124-01-13 04:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Episodes of Unresponsiveness, Gait Instability
Major Surgical or Invasive Procedure:
___: Sigmoid decompression, Colonoscopy
___: Exploratory laparotomy with left colectomy
History of Present Illness:
Ms. ___ is a ___ woman with a history of Dementia,
DMII, Hypertension, Hyperlipidemia and a history of recurrent
falls who presented to the ED on ___ for a fall, ?stroke which
was ruled out and she was discharged, then returned to the ED
for worsening gait instability the next day and was admitted
medicine.
Per chart review of ED, neurology, and neurosurgery notes (as
patient is very poor historian even with interpreter present and
there is no family at bedside):
___ the patient had a fall at her adult day program and at 415
she was getting off a bus and was unsteady and listing to the
right. Neuro exam that day showed a wide based gate that was
unsteady and an MRI of her brain showed atrophy. her MRI of
cervical spine showed severe spinal canal stenosis at C4/5 with
T2 cord hyperintensity concerning for edema. Signal change of
the
anterior longitudinal ligament concerning for ligament injury.
Neuro surgery was consulted and recommended a C-collar and
follow up.
The next presentation on ___, patient had an event at a grocery
store as she was seen fallen onto her knees grasping onto her
grocery cart appearing dazed. Her neice who was with her during
first admission and during these episodes splashed water on her
face to make her more alert which was successful and her neice
took her home. Event lasted ___ minutes without ___
biting, LOG, urinary incontinence, paroxysmal movements. Pt went
to sleep after event.
Pt was altered next morning and rolled eyes back and was stiff,
niece ___ water on her again and she was again recovering in
___ min without post-ictal findings. Neice brought her to the
ED and stated pt was not taking very good PO intake, but was
slightly improved at that time.
Per neurology - she was having episodes of the stiffness and eye
rolling backwards starting in ___ and was started on keppra
in ___, then neuro increased her keppra to 500 BID in
___.
Family not at bedside. Patient states she has no acute
complaints - has neck pain, chest pain, arm pain, dizziness that
have all been going on for greater than ___ year. She feels the
dizziness is the only thing that is potentially more acute. She
states the location is "14" and that she is here because
"ambulance". Per ED note, she is admitted for repeated falls,
and AMS. UA weakly positive. labs otherwise unremarkable, vitals
stable. Trop 0.02 without ischemia on EKG.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
-CKD stage III
-Diabetes mellitus
-Dementia: Prior to ___, she was seen by her niece ___ years
prior. At that time, she could have a limited conversation which
was apparently baseline
-Gait instability: Unclear exactly when this became an issue but
was using a walker prior to coming to her niece in ___
years ago she did not require a walker.
-Intellectual disability
-Hypertension
-Hyperlipidemia
-Vertigo, details unclear
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
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, 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 x 1 (person) EOMI, speech fluent -
appropriate but limited responses due to dementia, moves all
limbs, sensation to light touch grossly intact throughout. no
facial droop. ___ strength. ___ intact grossly. would not
cooperate with FNF
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS
___ 08:00PM BLOOD WBC-3.3* RBC-3.24* Hgb-9.3* Hct-29.7*
MCV-92 MCH-28.7 MCHC-31.3* RDW-14.7 RDWSD-49.9* Plt ___
___ 08:00PM BLOOD Neuts-57.8 ___ Monos-11.4
Eos-0.3* Baso-1.2* Im ___ AbsNeut-1.93 AbsLymp-0.97*
AbsMono-0.38 AbsEos-0.01* AbsBaso-0.04
___ 10:04PM BLOOD ___ PTT-24.9* ___
___ 08:00PM BLOOD Glucose-86 UreaN-32* Creat-1.2* Na-137
K-6.2* Cl-101 HCO3-22 AnGap-14
___ 08:00PM BLOOD ALT-44* AST-74* CK(CPK)-161 AlkPhos-67
TotBili-0.4
___ 08:00PM BLOOD Lipase-20
___ 08:00PM BLOOD Albumin-3.4*
CTA Head / Neck - IMPRESSION:
1. No evidence for acute intracranial process.
2. Multifocal atherosclerosis within the intracranial and
cervical
vasculature, as detailed above, without evidence of high-grade
stenosis, large
vessel occlusion, or aneurysm. Hypoplastic V4 segment of the
right vertebral
artery is unchanged compared to the prior exam.
3. Paranasal sinus disease and severe leftward nasal septal
deviation, as
above.
4. Severe, multilevel degenerative changes of the cervical
spine, better
assessed on subsequent MR cervical spine examination.
MRI Head - IMPRESSION:
1. No acute infarct is identified. Additional findings
described above.
2. Bilateral medial temporal atrophy is similar to ___.
3. Please refer to concurrent MRI cervical spine for additional
details.
MRI C-Spine - IMPRESSION:
1. Signal abnormality at the C4-5 and C6-7 anterior disc space
with
surrounding prevertebral soft tissue edema is suspicious for
anterior
longitudinal ligament injury, although no discrete defect is
identified.
2. There is cord signal abnormality at C4-5, suspicious for cord
edema, in
setting of severe spinal canal narrowing secondary to
degenerative changes.
3. Severe multilevel degenerative changes most notable for
severe spinal canal
narrowing at C4-5. Spinal canal narrowing is moderate at the
craniocervical
junction, C5-6, and C6-7 levels.
CXR - FINDINGS:
The lungs are clear without focal consolidation. No pleural
effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are
unremarkable. Mild cardiomegaly is stable. Gas distension of
the: Is
chronic.
IMPRESSION:
Stable mild cardiomegaly. Chronic gas distension of the colon.
EEG - IMPRESSION: This is a normal awake and asleep EEG. No
focal abnormalities or
epileptiform discharges are present.
RUS U/S - IMPRESSION:
Trace perihepatic ascites. Otherwise unremarkable abdominal
ultrasound.
TTE - The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is moderately-to-severely depressed (LVEF= 30
%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). 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 to moderate
(___) mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___,
left ventricular contractile function is significantly reduced.
P-MIBI
IMPRESSION : No anginal symptoms or ST segment changes. Nuclear
report
sent separately.
IMPRESSION: 1. Normal myocardial perfusion study. 2. Left
ventricular ejection
fraction is 57%.
CT A/P - IMPRESSION:
1. Findings of large bowel obstruction secondary to sigmoid
volvulus.
Findings are likely acute on chronic or intermittent given the
notable
distension of the bowel loops in ___. Evidence of mesenteric
stranding and
edema. No evidence of perforation.
2. Mild bilateral hydronephrosis likely secondary to urinary
bladder
distension.
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of Dementia,
DMII, Hypertension, Hyperlipidemia and a history of recurrent
falls who presented to the ED on ___ for a fall, ?stroke which
was ruled out and she was discharged, then returned to the ED
for worsening gait instability the next day and was admitted
medicine.
#Acute on Chronic sigmoid volvulus
#Leukocytosis
CT obtained ___ due to abdominal pain, which showed sigmoid
volvulus and obstruction, which appeared acute on chronic.
underwent colonoscopy and decompression on ___ and rectal tube
placement. Leukocytosis attributed to volvulus and started to
improve after decompression. The patient was taken to the OR on
___ for left colectomy with primary anastomosis.
Post-operatively the patients diet was gradually advanced until
she was tolerating a regular diet.
#Bladder distension/bilateral mild hydronephrosis
Noted on CT ___. Now s/p Foley placement.
# RECURRENT FALLS / GAIT INSTABILITY: The patient presented with
worsening gait instability as well as episodes concerning for
possible seizures. EEG was negative, and episodes have been felt
to be multifactorial in nature, including cervical cord
pathology as well as newly diagnosed systolic heart failure and
possible viral illness. No further episodes reported in the
hostpial. Neurology did have concern over her cervical cord
disease, for which close follow up is warranted. She was ordered
for c.collar when upright or OOB. She will need kind of hearts
monitor at discharge to evaluate for possible arrhythmic source
of syncope.
# ABDOMINAL PAIN
# TRANSAMINITIS
Pt with vague complaint of abdominal pain on exam, also with
intermittent emesis and diarrhea. LFT's were mildly elevated
earlier in hospital course but normalized. Lipase WNL. RUQ U/S
unremarkable. Hepatitis B and C serologies negative. Given
ongoing symptoms or unclear etiology, CT A/P was performed,
which showed concerns of sigmoid volvulus. GI and surgery were
consulted.
# SYSTOLIC vs DIASTOLIC HEART FAILURE:
New diagnosis this admission per TTE (new since ___, although
EF reported 57% on
subsequent nuclear stress. Etiology unclear, unlikely ischemic
heart disease
given normal stress. BNP mildly elevated, but no evidence of
volume overload on exam. Tn mildly elevated but flat. Denies any
chest pain. Kept on ASA, statin, BB, and ACEi. Will need
cardiology follow-up and repeat TTE in upcoming months.
# ___: Resolved with IVFs.
#CoNS in urine - low suspicion for UTI - likely contaminant vs
colonization
# HTN: On home regimen of lisinopril and metoprolol. HCTZ added
during admission due to erratic BPs. BP's remained somewhat
labile.
# HLD: On home statin.
# DM2: On insulin during admission in place of home oral meds.
# Disposition:
Patient did not have a HCP, however, she has a legal guardian
and the guardianship originally did not include the ability to
admit to ___. Insurance coverage did not cover rehab placement,
therefore arrangements were made for patient to be discharged
home with ___ assistance and home ___. Prior to discharge, the
patient was tolerating a regular diet, ambulating with physical
therapy, with pain controlled on oral medications.
=================================
Transitional issues/follow-up:
- will need TTE in upcoming months and cardiology follow-up;
continuation of beta blocker and ace inhibitor
- has follow up with neurologist Dr. ___ neuro
- should follow-up in ___ clinic with Papavassilliou
- continued titration of BP regimen
- order ___ of hearts monitor after discharge due to runs of
tachycardia
=================================
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 40 mg PO DAILY
2. LevETIRAcetam 500 mg PO BID
3. Atorvastatin 40 mg PO QPM
4. Metoprolol Succinate XL 50 mg PO DAILY
5. QUEtiapine Fumarate 25 mg PO BID
6. LOPERamide 2 mg PO QID:PRN diarrhea
7. GlipiZIDE 5 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Glucose Gel 15 g PO PRN hypoglycemia protocol
3. Polyethylene Glycol 17 g PO DAILY
4. Senna 8.6 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. GlipiZIDE 5 mg PO BID
8. LevETIRAcetam 500 mg PO BID
9. Lisinopril 40 mg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. QUEtiapine Fumarate 25 mg PO BID
12. Vitamin D 1000 UNIT PO DAILY
13. HELD- LOPERamide 2 mg PO QID:PRN diarrhea This medication
was held. Do not restart LOPERamide until you talk to your
primary care provider.
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Sigmoid volvulus
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. ___,
You were admitted to the Acute General Surgery Unit at ___ and
you were found to have a sigmoid volvulus. You first underwent
sigmoid decompression. You then underwent an exploratory
laparotomy with left colectomy. You have now recovered well and
are ready to be discharged.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
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.
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.
*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.
It has been a pleasure looking after you and we wish a speedy
recovery.
Followup Instructions:
___
|
19881575-DS-12
| 19,881,575 | 29,284,557 |
DS
| 12 |
2124-06-17 00:00:00
|
2124-06-18 20:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
near fall at home
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with history of
dementia, recurrent falls, cervical spondylosis, seizure
disorder
on levetiracetam, heart failure with borderline EF, CKD III,
T2DM, HTN, and dyslipidemia who presents after a near fall at
home. Patient lives with her niece (primary car giver), who is
able to provide the following history as patient is largely
non-communicative at baseline iso advancing dementia (oriented
only to person, unable to participate in conversation,
aggressive
at times with self-injurious behaviours including scratching).
Patient was by report walking down stairs early yesterday and
seemed to be about to fall, her head rolling about at her
shoulders and her legs appearing to almost give way. Luckily,
patient's niece caught her before she fell, no head strike.
Patient did not lose consciousness, no change from baseline
mental status thereafter. No incontinence/tongue biting.
Though
her communication is severely limited, patient's niece does say
that patient complained of feeling hot. Of note, patient has
had
two prior similar episodes over the past one month. The first
occurred while at a ___ in ___, thought to be related
to extreme heat. After returning to ___, patient had another
episode at home, also thought to be related to the heat. There
is an airconditioner at home, though patient often turns it off
as she seems to enjoy the heat, according to her niece.
Otherwise, patient's niece denies any acute symptoms. ROS is
notable for chronic intermittent diarrhea, unchanged. At
baseline, patient is unsteady on her feet (history of cervical
spondylosis), uses a walker for support. Given her concern for
serious injury from another fall, patient's niece brought her to
the ED for evaluation/management.
In the ED, initial VS were: 98.0 52 129/52 20 100% RA
Exam notable for:
Con: In no acute distress, very thin and elderly female
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Resp: Clear to auscultation, normal work of breathing
CV: Regular rate and rhythm, loud second heart sound, 2+ distal
pulses. Capillary refill less than 2 seconds.
Abd: Soft, Nontender, Nondistended
GU: No costovertebral angle tenderness
MSK: No deformity or edema
Skin: No rash, Warm and dry
Neuro: A+O to first name but not last and not to place or time,
CNs2-12 intact, sensation intact with ___ strength in upper and
lower extremities bilaterally, Babinski equivocal bilaterally,
___ negative, normal proprioception, finger-to-nose/rapid
alternating movement/pronator drift normal, broad based gait and
unsteady on feet
ECG: Sinus bradycardia, LAD, normal intervals, no acute ischemic
ST changes.
Labs showed:
CBC 5.3>9.2/28.2<174 (MCV 96, 65.5%PMNs)
BMP 142/4.8/104/27/45/1.8/202, 145/4.4/107/25/43/1.8/226
UA notable for 30protein and few bacteria
Imaging showed: NONE
Consults: Neurology (no concern for seizure, more likely
vasovagal syncope)
Patient received:
___ 19:14 IVF LR 1000 mL
Transfer VS were: 98.1 60 165/62 18 100% RA
On arrival to the floor, patient is able to say her name only.
She responds 'Yes' to nearly all other questions asked of her by
the phone interpreter. She does say 'No' when asked about any
pain or discomfort. Unable to perform 10-point ROS.
Past Medical History:
Dementia
Recurrent falls
Cervical spondylosis
Seizure disorder on levetiracetam
Heart failure with borderline EF
T2DM
HTN
Dyslipidemia
CKD stage III
Social History:
___
Family History:
Reviewed in OMR, non-contributory to this admission for
presyncope.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: 97.4 220/76 59 17 95 Ra
GENERAL: NAD, thin and smiling, only oriented to self.
HEENT: Anicteric sclera, PERRL, MMM.
NECK: JVP elevated 2cm above the clavicle with HOB at 45degrees.
CV: Bradycardic, regular rhythm, S1/S2, no murmurs, gallops, or
rubs.
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles.
GI: Abdomen soft, NABS, nondistended, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing, or edema.
PULSES: 2+ radial pulses bilaterally.
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric. PERRL/EOMI. Gait not assessed.
DISCHARGE PHYSICAL EXAM:
======================
Vitals: ___ ___ Temp: 97.4 PO BP: 190/67 L Lying HR: 56
RR:16 O2 sat: 100% O2 delivery: RA
___ 0615 BP: 124/74 L Standing
GENERAL: NAD, elderly female. only oriented to self.
HEENT: Anicteric sclera, EOMI
CV: Bradycardic, regular rhythm, S1/S2, no murmurs, gallops, or
rubs.
PULM: breathing comfortably on RA without use of accessory
muscles.
Abdomen: NABS. soft nondistended, nontender, no rebound or
guarding, no organomegaly.
EXTREMITIES: warm, well perfused. No edema
NEURO: Moving all extremities. No focal neurologic deficits
noted. Alert and interactive.
Pertinent Results:
ADMISSION LABS:
==============
___ 04:06PM PLT COUNT-174
___ 04:06PM NEUTS-65.5 ___ MONOS-5.9 EOS-6.6
BASOS-0.8 IM ___ AbsNeut-3.47 AbsLymp-1.11* AbsMono-0.31
AbsEos-0.35 AbsBaso-0.04
___ 04:06PM WBC-5.3 RBC-2.93* HGB-9.2* HCT-28.2* MCV-96
MCH-31.4 MCHC-32.6 RDW-14.1 RDWSD-49.3*
___ 04:06PM GLUCOSE-202* UREA N-45* CREAT-1.8*#
SODIUM-142 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-11
___ 10:05PM TSH-1.4
___ 10:05PM CK-MB-2 cTropnT-0.02*
___ 10:05PM CK(CPK)-101
___ 10:05PM GLUCOSE-226* UREA N-43* CREAT-1.8* SODIUM-145
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13
___ 10:20PM URINE MUCOUS-RARE*
___ 10:20PM URINE RBC-<1 WBC-3 BACTERIA-FEW* YEAST-NONE
EPI-2
___ 10:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 10:20PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:20PM URINE OSMOLAL-444
___ 10:20PM URINE HOURS-RANDOM CREAT-70 SODIUM-93
PERTINENT LABS:
==============
___ 05:38AM BLOOD %HbA1c-7.5* eAG-169*
MICROBIOLOGY:
=============
___ 3:35 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 9:56 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
IMAGING/OTHER STUDIES:
====================
___ Renal U/S
FINDINGS:
Right kidney: 10.5 cm. Severe grade 4 hydronephrosis.
Left kidney: 7 cm. No hydronephrosis.
The bladder is moderately well distended and normal in
appearance.
IMPRESSION:
Severe grade 4 hydronephrosis of the right kidney.
Hypotrophic appearance of the left kidney. No hydronephrosis.
___ Abdominal Xray
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
The sigmoid is noted to be redundant. Stool and gas are seen
within the ascending and descending colon.
Supine assessment limits detection for free air; there is no
gross pneumoperitoneum.
Osseous structures are notable for degenerative changes in the
lumbar spine and mild degenerative changes of both hips.
There are no unexplained soft tissue calcifications or
radiopaque foreign bodies.
IMPRESSION: Nonspecific, nonobstructive bowel gas pattern.
___ CT A/P WO Contrast
FINDINGS:
LOWER CHEST: There are trace bilateral pleural effusions. No
focal
consolidation. No pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation
throughout.
There is no evidence of hepatic mass within the limitations of
an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic
biliary
dilatation. The gallbladder is not visualized, likely
collapsed.
PANCREAS: There is moderate diffuse atrophy of the pancreas.
There is no main ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: There is severe right hydronephrosis to the level of
the
ureteropelvic junction, without obstructing stone or mass
identified. There is no left hydronephrosis. There is no
evidence of focal renal lesions within the limitations of an
unenhanced scan. There is no nephrolithiasis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is dilated and filled with oral
contrast and
air. Small bowel loops are normal in caliber. The patient has
history of
sigmoid volvulus, and is status post resection of the
rectosigmoid with left colorectal anastomosis on ___. The rectum is dilated up to 9.1 cm with moderate amount
of layering fluid. The distal colon is dilated with abrupt
transition point and twist in the midline upper pelvis (series
2, images 54-57), concerning for recurrent volvulus. Findings
appear less severe compared to prior episode from ___. No pneumatosis, free air, or ascites. The appendix is
not visualized.
PELVIS: The urinary bladder is decompressed with a Foley in
place. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is unremarkable. No adnexal
mass.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture. Severe degenerative changes of the
thoracolumbar spine are unchanged with grade 1 anterolisthesis
of L4 on L5.
SOFT TISSUES: There is diffuse anasarca.
IMPRESSION:
1. Dilated distal colon with abrupt transition and twist in the
midline upper pelvis, concerning for recurrent volvulus,
although less severe compared to prior episode from ___. No pneumatosis or free air.
2. Severe right hydronephrosis of unclear etiology to the level
of the
ureteropelvic junction, of unclear etiology.
3. Trace bilateral pleural effusions.
___ Renal Scan
IMPRESSION:
1. Findings compatible with partial obstruction likely at the
right UPJ.
2. Reduced bilateral blood flow, but essentially normal left
renal function.
3. Differential function of 51% on the left and 49% on the
right.
___ CT Head WO contrast
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
Mild brain parenchymal atrophy. Findings consistent with mild
chronic small vessel ischemic changes.
There is no evidence of fracture. Mild paranasal sinus disease.
Otherwise, the visualized portion of the paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable. Degenerative
changes spine. Additional nasal polyp the superior right nasal
cavity.
IMPRESSION: No acute findings.
DISCHARGE LABS:
==============
___ 06:05AM GLUCOSE-106 UREA N-38* CREAT-2.1.* SODIUM-141
POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-23 ANION GAP-17
___ 06:05AM CALCIUM-9.2 PHOSPHORUS-4.5 MAGNESIUM-2.3
___ 06:05AM WBC-6.3 RBC-2.85* HGB-8.7* HCT-27.6* MCV-97
MCH-30.5 MCHC-31.6 RDW-13.7 RDWSD-48.8*
___ 06:05AM PLT COUNT-183
Brief Hospital Course:
___ SUMMARY:
=====================
Ms. ___ is a ___ with history of dementia, recurrent falls,
cervical spondylosis, seizure disorder on keppra, HF with
borderline EF, CKD III, T2DM, HTN, and dyslipidemia who presents
after a near fall at home, evaluated by neurology in the ED who
did not feel that patient had a seizure, more etiology thought
to be more likely neurocardiogenic syncope. On further eval,
most likely cause of presyncopal episode was dehydration in the
setting of bradycardia on a beta blocker. Patient was also found
to have ___ on admission, with further workup revealing R
kidney hydronephrosis not amenable to intervention.
TRANSITIONAL ISSUES:
===================
[ ] Patient will need close monitoring of renal function by PCP
___ 1 week of discharge, along with post-hospitalization
follow up.
[ ] Her Keppra was dose-adjusted given her persistent ___. If
her ___ improves or worsens, this will need to be dose-adjusted
again.
[ ] If worsening renal function on next ___ check, will need
urgent referral to ___ in ___ clinic to discuss long
term management of UPJ obstruction. Please call ___.
[ ] Metoprolol was held given bradycardia during
hospitalization.
[ ] Glipizide was held given well-controlled A1c during
hospitalization and risk of hypoglycemia.
[ ] Patient is on aspirin- this medication was held during
hospitalization and should not be restarted until discussion
with PCP.
[ ] Lisinopril was held in the setting ___ during
hospitalization.
[ ] Follow up with neurologist Dr. ___ concern for
seizures precipitating falls/syncopal episodes
[ ] Continue wearing compression stockings to improve possible
orthostatic hypotension.
[ ] follow up with GI or surgery as an outpatient given chronic,
recurrent volvulus. Communicated recommendation to PCP who can
refer as needed
ACUTE/ACTIVE ISSUES
==================
# Acute kidney injury
Baseline Cr 0.7-1.1, elevated to 1.8 in ED. Initially thought
prerenal iso poor PO, but did not improve with fluids. Given
possible falls recently, rhabdomyolysis was considered, but CK
was normal. SPEP was normal. There was also concern for possible
intrinsic renal injury such as ATN given elevated urine Na, but
no casts were seen on U/A. Patient had renal ultrasound on ___
which showed grade 4 severe hydronephrosis of the R kidney and
hypotrophic L kidney. Patient had no signs of pyelonephritis or
infection at the time. Patient underwent CT abdomen/pelvis
without contrast, with no obstructing stone seen, but did show
acute on chronic large sigmoid volvulus with large bowel
obstruction likely causing moderate-severe R hydronephrosis by
mass effect. It is unclear if the hydronephrosis is acute or
chronic, and whether volvulus is related. ___ likely in setting
of unilateral hydronephrosis with hypotrophic L kidney. Urology
and renal were consulted and patient underwent renal nuclear
study on ___ to evaluate for UPJ obstruction and determine if
renal function was preserved. Scan showed partial obstruction at
the R UPJ, with decreased bilateral blood flow but essentially
normal L renal function. Given partial renal function and
discussion with patient's healthcare proxy of the patient's
goals of care in the setting of her comorbidities and baseline
dementia, urology team recommended attempting non-operative
treatment at this time as long as renal function remains
relatively stable. Patient will need renal function monitored
closely by her PCP given no plans for inpatient intervention at
this time. If renal function worsens in outpatient setting,
patient should be urgently referred to ___ in ___
___ clinic to discuss long term management of UPJ
obstruction. Patient's home lisinopril was held iso ___.
Discharge Creatinine of 2.1.
# Chronic large sigmoid volvulus, not actively obstructed
Patient has history of large bowel obstruction presenting with
subtle symptoms and is also s/p colectomy. Given history and
concern that patient unable to verbalize symptoms ___ baseline
dementia, patient underwent abdominal X-ray on ___ which showed
nonspecific non obstructive bowel gas pattern. Given R kidney
hydronephrosis (as detailed above) obtained CT A/P without
contrast that showed acute on chronic large sigmoid volvulus
with large bowel obstruction likely causing moderate-severe R
hydronephrosis by mass effect. Reassuring as it is acute on
chronic, imaging read as decreased compared to ___, and
patient hemodynamically stable. ACS was consulted and was not
concerned for clinical obstruction, therefore recommend
outpatient follow up and no need for emergent or urgent surgical
intervention. GI was consulted and did not feel there is a role
for colonoscopy at this point and thought that the patient needs
eventual, non-urgent surgical intervention. Serial abdominal
exams were monitored and reassuring.
#Unresponsive episode
Patient found to be unresponsive on ___ AM and was hypotensive
to 70/48, last seen normal 20 minutes prior. FSBG 142. Patient
was bolused IV fluids and SBP improved to 130s. After BP
improved, her mental status returned to baseline. Neuro exam at
this time was unremarkable, as was abdomen, cardiovascular and
respiratory exams. EKG revealed mild sinus bradycardia,
unchanged from prior. VBG notable for elevated CO2 but likely in
setting decreased respiration during episode. CT head WO
contrast was without acute findings. 24-hour EEG was reassuring
against seizure activity. Hypotension could be related to NPO
status and initiation of low dose amlodipine, although would not
expect such a quick response to anti-hypertensive. On review of
previous notes and in talking to niece, patient does have
history of possible orthostasis as well as autonomic
dysfunction, and niece notes several of these similar
unresponsive episodes at home over the past few months.
Orthostatic vital signs were positive but did not correct with
fluid resuscitation and therefore think patient may have some
underlying autonomic instability leading to these episodes. Also
concern for possible non-convulsive seizure vs post-ictal state
(which could also lead to autonomic dysfunction) given patient
has history of seizures. Patient did not have any incontinence
or tongue biting. Obtained 24hour EEG which was unremarkable. Of
note, her Keppra was dose-adjusted given her persistent ___ and
this will need to be monitored as an outpatient. Patient has
scheduled follow up with neurologist.
# Near fall at home, concern for presyncope
# History of vasovagal syncope
Patient presents after a third episode of presyncope. Likely
etiology is combination of dehydration in patient with
bradycardia on beta blocker. Neurology was consulted in ED and
mentioned a well-documented h/o vasovagal/neurocardio syncope
but unclear where this has been documented. Despite seizure hx,
neuro not concerned for seizure as etiology (previous seizures
have occurred iso acute illness eg volvulus/infection). Unlikely
infection given no leukocytosis, afebrile, negative U/A.
Orthostatics in ED were reportedly negative. Patient not
hypoglycemic on admission, although patient is on a sulfonylurea
so higher risk of low sugars. Patient noted bradycardic with HR
in ___ on metoprolol, so may have contributed to presentation.
No PR prolongation or e/o heart block on EKG. Last TTE was
___, had LVEF 30%. Troponin negative. Also was some
concern for hypothyroidism given patient always turns AC off per
niece, but TSH normal. No chest pain or hypoxia to suspect PE.
Patient at baseline mental status per niece. Patient was
monitored on telemetry during stay. TTE was not repeated because
thought unlikely to be high yield given no murmur on exam.
Patient's home metoprolol was held as below.
# Bradycardia - NSR in ___, concern for possible symptomatic
bradycardia as above. No PR prolongation or e/o heart block on
EKG. Trop negative, TSH normal. Patient was monitored on tele.
Home metoprolol was held as patient was likely symptomatic from
bradycardia. Plan to hold on discharge for patient to discuss
with PCP. HR has been stable in 50-60s.
# Hypertension
Patient hypertensive to 220/90 upon arrival to the floor, has
intermittently been so throughout prior admissions. Likely not
acute, will plan to only lower by ~20% to SBPs 160-170s. IV
hydralazine 10 x1 with subsequent drop to 90/50s. Patient's goal
BP while inpatient was 160-170s/90s. Home lisinopril 40mg qd was
held iso ___. As per above, she was briefly trialed on
Amlodipine 5mg but the patient became subsequently hypotensive -
as such, this was discontinued. If remains hypertensive at PCP
follow up, consider reinitiation of an anti-hypertensive.
CHRONIC ISSUES:
===============
# Normocytic anemia: Hb 9.2 on admission, at prior baseline. No
evidence of bleeding. CBC was trended daily and an active T&S
was maintained.
# Dementia: At baseline per niece. Patient oriented only to
self. Answers 'okay' to most questions in ___ and ___.
Patient continued on home quetiapine (no QTc prolongation on
admission ECG).
# Seizure disorder: Patient switched to renal dosing of keppra
250mg BID (home dose 500mg BID). Neuro consulted, not concerned
for seizure on presentation. Had an EEG which was reassuring.
# Chronic, intermittent diarrhea: Symptoms are unchanged as per
patient's niece. Continued home loperamide prn
# T2DM: Last A1c 7.7% ___. On glipizide at home. Repeat A1c
on admission was 7.5. Held glipizide while inpatient and also
considering discontinuing medication given risk of hypoglycemia.
On HISS during hospitalization.
# Dyslipidemia: Continued home atorvastatin
# Primary Prevention: Held home ASA, PCP to consider
discontinuation given risk of falls
#CODE: Full (presumed)
#CONTACT: ___ Phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. GlipiZIDE 5 mg PO DAILY
3. LevETIRAcetam 500 mg PO BID
4. Lisinopril 40 mg PO DAILY
5. Acetaminophen 650 mg PO TID
6. Glucose Gel 15 g PO PRN hypoglycemia protocol
7. Metoprolol Succinate XL 50 mg PO DAILY
8. LOPERamide 2 mg PO QID:PRN diarrhea
9. QUEtiapine Fumarate 25 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. Atorvastatin 40 mg PO QPM
12. Senna 8.6 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. LevETIRAcetam 250 mg PO Q12H
RX *levetiracetam 250 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Glucose Gel 15 g PO PRN hypoglycemia protocol
6. LOPERamide 2 mg PO QID:PRN diarrhea
7. Polyethylene Glycol 17 g PO DAILY
8. QUEtiapine Fumarate 25 mg PO BID
9. Senna 8.6 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. HELD- GlipiZIDE 5 mg PO DAILY This medication was held. Do
not restart GlipiZIDE until discussing with PCP
12. HELD- Lisinopril 40 mg PO DAILY This medication was held.
Do not restart Lisinopril until diuscussing with PCP
13. HELD- Metoprolol Succinate XL 50 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until discussing with PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
___
R Hydronephrosis
Pre-syncope
Bradycardia
Secondary diagnosis:
Chronic volvulus
Hypertension
Normocytic anemia
Dementia
Seizure disorder
Chronic intermittent diarrhea
Type 2 Diabetes
Dyslipidemia
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 to care for you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you almost fell in your
home.
What did you receive in the hospital?
- You received fluids because you were dehydrated.
- Your heart rate was low so we changed some of your home
medications.
- You were found to have abnormal kidney function tests and
underwent an ultrasound of your kidney that showed some swelling
inside of it.
- You had additional imaging of your kidneys to evaluate their
function. Since your renal function was stable while you were
here, you did not have any interventions. You will follow up
closely with your PCP and can see a urologist if necessary.
- You had a neurology study to see if you were having any
seizures that were causing you to have episodes of
unresponsiveness. We did not see any seizures on the study, but
you will follow up with your outpatient neurologist to discuss.
- Please try wearing compression stockings during the day to
help with your dizziness or lightheadedness
What should you do once you leave the hospital?
- You should attend all of your scheduled follow up appointments
(see below).
- You should take all of your prescribed medications as
directed.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19881575-DS-7
| 19,881,575 | 20,683,496 |
DS
| 7 |
2121-04-17 00:00:00
|
2121-04-17 17:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female, recently discharged for her recurrent
syncopal events, with a negative head MR, thought to be related
to beta blockers, presenting for recurrent syncope. The patient
is living at home with niece, who saw to episodes of recurrent
syncope. He says been keeping a close eye on patient, and caught
her both times, lowering her to a chair with no trauma. Niece
notes that patient had a blood pressure approximately 100/61
hour after this episode.
On interview with the patient and her neice the reports no pain.
Her neice notes that these episodes have worsened since taking
over her aunt's care in ___. She reports they have
increased in severity and frequency since that time. She notes
that currently the episodes consist of her shaking her arms, and
her eyes rolling back in her head. She will then pass out and
not remember the incident. Of note the pt does have a history of
dementia. There is no tongue biting associated with these
episodes but one two occasions there has been fecal
incontinence.
In the ED, initial vital signs were: T 96 P 85 BP 176/74 R 18 O2
sat. 100%
- Exam notable for: sacral decubitus ulcers.
- Labs were notable for... K of 3.4, otherwise normal metabolic
panel, no hypoglycemia
- Studies performed include... EKG notable for Qtc 442ms and
chest x-ray was negative.
- Patient was given... 1L NS bolus, 40 mEq K Cl
- Vitals on transfer: 98.2 169/72 70 19 99% RA
Upon arrival to the floor, the patient is resting comfortably
and denies HA, CP, palpitations, SOB, abd pain, N/V/D.
Past Medical History:
DIABETES MELLITUS
DEMENTIA/ MENTAL RETARDATION
?KIDNEY DISEASE
HYPERTENSION
HYPERLIPIDEMIA
Social History:
___
Family History:
Mother reportedly died of a stroke.
Physical Exam:
Physical exam on admission:
Vitals- 97.5 190/92 78 18 100% RA
General: Well nourished, well appearing female in NAD resting
in bed
HEENT: NCAT, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, no JVD
CV: RRR, no m/r/g
Lungs: CTAB without wheezing or crackles, normal effort
Abdomen: + bowel sounds, nt, nd, no organomegaly
GU: no foley
Back: no appreciable sacral decubitus ulcers
Ext: warm and well perfused, no clubbing or cyanosis, no
peripheral edema
Neuro: AOx2, CN ___ intact, moves all extremities purposefully
Skin: no rashes or lesions noted, no sacral decubitus ulcers,
well healed scar from site of previous ulcer on R ischial
tuberosity
Physical exam on discharge:
Vitals- 98.4, 97.8, 139/53, 67, 18, 98% RA
Orthostats lie 157/55 HR 78, sit 153/70 HR 80, stand 136/77 HR
91
General: Well nourished, well appearing female in NAD resting
in bed
HEENT: NCAT, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, no JVD
CV: RRR, no m/r/g
Lungs: CTAB without wheezing or crackles, normal effort
Abdomen: + bowel sounds, nt, nd, no organomegaly
GU: no foley
Ext: warm and well perfused, no clubbing or cyanosis, no
peripheral edema
Neuro: AOx2, CN ___ intact, moves all extremities purposefully
Pertinent Results:
Pertinent labs on admission:
___ 12:15PM BLOOD WBC-5.5 RBC-3.95 Hgb-11.6 Hct-36.5 MCV-92
MCH-29.4 MCHC-31.8* RDW-14.8 RDWSD-50.5* Plt ___
___ 12:15PM BLOOD Neuts-64.6 ___ Monos-6.2 Eos-4.4
Baso-1.3* Im ___ AbsNeut-3.52 AbsLymp-1.26 AbsMono-0.34
AbsEos-0.24 AbsBaso-0.07
___ 12:15PM BLOOD Glucose-172* UreaN-24* Creat-1.1 Na-141
K-3.2* Cl-96 HCO3-31 AnGap-17
___ 12:15PM BLOOD ALT-17 AST-23 AlkPhos-127* TotBili-0.5
___ 12:15PM BLOOD cTropnT-<0.01
___ 12:15PM BLOOD Albumin-4.3
Microbiology:
___ 11:04 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Reports:
___ Transthoracic echo
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Doppler parameters are most consistent with
Grade I (mild) left ventricular diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. No mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity size with preserved regional and global biventricular
systolic function. No valvular pathology or pathologic flow
identified. Mild pulmonary hypertension.
___ EKG
Sinus rhythm. Delayed R wave transition. Non-specific ST segment
changes.
Left ventricular hypertrophy with ST-T wave changes consistent
with
hypertrophy. Compared to the previous tracing of ___ the
ventricular rate is faster.
___ CXR
FINDINGS:
The lungs are clear without focal consolidation, effusion, or
edema. The
cardiomediastinal silhouette is within normal limits.
Atherosclerotic
calcifications are noted at the arch. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Pertinent labs on discharge:
___ 06:50AM BLOOD WBC-4.8 RBC-3.48* Hgb-10.1* Hct-32.3*
MCV-93 MCH-29.0 MCHC-31.3* RDW-15.0 RDWSD-51.2* Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:33AM BLOOD Glucose-145* UreaN-21* Creat-0.9 Na-138
K-3.7 Cl-102 HCO3-24 AnGap-16
___ 06:33AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.4* (repleted)
Brief Hospital Course:
___ female with PMHx of syncope believed to be d/t
orthostasis and metoprolol (since d/c'd), dementia, HTN and DM
presenting for recurrent syncope.
#Syncope Previously was attributed to autonomic dysfunction ___
DM and metoprolol. Pt's niece noted no relief with metoprolol
discontinuation. She still reported orthostatic symptoms at
home, with shaking, amnesia of the event and occasional fecal
incontinence. DDx concerning for seizure activity peristent
orthostatic hypotension and dehydration. Other possibilities
included acute drops in cardiac output due to persistent
orthostasis, or valvular abnormalities, though unlikely given no
murmurs. H/o vertigo, and she was recently restarted on
meclazine, which was held during this admission. Persistent and
significant orthostasis, even following IV fluid hydration and
thigh high compression stockings. Telemetry showed no evidence
of arrhythmia. ECHO showed only grade I diastolic dysfunction
and pulmonary artery hypertension. All of the patient's home
antihypertensives were discontinued in hopes that permissive
hypertension would help with her orthostasis. However, the pt
continued to have orthostasis and, in fact, her BP normalized
off antihypertensives. Her orthostatic vital signs, and
normalization off antihypertensives, were concerning for
autonomic dysfunction given consistent HR with orthostatic
blood pressures and history of long-term, uncontrolled diabetes.
The patient was trialed on fludrocortisone which improved the
orthostatic hypotension. Stopped all hypertensives.
Chronic issues
# Type II DM: Believed to be c/b autonomic dysfunction relating
to previous admission for syncope. Last A1c 7.2% in ___, A1c
8.8% now. On oral agents with blood sugars well controlled per
neice, however does have some complaints including peripheral
neuropathy and retinopathy. Initially the pt was started on a
low sliding scale to prevent hypoglycemia, however, this was
increased in the face of persistent hyperglycemia. She may
require tailoring of her diabetes regimen in the outpatient
setting while continuing to avoid hypoglycemia.
#Dementia: Pt with h/o dementia and developmental delay,
remained AOx2 throughout the admission with no evidence of
delirium.
#Anemia: Noted on previous admissions, followed during this
admission with daily CBC's, MCV in ___ with unclear etiology at
this time, no evidence of iron deficiency or other cytopenias on
CBC's.
#Vertigo: Hx in the past, pt restarted on meclazine in the
outpatient setting given her history and perisistent syncopal
episodes. This was held while the patient was in house in an
attempt to further characterize the etiology of her syncope.
Given her persistent orthostatic hypotension with optimal
therapy it was felt this was non-contributory and meclazine was
discontinued on discharge.
# Hyperlipidemia: Continued home atorvastatin.
Transitional Issues-
-The patient's home antihypertensives were discontinued during
her hospitalization given her persistent orthostasis. It was
decided to pursue a strategy of permissive hypertension given
her orthostasis that was unresponsive to IV fluids and
compression stockings.
-The patient was started on fludrocortisone for her orthostatic
hypotension during this admission which resulted in improvement
of orthostatic hypotension.
-There was no evidence on this admission of decubitus ulcers,
only evidence of well healed wounds on the pt's R buttock
-Pt had ECHO which revealed evidence of grade I diastolic
dysfunction and mild pulmonary arterial hypertension.
-___ plan:PLAN: Amb with RW and ___ 3x/day. Normalize sleep-wake
cycle to decrease risk of delirium.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Pioglitazone 30 mg PO DAILY
7. GlipiZIDE 5 mg PO BID
8. Meclizine 25 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Vitamin D ___ UNIT PO DAILY
4. GlipiZIDE 5 mg PO BID
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Pioglitazone 30 mg PO DAILY
7. Fludrocortisone Acetate 0.1 mg PO DAILY
RX *fludrocortisone 0.1 mg 1 tablet(s) by mouth once in the
morning Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Syncope
Orthostatic hypotension
Autonomic dysfunction
Chronic issues
Hypertension
Diabetes Mellitus
Anemia
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear ___-
___ was a pleasure taking part in your care during your
hospitalization at ___. You
were hospitalized for continued episodes of passing out when
getting up. It was discovered that your blood pressure drops
when you sit or stand up from lying down. You were monitored
for 48 hours on heart monitors which showed no irregular heart
rhythms. An ultrasound of your heart was taken, which showed
some mild dysfunction, but not worrisome for why you were
passing out. All of your blood pressure medications were stopped
during this admission. You were started on a medication to help
with your blood pressure dropping when you stand.
Please follow-up with your appointments as scheduled below, and
take all your medications as prescribed. Again, it was a
pleasure taking part in your care.
Best-
Your ___ Care Team
Followup Instructions:
___
|
19881575-DS-9
| 19,881,575 | 29,105,834 |
DS
| 9 |
2122-04-28 00:00:00
|
2122-04-28 14:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old female with a history of diabetes
mellitus, HTN, HLD, dementia and mental retardation s/p multiple
falls who presents after a fall at home.
History limited due to patient's cognitive deficits. As per
niece who is primary caretaker, patient was seated after eating
breakfast in the kitchen around 10am. Niece had gone to another
room when she heard patient fall. SHe states that patient most
likely tried to get up on her own, and fell in the process. She
found the patient on the floor, conscious, responsive. It
appears the patient did not lose consciousness although patient
could not verify this. Only complaint was headache at the site
of head strike. Niece denies any LOC, changes in behavior,
fevers, vomiting, chest pain, shortness of breath.
Neice reports patient has a long history of falls at home with
ROS positive for brief staring spells, brief periods of shaking
of extremities. Briefly, in ___, she had two ED visits for
possibly orthostatic syncope with negative workup, discharged
after metoprolol was dc'd. Again in ___, admitted for
syncope, attributed to othostatic hypotension (despite IVF and
compression stockings). All BP meds were held at ___ and trialed
on fludrocortisone. Workup included a TTE (only g1dd), MRI (just
showed mild mesial temporal atrophy), EEG (normal). Given
recurrent episodes, neurology trialed her on Keppra for possible
seizures. Per niece, no seizures since initiation of Keppra.
In ED, VS: 98.2 80 157/78 18 100% RA. Labs showed positive
UA (>182 WBC, mod bact, large ___, WBC 8.6, Cr 1.1, Mg 1.4. CT
spine with degenerative changes but no fracture. CT head without
contrast showed no ICH and small right frontal hematoma without
fracture. CXR without ingiltrates. UCX pending. Given Tylenol,
CTX 1gm IV, Mg SO4 2gm. Admitted to medicine for UTI
Past Medical History:
DIABETES MELLITUS
DEMENTIA/ MENTAL RETARDATION
?KIDNEY DISEASE
HYPERTENSION
HYPERLIPIDEMIA
Social History:
___
Family History:
Mother reportedly died of a stroke.
Physical Exam:
Admission PE
Gen: Pleasant, cooperative, oriented to self only (baseline)
HEENT: Small hematoma on right frontal area
Neck: No JVD, no carotid bruits
CV: RRR, nl S1 S2, no murmurs
Lungs: CTA b/l
Abd: Soft, non tender, non distended, +BS
Extremities: No edema
Skin: fragile skin
Neuro: CN II-XII grossly normal, moving all 4 extremities
grossly
Discharge PE:
98 118/69 62 18 100 RA
Gen: Pleasant, cooperative, oriented to self only (baseline)
HEENT: Small hematoma on right frontal area
Neck: No JVD, no carotid bruits
CV: RRR, nl S1 S2, no murmurs
Lungs: CTA b/l
Abd: Soft, non tender, non distended, +BS
Extremities: No edema
Neuro: CN II-XII grossly normal, moving all 4 extremities
equally
Pertinent Results:
___ 12:40PM CALCIUM-9.0 PHOSPHATE-3.5 MAGNESIUM-1.4*
___ 12:40PM WBC-8.6 RBC-3.64* HGB-11.2 HCT-34.5 MCV-95
MCH-30.8 MCHC-32.5 RDW-12.7 RDWSD-44.2
___ 12:40PM NEUTS-84.5* LYMPHS-7.3* MONOS-5.8 EOS-1.5
BASOS-0.6 IM ___ AbsNeut-7.24* AbsLymp-0.63* AbsMono-0.50
AbsEos-0.13 AbsBaso-0.05
___ 02:10PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
CT L-Spine
1. No evidence of acute lumbar spinal fracture.
2. Grade 1 anterolisthesis of L4 on L5.
3. Severe degenerative changes of the lumbar spine, most
pronounced at L3-L4 and L4-L5. At L3-L4, there is a large
posterior disc bulge causing moderate central canal narrowing.
Chest PA/L
No acute intrathoracic process. Gaseous distention of loops of
bowel
partially imaged and not well assessed on this study
CT head
1. No acute intracranial hemorrhage.
2. Small right frontal subgaleal hematoma without underlying
fracture.
3. Small focal polypoid lesion in the right nasal cavity is
unchanged since ___
CT c-spine
1. No evidence of fracture or malalignment.
2. Severe multilevel degenerative changes with severe spinal
canal narrowing and multiple levels of severe neural foraminal
narrowing are similar in appearance since ___.
TTE (___): The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Doppler parameters are most
consistent with Grade I (mild) left ventricular diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. No mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity size with preserved regional and global biventricular
systolic function. No valvular pathology or pathologic flow
identified. Mild pulmonary hypertension
EEG (___): Normal routine EEG in wakefulness. There were no
focal
abnormalities or epileptiform features.
___ 2:10 pm URINE
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 CFU/mL.
Brief Hospital Course:
A/P: ___ year old female with a history of diabetes mellitus,
HTN, HLD, mental retardation, history of multiple falls
(possibly due to seizures), who presents after a fall at home,
and found to have an UTI.
# Fall: Per her niece most likely a mechanical fall but unclear,
possibly a seizure. She is currently on Keppra 250mg daily,
which is a minimal dose, however this appears to have worked in
the recent past. Falls in elderly is multifactorial, and ddx
includes orthostasis (given known history and suspected
autonomic dysfunction), mechanical fall, etc. TTE and
EKG/telemetry findings have been normal in the past, therefore
low suspicion for cardiogenic causes. Also EEG has not shown any
abnormalities in ___. She had no further falls or concerning
events. Orthostatics were negative.
# UTI: Presents after a fall and found to have grossly positive
UA. Unclear if she is having symptoms but urine culture growing
>100,000 gram negative rods. Started on ceftriaxone. No known
history of resistant organisms.
- Discharged on 5 day course of Macrobid
- Follow up urine culture
# HTN: Normotensive currently. In the past, has been suspected
to have autonomic dysfunction associated orthostatic
hypotension.
- Continue home HCTZ, lisinopril and metoprolol XL.
# HLD
- Continue atorvastatin
# DM
- Continue home glipizide.
# FEN: Regular diet
# Access: PIV
# Code: Full (confirmed)
# PPX: SQH
# Dispo: home with services
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 250 mg PO DAILY
2. lisinopril-hydrochlorothiazide ___ mg oral DAILY
3. LOPERamide 2 mg PO TID:PRN diarrhea
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Aspirin 81 mg PO DAILY
7. GlipiZIDE 10 mg PO BID
8. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5
Days
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice a day Disp #*10 Capsule Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. GlipiZIDE XL 10 mg PO BID
5. LevETIRAcetam 250 mg PO DAILY
6. lisinopril-hydrochlorothiazide ___ mg ORAL DAILY
7. LOPERamide 2 mg PO TID:PRN diarrhea
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home with Service
Discharge Diagnosis:
UTI
Fall
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted after a fall at home and were found to have a
urinary tract infection (UTI). You were started on antibiotics.
You felt well and had no further falls. Your blood pressure
was normal. Please follow-up with your primary care physician
as scheduled.
Followup Instructions:
___
|
19881629-DS-3
| 19,881,629 | 28,055,087 |
DS
| 3 |
2157-06-09 00:00:00
|
2157-06-09 12:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
Found down, large extra-axial hemorrhage
Major Surgical or Invasive Procedure:
___ left craniectomy for evacuation of left subdural
hematoma
History of Present Illness:
The patient is reportedly a ___ male who was found down
today. History is limited due to poor neurological status and
absence of witnesses. He was found down at about 2am. He was
GCS 3 at the scene and was intubated; atropine was given at the
scene for bradycardia to the ___. He presents to ___ for
further work-up; his left pupil is noted to be fixed and
dilated.
Past Medical History:
Unknown
Social History:
___
Family History:
Unknown
Physical Exam:
On Admission:
Gen: Intubated. No eye opening. No motor response to noxious.
GCS 3t.
HEENT: Scalp hematoma consistent with head trauma.
Neck: Hard collar.
Extrem: Warm and well-perfused.
Neuro:
CN: Left pupil 5, NR; right pupil 3-->2. +Corneals.
Overbreathing ventilator.
Motor: No withdrawal or posturing to noxious.
On Discharge:
A&O to self
Pupils 2 and reactive
Follows simple commands with good strength in all extremities
Hard cervical collar in place
Incision: c/d/i with staples
Pertinent Results:
CT HEAD W/O CONTRAST ___
1. Multicomponent acute intracranial hemorrhages, as described
above, with apparent active bleeding into a left frontal
extra-axial hemorrhage with associated subfalcine , uncal and
trasntentorial herniation, as well as diffuse brainstem
hypodensity concerning for infarction.
2. Large skull fracture in a coronal plane extends through the
bilateral
frontal and temporal bones, as described above, with associated
extensive soft tissue swelling, subcutaneous emphysema, and
pneumocephalus.
3. Facial fractures are better assessed on concurrently
obtained facial bone CT.
CT C-SPINE W/O CONTRAST ___
Vertically oriented fracture through the C5 spinous process with
overlying posterior soft tissue swelling, as described above.
The overall
alignment is maintained, and no other fractures are identified.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST ___
1. Extensive facial and sinus fractures, as described above,
with a small
retro-orbital right hematoma, and no evidence of globe injury or
proptosis.
2. Intracranial pathology is better characterized on
concurrently obtained non-contrast CT of the head.
Final attending comment: also noted is a fracture through the
petrous carotid canal on the left( (2,67), consider further
evaluation with CTA to exclude carotid injury.
CT HEAD W/O CONTRAST ___
IMPRESSION:
1. Decrease in midline shift and uncal herniation status post
left craniectomy with evacuation of extra-axial hemorrhage.
2. Small right temporal extra-axial hemorrhage and several
subcentimeter
intraparenchymal contusions near the vertex are also stable.
3. Facial, skull base and calvarial fractures are
redemonstrated.
CT ABD & PELVIS WITH CONTRAST ___
IMPRESSION:
1. No acute solid organ, vascular, or hollow viscous injury in
the chest,
abdomen or pelvis.
2. Mild periportal edema, presumably due to IV fluid
resuscitation.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
9:27 AM
IMPRESSION:
1. ET tube 2 cm above the carina, at the lower limits of the
range of
positioning, pointing towards the right mainstem bronchus.
2. Developing left lower lobe collapse and/or consolidation.
Possible small left effusion.
3. Atelectasis in the right cardiophrenic region, which may be
slightly
worse.
4. Upper zone redistribution, without overt CHF.
5. There is some prominence of the right hilum compared to the
prior film, of uncertain etiology or significance. Possibly due
to vascular engorgement. Attention to this area on followup
films is requested.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
9:16 AM
IMPRESSION:
1. Small developing hypodensity in the inferolateral left
frontal lobe,
compatible with infarction or contusion.
2. Mild improvement in left hemispheric edema with slightly
decreased shift of midline structures. However, herniation of
the brain through left
craniectomy defect and ventricular effacement persist.
3. Stable appearance of intracranial hemorrhage compared to one
day earlier.
4. Bilateral calvarial and facial fractures are again noted.
Brief Hospital Course:
___ y/o M found down presents with large L SDH. He was given
mannitol and hyerventilated in ED. He was then taken emergently
to the OR for a L craniectomy for evacuation of L SDH. He was
transferred to the ICU post operatively. He remained intubated.
On exam, pupils are equal and reactive, localizes with BUE, L>R,
and spontaneous with BLE. A hard collar remained in place for a
C5 fracture. Social work was consulted as well and plastic
surgery and optho for facial fractures and orbital hematoma.
on ___ a right frontal ICP bolt was placed for ICP monitoring.
Patient's exam was stable with no Eye opening and no following
of commands, he wa started on hypertonic saline at 30 cc / hr on
___.
On ___, An intercranial Bolt was placed to monitor intercranial
pressures.
On ___, The intercranial Bolt exhibited poor waveform appeared
to be dislodged. A Bronchoscopy was performed and revealed a
pneumonia and the patient remained intubated. At 1100 a
intercranial Bolt was replaced and there was a good waveform.
The intercranial presures were low. The normal saline 3% was
discontinued at 2100.
On ___, The right arm exhibited no movement to noxious
stimulous. A sts NCHCT was performed and found to be stable.
The EEG was consistent with no seizures and diffuse slowing more
on the left consistent with left sided hemisphere edema. The
intercranial pressures remained low and the intercranial bolt
was discontinued. The patient was extubated at 1500. The serum
sodium was 152 and serum sodiums were assessed ever 6 hours.
Consults for ___ and speech were placed.
On ___, The patient was slightly more wakeful. The patients
eyes opened to voice. He moved all extremities antigravity and
purposefully. The patient remained in the ICU for close
neurological assessment. On ___ he was transferred to the SDU
on Cefepime for VAP and remained stable thru ___. Patient
remained stable and remained waiting for rehab bed. He was
transferred out of SDU status and his diet was advanced. On ___
- there were no changes and he remained waiting for disposition.
He remained requiring a posey overnight and received Haldol prn.
On ___, he continued to await for a rehab bed. He remained
agitated overnight and required restraints. On ___, he remained
unchanged on examination. He was screened by ___
facility and was accepted. He was discharged to rehab.
Medications on Admission:
Unknown
Discharge Medications:
1. Acetaminophen IV 1000 mg IV Q6H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
3. Artificial Tear Ointment 1 Appl BOTH EYES QID:PRN
pain/itching
4. Bacitracin Ointment 1 Appl TP BID
5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
6. Ciprofloxacin 0.3% Ophth Soln 5 DROP LEFT EAR BID Duration:
10 Days
For 10 days, stop after ___ dose.
7. Dexamethasone Ophthalmic Soln 0.1% 5 DROP LEFT EAR BID
Duration: 10 Days
For 10 days, stop after ___ dose.
8. Docusate Sodium 100 mg PO BID
9. LeVETiracetam 1000 mg IV BID
Continue to take until follow up.
10. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
11. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
12. Heparin 5000 UNIT SC TID
13. Nystatin Cream 1 Appl TP BID
Continue to take until clear.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left subdural hematoma
Cerebral edema
Klebsiella VAP
C5 spinous process fracture
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Confused - sometimes.
Discharge Instructions:
Have a friend/family member check your incision daily for signs
of infection.
¨ Take your pain medicine as prescribed.
¨ Exercise should be limited to walking; no lifting,
straining, or excessive bending.
¨ **Your wound was closed with staples. You may wash your
hair only after your staples have been removed.
¨ You may shower before this time using a shower cap to
cover your head.
¨ Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
¨ Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
¨ **You have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
¨ Clearance to drive and return to work will be addressed at
your post-operative office visit.
¨ Make sure to continue to use your incentive spirometer
while at home, unless you have been instructed not to.
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:
___
|
19881755-DS-20
| 19,881,755 | 26,848,473 |
DS
| 20 |
2155-09-19 00:00:00
|
2155-09-19 16:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Geodon / Wellbutrin
Attending: ___
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
Intubation ___
History of Present Illness:
The patient is a ___ year old man with PMHx of epilepsy,
schizophrenia, hypothyroidism, HTN/HLD who presented to the ED
as
a transfer from ___ for seizures.
Patient reportedly presented to the ___ for headache
x1 day and confusion. On evaluation in the ___,
patient reported headache associated with photo and phonophobia
x1 day, some confusion and concern for meningeal irritation. He
denied any infectious symptoms. There, he was afebrile, BP
166/96, pulse 61 and saturations 100% on room air. On exam, he
was neurologically intact. Labs notable for leukocytosis 11.9,
sodium 124, chloride 85, ammonia 11, normal cardiac enzymes, a
clean UA, and negative urine tox. LP was done which was clear
and
had 1 WBC, 1 RBC, 60 glucose and 14 protein. CTH was performed
which showed no intracranial process, and CXR showed no
consolidation.
In the ___, patient reportedly had an episode that
was
thought to be consistent with prior non-epileptic events. There
is no description of what was seen during this, but in the chart
there is mention that during the episode patient had his eyes
closed and forcefully kept them shut, was able to follow
commands
and had no rigidity, tremulousness. There was low suspicion that
this was a seizure. After this, patient had a witnessed GTC for
which he received 2mg IV Ativan which broke the seizure. He then
had another GTC which was not broken by 2mg IV Ativan so patient
was intubated and transferred to ___. Per report, patient had
missed a few days of his AEDs due to non-compliance.
In terms of patient's epilepsy history, little is known as
patient has not been seen by neurology at ___ and the
electronic link to ___ EMR is not active.
Unable to obtain ROS as patient intubated.
Past Medical History:
epilepsy, schizophrenia, hypothyroidism, HTN/HLD
Social History:
___
Family History:
Unable to obtain.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T:98.1 P:60 R: 16 BP: 100/60 SaO2:100% vent
General: intubated, sedated obese man
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple, no carotid bruits appreciated.
Pulmonary: mechanical breath sounds
Cardiac: RRR, good peripheral perfusion
Abdomen: obese, soft
Extremities: No ___ edema.
Skin: areas of hyperpigmentation on bilateral lower
extremities.
Neurologic:
-Mental Status: intubated, off sedation x10 minutes. Does not
open eyes or follow commands.
-Cranial Nerves:
Pupils 1-->0.5 mm bilaterally. Doll's eyes present. Does not
BTT
reliably. Corneals present bilaterally. No obvious facial
asymmetry. Cough and gag present.
-Sensorimotor: withdraws to noxious in plane of bed in bilateral
upper extremities. Briskly withdraws bilateral legs to noxious,
almost lifting them antigravity.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was extensor bilaterally.
-Coordination: Unable to assess.
-Gait: Unable to assess.
DISCHARGE PHYSICAL EXAM
========================
-Mental Status: A&o to person, place, time. Able to name ___
backwards. Perseverative. Fluent speech.
-Cranial Nerves:
Pupils 1-->0.5 mm bilaterally, brisk. EOMI, few beats of end
gaze
nystagmus on left gaze. jerky eye movements with smooth pursuit.
face symmetric. no dysarthria palate elevates symmetrically.
tongue midline, no weakness on tongue to cheek protrusions.
-Sensorimotor: No drift in upper extremities. full motor
strength
throughout, no deficit to light touch in all extremities
-Coordination: FNF normal, HTS normal bilaterally
-Gait: slow ambulation but steady with negative Romberg
Pertinent Results:
ADMISSION LABS
==============
___ 09:45PM BLOOD WBC-11.1* RBC-4.03* Hgb-12.8* Hct-37.5*
MCV-93 MCH-31.8 MCHC-34.1 RDW-12.9 RDWSD-44.2 Plt ___
___ 08:00AM BLOOD WBC-16.1* RBC-4.51* Hgb-14.5 Hct-43.1
MCV-96 MCH-32.2* MCHC-33.6 RDW-12.8 RDWSD-44.2 Plt ___
___ 01:46AM BLOOD WBC-14.6* RBC-3.96* Hgb-12.6* Hct-36.8*
MCV-93 MCH-31.8 MCHC-34.2 RDW-12.5 RDWSD-42.7 Plt ___
___ 01:46AM BLOOD Neuts-66.3 Lymphs-18.1* Monos-12.0
Eos-0.1* Baso-0.1 Im ___ AbsNeut-9.67* AbsLymp-2.64
AbsMono-1.75* AbsEos-0.01* AbsBaso-0.01
___ 01:46AM BLOOD Plt ___
___ 08:00AM BLOOD ___ PTT-22.7* ___
___ 09:45PM BLOOD Plt ___
___ 01:46AM BLOOD Glucose-68* UreaN-15 Creat-0.7 Na-122*
K-4.7 Cl-88* HCO3-29 AnGap-5*
___ 01:46AM BLOOD ALT-36 AST-27 AlkPhos-28* TotBili-0.3
___ 01:46AM BLOOD Lipase-19
___ 01:46AM BLOOD Albumin-2.6* Calcium-7.8* Phos-5.2*
Mg-2.1
___ 01:46AM BLOOD Osmolal-269*
___ 06:15PM BLOOD TSH-4.0
___ 06:15PM BLOOD Cortsol-2.3
___ 12:40AM BLOOD Valproa-43*
___ 01:46AM BLOOD Valproa-24*
___ 01:46AM BLOOD ASA-NEG Ethanol-10 Acetmnp-NEG
Tricycl-NEG
___ 02:09AM BLOOD ___ pO2-33* pCO2-63* pH-7.30*
calTCO2-32* Base XS-1
___ 11:04PM BLOOD Glucose-74 Lactate-0.9 Na-128* K-3.7
Cl-95*
___ 11:04PM BLOOD freeCa-1.07*
DISCHARGE LABS
==============
___ 05:49AM BLOOD WBC-10.0 RBC-3.56* Hgb-11.3* Hct-33.0*
MCV-93 MCH-31.7 MCHC-34.2 RDW-12.3 RDWSD-41.8 Plt ___
___ 05:10AM BLOOD ___ PTT-27.0 ___
___ 05:49AM BLOOD Glucose-97 UreaN-10 Creat-0.5 Na-128*
K-4.1 Cl-90* HCO3-28 AnGap-10
___ 05:49AM BLOOD ALT-29 AST-20 LD(LDH)-206 AlkPhos-43
TotBili-0.3
___ 05:49AM BLOOD Albumin-3.5 Calcium-8.5 Phos-3.7 Mg-1.6
___ 05:49AM BLOOD Valproa-53
BRAIN MRI:
===========
Final report pending
Brief Hospital Course:
Mr. ___ is a ___ year old man from group home with a past
medical history of epilepsy, schizophrenia, ETOH use disorder,
depression with multiple suicide attempts, chronic hyponatremia
(baseline Na 128-129), hypothyroidism, HTN, HLD who presented
after being found unresponsive at group home with eye
fluttering, subsequently had 2 witnessed GTC's at OSH s/p
intubation for airway protection transferred to ___ for
further care.
#Seizures:
Etiology of breakthrough seizures unclear most likely AED
noncompliance, supported by subtherapeutic Valproic Acid on
admission. Home AEDs include depakote ER 1500 daily, keppra ___
mg daily. Although history of ETOH use and elevated serum level
on admission, there was low suspicion for ETOH withdrawal as he
did not score on CIWA, with negative serum ETOH at OSH. Other
etiologies to consider for seizures include hypoglycemia,
although glucose was 70 when first seizure occurred. In the ICU,
he was intubated for airway protection for approximately 2 days.
His home AEDs were restarted with no dose adjustments. Video EEG
>24 hours demonstrated mild encephalopathy and left temporal
slowing with no seizures. He was on propofol while intubated
which was weaned prior to extubation. His blood pressure dropped
to ___ on propofol and he was given norepinephrine peripherally
for approximately 1 day. Upon transfer out to the floor on ___,
he was at his baseline. Given the left temporal slowing noted on
EEG, he underwent MRI to evaluate for possible lesion there but
upon prelim read it was normal. Final read pending.
#Hypoglycemia:
No known history of diabetes or insulin use. Low finger sticks
when admitted (nadir around 30), however whole blood sugars
60-120. His hypoglycemia on fingerstick checks may have been due
to poor peripheral perfusion (hands were cool, weak radial
pulses although dopplerable). He may have been hypoglycemic
following seizure, or also may not have been eating prior to
admission. Was briefly given D10 which was held to check
proinsulin and cpeptide levels. D10 was not restarted since his
sugars normalized spontaneously. Low suspicion for adrenal
insufficiency given prednisone use for asthma exacerbation as
below. HgA1c 5.2.
#Hyponatremia:
Chronic, baseline 128-129. Initial Na 122, received 50 cc 3% in
ED, then 3% hypertonic infusion in ICU, sodium corrected to 134,
thus increased 12 units in 6 hours, hypertonic saline was
discontinued. Subsequent sodium levels stable in mid ___.
Studies most consistent with SIADH (high urine Na, low plasma
osm).
#Steroid use
#History of asthma:
Tapered home prednisone, per chart review on taper for asthma
exacerbation. Continued home nebs.
#Schizophrenia
#Depression:
History of multiple suicide attempts and inpatient psychiatric
hospitalizations. Continued home Paxil, Vistaril, Mirtazapine,
Zyprexa, Seroquel.
#Nutrition:
Noted to aspirate thin liquids per nursing evening of
extubation. Evaluated by speech and swallow, initiated soft
solid diet with nectar thick liquids, advanced to **.
#Hypertension
Held home propranolol, lisinopril in setting of hypotension as
above. Restarted home lasix due to concern for small R effusion
on CXR.
#HLD:
Continued home simvastatin.
#CODE: full
#CONTACT: sister, ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex (EXTended Release) 500 mg PO QAM
2. Divalproex (EXTended Release) 1000 mg PO QPM
3. PARoxetine 20 mg PO DAILY
4. LevETIRAcetam 1000 mg PO BID
5. OLANZapine 15 mg PO BID
6. Propranolol 20 mg PO BID
7. QUEtiapine Fumarate 200 mg PO QHS
8. Mirtazapine 7.5 mg PO QHS
9. ChlorproMAZINE 100 mg PO Q4H:PRN agitation
10. HydrOXYzine 25 mg PO Q4H:PRN anxiety
11. Lisinopril 10 mg PO DAILY
12. Furosemide 20 mg PO QAM
13. Levothyroxine Sodium 88 mcg PO QAM
14. Vitamin D ___ UNIT PO DAILY
15. Simvastatin 20 mg PO QPM
16. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
17. Albuterol Inhaler 2 PUFF IH Q6H:PRN asthma
18. PredniSONE 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN asthma
3. ChlorproMAZINE 100 mg PO Q4H:PRN agitation
4. Divalproex (EXTended Release) 500 mg PO QAM
5. Divalproex (EXTended Release) 1000 mg PO QPM
6. Furosemide 20 mg PO QAM
7. HydrOXYzine 25 mg PO Q4H:PRN anxiety
8. LevETIRAcetam 1000 mg PO BID
9. Levothyroxine Sodium 88 mcg PO QAM
10. Lisinopril 10 mg PO DAILY
11. Mirtazapine 7.5 mg PO QHS
12. OLANZapine 15 mg PO BID
13. PARoxetine 20 mg PO DAILY
14. PredniSONE 10 mg PO ONCE Duration: 1 Dose
LAST DOSE ___. Propranolol 20 mg PO BID
16. QUEtiapine Fumarate 200 mg PO QHS
17. Simvastatin 20 mg PO QPM
18. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Epilepsy
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ___ Neurology Service because you had
multiple seizures because you were not taking your seizure
medicines. You received medications to stop your seizures but
then you needed a breathing tube for a time due to the strong
medicines that were needed to stop the seizures. You did not
have any further seizures. You were restarted on your home doses
of Keppra and Depakote.
IT IS VERY IMPORTANT THAT YOU TAKE YOUR MEDICATIONS AS
PRESCRIBED TO PREVENT FUTURE SEIZURES AND HOSPITALIZATIONS.
We also reviewed seizure precautions with you, and they are
again listed below in writing.
SEIZURE PRECAUTIONS:
Helpful Websites: epilepsyfoundation.org
epilepsy.com
In case of seizure: 1. Stay Calm. 2 Keep Safe, place on side.
3. Call ___ if seizure is greater than 5 minutes or if there are
other concerns.
By ___ Law - no driving for six months following
altered consciousness - also avoid active participation in
traffic
Avoid bathing/swimming alone. Okay to shower alone.
Avoid climbing
Avoid using sharp moving objects
Avoid unsupervised exposure to heat sources (open fires, stoves)
Wear protective gear for sports
Avoid being alone in locked setting
Avoid situations where altered consciousness could prove to be
dangerous
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19882137-DS-20
| 19,882,137 | 21,995,360 |
DS
| 20 |
2162-06-30 00:00:00
|
2162-06-30 18:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
codeine
Attending: ___
Chief Complaint:
Low back pain, incontinence
Major Surgical or Invasive Procedure:
___: L2-L4 laminectomies for intradural tumor resection
History of Present Illness:
___ year old female, PMH of HTN and lower back pain presenting
with worsening back pain and non-urge related urinary
incontinence. She underwent MRI on ___ and was found to have
an L3 spinal canal mass. MRI here remonstrates that lesion.
Past Medical History:
No history of known cancer
hypertension
Social History:
___
Family History:
Mother: diagnosed with breast cancer in her ___, treated and
into
remission. Deceased as of ___ decade of life
Father: Liver cancer without history of alcohol abuse
Physical Exam:
AT ADMISSION:
Gen: WD/WN. Uncomfortable in bed and throughout exam
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.
Motor:
Deltoid BicepTricepGrip
IPQuadHamATEHLGast
No Clonus
Negative ___
Sensation intact to light touch
Propioception intact
Rectal exam normal sphincter control
UPON 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
Speech Fluent: [x]Yes [ ]No Comprehension intact: [x]Yes [
]No
Motor:
TrapDeltoidBicepTricepGrip
___
IPQuadHamATEHLGast
___ 5 5
Left___ 5 5
[x]Sensation intact to light touch
Dressing:
[x]Incision clean, dry and intact
[x]sutures
Pertinent Results:
Please refer to ___ for relevant imaging and lab results
Brief Hospital Course:
___ with a lumbar spinal canal mass who presented to ED for
further evaluation. Patient was admitted and taken to the OR for
L2-4 laminectomy and intradural tumor resection.
#Spinal mass
Patient was admitted to the neurosurgery floor from the ED. MRI
lumbar spine was obtained which re-demonstrated a known lumbar
spine lesion. Patient was pre-op and consented for surgical
intervention. On ___ patient was taken to the OR for L2-L4
laminectomy and intradural tumor resection which she tolerated
well. Please see the formal op report in ___ for further
intraoperative details. Patient was transferred to the PACU for
post op care and later transferred to the floor. She remained
flat for 48 hours. Activity was liberalized on ___ with the
patient ambulating on ___ her incision at that time remained
dry and she had no complaint of headaches. Patient's pain meds
were adjusted titrated for adequate pain control. She worked
with physical therapy multiple times. They ultimately
recommended discharge to home with a rolling walker.
#Sinus tachycardia
Patient was noted to be tachycardic up to the 120s sustained on
multiple occasions. Electrolytes were checked and all within
normal limits. EKG was obtained which demonstrated sinus
tachycardia but unable to r/o anterior wall infarct. Given this,
cardiac enzymes were sent and returned normal.
#Urinary Retention
Paient's foley catheter was removed on ___ when activity
restriction was lifted. Patient difficulty urinating with high
post void residuals. She was straight cathed multiple times. On
___ Flomax was started, and patient's voiding difficulties
resolved. She was referred to her PCP for ___.
Medications on Admission:
acetaminophen PRN
amlodipine 2.5 mg tablet oral 1 tablet(s) Once Daily
hydrocodone 5 mg-acetaminophen 325 mg tab q4-6 hrs, PRN
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. Cyclobenzaprine 10 mg PO TID:PRN muscle spasms
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth Q8H PRN Disp #*21
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Severe
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q4-6
hours PRN Disp #*60 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
7. Senna 17.2 mg PO QHS
8. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
9. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
10. amLODIPine 2.5 mg PO DAILY
11.Rolling Walker
Dx: L3 intradural spinal lesion
Ppx: Good
___: 13 months
Discharge Disposition:
Home
Discharge Diagnosis:
L3 intradural spinal lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Surgery
Your incision is closed with sutures. You will need suture
removal. Please keep your incision dry until suture removal.
Do not apply any lotions or creams to the site.
Please avoid swimming for two weeks after suture 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 ___ 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:
___
|
19882171-DS-29
| 19,882,171 | 27,855,058 |
DS
| 29 |
2156-12-13 00:00:00
|
2156-12-13 17:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Found down, fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of afib on coumadin, AVR and MVR in ___ for
rheumatic heart disease, ___ with last EF of 35%, frequent
UTIs, frequent falls who presented after she was found down in
her bedroom. Her family relays the story as she is unable to.
Her husband found her down on her knees clutching the bed. He
does not beleive she had a head strike. She was not witnessed to
have loss of consciousness. She denied any chest pain or
shortness of breath. She denied dizziness. Of note, per the
family she has multiple falls in the setting of weak lower
extremities. None of these falls have been accompanied by loss
of consciousness. She has no fevers or chills currently. She has
had no chest pain or shortness of breath recently. She appears
chronically ill but the family states that her mental status,
her respiratory status, her weight all seem to be at her
baseline.
In the ED intial vitals were: 95.6 84 117/70 18 96% RA
Patient was given: Full dose aspirin
Vitals on transfer: 98.9 73 123/61 17 97% RA
On the floor the entire history was acquired from the family.
Past Medical History:
- DM
- Afib on Coumadin
- CHF: EF 35%
- s/p bioprosthetic aortic and mitral valves
- s/p bilateral knee replacement
- s/p partial colectomy for diverticulitis
Social History:
___
Family History:
Notable for diabetes mellitus, hypertension, and coronary artery
disease.
Physical Exam:
Admission Physical
=====================
VS: 98.1 97.8 126-139/53-59 ___ 95%RA
GENERAL: NAD AAOx1, chronically ill appearing
HEENT: Normocephalic and atraumatic. The oropharynx is benign.
The sclerae are anicteric.
NECK: Supple. There is no jugular venous distention. The
carotid upstrokes are normal in volume and contour. There are
no
carotid bruits. The trachea is on midline and mobile. There is
no palpable cervical lymphadenopathy or thyromegaly.
CHEST: +crackles throughout lung fields
HEART: Irregular rhythm with normal S1, widely and
paradoxically
split S2. SEM at LUSB ___.
ABDOMEN: Benign, without masses, tenderness, organomegaly,
+distention. Hyperactive bowel sounds.
EXTREMITIES: Warm extremities, 2+ pitting edema to thighs, upper
extremity edema
NEUROLOGIC: The patient is nonparticipatory on exam, but does
have PERRLA, notably she has left wrist drop with weakness.
SKIN: No suspicious lesions on gross visual inspection
Discharge Physical
======================
VS: 98.6 97.6 118-147/48-67 ___ 18 100%RA
Weight: 77kg, 76.5kg yesterday, 88.1kg on admission
GENERAL: NAD AAOx1, chronically ill appearing
HEENT: Normocephalic and atraumatic. The oropharynx is benign.
The sclerae are anicteric.
NECK: Supple. No appreciable elevated JVD. There are no
carotid bruits. The trachea is on midline and mobile. There is
no palpable cervical lymphadenopathy or thyromegaly.
CHEST: CTAB/L no wheezes, rhonchi, rales
HEART: Irregular rhythm with normal S1, widely and
paradoxically
split S2. SEM at LUSB ___.
ABDOMEN: Benign, without masses, tenderness, organomegaly,
+distention. Hyperactive bowel sounds.
EXTREMITIES: Warm extremities, trace pitting edema to shins,
mottled lower extremities
NEUROLOGIC: The patient is nonparticipatory on exam, but does
have PERRLA, notably she has left wrist drop with weakness.
SKIN: No suspicious lesions on gross visual inspection
Pertinent Results:
Admission Labs
=================
___ 08:55AM BLOOD WBC-13.8*# RBC-3.74* Hgb-10.5* Hct-33.9*
MCV-91 MCH-28.2 MCHC-31.1 RDW-14.2 Plt ___
___ 08:55AM BLOOD ___ PTT-30.0 ___
___ 08:55AM BLOOD Glucose-127* UreaN-32* Creat-1.3* Na-134
K-4.4 Cl-96 HCO3-26 AnGap-16
___ 08:55AM BLOOD Albumin-3.7 Calcium-9.1 Phos-3.7 Mg-1.6
Other Notable Labs
==================
___ 05:50AM BLOOD VitB12-1135*
___ 05:50AM BLOOD TSH-0.72
___ 08:55AM BLOOD Digoxin-1.2
___ 09:15AM BLOOD Lactate-1.8
Cardiac Labs
==============
___ 08:55AM BLOOD CK(CPK)-1036*
___ 04:55PM BLOOD CK(CPK)-773*
___ 09:07PM BLOOD CK(CPK)-623*
___ 08:55AM BLOOD CK-MB-14* MB Indx-1.4 proBNP-4032*
___ 08:55AM BLOOD cTropnT-0.32*
___ 04:55PM BLOOD CK-MB-10 MB Indx-1.3 cTropnT-0.35*
___ 09:07PM BLOOD CK-MB-8 cTropnT-0.32*
Urinalysis
==============
___ 04:53PM URINE Color-Straw Appear-Hazy Sp ___
___ 04:53PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 04:53PM URINE RBC-16* WBC->182* Bacteri-MOD Yeast-NONE
Epi-1 TransE-<1
Microbiology
=============
___ 8:55 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:25 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:53 pm URINE Source: Catheter.
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of 2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Imaging
============
CT Head ___
IMPRESSION:
1. No acute intracranial abnormality.
2. Periventricular white matter changes compatible with sequela
of chronic
small vessel disease present on prior examinations and stable.
CT Spine ___
IMPRESSION:
1. Multi-level degenerative changes with mild disc disease, most
prominently at the C5-C6 level. No evidence of cervical
malalignment or fracture.
2. Enlarged thyroid gland with calcifications, present on prior
examination
dated ___ and stable. Clinical correlation is
recommended and a non urgent ultrasound can be performed as
needed.
Left Wrist Xray ___
IMPRESSION: No fracture or dislocation identified. Significant
degenerative changes about the ___ CMC joint. Soft tissue
swelling about the distal wrist along the dorsal and medial
aspect.
Bilateral Hip Xray ___
IMPRESSION:
1. Significant degenerative changes within the lower lumbar
spine, similar in appearance when compared to prior examination
dated ___.
2. Moderate degenerative changes about bilateral hip joints.
3. No acute fracture or dislocation.
Chest Xray ___
IMPRESSION:
1. Cardiomegaly, stable in appearance since prior examination
dated ___.
2. Mild interstitial pulmonary edema.
3. Right 8th rib fracture with small left sided pleural
effusion. No
pneumothorax.
TTE ___
The left atrial volume index is severely increased. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is abnormal septal motion (?post op) with preservation of
other segments, especially apical segments. Quantitative
(biplane) LVEF = 40 % Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. A well seated
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis leaflets appear to move normally with normal
gradient. Trace aortic regurgitation is seen. A bioprosthetic
mitral valve is seen. It is well seated with normal leaflet
motion. The transmitral gradient is normal for this prosthesis.
No mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Well seated normal functioning bioprosthetic aortic
and mitral valves. Mild symmetric left ventricular hypertrophy
with septal dysfunction and mildly depressed global function.
Compared with the prior study (images reviewed) of ___,
the estimated PA systolic pressure is slightly lower.
Brief Hospital Course:
___ with history of AVR/MVR s/p replacement in ___, ___ with
EF last 35%, atrial fibrillation on coumadin, DM2 who presented
to the ED after a fall found to have a troponin of 0.32 and with
notable volume overload.
# Decompensated Chronic Systolic Heart Failure: Initially with
her elevated troponin level there was concern she may have a
heart failure exacerbation secondary to an MI. Patient had no
signs or symptoms consistent with this as EKG shows no changes
with persistent RAD, LBBB, no ST changes, and atrial
fibrillation. Patient is supposedly on 1L fluid restriction at
home, but unclear if she is compliant. Per the family they did
not see any recent change in her volume status, or in the
swelling in her lower extremities. She appears mildly dyspneic
but per the family they thought that this was her baseline. Her
BNP elevated to greater than 7000. TTE largely unchanged with
mild septal and global dysfunction. She was initially
aggressively diuresed as she was grossly volume overloaded. It
was thought that this was secondary to a slow build up of
volume. She diuresed well with a discharge weight of 77kg which
is likely her dry weight from an admission weight of 88kg. She
was transitioned to 10mg of PO torsemide with the plan to
maintain euvolemia on this new dose. The rest of her cardiac
medications including carvedilol, atorvastatin, lisinopril were
continued.
- Her diuresis was changed from lasix to torsemide and she
should have close following of her volume status and have a
chem10 checked on ___.
# Elevated troponin: Patient had no chest pain, no new shortness
of breath and no new EKG changes. Her troponin peaked at 0.34
and then downtrended, MB-index was not elevated so given the
entire picture this was thought unlikely to be ACS. Throughout
her hospital stay she had no chest pain, or worsening shortness
of breath. It was thought her troponin level was due to demand
on the heart given her volume overload.
# Fall: This was not witnessed at home. Multiple previous falls
have been in the setting of lower extremity weakness and
unsteadiness, never with loss of consciousness. As patient found
on knees holding on to bed, this was likely to be a mechanical
fall as well. She has no other known history of arrhythmia
besides atrial fibrillation and was monitored on telemetry with
no other notable arrhythmias. She had imaging of her head,
wrist, hips, chest, and spine with only notable finding being a
R 8th rib fracture. Per the family this was an old finding.
# Atrial fibrillation: CHADS2=4. She had been rate ctonrolled as
an outpatient with carvedilol. She was on coumadin at home. Her
INR was slightly subtherapeutic on admission, but when continued
on home dose of coumadin 2mg she became supratherapeutic. She
was switched from 2mg daily to 1mg on ___ and became
subtherapeutic. She was then increased to 1mg coumadin 3x/week
and 2mg coumadin 4x/week. Her carvedilol was continued at home
dose and she was well rate controlled.
- She should have her INR checked ___. Her coumadin has been
readjusted given her supratherapeutic levels on her oupatient
dose of 2mg. It is now 2mg 4x/week and 1mg 3x/week.
# UTI - Patient the morning of ___ seemed more agitated than
baseline. UA showed leuk esterase and WBCs. At the time she had
a foley. She was started on ceftriaxone and her urine culture
eventually grew out cipro resistant E. Coli.
- She should be continued on IV ceftriaxone for a full seven day
course through ___.
# Acute kidney injury: Patient creatinine increased from
baseline of 1.1 to 1.3 on admission. With diursesis patient
improves to baseline patient stable at 1.1.
# Left wrist drop - Patient noted to have wrist drop after
having fall and being found down. No pain tenderness on exam. CT
head negative for stroke. No evidence of fracture on wrist xray.
Most likely this was a radial nerve palsy. Patient was seen by
OT and fitted with a splint.
- She should continue to be follow by OT for her left wrist and
remain in the splint until determined her functional ability has
improved.
- If this does not resolve she should follow up with potential
neuromuscular evaluation
# R knee hematoma - Likely secondary from fall. No evidence of
effusion of the knee itself. Patient initially had pain and was
placed on tylenol. Throughout her stay her symptoms improved and
her hematoma resolved.
# Mood - Patient appears depressed and withdrawn in hospital.
Family notes that patient used to be very active but has been
progressively weakening and has become very withdrawn. Patient
also was confused. Psychiatry evaluated patient and determined
that she was off her baseline and likely had dementia and
delirium.
- She should be reevaluated by psychiatry while in rehab. She
should follow up with outpatient neurology and geriatric
psychiatry as an outpatient.
#DMII: She was on metformin 500mg BID at home. This was held in
hospital and she was continued on an insulin sliding scale.
#GERD: She was continued on omeprazole.
#Leg weakness: Has weakness at baseline that is symmetric (uses
walker). Per family they do not think she looks any different
than previously in terms of her leg weakness. Patient remained
functionally limited needing assistant to get out of bed and to
chair.
- She had noted on CT spine an enlarged thyroid gland with
calcifications, present on prior examination dated ___
and stable. A nonurgent ultrasound should be performed if this
workup has not been completed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 2 mg PO DAILY16
2. Atorvastatin 20 mg PO DAILY
3. Digoxin 0.125 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Carvedilol 12.5 mg PO BID
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
10. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. Cyanocobalamin 1000 mcg PO DAILY
4. Digoxin 0.125 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Warfarin 1 mg PO DAYS (___)
8. Warfarin 2 mg PO DAYS (___)
9. Acetaminophen 650 mg PO TID
10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Torsemide 10 mg PO DAILY
13. Senna 17.2 mg PO HS
14. Docusate Sodium 100 mg PO BID
15. CeftriaXONE 1 gm IV Q24H
Discharge Disposition:
Extended Care
Facility:
___
___ and ___)
Discharge Diagnosis:
Primary Diagnosis
- Acute systolic heart failure exacerbation
- Radial nerve palsy
- UTI
Secondary Diagnosis
- Delirium
- Dementia
- Atrial Fibrillation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. ___,
It was our pleasure caring for you at ___
___. You were admitted after a fall at home. You had
multiple xrays that were performed and none showed a new
fracture. You were found to have a lot of extra fluid from your
heart failure. You were given medications to remove this fluid.
You also were found to have a urinary tract infection so you
were started on antibiotics. You were confused during your
hospital stay likely secondary to your infection, your heart
failure, and being in the hospital. You had an injury to one of
the nerves in your arm which caused weakness of your left hand.
You had it placed in a splint and should continue keeping it in
a splint and working with occupational therapists.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Your discharge weight was 76.5kg which is 168lbs.
You were admitted at 88kg which is 193lbs.
Followup Instructions:
___
|
19882347-DS-16
| 19,882,347 | 26,838,579 |
DS
| 16 |
2170-07-23 00:00:00
|
2170-07-23 19:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Ceclor /
Macrobid
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ Ex-lap, lysis of adhesions
History of Present Illness:
This patient is a ___ year old female with a history of IBS
who presents with abdominal pain, nausea and vomiting. She
was seen at ___ and was sent here for CT scan. She
received morphine at the OSH which helped to relieve her
pain.
Past Medical History:
IBS
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION upon admission; ___
Temp: 98.8 HR: 95 BP: 120/66 Resp: 16 O(2)Sat: 93 Normal
Constitutional: Constitutional: comfortable
Head
/ Eyes: NC/AT
ENT: OP WNL
Resp: CTAB
Cards: RRR. s1,s2. no MRG.
Abd: S/+lower and tnderness/ND
Flank: no CVAT
Skin: no rash
Ext: No c/c/e
Neuro: speech fluent
Psych: normal mood
Pertinent Results:
___ 01:50PM BLOOD WBC-6.1 RBC-4.25 Hgb-13.0 Hct-39.5 MCV-93
MCH-30.7 MCHC-33.0 RDW-11.9 Plt ___
___ 05:30AM BLOOD WBC-6.6 RBC-4.05* Hgb-12.7 Hct-37.4
MCV-92 MCH-31.2 MCHC-33.9 RDW-11.9 Plt ___
___ 06:50AM BLOOD WBC-15.4* RBC-5.06 Hgb-15.7 Hct-47.1
MCV-93 MCH-31.0 MCHC-33.4 RDW-11.6 Plt ___
___ 10:36AM BLOOD Neuts-75.1* ___ Monos-3.3 Eos-2.4
Baso-0.6
___ 01:50PM BLOOD Plt ___
___ 05:30AM BLOOD ___ PTT-26.0 ___
___ 04:55AM BLOOD Glucose-119* UreaN-3* Creat-0.5 Na-142
K-4.1 Cl-106 HCO3-28 AnGap-12
___ 07:18AM BLOOD Glucose-128* UreaN-4* Creat-0.5 Na-142
K-3.7 Cl-104 HCO3-31 AnGap-11
___ 06:50AM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-143
K-3.9 Cl-104 HCO3-22 AnGap-21*
___ 04:55AM BLOOD Calcium-8.7 Phos-4.0# Mg-1.9
___ 10:52AM BLOOD Lactate-0.8
___: cat scan of the abdomen:
IMPRESSION:
1. Findings consistent with high grade small bowel obstruction
with the
transition point in the mid lower anterior abdomen. There is
small amount of ascites in the right upper quadrant and left
paracolic gutter, which is nonspecific but can be seen in
ischemia. No definite sign of ischemia.
2. Renal cysts
___: EKG:
Sinus tachycardia. Non-specific anterior t wvae changes. Low
QRS voltage in the precordial leads. No previous tracing
available for comparison.
___: chest x-ray:
IMPRESSION: Tiny bibasilar pleural effusions with adjacent
atelectasis, right greater than left.
Brief Hospital Course:
The patient was admitted to the hospital with abdominal pain,
nausea and vomiting. She underwent a cat scan of the abdomen
which showed a small bowel obstruction. Blood work on admission
showed an elevated white blood cell count. The patient was made
NPO, placed on bowel rest, and had a nasogastric tube placed for
bowel decompression. The patient underwent serial abdominal
examinations. Despite interventions, the abdominal pain
continued and the patient was taken to the operating room where
she underwent an exploratory laparotomy and lysis of adhesions.
The operative course was stable with minimal blood loss. The
patient was extubated after the procedure and monitored in the
recovery room.
The post-operative course was stable. On POD #2, the patient had
return of bowel function and the nasogastric tube was removed.
The patient was started on sips and advanced to a regular diet.
She was transitioned to oral analgesia for management of pain.
The patient's vital signs remained stable and she remained
afebrile. The patient was discharged home on POD # 4. An
appointment for follow-up was made in the acute care clinic.
Medications on Admission:
multivitamin capsule oral, Bentyl 10'''', Glucosamine 500 mg
tablet oral 1.5 tablet(s) Once Daily, cetirizine 5 mg tablet
oral
2 tablet(s) Once Daily, as needed, Citrucel 500 mg tablet oral 1
tablet Caltrate 600+D''
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
2. Docusate Sodium 100 mg PO BID constipation
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*25 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ were admitted to the hospital with abdominal pain, nausea
and vomitting. ___ underwent a cat scan of the abdomen which
showed a small bowel obstruction. ___ were taken to the
operating room where ___ underwent an exploratory laparotomy and
removal of adhesions from the bowel. ___ are slowly recovering
from your surgery and ___ are preparing for discharge home with
the following instructions:
ACTIVITY:
Do not drive until ___ have stopped taking pain medicine and
feel ___ could respond in an emergency.
___ may climb stairs.
___ may go outside, but avoid traveling long distances until ___
see your surgeon at your next visit.
Don't lift more than ___ lbs for 6 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.)
___ may start some light exercise when ___ feel comfortable.
___ will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when ___
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
___ may resume sexual activity unless your doctor has told ___
otherwise.
HOW ___ MAY FEEL:
___ may feel weak or "washed out" for 6 weeks. ___ might want to
nap often. Simple tasks may exhaust ___ may have a sore throat because of a tube that was in your
throat during surgery.
___ might have trouble concentrating or difficulty sleeping. ___
might feel somewhat depressed.
___ could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red aroudn the stitches or
staples. This is normal.
___ may gently wash away dried material around your incision.
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).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless ___ were told
otherwise.
___ may see a small amount of clear or light red fluid staining
your dressing r clothes. If the staining is severe, please call
your surgeon.
___ may shower. As noted above, ask your doctor when ___ may
resume tub baths or swimming.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, ___ may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. ___ can get both of these
medicines without a prescription.
If ___ go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
After some operations, diarrhea can occur. If ___ get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluitds and
see if it goes away. If it does not go away, or is severe and
___ feel ill, please call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If ___ find the pain is
getting worse instead of better, please contact your surgeon.
___ will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if ___ take it before your
pain gets too severe.
Talk with your surgeon about how long ___ will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
IF ___ are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when ___ cough
or when ___ are doing your deep breathing exercises.
If ___ experience any of the folloiwng, 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 ___ were on before the operation just as
___ did before, unless ___ have been told differently.
In some cases ___ will have a prescription for antibiotics or
other medication.
If ___ have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if ___ develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
19882852-DS-3
| 19,882,852 | 26,983,593 |
DS
| 3 |
2184-07-29 00:00:00
|
2184-07-27 11:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left distal tibia/fibula fracture
Major Surgical or Invasive Procedure:
Left tibia intramedullary nail
History of Present Illness:
From Admission HPI:
Ms. ___ is a ___ who p/w LLE pain and deformity after a
physical assault. The patient reports her boyfriend struck her
multiple times with his fist and feet. She believes she fell and
likely +HS and LOC. She had immediate pain, deformity and
inability to bear weight in the LLE and was brought into
___. She was found to have a distal tib/fib fx and
was transferred to ___ for further eval and management.
Past Medical History:
Asthma
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
___: Mild distress, nauseous bruising to L face,
Vitals:
98.1 87 100/55 18 100% RA
Left lower extremity:
- Skin intact
- no pain w/ passive stretch, compartments soft, compressible
- Soft, non-tender thigh and leg
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
ADMISSION PHYSICAL EXAMINATION:
___: no acute distress
Vitals: vital signs stable
CV: S1S2 normal, RRR, no m/r/g
Pulmonary: clear bilateral breath sounds
Abdomen: soft, nontender, nondistended
Left lower extremity:
- Skin intact, lower extremity splint in place
- no pain w/ passive stretch, compartments soft, compressible
- Soft, non-tender thigh and leg
- ___ fire, unable to assess ___ due to splint
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
LABS
___ 06:11AM BLOOD WBC-10.7* RBC-3.81* Hgb-11.1* Hct-34.5
MCV-91 MCH-29.1 MCHC-32.2 RDW-13.1 RDWSD-43.1 Plt ___
___ 04:50AM BLOOD WBC-7.6 RBC-3.19* Hgb-9.2* Hct-29.0*
MCV-91 MCH-28.8 MCHC-31.7* RDW-12.7 RDWSD-42.1 Plt ___
___ 06:11AM BLOOD Neuts-63.6 ___ Monos-6.1 Eos-1.1
Baso-0.3 Im ___ AbsNeut-6.84* AbsLymp-3.07 AbsMono-0.65
AbsEos-0.12 AbsBaso-0.03
___ 06:11AM BLOOD Glucose-148* UreaN-8 Creat-0.7 Na-137
K-4.1 Cl-104 HCO3-21* AnGap-16
___ 04:50AM BLOOD Glucose-110* UreaN-9 Creat-0.6 Na-137
K-3.6 Cl-101 HCO3-28 AnGap-12
___ 04:28AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.1
IMAGING
IMPRESSION:
Intraoperative Fluoroscopy ___:
Fluoroscopic images show placement of an intramedullary rod
about a fracture of the lower shaft of the tibia. Adjacent
fibular fracture is seen. For information can be gathered from
the operative report.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left distal tibial/fibular and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for Intramedullary nail placement in
left tibia , which the patient tolerated well. For full details
of the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touch down weight bearing and range of motion as tolerated in
the left lower extremity, and will be discharged on lovenox 40mg
SC daily 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:
Albuterol inhaler PRN wheezing
Discharge Medications:
Albuterol inhaler PRN wheezing
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left distal tibia/fibula fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touchdown weight bearing LLE
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40 mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Followup Instructions:
___
|
19882955-DS-11
| 19,882,955 | 22,092,141 |
DS
| 11 |
2194-09-13 00:00:00
|
2194-09-13 19:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / lisinopril
Attending: ___.
Chief Complaint:
confusion, visual hallucinations
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ with EtOH use disorder, h/o alcoholic hepatitis, CKD stage/
III, HTN who presents with confusion and visual hallucinations.
She had been drinking several drinks per night until a couple of
days ago when she stopped drinking (last drink ___. She
also reports vomiting and abdominal distension without pain.
Denies fevers or dysuria.
Was recently seen in urgent care at ___ twice for sciatic nerve
pain; the first time she was given percocet and cyclobenzaprine
and the second time she was given a prednisone taper (60mg on
___, decrease by 10mg a day until completed).
Also recently completed 10 day course of levofloxacin for PNA.
Pertinent ED course: Vitals were notable for T 99.7 and sinus
tachycardia 100s-110s. Exam: Tachycardic and tremulous with
outstretched hands. Emotionally labile and described seeing
monsters. Received 10mg diazepam x2, 1L IVF, 100mg IV thiamine.
Labs notable for Cr 1.8, AST/ALT 58/20, Alk phos 152, WBC 13.3.
Upon arrival to the floor, pt was tachycardic to 100s. The
patient
reports seeing an additional person in the room, who is not
there. She denies headache, SOB, cough, abdominal pain, N/V,
dysuria. She is feeling constipated.
Past Medical History:
Alcohol use disorder
Hypertension
CKD, stage III
UPJ obstruction
n/o alcoholic hepatitis
Subclinical hypothyroidism
Prediabetes
Social History:
___
Family History:
No family history of seizures
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 98.6, BP 142/84, HR 105, RR 20, SpO2 90/RA
GENERAL: well-dressed, lying in bed mumbling, picking at IV and
sheets. Pleasant and cooperative. Oriented to self and ___.
Thinks it is ___ and that we are at a restaurant in
___.
EYES: pupils 2mm, sluggish reaction to light. EOMI, no
nystagmus.
ENT: MMM
CV: tachycardic, S1+S2, no M/R/G
RESP: CTAB, no W/R/C
GI: distended, firm, no TTP
EXT: WWP, non-pitting edema in feet and ankles
NEURO: follows commands, tremulous. Moves all 4 extremities with
purpose.
DISCHARGE PHYSICAL EXAM:
T: 98.0, HR 82, BP: 150s/80s, RR 20 SaO2 94% on RA.
PHYSICAL EXAM:
GENERAL: No acute distress
HEENT: NCAT, EOMI, moist mucous membranes, oropharynx clear
NECK: supple
CV: RRR, S1S2 appreciated without extra heart sounds, 2+ radial
pulses b/l
RESP: no increased work of breathing, diminished breath sounds
at
the right lung base.
GI: normoactive bowel sounds, soft, NDNT, no organomegaly
EXTREMITIES: non-pitting edema of the lower extremities b/l L >
R, no cyanosis or clubbing. Left knee appears similar in size to
right knee, non-erythematous, no effusion.
SKIN: No rashes or petechiae
NEURO: AAOx3, strength and sensation grossly normal throughout
PSYCH: normal affect, poor understanding of how her alcoholism
has affected her health.
Pertinent Results:
ADMISSION LABS:
___ 07:45PM BLOOD WBC-13.3* RBC-4.81 Hgb-14.2 Hct-41.9
MCV-87 MCH-29.5 MCHC-33.9 RDW-13.5 RDWSD-42.5 Plt ___
___ 07:45PM BLOOD Neuts-69.8 Lymphs-12.9* Monos-16.4*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-9.27* AbsLymp-1.71
AbsMono-2.17* AbsEos-0.01* AbsBaso-0.02
___ 07:45PM BLOOD Glucose-96 UreaN-35* Creat-1.8* Na-134
K-6.9* Cl-92* HCO3-22 AnGap-20*
___ 07:45PM BLOOD ALT-20 AST-58* AlkPhos-152* TotBili-0.7
___ 07:45PM BLOOD Albumin-3.7 Calcium-10.2 Phos-4.9* Mg-2.0
___ 07:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:02PM BLOOD Type-ART pO2-140* pCO2-27* pH-7.50*
calTCO2-22 Base XS-0
___ 07:54PM BLOOD Lactate-1.9 K-4.3
DISCHARGE LABS:
___ 05:57AM BLOOD WBC-11.7* RBC-4.58 Hgb-13.0 Hct-40.0
MCV-87 MCH-28.4 MCHC-32.5 RDW-13.1 RDWSD-41.8 Plt ___
___ 08:44AM BLOOD Neuts-76.4* Lymphs-13.7* Monos-7.9
Eos-0.9* Baso-0.5 Im ___ AbsNeut-10.09* AbsLymp-1.81
AbsMono-1.05* AbsEos-0.12 AbsBaso-0.06
___ 05:57AM BLOOD Glucose-104* UreaN-13 Creat-0.8 Na-135
K-4.8 Cl-96 HCO3-22 AnGap-17*
___ 05:57AM BLOOD ALT-48* AST-46* AlkPhos-349* TotBili-0.3
=====================
IMAGING:
CT HEAD W/O CONTRAST ___:
FINDINGS:
The study is mildly degraded by motion.
There is no evidence of acute major vascular territorial
infarction,hemorrhage,edema, or mass. The ventricles and sulci
are normal in
size and configuration.
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:
No acute intracranial process identified, within the confines of
this mildly motion limited study.
CXR ___:
FINDINGS:
There is opacity at the right lung base, some of which appears
linear
suggesting atelectasis. Elsewhere, lungs are clear.
Cardiomediastinal
silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
Right basilar consolidation, in part due to atelectasis though
infection would be possible in the proper clinical setting.
--------------------
___ MR Spine:
1. Motion limited, incomplete exam secondary to patient
discomfort.
2. Edema within bilateral L4-5 facet joints, and posterior
elements, more
prominent on the right. Differential considerations include
reactive change,
inflammatory arthritis, septic arthritis.
3. Edema of the paravertebral muscles and prevertebral fluid in
the lower
lumbar and sacral spine may be reactive or inflammatory.
4. No evidence of discitis, osteomyelitis, epidural collection,
or fracture.
5. Mild congenital spinal canal narrowing, and degenerative
changes, as above.
-------
L Foot XRAY ___:
fracture, dislocation, gouty arthritis.
Brief Hospital Course:
___ female with history of EtOH use disorder, alcoholic
hepatitis, admitted for delirium tremens ___ (last EtOH ___
s/p diazepam failure, requiring MICU-level care for hemodynamic
instability consistent with delirium tremens. She received
phenobarbital taper; hospital course complicated by community
acquired pneumonia vs aspiration pneumonia, myopathy resolving,
with residual weakness due to known sciatica, and foot pain.
ACUTE/ACTIVE PROBLEMS::
#) Delirium tremens, EtOH-use disorder: last EtOH estimated 48
hours prior to presentation (___). Hemodynamic instability s/p
diazepam failure, requiring MICU-level care s/p precede gtt and
phenobarbital taper. Hemodynamics stabilized upon transfer to
floor. CIWA scores 0. Patient received high-dose thiamine IV.
___ history of nightly EtOH use (i.e., 3x glasses of gin).
Evaluated by social work. Dual-diagnosis in the context of prior
emotional/psychological trauma versus intensive outpatient
therapy will be in order. Patient in contemplative-preparatory
phase of change. Social work gave patient resources for
outpatient and intensive outpatient programs to support her
efforts to abstain from drinking.
#) Myopathy, unspecified: versus global asthenia. ___ > distal
muscle weakness in the absence of myalgia. Suspect
ICU-myopathy/deconditioning. EtOH-myopathy or steroid-myopathy
(had steroids prior to admission for back pain)
but thought unlikely in the absence of rhabdomyolysis.
Neuroimagin, electrolytes were within normal limits. She
proximal arm strength improved and was back to baseline at
discharge. She had residual proximal lower extremities L>R, MRI
obtained in the setting of chronic buttock pain with
radiculopathy to consistent with known sciatica with no nerve
root compression. Improved throughout hospital stay. Discharged
to rehab to work on strength and conditioning.
#) CAP vs Aspiration pneumonitis: She had a right lower lobe
opacity on serial chest xray in ICU. Covered with broad spectrum
and ultimately narrowed to ceftriaxone/azithromycin for possible
community acquired pneumonia. Ultimately aspiration PNA most
likely in the setting of altered mental status. Her respiratory
status improved.
#) Foot/ankle arthralgia, bilateral: LENIS negative for DVT.
Film
negative for fracture/dislocation. Foot pain localized to
mid-foot, plantar surface. Tender with manipulation or when
weight-bearing. Most likely gout flare in the context of
alcoholism and outpatient hyperuricemia although no erosive
changes on xray. Responded to colchicine load. Discharged on
limited trial of NSAIDS.
#) Alcoholic hepatitis: reportedly, liver bx obtained at ___.
Minor transaminitis and hypoalbuminemia. Synthetic function
otherwise intact. CBC stable. No stigmata of cirrhosis, though
minor non-pitting anasarca.
#) Toxic metabolic encephalopathy in the setting of alcohol
withdrawal. Resolved. A nonconhead CT was unremarkable.
TRANSITIONAL ISSUES:
[]Please ensure follow up with primary care doctor
[]trend volume exam, daily weights. can restart held
Spironolactone 50 mg PO DAILY.
[]At ___, please coordinate social work to
connect her with resources to abstain from alcohol
[]started on trial of NSAIDs for gout flare; please ensure this
is discontinued after acute administration.
[]consider podiatry evaluation of L foot pain if not continuing
to improve after NSAID trial
[]consider referral to hepatology for regular follow up, work up
for cirrhosis if not complete.
[]noted thrombocytosis. would monitor, follow up with CBC in ___
weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Spironolactone 50 mg PO DAILY
5. Torsemide 10 mg PO DAILY
6. Vitamin B Complex 1 CAP PO DAILY
7. Cyclobenzaprine 10 mg PO HS:PRN muscle spasm
8. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
9. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QPM Pain
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Naproxen 500 mg PO Q12H Duration: 5 Days
4. Nicotine Patch 14 mg TD DAILY
5. amLODIPine 10 mg PO DAILY
6. Atenolol 50 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Thiamine 100 mg PO DAILY
9. Torsemide 10 mg PO DAILY
10. Vitamin B Complex 1 CAP PO DAILY
11. HELD- Cyclobenzaprine 10 mg PO HS:PRN muscle spasm This
medication was held. Do not restart Cyclobenzaprine until you
follow up with your primary care doctor
12. HELD- Spironolactone 50 mg PO DAILY This medication was
held. Do not restart Spironolactone until you follow up with
your primary care doctor, or see your rehabilitation center
doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Alcohol use disorder
Acute alcohol withdrawal, delirium tremens
Sciatica
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 caring for you at ___
___!
WHY WERE YOU ADMITTED?
-You were weak.
WHAT HAPPENED IN THE HOSPITAL?
-You were treated for withdrawal for alcohol. You were in the
intensive care unit.
-You had pneumonia that was treated with antibiotics
-You had weakness that improved. This was likely due to your
severe illness, on top of your sciatica
WHAT SHOULD YOU DO AT HOME?
-Follow up with your primary care provider after rehabilitation
-___ up with resources that ___, our social worker, found to
get help with alcohol use
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
19882958-DS-10
| 19,882,958 | 29,628,147 |
DS
| 10 |
2182-09-03 00:00:00
|
2182-09-04 20:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Gallstone pancreatitis
Major Surgical or Invasive Procedure:
___: ERCP with ___ x 7 cm straight plastic biliary stent
___: Laparoscopic cholecystectomy
History of Present Illness:
Mr. ___ is an ___ yo M with history of CAD (s/p 2 stents in
___, and gastric tumor (benign per patient, s/p
gastrojejunostomy bypass in ___ who initially presented with
upper abdominal pain and fevers x2 days.
Patient reports history of upper abdominal pain about 2 months
ago that was self-limited. Per patient's report, he went to the
ED in ___, and was told 'everything looked good.' His pain
quickly subsided without intervention. He noted that the pain
returned 3 days ago, and was about ___, to ___ 2 days ago.
It was waxing and waning in nature. He also noted fevers/chills
to 103 at home during this time. He had one episode of NBNB
emesis at OSH. No current nausea, no diarrhea. No dysuria.
At ___, patient was found to have CT scan showing cholecystitis,
pancreatitis with a gallstone in the neck of the gallbladder.
Was transferred here for further surgical evaluation because the
outside hospital was unable to do any procedures. In transit to
___ the patient had low blood pressures to 78 systolic, was
started on peripheral neo. His pressor was initially taken off
at ___, but restarted (with levo) for soft blood pressures.
While in ___ ED, OSH called and reported 2 bottles GNRs
growing from blood.
In ED initial VS: 98.2 80 108/62 95% ___ NC
- Initial labs notable for ALT/AST 292/289, AP 79, Lipase 2317,
Tbili 3.5, Alb 3.7. Chem 7 notable for BUN/Cr ___, CBC
27.4/12.6/38.3, INR 1.5. UA with 12 WBC, no bacteria, Nitr
negative. Lactate 2.1. VBG 7.32/40/46
- Patient was administered 1 L NS and 1L LR, started on
phenylephrine and norepinephrine gtt, and given vancomycin and
zosyn x1
- ERCP, ___, and ACS were consulted. ERCP to be performed and ACS
is following for potential CCY once stable
VS prior to transfer: 98.2 71 109/55 21 99% ___ NC
Patient was initially admitted to MICU Red and transferred to
the ___ for ERCP. On arrival to the ___, initial vitals T 98.3
P 90 BP 133/60 RR 20 O2 93% on RA. He endorses some nausea,
which has since resolved after receiving Zofran. Denies
abdominal pain, vomiting, fevers, chills, or other pain.
Confirms the above history.
Past Medical History:
Past medical history:
Gastric inflammatory mass (pathology benign per patient)
CAD s/p stents x 2 (___)
Past surgical history:
Exploratory lap, perigastric LN biopsy, gastrojejunostomy bypass
(___)
left hip replacement
left open inguinal hernia repair (___)
circumcision (___)
Social History:
___
___ History:
Son with lung cancer, no family history of pancreatitis,
gallstones that patient is aware of
Physical Exam:
Admission exam:
VITALS: T 98.3 P 90 BP 133/60 R 20 O2 93% 2LNC
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, mildly distended. Non-tender to palpation. No
evidence of peritoneal signs.
GU: foley in place draining clear yellow urine
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No visible ulcers, rashes, warm
NEURO: AAO x3. No focal neurological deficits.
Discharge exam:
VITALS: T 98.0 HR 63 BP 113/65 R 18 96% O2 on RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non distended, non tender. No evidence of peritoneal
signs.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No visible ulcers, rashes, warm
NEURO: AAO x3. No focal neurological deficits.
Pertinent Results:
Admission and notable labs:
___ 11:20AM BLOOD WBC-27.4* RBC-4.16* Hgb-12.6* Hct-38.3*
MCV-92 MCH-30.3 MCHC-32.9 RDW-12.5 RDWSD-42.1 Plt ___
___ 11:20AM BLOOD ___ PTT-25.4 ___
___ 11:20AM BLOOD Glucose-101* UreaN-24* Creat-1.8* Na-141
K-4.1 Cl-105 HCO3-21* AnGap-15
___ 11:20AM BLOOD ALT-292* AST-289* AlkPhos-79 TotBili-3.5*
___ 11:20AM BLOOD Albumin-3.7 Calcium-8.9 Phos-2.2* Mg-1.7
___ 11:20AM BLOOD Lipase-2317*
___ 06:52PM BLOOD ___ pO2-46* pCO2-40 pH-7.32*
calTCO2-22 Base XS--5
___ 11:24AM BLOOD Lactate-2.1*
___ 11:40AM URINE Blood-TR* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM*
___ 11:40AM URINE Color-Yellow Appear-Clear Sp ___
___ 11:40AM URINE RBC-8* WBC-12* Bacteri-NONE Yeast-NONE
Epi-<1
___ 07:10AM BLOOD WBC-10.3* RBC-3.52* Hgb-10.7* Hct-31.4*
MCV-89 MCH-30.4 MCHC-34.1 RDW-12.7 RDWSD-41.5 Plt ___
___ 07:10AM BLOOD WBC-11.0* RBC-3.55* Hgb-11.1* Hct-31.5*
MCV-89 MCH-31.3 MCHC-35.2 RDW-12.9 RDWSD-42.3 Plt ___
___ 07:35AM BLOOD WBC-12.4* RBC-3.67* Hgb-11.0* Hct-33.7*
MCV-92 MCH-30.0 MCHC-32.6 RDW-13.2 RDWSD-44.0 Plt ___
Microbiology:
___ Ucx: negative
___ Blood Cx: pending
IMAGING:
___ CXR: IMPRESSION: The tip of a right internal jugular
central venous catheter projects over the low SVC. No
pneumothorax.
Brief Hospital Course:
___ yo M with history of CAD (s/p 2 stents in ___, and gastric
tumor (benign per patient, s/p gastrojejunostomy bypass in ___
who presented with upper abdominal pain and fevers for 2 days,
found to have septic shock w likely biliary source.
ACTIVE PROBLEMS:
#Septic shock
#GNR bacteremia
#Cholangitis- Patient initially presented with hypotension,
fevers, bacteremia with known cholecystitis/pancreatitis seen on
CT done at ___, requiring pressor support. Patient
received 7L fluid resuscitation in total and was started on
zosyn and levophed. He underwent ERCP on ___. No stones were
visualized. CBD measured 7mm and there was noted to be purulent
drainage. CBD stent was placed. Sphincterotomy was not performed
given elevated INR. Will require repeat ERCP in 4 weeks for
stent pull. Pressors were eventually weaned off on ___
___ bld cx grew Klebsiella in ___ bottles. Sensitivities showed
***.
#Gallstone pancreatitis - Patient presented with abdominal pain,
lipase elevation, and CT findings concerning for pancreatitis
with gallstone. No evidence of exocrine/endocrine dysfunction
with normal glucose. ACS was consulted and will likely undergo
cholecystectomy once more stable.
___ vs. CKD. Patient initially presented with a Cr. of 1.8 in
setting of septic shock. He was producing adequate urine and
after fluid resuscitation Cr downtrended to 1.5 on ___.
Unclear baseline. He maintained adequate urine production.
==================
Patient was then transferred to ___ for a laparoscopic
cholecystectomy. The patient underwent laparoscopic
cholecystectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
and was hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Quinapril 10 mg PO DAILY
4. Rosuvastatin Calcium 40 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 #*28 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Quinapril 10 mg PO DAILY
5. Rosuvastatin Calcium 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Ascending cholangitis
Acute pancreatitis
Blood stream infection
___
Acute hypoxic respiratory failure
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 ___ and
underwent an ERCP and laparoscopic cholecystectomy. You are
recovering well and are now ready for discharge. Please follow
the instructions below to continue your recovery:
You were admitted to the hospital with septic shock secondary to
gram negative rod bacteremia with cholangitis & pancreatitis.
You were originally managed by the medicine team and had an ERCP
performed. You were then 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 within 10 days
of discharge
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:
___
|
19883311-DS-22
| 19,883,311 | 27,934,870 |
DS
| 22 |
2146-01-27 00:00:00
|
2146-01-28 00:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Erythromycin Base / Cephalosporins /
Biaxin / disposable gloves / Morphine / Levofloxacin / Latex /
Iodinated Contrast- Oral and IV Dye
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient reports that she was in her usual health until about
2.5 weeks prior to present, when she developed a dry cough and
shortness of breath. She reports left-sided chest pain provoked
by coughing. She has no chest pain at rest. She does have some
chest pain with exertion, such as climbing the hill near her
house. She has discussed this with her cardiologist, and is
planned for a stress test. She reports that she has also noticed
some swelling in her legs when she walks. She reports her dry
weight is around 157 pounds, however, per review of her
outpatient records her weights has been in the 160s-170s over
the past year, most recently 160.0 in ___. She reports that for
the last two weeks she has been sleeping upright because she
feels short of breath when she lies flat. She reports she
stopped taking Lasix at the direction of her cardiologist about
1 month ago. She reports that she had stopped her lisinopril
also at the direction of her cardiologist due to chronic cough,
but stopping the medicine did not improve her cough so it was
resumed.
She reports that she saw her PCP ___ week ago for these symptoms.
She reported to her PCP that she was using her albuterol inhaler
every 2 hours for shortness of breath. She reports that she did
not undergo at chest Xray at that time. Her PCP prescribed ___
course of steroids, which the patient completed two days prior
to present. She states that the steroids did not improve her
breathing. Two days prior to admission, she developed fevers to
101, chills, and body aches. One day prior to admissions, her
cough became so severe that she had post-tussive emesis. She
used Halls cough drops, but this did not help. She presented to
the ED for further evaluation.
Past Medical History:
1. Type II diabetes mellitus (last HbA1c 12.4% ___
2. CAD, status post CABG ___, left RAG-RCA
___, complicated by post operative atrial fibrillation
3. Hypertension
4. Hyperlipidemia
5. Complex migraine
6. Right carpal tunnel syndrome
7. Asthma
Social History:
___
Family History:
Grandmother with a history of stroke, dementia and seizures (all
later in life). Mother with CAD, status post CABG x 3 at age ___.
Also with history of DVT. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
Admission Exam
VITALS: 99.8 90/55 100 22 96 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, JVP to ~8 cm
RESP: Mildly tachypneic. Lungs clear to auscultation without
wheezing or rales. Intermittent dry cough during exam.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs, no peripheral edema
SKIN: No rashes or ulcerations noted; well-healed sternal scar
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Very pleasant, appropriate affect
Discharge Exam:
VITALS: 99.0 ___
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4.
RESP: Good air movement; CTA no crackles
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
MSK: Neck supple, moves all extremities
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
===========
___ 05:00PM BLOOD WBC-12.7* RBC-5.03 Hgb-13.1 Hct-41.3
MCV-82 MCH-26.0 MCHC-31.7* RDW-12.9 RDWSD-38.5 Plt ___
___ 04:10PM BLOOD WBC-PND RBC-PND Hgb-PND Hct-PND MCV-PND
MCH-PND MCHC-PND RDW-PND RDWSD-PND Plt Ct-PND
___ 05:00PM BLOOD ___ PTT-27.1 ___
___ 05:00PM BLOOD Glucose-329* UreaN-7 Creat-0.7 Na-135
K-6.2* Cl-94* HCO3-23 AnGap-18
___ 08:35PM BLOOD Glucose-173* UreaN-13 Creat-0.7 Na-139
K-4.0 Cl-98 HCO3-26 AnGap-15
___ 06:02AM BLOOD cTropnT-<0.01
___ 05:00PM BLOOD cTropnT-<0.01
___ 05:00PM BLOOD proBNP-296*
INTERVAL LABS:
==========
___ 08:58PM BLOOD pO2-48* pCO2-58* pH-7.30* calTCO2-30 Base
XS-0
___ 08:58PM BLOOD Lactate-3.1*
___:49AM BLOOD ___ pO2-102 pCO2-46* pH-7.40
calTCO2-30 Base XS-2 Comment-GREEN TOP
DISCHARGE LABS:
===========
___ 04:10PM BLOOD WBC-13.9* RBC-4.35 Hgb-11.2 Hct-36.5
MCV-84 MCH-25.7* MCHC-30.7* RDW-12.8 RDWSD-38.8 Plt ___
___ 04:10PM BLOOD Glucose-96 UreaN-11 Creat-0.6 Na-139
K-4.5 Cl-102 HCO3-23 AnGap-14
MICROBIOLOGY:
===========
___ 3:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
___ Culture, Routine-x 2 PENDING
___ 8:43 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
IMAGING:
======
CXR ___
New airspace opacification in the left upper lobe is most
consistent with pneumonia. Previously seen airspace opacity
projecting over the right midlung region has resolved in
comparison to the CT chest dated ___. Nodular
opacity in the AP window may reflect a lymph node. No large
pleural effusion, pneumothorax or pulmonary edema.
Cardiomediastinal silhouette is
unremarkable. Patient is status post median sternotomy. No
acute osseous abnormality appreciated.
IMPRESSION:
Left upper lobe pneumonia.
RECOMMENDATION(S): Post treatment radiograph is recommended in
___ weeks to
document resolution.
CT A/P ___. Diffuse hepatic hypoattenuation consistent with steatosis.
Steatohepatitis or more advanced forms of hepatic disease cannot
be excluded.
2. Slightly hooked appearance of the celiac trunk is nonspecific
in the absence of intravenous contrast. Median arcuate ligament
syndrome could be considered in the appropriate clinical
presentation.
3. Indeterminate 1.4 cm left adrenal nodule which probably
represents an adenoma. If there is no history of malignancy,
this is probably benign.
Follow up dedicated adrenal CT or MR in 12 months could be
considered. If
there is a history of malignancy, a dedicated adrenal CT is
recommended.
Recommendations based on ___ ACR guidelines:
___
4. Small to moderate hiatal hernia. Small Bochdalek's hernia.
Brief Hospital Course:
Ms. ___ is a ___ woman with history of CAD s/p CABG,
dCHF, HTN, HLD, IDDMII (last A1c 12.8), asthma presenting with
shortness of breath, found to have pneumonia. She was treated
with doxycycline and improved, but developed persistent
hyperglycemia that required addition of mealtime insulin;
glipizide was held given her reports of symptomatic hypoglycemia
at home. On ___ she developed new onset vomiting with elevated
lactate, normal BG, with unrevealing Ct abdomen and pelvis; her
symptoms resolved and were concluded to be due to likely food
poisoning vs food allergy.
ACUTE/ACTIVE PROBLEMS:
# Sepsis
# Community-acquired pneumonia, Left upper lobe
Presented with fever, leukocytosis, tachycardia, tachypnea
consistent with sepsis, with concern for LUL pneumonia on CXR.
Started doxycycline 100 mg BID per prior ID recommendations,
first full day ___. Did not provide sputum for culture.
Legionella Ag negative, strep pneumo pending on discharge. She
was treated symptomatically for cough and improved. She was
discharged with 7 day total course of doxycycline to end ___.
# Chronic diastolic congestive heart failure: LVEF>55%. Missed
her last appointment because she was out of town. This was
rescheduled for her. She did not appear to be in acute
exacerbation. Multiple cardiac medications were held on
discharge for borderline BPs (lisinopril, imdur, nifedipine).
# IDDMII: Poorly-controlled overall, had a few isolated episodes
of hyperglycemia to 400s.
Discussed with ___, who recommended restarting mealtime
coverage in place of glipizide as she had confirmed lows with
glipizide. Noted that PCP had taken her off of it but she did
not know why and that she was going to start Trulicity but had
not yet picked it up. She continued 40u Lantus and 8u standing
with meals. Continued home Novolog sliding scale at bedtime (not
with meals to simplify regimen). Contacted PCP to discuss this.
She will have very close followup, and consider ___ referral
if she desired/needed, but will start with PCP and ___
followup at ___. Home metformin briefly held inpatient.
# Hypotension: resolved;
# History of hypertension
Bordeline BPs initially in Systolic ___, then improved to
110s-120s. She says she takes all of her medications at home but
does not monitor her blood pressure. Labetalol resumed at
reduced dose 200 mg BID (preferentially started given some
borderline tachycardia and concern for beta blocker withdrawal).
Held others at discharge. Encouraged her to obtain home BP cuff,
monitor and bring to her followup appointment.
# Nausea/vomiting/diarrhea
# Lactic acidosis
Self-limited episode of nausea, vomiting, diarrhea shortly after
eating dinner. Initially concerning for food poisoning.
Discussed with food services. They note she had a salad that may
have had tomatoes on it despite food allergy noted on her
record. Unclear timing though because she had that salad for
lunch and got sick after dinner. Did not reoccur.
CHRONIC/STABLE PROBLEMS:
# CAD s/p CABG ___: No chest pain currently, but patient has
been experiencing exertional chest pain for several months.
Stress echo in ___ showed non-specific ECG changes, 2D
echocardiographic evidence of prior infarction with no inducible
ischemia. Continued ASA, statin, labetalol. Rescheduled
Cardiology appointment as above.
# pAF: Occurred post-operatively after CABG. Labetalol as above.
Not on anticoagulation.
# HLD: Continued statin, per cardiology last note ___ need to
consider psk9 inhibitor.
# Asthma: No evidence of acute exacerbation. Continued inhalers
as needed.
# GERD: No longer taking ranitidine; Tums as needed
TRANSITIONAL ISSUES:
==============
[] discharged with ___ for blood sugar monitoring
[] needs diabetes followup, will start in ___ but may follow
up with ___ if desired, resumed mealtime insulin
[] resume antihypertensives/cardiac meds as able
[] should have ambulatory BP monitoring
[] finish course of doxycycline ___
[] radiology recommends followup chest xray in ___ weeks to
ensure resolution of pneumonia
[] needs outpatient cardiology followup
[] blood cultures pending on discharge
Incidental findings:
- Diffuse hepatic hypoattenuation consistent with steatosis.
Steatohepatitis or more advanced forms of hepatic disease cannot
be excluded.
[] would emphasize lifestyle changes and obtain RUQ U/s in 6 mo
to assess improvement
- Small to moderate hiatal hernia. Small Bochdalek's hernia.
- Indeterminate 1.4 cm left adrenal nodule which probably
represents an adenoma. If there is no history of malignancy,
this is probably benign. Follow up dedicated adrenal CT in 12
months could be considered.
>30 minutes spent in discharge coordination and plannin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
3. Aspirin EC 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Labetalol 300 mg PO BID
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. NIFEdipine (Extended Release) 30 mg PO DAILY
9. Glargine 40 Units Breakfast
Insulin SC Sliding Scale using Novolog Insulin
10. Lisinopril 20 mg PO DAILY
11. GlipiZIDE XL 10 mg PO DAILY
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO BID Duration: 7 Doses
through ___
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*7 Tablet Refills:*0
2. GuaiFENesin-Dextromethorphan 5 mL PO Q6H:PRN Cough
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
4. Glargine 40 Units Breakfast
Novolog 8 Units Breakfast
Novolog 8 Units Lunch
Novolog 8 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
RX *insulin aspart U-100 [Novolog Flexpen U-100 Insulin] 100
unit/mL (3 mL) AS DIR AS DIR Disp #*2 Syringe Refills:*1
5. Labetalol 200 mg PO BID
RX *labetalol 100 mg 2 tablet(s) by mouth twice a day Disp #*120
Tablet Refills:*0
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
7. Aspirin EC 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. MetFORMIN (Glucophage) 1000 mg PO/NG BID
10. HELD- Isosorbide Mononitrate (Extended Release) 30 mg PO
DAILY This medication was held. Do not restart Isosorbide
Mononitrate (Extended Release) until talking to your doctor
11. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until talking to your doctor
12. HELD- NIFEdipine (Extended Release) 30 mg PO DAILY This
medication was held. Do not restart NIFEdipine (Extended
Release) until talking to your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Diabetes Mellitus Type II with hyperglycemia
Nausea/vomiting/diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___, you were admitted to the hospital for a new
pneumonia, which was your third one this year. You were treated
with antibiotics and improved, but while you were in the
hospital your blood sugars went too high. We discussed that you
have both highs and lows at home and that glipizide may be
making your blood sugar too low, so we started you back on
insulin with meals and had you stop the glipizide.
You also had somewhat low blood pressure in the hospital and you
should not take some of your blood pressure medicine. Please get
a blood pressure cuff and measure it daily. Take it with you to
your primary care appointment.
It was a pleasure caring for you and we wish you the best,
Your ___ Team
Followup Instructions:
___
|
19883311-DS-23
| 19,883,311 | 23,262,610 |
DS
| 23 |
2146-02-23 00:00:00
|
2146-02-23 16:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Erythromycin Base / Cephalosporins /
Biaxin / disposable gloves / Morphine / Levofloxacin / Latex /
Iodinated Contrast- Oral and IV Dye
Attending: ___.
Chief Complaint:
Productive cough and pleuritic chest pain
Major Surgical or Invasive Procedure:
___ cardiac catheterization
History of Present Illness:
___ admitted at ___ ___ for CAP and was treated with a
7-day course of doxycycline given her numerous serious drug
allergies, including to PCN and cephalosporins admitted to ___
___, who presented with productive cough and pleuritic chest
pain now treating for HAP, requiring ICU transfer for cefepime
desensitization course complicated by type II NSTEMI, PNA, CP, +
trops, TTE with WMA and transferred to ___, admit to
cardiology and cath ___.
Past Medical History:
1. Type II diabetes mellitus (last HbA1c 12.4% ___
2. CAD, status post CABG ___, left RAG-RCA
___, complicated by post operative atrial fibrillation
3. Hypertension
4. Hyperlipidemia
5. Complex migraine
6. Right carpal tunnel syndrome
7. Asthma
Social History:
___
Family History:
Grandmother with a history of stroke, dementia and seizures (all
later in life). Mother with CAD, status post CABG x 3 at age ___.
Also with history of DVT. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
Temp: 99.1 PO BP: 118/81 L Lying HR: 108 RR: 18 O2
sat: 93% O2 delivery: RA FSBG: 156.
Physical examination:
HENT atraumatic, oropharynx clear with moist mucous
membranes. JVP 8 cm. Full carotid upstrokes without bruits.
Regular rate and rhythm, normal S1 and physiologically-split S2.
No gallops or murmurs. Clear lungs with normal respiratory
effort. Soft, nontender abdomen without hepatomegaly. No pedal
edema. Strong/symmetric peripheral pulses. No xanthelasma or
venous stasis changes. Gait and muscle tone normal. Appropriate
affect, alert and oriented to person, place and time.
Pertinent Results:
ON ADMISISON:
================
___ 02:21AM BLOOD WBC-13.5* RBC-4.28 Hgb-10.7* Hct-35.0
MCV-82 MCH-25.0* MCHC-30.6* RDW-13.8 RDWSD-40.7 Plt ___
___ 02:21AM BLOOD Neuts-79.8* Lymphs-14.3* Monos-4.3*
Eos-0.5* Baso-0.4 Im ___ AbsNeut-10.79* AbsLymp-1.94
AbsMono-0.58 AbsEos-0.07 AbsBaso-0.05
___ 02:21AM BLOOD ___ PTT-30.7 ___
___ 02:21AM BLOOD Glucose-445* UreaN-7 Creat-0.7 Na-137
K-5.1 Cl-95* HCO3-27 AnGap-15
___ 02:21AM BLOOD cTropnT-0.03*
___ 08:55PM BLOOD Calcium-9.2 Phos-3.0 Mg-1.8
___ 02:21AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:21AM BLOOD VoidSpe-EXTREMELY
___ 02:20AM BLOOD Lactate-1.9
___ 03:45AM URINE Color-Straw Appear-CLEAR Sp ___
___ 03:45AM URINE Blood-NEG Nitrite-NEG Protein-20*
Glucose->1000* Ketone-10* Bilirub-NEG Urobiln-NORMAL pH-7.0
Leuks-SM*
___ 03:45AM URINE RBC-25* WBC-5 Bacteri-FEW* Yeast-NONE
Epi-2
DIAGNOSTICS:
==============
___ Imaging CHEST (PA & LAT)
FINDINGS:
PA and lateral views of the chest provided. Redemonstrated is a
left upper lobe airspace opacification demonstrating decreased
density and enlargement compared to prior. The right lung is
clear. There is no effusion, or pneumothorax. There are no
signs of congestion or
edema. The cardiomediastinal silhouette is normal. No evidence
of displaced fracture. Sternotomy wires are intact.
IMPRESSION:
Worsening left upper lobe pneumonia.
___ Cardiovascular Transthoracic Echo Report
CONCLUSION:
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is ___ mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is a small to
moderate area of regional left ventricular systolic dysfunction
with hypokinesis of the basal inferior wall and distal half of
the septum (see schematic) and preserved/normal contractility of
the remaining segments. The visually estimated left ventricular
ejection fraction is 40-45%. There is no resting left
ventricular outflow tract gradient. Normal right ventricular
cavity size with normal free wall motion. The aortic sinus
diameter is normal for gender with a normal ascending aorta
diameter for gender. The aortic arch diameter is normal with a
normal descending aorta diameter. There is no evidence for an
aortic arch coarctation. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis.
There is no aortic regurgitation. The mitral valve leaflets
appear structurally normal with no mitral valve prolapse. There
is mild to moderate [___] mitral regurgitation. The pulmonic
valve leaflets are normal. The tricuspid valve leaflets appear
structurally normal. There is physiologic tricuspid
regurgitation. The pulmonary artery systolic pressure could not
be estimated. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction most c/w multivessel coronary artery
disease. Mild-moderate mitral regurgitationmost likely due to
papillary muscle dysfunction.
Compared with the prior TTE (images not available for review) of
___ , regional left ventricular systolic dysfunction is
now more extensive and the severity of mitral regurgitation has
increased.
___ cardiac catheterization:
Coronary Description
The coronary circulation is right dominant.
LM: The Left Main, arising from the left cusp, is a medium
caliber vessel. This vessel bifurcates into the Left Anterior
Descending and Left Circumflex systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a medium caliber vessel. There is a 100% stenosis in the
proximal segment. There is a 90% stenosis in the proximal
segment. The Diagonal, arising from the proximal segment, is a
small caliber vessel. There is mild tortuosity beginning in the
distal segment.
The Inferior lateral of the Diag, arising from the proximal
segment, is a small caliber vessel. There is mild tortuosity
beginning in the distal segment.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel. There is a 50% stenosis in the ostium. There is
a 50% stenosis in the mid segment. The ___ Obtuse Marginal,
arising from the proximal segment, is a very small caliber
vessel. There is a
100% stenosis in the proximal segment. The ___ Obtuse Marginal,
arising from the proximal segment, is a small caliber vessel.
There is
moderate tortuosity beginning in the mid segment. The ___ Obtuse
Marginal, arising from the mid segment, is a small caliber
vessel.
RCA: The Right Coronary Artery, arising from the mid cusp, is a
medium caliber vessel. There is moderate tortuosity beginning in
the mid segment. There is a 70% stenosis in the proximal
segment.
The Acute Marginal, arising from the proximal segment, is a
medium caliber vessel. The Right Posterior Descending Artery,
arising from the distal segment, is a small caliber vessel. The
Right Posterolateral Artery, arising from the distal segment, is
a medium caliber vessel.
Bypass Grafts:
LIMA: A medium caliber arterial LIMA graft connects to the
proximal segment of the LAD. There is a 90% stenosis in the
anastomotic segment. A medium caliber arterial LIMA graft
bifurcates to the
proximal segment of the Diag. This graft is also patent.
RIMA: A very small caliber arterial RIMA graft connects to the
proximal segment of the ___ OM. This graft is patent.
RAD: A very small caliber arterial RAD graft connects to the
proximal segment of the RPDA. This graft is patent.
On Discharge:
___ 05:45AM BLOOD WBC-16.3* RBC-3.87* Hgb-9.5* Hct-31.4*
MCV-81* MCH-24.5* MCHC-30.3* RDW-14.4 RDWSD-42.2 Plt ___
___ 05:45AM BLOOD Neuts-76.2* Lymphs-14.9* Monos-6.6
Eos-0.9* Baso-0.2 Im ___ AbsNeut-12.40* AbsLymp-2.43
AbsMono-1.07* AbsEos-0.15 AbsBaso-0.04
___ 05:45AM BLOOD Glucose-161* UreaN-11 Creat-0.6 Na-140
K-4.8
Brief Hospital Course:
Summary: ___ yo woman with a history of CAD, T2DM, hypertension,
and hyperlipidemia admitted with NSTEMI in the setting of
hospital-acquired pneumonia.
#CAD/NSTEMI: 90% stenosis at the LIMA-LAD anastomosis. Plan for
medical management as NSTEMI was in the setting of PNA.
-___ medical management
-Consider CTO PCI of the LAD if anginal symptoms occur
-Continue on ASA 81, atorvastatin 80, and metoprolol
#Fever
#Leukocytosis
#Pneumonia: Day 6 of ___ppreciate ID recs. Received
PCV13 and influenza vaccines yesterday.
-Blood cultures from ___ - no growth to date.
-CBC and BMP f/u within one week post discharge
-Continue cefepime 2g IV BID while in hospital.
-Plan to discharge on cefpodoxime 200mg po q12h on day seven to
complete course
(7 day course (___).
#CHF, chronic systolic: Stable and euvolemic.
-Continue metoprolol succinate
-Stop taking lisinopril,
-Continue losartan 25 mg
#DM: Metformin 1000 mg BID, Lantus 40 qam, and NovoLog 8u with
meals at home. ___ stable.
- Continue Metformin
- Continue lantus 40
#HTN: Controlled/low. Goal BP <130/80.
-Start losartan 25 today
-Stop taking Nifedipine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GuaiFENesin-Dextromethorphan 5 mL PO Q6H:PRN cough
2. Acetaminophen 1000 mg PO TID:PRN Pain - Mild/Fever
3. Labetalol 200 mg PO BID
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing/SOB
5. Aspirin 81 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Atorvastatin 80 mg PO QPM
8. Glargine 40 Units Breakfast
undefined 8 Units Breakfast
undefined 8 Units Lunch
undefined 8 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. NIFEdipine (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. Losartan Potassium 25 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Glargine 40 Units Breakfast
Novolog Flexpen U-100 7 Units Breakfast
Novolog Flexpen U-100 7 Units Lunch
Novolog Flexpen U-100 5 Units Dinner
4. Acetaminophen 1000 mg PO TID:PRN Pain - Mild/Fever
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing/SOB
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. GuaiFENesin-Dextromethorphan 5 mL PO Q6H:PRN cough
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. HELD- NIFEdipine (Extended Release) 30 mg PO DAILY This
medication was held. Do not restart NIFEdipine (Extended
Release) until follow-up with Dr. ___
___ Disposition:
Home
Discharge Diagnosis:
PRIMARY:
===============
recurrent left upper lobe pneumonia
type II NSTEMI
history of allergic reaction to multiple antibiotics
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Temp: 99.1 PO BP: 118/81 L Lying HR: 108 RR: 18 O2
sat: 93% O2 delivery: RA FSBG: 156.
Physical examination:
HENT atraumatic, oropharynx clear with moist mucous
membranes. JVP 8 cm. Full carotid upstrokes without bruits.
Regular rate and rhythm, normal S1 and physiologically-split S2.
No gallops or murmurs. Clear lungs with normal respiratory
effort. Soft, nontender abdomen without hepatomegaly. No pedal
edema. Strong/symmetric peripheral pulses. No xanthelasma or
venous stasis changes. Gait and muscle tone normal. Appropriate
affect, alert and oriented to person, place and time.
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had a cough and were found to
have ongoing pneumonia.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were treated with intravenous antibiotics for your
pneumonia. Because of your multiple drug allergies, you went to
the ICU to be desensitized to meropenem.
- You will finish your course of antibiotic on ___.
- Because your lab results showed an elevation in cardiac
biomarker, you underwent a cardiovascular catherization on the
___ which showed severe stenosis to one of your surgical
grafts. However, no intervention is required at this time.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- You will begin to take new medications upon discharge to help
control your blood pressure and lower the risk of cardiovascular
events.
- Be sure to take all your medications and attend all of your
appointments listed below. Stop taking lisinopril and Nifedipine
at this time.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs in 2 days or 5 lbs in 1 week.
- If you continue to have high fevers or worsening of pneumonia
symptoms, please return for further management.
Followup Instructions:
___
|
19883387-DS-24
| 19,883,387 | 25,729,919 |
DS
| 24 |
2136-12-13 00:00:00
|
2136-12-14 13:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Neurontin / Ciprofloxacin
Attending: ___.
Chief Complaint:
Left leg swelling and pain
Urinary Frequency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ woman with a history of DMT2,
CAD/hyperlipidemia, diastolic CHF, hypothyroidism, esophagitis,
and hypertension who presents after having pain and swelling in
her left lower leg. The patient reports that yesterday evening
she began to have the sensation that her lower left leg was hot.
She denies that it was especially painful, but does report that
it felt hot. This morning the patient's nurse at ___
noted that her lower left leg was swollen and red. Ms. ___
herself started to note that it was more difficult to walk with
her walker this afternoon. She visited with her primary care
physician, who decided that she had a cellulitis and should come
to the hospital for IV antibiotics. The patient denies feeling
any fever. She denies any significant pain or numbness in this
left leg. The patient further denies any other symptoms, such as
cough, nausea, vomiting, diarrhea. She does not know of any sick
contacts, but lives in an assisted living facility.
.
In the ED, initial vital signs were Pain ___, T 98.8, BP
166/58, RR 18, 99% O2 sat on room air. The patient's UA was
suggestive of infection, so she received ceftriaxone. Her area
of erythema was marked, and she also received vancomycin. Her
last vitals in the Emergency Department were T 98.0, HR 64 RR 18
BP 152/42 97% RA.
.
On ___ 2, the patient was resting comfortably. She was
tangential but capable of giving a history. She is not aware of
all of her medications but has a vague sense of how many pills
she takes and when. She denies any current pain.
.
REVIEW OF SYSTEMS:
Denies fever, chills, headache, rhinorrhea, congestion, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria. She does complain of recent
urinary frequency.
Past Medical History:
ANEMIA Fe deficiency
CHRONIC LOW BACK PAIN spinal stenosis; s/p surgery
CONGESTIVE HEART FAILURE Echo (___) - EF normal ; ?diastolic
dysfunction
CORONARY ARTERY DISEASE MIBI-ETT (___) - no ischemia
DEGENERATIVE JOINT DISEASE R wirst ; s/p surgical repair
DIABETES TYPE II
DIABETIC NEPHROPATHY microalbuminuria
ESOPHAGITIS EGD (___) - GE ulcer/esophagitis + gastritis
GASTROINTESTINAL BLEEDING colonoscopy (___) - diverticulosis,
bleeding AVMs in cecum
HYPERLIPIDEMIA
HYPERTENSION
HYPOTHYROIDISM
MELANOMA L calf ; excised
OSTEOARTHRITIS
OSTEOPOROSIS: RECLAST
SKIN CANCERS squamous cell ca in-situ (R hand) ; keratoacanthoma
(L calf)
TRANSFUSION OF PRBC
UTERINE FIBROIDS s/p TAH
Social History:
___
Family History:
No family history of cancer obtained.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 97.5F, BP 173/68, HR 73, R 18, O2-sat 98% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no cervical LAD palpated
LUNGS - CTA bilaterally, no rales or crackles, good air
movement, resp unlabored, no accessory muscle use
HEART - S1, S2, no murmurs auscultated
ABDOMEN - NABS, soft, non-tender, no tenderness to suprapubic
palpation, no rebound/guarding, protuberant
EXTREMITIES - Warm, well-perfused, patient has 10-12 cm
circumferential erythema with taut swelling from just above
malleolus extending proximally, already receding approximately
1cm from border marked in Emergency Department, 2+ pedal pulses,
sensation intact in feet
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle
strength ___ throughout, sensation grossly intact throughout,
sensation and strength intact in lower extremities.
.
DISCHARGE PHYSICAL EXAM:
VS - 98.0 98.0 147/57 59 18 97%/RA FSG 153
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no cervical LAD palpated
LUNGS - CTA bilaterally, no rales or crackles, good air
movement, resp unlabored, no accessory muscle use
HEART - S1, S2, no murmurs auscultated
ABDOMEN - Soft, non-tender, no tenderness to suprapubic
palpation, no rebound/guarding, protuberant
EXTREMITIES - Warm, well-perfused, patient has 10-12 cm
circumferential erythema with taut swelling from just above
malleolus extending proximally, receding approximately 2cm from
border marked in Emergency Department, 2+ pedal pulses,
sensation intact in feet
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle
strength ___ throughout, sensation grossly intact throughout,
sensation and strength intact in lower extremities.
Pertinent Results:
___ 04:45PM GLUCOSE-132* UREA N-23* CREAT-1.0 SODIUM-134
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-26 ANION GAP-12
___ 04:45PM WBC-10.3 RBC-3.50* HGB-10.9* HCT-32.0* MCV-92
MCH-31.0 MCHC-33.9 RDW-14.3
___ 04:45PM NEUTS-74.3* ___ MONOS-6.1 EOS-0.9
BASOS-0.3
___ 04:45PM PLT COUNT-221
___ 05:15PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:15PM URINE BLOOD-TR NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
___ 05:15PM URINE RBC-3* WBC-31* BACTERIA-MANY YEAST-NONE
EPI-1
.
STUDIES:
LEFT LOWER EXTREMITY ULTRASOUND: There is normal
compressibility, flow, and augmentation in the bilateral common
femoral and left greater saphenous, superficial and deep
femoral, and popliteal veins. Color flow is also noted in the
posterior tibial and peroneal veins.
.
Diffuse subcutaneous edema is present, most severe in the distal
calf and ankle, without drainable collection seen. Note is made
of a 7-mm reactive left inguinal lymph node with fatty hilum.
.
IMPRESSION: No evidence of left lower extremity DVT.
Subcutaneous edema.
Brief Hospital Course:
The patient is a ___ woman with a history of DMT2,
CAD/hyperlipidemia, diastolic CHF, hypothyroidism, esophagitis,
and hypertension who presents with a cellulitis of lower left
leg and a likely UTI.
.
1. LLE cellulitis: Ultrasound negative for any DVT or any
drainable collection. The patient denies any constitutional
symptoms and has been afebrile, no leukocytosis. No known
history of trauma. The patient lives in assisted living but does
not appear to have specific risk factors for MRSA. The patient
received first dose of vancomycin in ED. The morning after
admission, her cellulitis was already markedly improved. She was
transitioned to cefpodoxime and bactrim, and will complete a 7
day total course of antibiotics, with PCP follow up to asses for
improvement or concerns.
- blood cultures are still pending
.
2. Urinary tract infection: The patient's urinalysis suggestive
of infection, and the patient complains of urinary frequency.
She received a dose of ceftriaxone in the ED. She will be
adequatel covered by 7 day course of cefpodoxime and bactrim.
- Urine culture still pending
.
3. Diabetes mellitus: The patient is normally on glipizide at
home. No changes were made to her diabetes medications.
.
4. Hypertension: Continued patient's home regimen of felodipine,
metoprolol, and lisinopril.
.
5. Hyperlipidemia/Coronary artery disease: Continued patient's
home regimen of simvastatin.
.
6. Diastolic heart failure: Last Echo in records in ___, with
LVEF > 55%. No current signs or symptoms of acute
decompensation.
- Continued home furosemide, lisinopril, metoprolol.
.
7. Anemia: Patient's hematocrit is near baseline. Normocytic.
Iron studies in ___ show high TIBC and transferrin, low
ferritin indicative of iron deficiency, but she is not on iron
supplementation. Repeat iron studies did not suggest iron
deficiency anemia. Anemia of chronic disease, possibly related
to ___ be a better explanation, though further work-up can
be pursued in outpatient setting
.
8. Hypothyroidism: Continued home levothyroxine.
.
9. Osteoporosis: Continued home calcium and vitamin D
supplementation.
================
Transitional issues
# Follow up final blood and urine cultures
Medications on Admission:
FELODIPINE - 5 mg Tablet Extended Release 24 hr - 1 Tablet(s) by
mouth once a day in the evening for BP
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day
GLIPIZIDE - (Dose adjustment - no new Rx) - 2.5 mg Tablet
Extended Rel 24 hr - 3 Tablet(s) by mouth once a day
LEVOTHYROXINE - 88 mcg Tablet - 1 Tablet(s) by mouth once a day
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth daily
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually every 5 minutes as needed for chest pain (max 3)
NYSTATIN - 100,000 unit/gram Cream - apply to rash twice a day
until clear
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day for
chol
Medications - OTC
CALCIUM CARBONATE-VITAMIN D3 [OS-CAL 500 + D] - (OTC) - 500 mg
(1,250 mg)-400 unit Tablet - One Tablet(s) by mouth twice a day
Discharge Medications:
1. felodipine 5 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: Three (3)
Tablet Extended Rel 24 hr PO once a day.
4. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
10. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO BID (2 times a day).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
12. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days: start on ___ as got IV
antibiotics on ___.
Disp:*6 Tablet(s)* Refills:*0*
13. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 6 days: start on ___
(___) as got IV antibiotics on ___.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis, Urinary tract 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:
Dear Ms ___,
You were admitted for an infection in your left leg called
cellulitis, and also a urinary tract infection (UTI). For this,
you were treated with IV antibiotics. As you responded quickly,
you will not require further IV antibiotics, but will instead
take 1 week of oral antibiotics.
Because of your heart feailurem weigh yourself every morning,
call MD if weight goes up more than 3 lbs. Increasing weight is
a heart failure danger sign.
The following changes were made to your medications
** START cefpodoxime (antibiotic) for 6 more days
** START bactrim (antibiotic) for 6 more days
Followup Instructions:
___
|
19883978-DS-16
| 19,883,978 | 23,565,279 |
DS
| 16 |
2141-06-22 00:00:00
|
2141-06-22 17:51:00
|
Name: ___ ___ 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:
___: Exploratory laparotomy and lysis of adhesions
History of Present Illness:
___ is a ___ who is presenting here to
the ED w/ acute onset nonradiating periumbilical pain starting
this morning. He says he has never has these sx before. He
thought the pain may be ___ having had a beer last night, and
had
some milk. He also had a BM. On presentation to the ED, he
vomited cloudy yellow fluid. He notes some sweats, denies f/c.
He
denies weight loss, chest pain, SOB, lightheadedness and/or
dizziness, blurry vision, h/a's, or difficulty urinating; ROS is
o/w -ve except as noted above. Here his labs showed WBC 11.1 and
lactate 2.9. A CT A/P was obtained which showing prominent bowel
loops and two transition points c/f early SBO.
Past Medical History:
PMH: hx of pericarditis in retting of URI
PSH: none
Social History:
___
Family History:
grandmother - colon CA
Physical Exam:
Admission Phys Ex:
VS - T:98.3 BP:111/69 HR:102 RR:18 O2:96 RA
Gen - NAD
CV - RRR
Pulm - non-labored breathing, no resp distress
Abd - soft, mildly distended, mild periumbilical ttp w/ no
guarding
Incision: C/D/I
Pertinent Results:
Imaging:
CT A/P ___
1. Small-bowel obstruction with at least 2 transition points
without obvious cause of obstruction. If there is clinical
history of prior surgery this could be secondary to adhesions.
No
evidence of wall ischemia at this point.
CT A/P ___
1. Mild diffuse dilatation of small bowel with few air-fluid
levels with air and fluid within the colon likely representing a
mild postoperative ileus. No frank areas of transition to
suggest a recurrence small-bowel obstruction. No evidence for
intra-abdominal phlegmonous collection or abscess.
2. New small bilateral pleural effusions with overlying
atelectatic collapse.
3. Small volume free pelvic fluid is likely postoperative.
Labs:
Brief Hospital Course:
The patient was admitted to the General Surgical Service on ___
for evaluation and treatment of abdominal pain. Admission
abdominal/pelvic CT revealed small-bowel obstruction with at
least 2 transition points. Non-operative management with bowel
rest, IV fluids, and nasogastric tube decompression was
unsuccessful, as the patient's exam worsened on HD2. Therefore,
the patient was brought to the operating room for definitive
management. The patient underwent exploratory laparotomy and
lysis of adhesions, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
with an NGT, on IV fluids, and PCA for pain control. The
patient was hemodynamically stable.
POD3, the patient was passing flatus. The NGT was removed and
diet was advanced. POD4, the patient was transitioned to oral
pain medicine. POD5 the patient was having bowel movements but
was also increasingly distended and having poorly controlled
pain management. POD7 the patient had emesis and was backed down
to NPO with IV fluids. Abdominal x-ray was consistent with
ileus. POD8 the patient had more emesis, distention, and WBC
bumped up to 13.7. NGT was replaced with large amount of bilious
output. CT abdomen / pelvis was obtained which showed
postoperative ileus. There was no recurrence of obstruction.
POD10, the patient was given oral contrast down his NGT. An
abdominal x-ray eight hours after administration of oral
contrast showed contrast in the rectum. POD11, the patient was
having bowel function. The NGT was removed and the patient was
again given clear liquids which were advanced to regular food
with good tolerability.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. The patient voided
without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, having bowel
movements, and pain was well controlled on tylenol. The patient
was discharged home without services. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl 10 mg PO DAILY
3. Polyethylene Glycol 17 g PO DAILY Constipation - Third Line
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Post-operative ileus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with abdominal pain. CT scan showed a
small bowel obstruction. Initially you received non-operative
management with bowel rest, IV fluids, and a nasogastric tube
for stomach decompression. However, your pain worsened and so
you were taken to the operating room for definitive management.
You underwent an exploratory laparotomy and lysis of adhesions.
You tolerated this well. Post-operatively you had a prolonged
ileus, and it took several days to get your bowels to start
functioning again. You required a nasogastric tube be reinserted
on post-op day 8 for gastric decompression. The NGT has since
come out. You are now eating a regular diet and your pain is
under control with oral medication. You are moving your bowels.
You are ready to be discharged home to continue your recovery.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
___
|
19884061-DS-16
| 19,884,061 | 22,201,399 |
DS
| 16 |
2147-05-09 00:00:00
|
2147-05-09 11:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
prednisone
Attending: ___.
Chief Complaint:
Double vision
Major Surgical or Invasive Procedure:
- Radiation therapy (___)
History of Present Illness:
Mr. ___ is a ___ right handed man with a past
medical
history of Stage ___ Metastatic prostate cancer and a prior Right
microvascular ___ nerve palsy presenting for 1 week of left eye
ptosis and new onset vertical diplopia.
History is gathered from the patient and his girlfriend/HCP
___ who are at bedside.
He reports first being diagnosed with prostate cancer in ___.
He underwent radical prostatectomy, but was told it was stage 4.
He has known multiple mets to the bone including l-spine,
sacrum,
ribs, in addition to possible lung disease. He has been on
multiple different agents over the past several year including
Bicalutamide (Casodex, developed "resistance to this"), Zoladex,
and Xgiva.
Neurologically, he first came to attention in ___ when he
reports waking up with acute onset horizontal double vision,
worst at distance. He saw neuro-ophthalmology and underwent
testing, before being finally diagnosed with a microvascular
right ___ nerve palsy. He patched his eye and did well.
Recovery was slow, but he started noticing clear improvement
later in the year. By ___, he was "90%" better and
had
stopped wearing the patch. He never underwent LP.
In late ___, roughly 1 week after starting the
enzalutamide,
he developed a new type of severe headache. It is principally a
left, retro-orbital headache. It can feel like a severe
pressure, occasionally with a sharp or stabbing pain behind his
left eye. This headache tended to be worse when laying flat,
and woke him at night on several occasions. IF he does not take
naproxen, the headaches can last for the full day and be quite
debilitating. He followed with neurology, and underwent testing
including MRI Orbits (see copy in chart or my typed assessment
below), most notable for a left cavernous sinus lesion of
unclear
etiology.
He was referred to ___ for a possible biopsy, but after
conversation, decision was made to first stop enzalutamide
before
proceeding with invasive procedure. enzalutamide has known SE
of
headache. This was stopped late ___. His headaches
improved
(less frequent, now only every ___ days) but did not resolve.
In the past week however, things have changes. He has noticed
new onset of vertical double vision (resolves with closing one
eye). This is quite different from his prior horizontal double
vision. Additionally, he has had progressive left eye ptosis.
It was subtle when it first began ("like he tired") but then
progressed and became quite prominent. Additionally, he was
noticed to have a new onset anisacoria, with enlargement of the
left pupil.
He spoke with his neurologist, and in fact has a pending
appointment with Dr. ___ Neuro-Oncology. However, as
this
appointment could not be moved up and symptoms were quickly
progressive, he was referred in for more urgent evaluation.
On further discussion of symptoms, or the past week or 2 he has
had intermittent sensory change of his left face. It involves
his forehead and cheek and spares the chin. It is a tingling
paresthesia that lasts ___ mintues and then spontaneously
resolved. He has perhaps ___ episodes a day. No clear inciting
or remitting events.
Otherwise, he endorses a relatively constant mild headache of
"pressure". He has orthostatic light headedness with standing.
He has had b/l sciatica in the setting of known spinal epidural
mets, but does well. He has also been took prednisone 5mg QD on
___ and ___ (due to low energy, not directed by a
physician). Thinks this may have helped.
On neurologic review of systems, the patient denies confusion.
Denies difficulty with producing or comprehending speech. Denies
loss of vision, vertigo, tinnitus, hearing difficulty,
dysarthria, or dysphagia. Denies focal muscle weakness, other
numbness or parasthesia. Denies loss of sensation. Denies bowel
or bladder incontinence or retention. Denies difficulty with
gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain. No recent change in
bowel or bladder habits. Denies dysuria or hematuria.
Past Medical History:
- Prostate Cancer.
- Macular Degenration
- Right ___ Nerve palsy- reportedly microvascualr
- B/l Sciatica
- Vasectomy
- Right rotator and Biceps tendon repair
- Right knee Arthroscopy
- s/p Radical Prostatectomy.
Social History:
___
Family History:
- Father and oldest brother deceased ___ MI. Macular ___ in
the family. Mother with dementia in old age.
Physical Exam:
==============
ADMISSION EXAM
==============
General: NAD, thin.
HEENT: NCAT, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND
Extremities: WWP
Neurologic Examination:
MS: Awake, alert, oriented x 3. Able to relate a clear and
concise history without difficulty. Attentive, able to name ___
backward without difficulty. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. No dysarthria. Normal prosody.
Able to register 3 objects and recall ___ at 5 minutes. No
apraxia. No evidence of hemineglect. No left-right confusion.
Able to follow both midline and appendicular commands.
Cranial Nerves - Anisacoria, left pupil 4mm-->3mm. Right pupil
3mm-->1.5mm. Difference is greatest in the light, left eye abn.
VF full to number counting. Several extraocular movement abn.
There is a skew on primary gaze, with elft eye slightly
depressed
compared to right. Right eye does not bury fully on lateral
gaze,
but otherwise EOMI in right. Left eye has limited upgaze,
downgaze as well as subtle limitation medially. V1-V3 without
deficits to light touch or pinprick bilaterally. There is clear
left eye ptosis, does not fatigue. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. Trapezius strength ___
bilaterally. Tongue midline.
Motor - Normal bulk and tone. No drift. No tremor or asterixis.
[Delt] [Bic] [Tri] [ECR] [IP] [Quad] [Ham] [TA] [Gas]
L 5 5 4+ 5 5- 5 5 5 5
R 5 5 4+ 5 5- 5 5 5 5
Sensory - There is subtle decreased sensation to pinprick on the
medial and psoterior aspect of the right leg. Otherwise intact.
to light touch, pin, or moderate movement proprioception
bilaterally. No extinction to DSS.
DTRs:
[Bic] [Tri] [___] [Quad]
L 2+ 2+ 2+ 2+
R 2+ 2+ 2+ 2+
Plantar response flexor bilaterally.
Coordination - No dysmetria with finger to nose testing
bilaterally. Finger tapping is clumsy bilaterally, left worse
than right. Pronation-supination intact. Heel shin intact..
Gait - Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway. Negative Romberg.
==============
DISCHARGE EXAM
==============
Essentially unchanged. Normal except for: Anisacoria. Left
partial ___ nerve palsy, involving pupil (diminished light
reflex), impaired up and downgaze. Right lateral rectus paresis.
Pertinent Results:
====
LABS
====
___ 12:45PM BLOOD WBC-6.4 RBC-4.09* Hgb-11.8* Hct-36.9*
MCV-90 MCH-28.9 MCHC-32.0 RDW-15.6* RDWSD-51.5* Plt ___
___ 06:15AM BLOOD WBC-6.1 RBC-3.98* Hgb-11.4* Hct-36.1*
MCV-91 MCH-28.6 MCHC-31.6* RDW-15.7* RDWSD-51.6* Plt ___
___ 12:45PM BLOOD Neuts-57.3 ___ Monos-7.5 Eos-1.9
Baso-0.6 Im ___ AbsNeut-3.65 AbsLymp-2.05 AbsMono-0.48
AbsEos-0.12 AbsBaso-0.04
___ 12:45PM BLOOD ___ PTT-31.1 ___
___ 06:15AM BLOOD ___ PTT-30.9 ___
___ 12:45PM BLOOD Glucose-95 UreaN-12 Creat-0.8 Na-137
K-5.3* Cl-100 HCO3-25 AnGap-17
___ 06:15AM BLOOD Glucose-88 UreaN-11 Creat-0.8 Na-139
K-5.6* Cl-102 HCO3-23 AnGap-20
___ 12:45PM BLOOD ALT-10 AST-17 AlkPhos-267* TotBili-0.3
___ 06:15AM BLOOD ALT-9 AST-15 AlkPhos-243* TotBili-0.4
___ 12:45PM BLOOD Albumin-4.3 Calcium-9.2 Phos-3.2 Mg-2.5
___ 06:15AM BLOOD TotProt-5.6* Albumin-3.9 Globuln-1.7*
Calcium-8.4 Phos-3.2 Mg-2.8*
___ 06:15AM BLOOD VitB12-743
___ 06:15AM BLOOD TSH-3.1
___ 06:15AM BLOOD ANCA-NEGATIVE B
___ 06:15AM BLOOD ___ PSA-33.8*
___ 12:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:15AM BLOOD PEP-NO SPECIFI
ACE, SERUM 59
=======
IMAGING
=======
- ___ CTA Head & Neck
1. No intracranial hemorrhage.
2. Extensive sclerotic osseous metastatic disease, as described,
with
involvement of the skullbase.
3. Irregular expansion and enhancement of the left cavernous
sinus is better characterized on the concurrent MR examination.
4. Patent intracranial arterial vasculature without significant
stenosis, occlusion, or aneurysm.
5. Patent cervical vasculature without significant stenosis,
occlusion, or dissection.
- ___ MRI/MRA Head & Neck
1. Unchanged enhancing lesion measuring 23 x 7 mm in the left
cavernous sinus tracking along the left middle cranial fossa
through foramen ovale, suggesting a process involving V3 branch
of the trigeminal nerve. Differential considerations include
sarcoid, meningioma, or lymphoma. Given extensive sclerosis of
the adjacent skull base and interval change between ___
and
___, metastatic disease would also be possible.
2. Unchanged pre clival dural thickening and enhancement with
extension into right Dorello's canal (CN 6) may be related to
the
process involving the left cavernous sinus. Recommend
correlation with CSF studies, if not already performed.
3. Previously noted punctate foci of enhancement at the level of
the orbital apices are not visualized on the current
examination.
4. No parenchymal enhancing mass.
5. Patent intracranial arterial vasculature without significant
stenosis, occlusion, or aneurysm.
6. No evidence of cerebral venous thrombosis.
7. Patent cervical arterial vasculature without significant
stenosis or occlusion.
- ___ MRI L-spine WWO Contrast
1. Study is moderately degraded by motion.
2. Diffuse sclerotic osseous metastatic disease, all visualized
osseous structures, grossly unchanged since ___.
3. No evidence of pathologic fracture.
4. Unchanged anterior presacral and anterior epidural soft
tissue
extension of enhancing tumor, grossly unchanged, with anterior
epidural soft tissue component mildly narrowing the spinal
canal,
encasing the bilateral exiting S1 nerve roots through the neural
foramina with possible compression, also displacing the
traversing S2 nerve roots with possible compression, with
additional minimal extension into the left L5-S1 neural foramen.
5. Multilevel lumbar spondylosis, as described, grossly
unchanged
since ___. No definite moderate to severe spinal
canal or neural foraminal narrowing.
- ___ CT Chest W Contrast
Multiple small pleural tumor deposits related to local invasion
of extensive blastic metastases throughout the chest cage. No
appreciable pleural effusion.
No lung lesions.
Solitary borderline enlarged left hilar lymph node, significance
indeterminate.
Brief Hospital Course:
Mr. ___ is a ___ right handed man with a past
medical
history of Stage 4 prostate cancer with multiple bony metastasis
and a recent right ___ nerve palsy, presumed microvascular who
presents with 1 week of left eye ptosis and new onset vertical
diplopia. His exam is notable for prior right ___ nerve palsy
and left oculomotor (cranial nerve 3) and trochlear (cranial
nerve 4) involvement concerning for left cavernous sinus process
secondary to metastatic prostate cancer. At the time of
presentation, his labs were notable for an elevated alkaline
phosphatase in the setting of metastatic bony lesions and
elevated PSA to 33.8.
Neurosurgery, radiation oncology, and neuro-oncology were
consulted this admission to discuss the possibility of biopsy of
left cavernous sinus lesion. MRI Head on ___ showed a lesion in
the left cavernous sinus measuring 23x7mm (unchanged from prior
imaging) tracking along the left middle cranial fossa and
extensive sclerosis of skull base suggestive of metastatic
disease. An LP was not preformed because MRI L-spine ___ showed
presacral and anterior epidural soft tissue extension of
enhancing tumor narrowing the spinal canal and encasing the
bilateral S1 nerve roots. Ultimately, given the extent of his
tumor burden, an interdisciplinary decision was made not to
pursue biopsy and initiate palliative radiation therapy,
instead.
He received two cycles of palliative radiation therapy on ___
and ___ prior to discharge. He was started on Decadron 2g Q8H
and increased to 4mg Q8H upon discharge. He will follow up with
radiation oncology two days following discharge on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Goserelin Acetate 10.8 mg SC Q 3 MONTHS
2. Denosumab (Xgeva) 120 mg SC Q 3 MONTHS
3. aflibercept 2 mg/0.05 mL Other Q4-8 weeks
4. enzalutamide 160 mg oral currently on hold
5. lutein 20 mg oral DAILY
6. eye lubricant combination ___ mg ophthalmic DAILY:PRN
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergic
rhinitis
8. Amitriptyline 10 mg PO QHS
9. Vitamin D 1000 UNIT PO DAILY
10. Cyanocobalamin 100 mcg PO DAILY
11. Naproxen 440 mg PO Q12H:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN Headache
RX *acetaminophen-codeine 300 mg-60 mg ___ tablet(s) by mouth
Q6H PRN Disp #*20 Tablet Refills:*0
2. Dexamethasone 4 mg PO Q8H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
3. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
4. Amitriptyline 25 mg PO QHS
RX *amitriptyline 25 mg 1 tablet(s) by mouth AT BEDTIME Disp
#*30 Tablet Refills:*2
5. aflibercept 2 mg/0.05 mL Other Q4-8 weeks
6. Cyanocobalamin 100 mcg PO DAILY
7. Denosumab (Xgeva) 120 mg SC Q 3 MONTHS
8. enzalutamide 160 mg oral CURRENTLY ON HOLD
9. eye lubricant combination ___ mg ophthalmic DAILY:PRN
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergic
rhinitis
11. Goserelin Acetate 10.8 mg SC Q 3 MONTHS
12. lutein 20 mg oral DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. HELD- Naproxen 440 mg PO Q12H:PRN Pain - Moderate This
medication was held. Do not restart Naproxen until off steroids
and told okay to resume by medical provider.
Discharge Disposition:
Home
Discharge Diagnosis:
Cranial polyneuropathy (CN 3,4,5) due to metastatic prostate
cancer.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were seen in the hospital for symptoms of double vision and
drooping left eyelid. Upon further examination, your symptoms
were consistent with a problem affecting the left ___, and
___ cranial nerves. Imaging showed that this was likely due to
metastases from your prostate cancer affecting the bone at the
base of your skull. You were seen by radiation oncology (Dr.
___, neurosurgery (Dr. ___, and neuro-oncology (Dr.
___. You have started radiation to help reduce the impact of
these metastases. You will be following-up with these physicians
in the coming days.
The following changes were made to your medications:
- START Decadron 4mg EVERY 8 HOURS. This is a steroid that is
used with radiation treatments.
- START omeprazole 40mg TWICE DAILY. This is a stomach acid
reducer that will help prevent ulcers which can be caused when
taking steroids.
- DO NOT USE naproxen, ibuprofen, or other NSAIDs for headache
pain, as these also increase the risk of stomach ulcers.
- INCREASE amitriptyline to 25mg EVERY NIGHT.
- DO NOT USE tramadol (Ultram) for pain while on amitriptyline
as it carries a risk of seizure.
- START Tylenol with codeine (Tylenol #3) EVERY 6 HOURS AS
NEEDED FOR BREAKTHROUGH PAIN.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19884061-DS-18
| 19,884,061 | 25,671,112 |
DS
| 18 |
2148-12-09 00:00:00
|
2148-12-09 19:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
prednisone / gabapentin / Lyrica
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
B/L therapeutic thoracentesis ___
History of Present Illness:
___ is a ___ year old man with progressive
metastatic prostate cancer who is admitted from the ED after a
fall.
Patient reports several weeks of increasing dyspnea on exertion
with associated fatigue, which he attributes to his recent XRT.
On ___ morning at 630am, he was walking from his bathroom to
his living room when he began feeling dizzy and off balance. At
that point he fell and struck his head. He denies LOC and got up
on his own power. He notes the dizziness occurred after he had
been walking for several steps. He denied preceeding chest pain
or palpitations. He thinks his symptoms were similar to prior
events of dizziness with over exertion. After his fall he
developed new diplopia on upward gaze (notably has previously
had
vertical and lateral diplopia, which had resolved) along with
pain of L cheek region. He notes decreased visual acuity and
blurry vision in both eyes, L>R. He also has chronic floaters in
his right eye.
He otherwise denies recent fevers or chills. No headaches. He
has
chronic dysphagia, but no odynophagia. He has chronic upper and
lower back pain from his widespread osseous metastaic disease,
and has noted some bony chest pain as well. He has chronic
cough.
Notes occaisional nausea but no emesis, appetite is 'mediocre'
and weight is stable. Normal BM. Noted some increasing swelling
in his legs last week that has resolved. He has chronic
bilateral
lower extremity neuropathy.
In the ED, initial VS were pain 0, T 96.9, HR 78, BP 99/54, RR
19, O2 100%RA. Labs notable for Na 134, K 4.5, HCO3 21, Cr 0.9,
Ca 7.9, Mg 2.5, P 2.2, WBC 7.5, HCT 26.7, PLT 155. Trop negative
x2. CT head revealed blowout fracture of left orbital floor. CT
C-spine showed nondisplaced C5 pedicle fracture involving right
vertebral foramina. CTA neck redemonstrated C5 pedicle fracture
with associated narrowing of the right vertebral artery. CT
chest
without contrast showed known widespread osseous metastatic
disease with progression of widespread lymphadenopathy, new
liver
lesions, large right and moderate left pleural effusions, and
interlobular septal thickening concerning for underlying
lymphangitic metastatic disease. Ophthalmology, plastic surgery,
spine surgery, and trauma surgery were all consulted on the
patient. Ultimately, no immediate surgical interventions
planned.
Plastic surgery did recommend maintaining sinus precautions with
consideration of non-urgent operative repair of orbital
fracture,
and spine recommended maintaining hard cervical collar until
outpatient follow up. Patient spent an extended time in the
emergency room, and received pain control with IV morphine and
po oxcydone. Also received IVF and his home medications of
ramelteon, zinc, dexamethasoene, omeprazole, and Bactrim.
Decision was made to admit to oncology service for discharge
planning purposes. VS prior to transfer were T 98.3, HR 60, BP
112/67, RR 16, O2 92%RA.
Past Medical History:
PAST ONCOLOGIC HISTORY (Per OMR, reviewed):
___ Prostate cancer
Radical prostatectomy
___ Brain MRI showed left cavernous sinus mass
___ Brain MRI stable
___ Diplopia and left-sided ptosis started
___ - ___ XRT to left cavernous sinus 5x4 Gy (NOT SRS)
___ Brain MRI stable
___ Brain MRI stable
___ - ___ XRT to L4-S3
Leuprolide-denosumab-enzalutamide
___ Brain MRI stable
___ Brain MRI stable
___ C1 Enzalutamide
___ Radium-223
___ C2 Enzalutamide, Radium-223
___ Brain and skull base MRI stable
___ C3 Radium-223
___ Enzalutamide, Radium-223
___ CT torso showed progression
___ Skull base MRI stable
___ T-spine MRI stable
___ Brain MRI stable
___ C1 Docetaxel
___ C2 Docetaxel
PAST MEDICAL HISTORY (Per OMR, reviewed):
-Macular degeneration, bilateral
-Shoulder surgery
-Sinus thrombosis
Social History:
___
Family History:
Of his five siblings, one brother died at ___ with a heart
attack.
Two sisters have macular degeneration. One brother has a heart
murmur since childhood, and one other brother is healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.2 HR 58 BP 104/57 RR 18 SAT 93% O2 on RA
GENERAL: Pleasant chronically ill appearing man in hard cervical
collar sitting up in bed in NAD.
EYES: Edema and bruising surrounding left eye with multiple
excoriations. Able to open eye. Decreased upward gaze of left
eye. Otherwise tandem gaze intact. PERRL.
ENT: Oropharynx clear without lesion, hard cervical collar in
place
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops
RESPIRATORY: Appears in no respiratory distress. Decreased
breath
sound halfway up right lung on anterior ausculation
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Decreased bulk
NEURO: Alert, oriented x3, rightward deviation of tongue, motor
and sensory function grossly intact
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM:
==========================
Vitals
Temp: AFebrile BP: 100s/70s HR: 64 RR: 18 O2 sat: 96% RA
GEN: elderly man resting in bed comfortably with stiff cervical
collar
HEENT: ecchymosis surrounding left eye; wearing hard cervical
collar; EOMI
CV: RRR
Pulm: CTAB with chest tubes removed and dressings c/d/i
Abd: soft NT ND BS+
Neuro: diplopia elicited on leftward gaze; tongue deviates to
left consistent with prior exams; otherwise no focal neurologic
deficits
MSK: moves all extremities with purpose; ___ strength in UE and
___ bilaterally
Pertinent Results:
ADMISSION LABS:
==================
___ 04:58PM BLOOD WBC-5.1 RBC-2.80* Hgb-8.6* Hct-26.8*
MCV-96 MCH-30.7 MCHC-32.1 RDW-19.1* RDWSD-65.9* Plt ___
___ 01:17PM BLOOD Neuts-78.9* Lymphs-12.6* Monos-3.6*
Eos-0.7* Baso-0.3 Im ___ AbsNeut-5.91 AbsLymp-0.94*
AbsMono-0.27 AbsEos-0.05 AbsBaso-0.02
___ 05:52AM BLOOD Glucose-83 UreaN-10 Creat-0.8 Na-134*
K-4.2 Cl-103 HCO3-19* AnGap-12
___ 05:52AM BLOOD Calcium-7.2* Phos-2.0* Mg-2.3
IMAGING:
=========
IMPRESSION:
1. Widespread sclerotic osseous metastases, not significantly
changed compared
to prior. No acute fracture is noted within the bony thorax.
2. Worsening supraclavicular, axillary, mediastinal, and hilar
lymphadenopathy, concerning for worsening metastatic disease.
3. Multiple liver hypodensities are seen, all of which are new
compared to
___, measuring up to 1.5 cm in segment ___. These
findings are
incompletely characterized on today's exam, but are highly
concerning for new
metastatic disease. Further evaluation can be performed by
contrast enhanced
CT exam on a nonemergent basis.
4. Interval increase in now large right and moderate left
pleural effusions.
Pleural thickening and nodularity as well as paravertebral soft
tissue lesions
are difficult to compare to prior exam, but overall appear
grossly stable.
5. No pulmonary masses are identified. There is nodular
interlobular septal
thickening concerning for underlying lymphangitic spread.
RECOMMENDATION(S): Multiple liver hypodensities are seen, all
of which are
new compared to ___, measuring up to 1.5 cm in segment
___. These
findings are incompletely characterized on today's exam, but are
highly
concerning for new metastatic disease. Further evaluation can be
performed by
contrast enhanced CT exam on a nonemergent basis.
CTA Neck ___:
===============
IMPRESSION:
1. Moderate narrowing of the right V2 segment at the C5
vertebral level, in the region of a right C5 pedicle/transverse
foramen fracture may be secondary progressive atherosclerotic
disease as this appears similar to examination of
___ allowing for technical differences. However,
given the
differences in modality, sequela of dissection is not entirely
excluded and if there is high clinical suspicion further
evaluation with MRI of the neck utilizing axial fat saturated T1
sequences may be of benefit.
2. Unremarkable left vertebral and bilateral internal carotid
arteries.
3. Additional findings as described above.
Brief Hospital Course:
SUMMARY:
___ is a ___ year old man with progressive
metastatic prostate cancer who is admitted from the ED after a
fall that resulted in rather extensive traumatic injuries for
his fall including left orbital fracture and C5 pedicle
fracture. Ultimately decided on non-operative management, plan
to go home on hospice with pain control.
ACUTE ISSUES:
=================
# Orbital fracture:
Plastic surgery saw patient in emergency department and
recommended:
- Maintain sinus precautions (no nose blowing, straws, smoking
for 2 weeks, sneeze with mouth open)
- Optho consult if develops worsening vision or floaters
- Pain control with home oxycodone and naproxen, will be given
prescription for IV morphine since going home on hospice.
# Cervical pedicle fracture
# Associated vertebral artery narrowing:
Seen by neurosurgery spine service, who recommended that patient
maintain hard C-collar at all times due to high risk of
paralysis if collar comes off. On discharge family was concerned
about neck collar positioning but NOPCO tech not available to
assess. They said they would try to contact the patient at home,
otherwise they left a number at ___ to call if the
family has questions.
# Metastatic castrate resistant prostate cancer:
Held enzalutamide 160mg daily as patient made hospice while in
patient. Decision was made to continue dexamethaseon 4mg daily
with Bactrim ppx due to the fact that he has been on long-term
steroid therapy. Discontinuing Lupron and Xgeva due to hospice
transition.
# Bilateral pleural effusions due to metastatic disease:
Underwent bilateral therapeutic thoracentesis ___ with 2.2L out
of R lung and 690mL out of L lung, with improvement in symptoms.
Patient can follow up with IP as needed in the future for
additional therapeutic thoracenteses. Chest tubes removed on
discharge.
# Hypoglossal nerve palsy:
Chronic and stable.
# Cavernous sinus mass:
Presumed prostate cancer, not biopsy proven. Dr ___
___, had entertained idea of diagnostic LP; but now
hospice DC.
# Severe protein calorie malnutrition:
Continued dronabinol, dexamethasone, received home IVF q week,
which is no longer necessary given hospice discharge.
# Sinus thrombosis:
SP 6 months of lovenox treatment; now off lovenox.
# Hypothyroidism:
Not on thyroid replacement, not indicated given GOC and hospice
discharge.
=======================
TRANSITIONAL ISSUES:
=======================
[] Can follow up with IP in 2 weeks if patient feels he needs
another therapeutic thoracentesis.
[] Continuing steroid therapy and Bactrim given long-term
steroid use and desire to avoid adrenal insufficiency. This can
be discontinued at discretion of hospice and GOC.
[] follow up for pain control, adjust medication regimen if
needed
[] family can call ___ if they have further questions
regarding the neck brace
[] for orbital fracture, plastic surgery recommended to maintain
sinus precautions (no nose blowing, straws, smoking for 2 weeks,
sneeze with mouth open), pain control, and optho consult if
develops worsening vision or floaters
- Pain control with home oxycodone and naproxen, will be given
prescription for IV morphine since going home on hospice.
# CODE: DNR/DNI/No ICU
# EMERGENCY CONTACT HCP: ___ (wife)
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Cyanocobalamin 100 mcg PO DAILY
3. Dexamethasone 4 mg PO DAILY
4. Dronabinol 5 mg PO QPM
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergic
rhinitis
6. Omeprazole 20 mg PO DAILY
7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Multivitamins W/minerals 1 TAB PO DAILY
11. aflibercept 2 mg/0.05 mL Other Q4-8 weeks
12. lutein 20 mg oral DAILY
13. melatonin 5 mg oral QHS
14. enzalutamide 160 mg oral DAILY
15. Zinc Sulfate 220 mg PO DAILY
16. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
17. eye lubricant combination ___ % ophthalmic (eye)
DAILY:PRN
18. Leuprolide Acetate Dose is Unknown IM ASDIR
19. Lidocaine 5% Patch 1 PTCH TD QAM
20. Naproxen 250 mg PO Q8H:PRN Pain - Moderate
21. Acetaminophen 1000 mg PO Q6H:PRN Pain - Moderate
22. LOPERamide 4 mg PO QID:PRN diarrhea
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Dulcolax Stool Softener (dss)] 100 mg 1
capsule(s) by mouth twice daily as needed Disp #*30 Capsule
Refills:*0
2. Morphine Sulfate 2 mg IV Q4 BREAKTHROUGH PAIN
RX *morphine (PF) in dextrose 5 % 100 mg/100 mL (1 mg/mL) 2 mg
IV every 4 hours as needed Disp #*1 Bag Refills:*0
3. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 10 mg 1 tablet(s) by mouth every 4 hours as needed
Disp #*84 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q6H:PRN Pain - Moderate
5. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
6. Dexamethasone 4 mg PO DAILY
7. Dronabinol 5 mg PO QPM
8. eye lubricant combination ___ % ophthalmic (eye)
DAILY:PRN
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. melatonin 5 mg oral QHS
11. Naproxen 250 mg PO Q8H:PRN Pain - Moderate
12. Omeprazole 20 mg PO DAILY
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
-------------
metastatic prostate cancer
left orbital fracture
C5 pedicle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had a fall at home and hit your head.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Imaging was done that showed a vertebrae fracture as well as
fracture of the bone under your left eye. Surgical services saw
you and you opted not to pursue surgical treatment for these
fractures.
- You were placed in a stiff neck brace, which you will need to
continue to wear at all times due to the high risk of paralysis
if you remove it.
- Hospice services were set up for you to go home with, to make
you as comfortable as possible at home.
- Pulmonology placed chest tubes to drain fluid in your lungs to
help you breathe better.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Follow up with interventional pulmonology in 2 weeks as needed
for increasing difficulty breathing.
** For your eye injury, plastic surgery recommends the
following:
-----You can use bacitracin ointment on the open cuts.
-----Sinus precautions for 2 weeks (no nose blowing, no straws,
no
smoking, open mouth to sneeze).
** For your neck injury, neurosurgery recommends the following:
- use stiff cervical collar at all times due to high risk of
paralysis if it is removed
- it is okay for you to use a pillow or sleep on your side, as
long as you have the cervical collar on while doing this.
- A technician may call you to help make sure you are
comfortable with the neck brace. Otherwise the number to reach
them at is ___
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19884207-DS-7
| 19,884,207 | 25,299,236 |
DS
| 7 |
2125-02-21 00:00:00
|
2125-02-25 19:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Keflex
Attending: ___.
Chief Complaint:
Lower Extremity Swelling
Major Surgical or Invasive Procedure:
___: Esophagogastroduodenoscopy
History of Present Illness:
___ y/o M with a history of T2DM, HTN, HLD, AFib on Coumadin,
stage I prostate cancer who presents with 2 weeks of leg
swelling and dypsnea on exertion and 2 days of scrotal swelling
Past Medical History:
-Atrial fibrillation, status post DC cardioversion x 2, failed
flecainide, offered PVI but did not have this procedure.
Currently on coumadin.
-T2DM
-HTN
-HLD
-Stage I prostate cancer
-Sleep apnea
-Degenerative joint disease
Social History:
___
Family History:
His father died at age ___ of lung cancer. His mother died at age
___ of lung cancer. He has one brother, one sister, two sons and
a daughter. One of his brothers has hyperlipidemia. One of his
brothers recently had esophageal cancer iso smoking history.
There is no family history notable for stroke, hypertension,
diabetes, early coronary artery disease or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Temp 98.3 BP 125/76 HR 91 RR 18 O2 Saturation 94% on RA
GENERAL: Alert and interactive, but agitated and stressed
HEENT: No scleral icterus or conjunctival pallor. MMM.
Oropharynx
clear.
NECK: Supple. No lymphadenopathy. JVP not visualized.
CV: Irregularly irregular rhythm. I/VI systolic ejection murmur
heard ___ RUSB, no radiation, no additional heart sounds.
RESPIRATORY: NL WOB. No accessory muscle use. Decreased breath
sounds R>L, no crackles, wheezes, rhonchi.
ABDOMEN: Soft, NTND.
EXTREMITIES: b/l 2+ pitting edema of lower extremities, up to
the
knees. No clubbing or cyanosis. Radial pulses palpable and
symmetric. Faint ___.
NEUROLOGIC: No facial asymmetry or nasolabial flattening.
PERRLA,
EOMI. Moves all extremities symmetrically.
DISCHARGE PHYSICAL EXAM
VITALS:
24 HR Data (last updated ___ @ 602)
Temp: 97.6 (Tm 98.3), BP: 130/57 (125-130/57-76), HR: 64
manual (64 manual-149), RR: 18, O2 sat: 98% (94-98), O2
delivery:
Ra, Wt: 323.19 lb/146.6 kg
GENERAL: Alert and interactive, but agitated and stressed
HEENT: No scleral icterus or conjunctival pallor. MMM.
NECK: Supple. No lymphadenopathy. JVD 10cm.
CV: Irregularly irregular rhythm. ___ systolic ejection murmur
heard ___ at the apex, radiating to the axilla.
RESPIRATORY: NL WOB. No accessory muscle use. Bibasilar
crackles.
ABDOMEN: Soft, NTND.
EXTREMITIES: b/l 2+ pitting edema of lower extremities, up to
the
knees. No clubbing or cyanosis. Radial pulses palpable and
symmetric. Faint ___.
NEUROLOGIC: A&Ox3. CNII-XII grossly intact.
Pertinent Results:
ADMISSION LABS
___ 12:57PM BLOOD WBC-4.4 RBC-2.74* Hgb-8.6* Hct-27.1*
MCV-99* MCH-31.4 MCHC-31.7* RDW-16.2* RDWSD-57.6* Plt ___
___ 12:57PM BLOOD Neuts-64.6 ___ Monos-10.9 Eos-1.8
Baso-0.2 Im ___ AbsNeut-2.85 AbsLymp-0.96* AbsMono-0.48
AbsEos-0.08 AbsBaso-0.01
___ 12:57PM BLOOD Glucose-198* UreaN-10 Creat-0.7 Na-140
K-4.3 Cl-105 HCO3-24 AnGap-11
___ 12:57PM BLOOD proBNP-344*
DISCHARGE LABS
___ 06:59AM BLOOD WBC-5.0 RBC-2.89* Hgb-9.1* Hct-28.7*
MCV-99* MCH-31.5 MCHC-31.7* RDW-16.5* RDWSD-60.1* Plt ___
___ 05:07PM BLOOD Neuts-71.0 Lymphs-17.0* Monos-9.5 Eos-1.5
Baso-0.4 Im ___ AbsNeut-3.73 AbsLymp-0.89* AbsMono-0.50
AbsEos-0.08 AbsBaso-0.02
___ 06:59AM BLOOD Glucose-146* UreaN-8 Creat-0.6 Na-139
K-4.2 Cl-102 HCO3-25 AnGap-12
IMAGING
EGD ___
mucosa suggestive of ___ esophagus
erythema in the stomach compatible with gastritis
3cm diameter mass in the antrum next to the pylorus. 2 8mm
superficial clean based ulcers over the mass. EUS features more
suggestive of a lipoma although GIST and pancreatic rest are in
the differential. FNB was not performed due to elevated IRN.
Erosions in the duodenum
Brief Hospital Course:
ADMISSION
=========
___ y/o M with a history of T2DM, HTN, HLD, AFib on Coumadin,
stage I prostate cancer who presents with 2 weeks of leg
swelling
and dypsnea on exertion and 2 days of scrotal swelling. He
states
his symptoms have remained the same and not gotten progressively
worse. His swelling is worse at night, especially after working
all day, better in the morning. He is not having any chest pain,
orthopnea or PND. He works as a ___ and denies exercise
intolerance. He has a history of obstructive sleep apnea for
which he uses his CPAP intermittently. He had an echo in ___
which showed hypertensive heart disease, marked left atrial
dilation, mild right ventricular dilation with normal function
and a LVEF of >60%.
He also endorses ___ days of black tarry stools several weeks
ago, approximately around the same time when he began to notice
swelling in his legs. He denies abdominal pain, nausea,
vomiting,
diarrhea or constipation. He denies a history of black tarry
stools or hematochezia in the past. He had a colonoscopy several
years ago, has never had an endoscopy. Denies frequent NSAID
use.
Otherwise, he denies fever, night sweats, chills, loss of
appetite, dysuria, hematuria, urgency, frequency. Notes
intentional weight loss last year when he joined Weight
Watchers,
but has since gained back the weight (~40lbs).
In the ED:
Patient was seen by GI consult team. His hemoglobin was found to
be in the 8s compared to normal at baseline. Given dark stools,
concern for GI blood loss related anemia. Patient's vital signs
were currently stable. He had no frank melena or BRBPR. Repeat
Hb
was 8.8 at 5:30PM. His coumadin was held. He received IV
pantoprazole 40mg and IV lasix 40mg.
Initial vital signs were notable for: Temp 98.0 HR 73 BP 114/59
RR 17 O2 Saturation 100% on RA
Exam notable for: Irregularly irregular rhythm, soft systolic
murmur ___ heard at LUSB, faint crackles at the R lung base, 2+
pitting edema to the knees, guaiac negative
Labs were notable for:
proBNP 344
Troponin <0.01
Lactate 1.5
Hgb 8.6 -> 8.8, Hct 27.1 -> 28.1 (down from 14.3 Hgb baseline)
U/A bland
Mildly elevated ALT, but otherwise normal LFTs
BMP wnl
___ 27.2 PTT 36.7 INR 2.5
Studies performed include:
CXR: small bilateral pleural effusions and mild pulmonary
vascular congestion
Vitals on transfer: Temp 98.3 BP 125/76 HR 91 RR 18 O2
Saturation
94% on RA
On arrival to the floor, patient is doing well. He denies chest
pain and shortness of breath?***. He is on telemetry for cardiac
monitoring. He is on clear fluid as diet and will be NPO after
midnight for EGD tomorrow.
ACUTE ISSUES
============
# Melena:
# Anemia:
Patient presented with melanotic stools around 10 days prior to
admission. His hemoglobin on admission was 8.6. EGD ___ showed
a 3cm diameter mass in the antrum next to the pylorus. There
were 2 8mm superficial clean based ulcers over the mass. EUS
features were more suggestive of a lipoma (although GIST and
pancreatic cancer are included in the differential). Fine needle
biopsy was not done due to his elevated INR. The EGD also showed
gastritis, erosions in the duodenum and mucosa suggestive of
___ esophagus. He will require MRI Abdomen with contrast
to differentiate the mass, as well as follow up with general
surgery for biopsy or excisional biopsy pending imaging results.
He should continue taking a PO PPI and will require H. Pylori
testing as an outpatient.
# Dyspnea on exertion:
# Bilateral ___ edema:
# HFpEF (EF >=60% ___:
# Mild Heart Failure Exacerbation:
Patient presented with 2 weeks of lower extremity and scrotal
swelling with dyspnea. His swelling was in setting of high
intake of salty foods and alcohol earlier in the week. His last
TTE showed HFpEF with an LVEF of >60% in ___. A TTE was ordered
but not completed prior to admission. He was given 40mg IV Lasix
in the ED and responded appropriately, and he was given another
40mg IV Lasix on the floor. He was continued on his home
diltiazem and lisinopril. He should have a follow-up TTE as an
outpatient to re-evaluate his cardiac function. He was started
on furosemide 40mg PO daily prior to discharge.
CHRONIC ISSUES:
===============
#Atrial fibrillation:
The patient's warfarin was held in the setting of an upper GI
bleed. He was rate controlled with his home diltiazem. Per GI,
the patient is safe to restart anti-coagulation after discharge.
#Hypertension
His home diltiazem and lisinopril were continued.
#Diabetes
- His home metformin and glimepiride were held but resumed on
discharge.
#Hyperlipidemia
- His home atorvastatin 20 mg PO daily was continued.
#Obstructive Sleep Apnea
- CPAP was continued
#Stage I prostate ca
- has been following up with Dr. ___ at ___.
- Last follow up was in ___ with PSA Z85.46.
#Alcoholic use disorder
- Diazepam per ___ protocol was ordered but not required.
TRANSITIONAL ISSUES
===================
[ ] MRI Abdomen within 1 week of discharge from ___
[ ] Follow up with ___ General Surgery Dr. ___
[ ] Follow up with ___ Cardiology Dr. ___ heart failure
exacerbation
[ ] Follop up with PCP ___
[ ] please check hemoglobin in one week to follow up anemia
[ ] please check INR within 1 week and adjust warfarin
accordingly
[ ] please start omeprazole 20mg PO daily
[ ] please get an echo after discharge to evaluate cardiac
function
[ ] please titrate 40mg furosemide daily based on volume status
and renal function, discharge creatinine is 0.6
#CODE: Full
#CONTACT:
Wife: ___
___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem 360 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Warfarin 7.5 mg PO DAILY
5. MetFORMIN (Glucophage) ___ mg PO DAILY
6. glimepiride 2 mg oral DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
2. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Atorvastatin 20 mg PO QPM
5. Diltiazem 360 mg PO DAILY
6. glimepiride 2 mg oral DAILY
7. Lisinopril 10 mg PO DAILY
8. MetFORMIN (Glucophage) ___ mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Warfarin 7.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
#Gastric Mass
#Heart Failure with Preserved Ejection Fraction
Secondary Diagnosis
=================
#Atrial Fibrillation
#Acute on Chronic Blood Loss Anemia
#Hypertension
#Type II Diabetes
#Hyperlipidemia
#Obstructive Sleep Apnea
#Stage I prostate Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had dark stools
and swelling in your legs.
WHAT WAS DONE IN THE HOSPITAL?
- You had a procedure called EGD - or esophagogastroduodenoscopy
- which is a camera that we use to take pictures of your
esophagus, stomach and duodenum.
- The EGD showed that there is a mass inside the tissue of your
stomach.
- You were given a medication called furosemide, or Lasix, to
help remove extra fluid from your body.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- You should follow up with ___ Radiology for scheduling of
your outpatient MRI which you will need this week.
- You should follow up with Dr. ___ at ___
___ after your MRI to discuss the results and schedule your
surgery.
- You should follow up with your primary care provider ___.
___ week.
- You should follow up with your cardiology within the next two
weeks to discuss your leg swelling.
We wish you all the ___.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19884707-DS-21
| 19,884,707 | 22,223,949 |
DS
| 21 |
2119-03-05 00:00:00
|
2119-03-05 14:58:00
|
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: fever and rash
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
___ year old ___-speaking woman with no significant PMH who
presents with three days of fever and body aches and one day of
diffuse rash.
The fevers started three days ago and have worsened over the
past
day prior to he presentation. On the morning of presentation,
she
awoke with a diffuse rash, which was not present the night prior
and has not spread or evolved notably in the intervening day.
The
rash is all over, but is worst on her hands. It is not pruritic.
She is otherwise without localizing symptoms; her voice sounds a
bit hoarse to me, but she denies noticing any changes.
She presented initially to ___ where her LFTs were found to be
abnormal (AST 83, ALT 139, ALP 118, Tbili 0.7) and she was found
to have WBC 11.2 with 14% bands. Given the LFTsm the ED provider
there was worried for cholangitis. She was given Zosyn
empirically and sent to the ___ ED.
Vitals in the ___ ED were: 101.9°F, 100, 18, 99/63, 97%. LFTs
were improving and a CT abdomen/pelvis did not show any acute
hepatobiliary pathology. CXR showed no evident pneumonia. UA
showed no pyuria. LP in the ED was a bloody tap and the number
of
white blood cells is proportionate to what would be expected
from
bleeding; CSF protein was not elevated.
REVIEW OF SYSTEMS
GEN: +fevers/chills
CARDIAC: denies chest pain or palpitations
PULM: denies new dyspnea or cough
GI: mild nausea, denies change in bowel habits
GU: denies dysuria or change in appearance of urine. LMP was a
few weeks ago and she denies any foreign bodies in the vagina.
Full 14-system review of systems otherwise negative and
non-contributory.
Past Medical History:
H pylori with gastritis (treated in ___
Halitosis, s/p negative EGD
She was vaccinated to ___ immigration standards when she came to
the ___.
Social History:
___
Family History:
Patient unable to provide a detailed FH.
Physical Exam:
CONSTITUTIONAL: NAD
EYE: sclerae anicteric, EOMI
ENT: audition grossly intact, MMM, OP clear. She has a
chonically rotten tooth on the lower R, but it is not tender to
palpation and has no obvious abscess or erythema.
LYMPHATIC: No LAD
CARDIAC: RRR, no M/R/G, JVP not elevated, no edema
PULM: normal effort of breathing, LCAB
GI: soft, NT, ND, NABS
GU: no CVA tenderness, suprapubic region soft and nontender
MSK: no visible joint effusions or acute deformities.
DERM: macular rash significantly improved since coming in
NEURO: AAOx3. No facial droop, moving all extremities.
PSYCH: Full range of affect
Pertinent Results:
Admission Labs
___ 03:14PM BLOOD WBC-9.8 RBC-4.35 Hgb-12.9 Hct-37.8 MCV-87
MCH-29.7 MCHC-34.1 RDW-13.5 RDWSD-42.7 Plt ___
___ 03:14PM BLOOD Neuts-79.4* Lymphs-9.5* Monos-2.9*
Eos-7.6* Baso-0.2 Im ___ AbsNeut-7.74* AbsLymp-0.93*
AbsMono-0.28 AbsEos-0.74* AbsBaso-0.02
___ 07:05AM BLOOD ___
___ 03:14PM BLOOD Glucose-100 UreaN-5* Creat-0.6 Na-138
K-3.8 Cl-103 HCO3-19* AnGap-16
___ 03:14PM BLOOD ALT-108* AST-71* CK(CPK)-68 AlkPhos-96
TotBili-0.9
___ 07:05AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.8
CT Abdomen
EXAMINATION: CT abdomen and pelvis with intravenous contrast
INDICATION: ___ female with fever and elevated liver
enzymes.
Evaluate for cholangitis or liver abscess.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images
were acquired
through the abdomen and pelvis following intravenous contrast
administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
DOSE: Total DLP (Body) = 540 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
A 6 mm hypodensity in the lower pole of the right kidney (05:40)
and 4 mm
hypodensity in the interpolar left kidney are too small to
characterize.
There is no hydronephrosis or perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The
colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: There is an involuting left corpus luteum
cyst (5:62).
Right adnexa is unremarkable. The uterus is unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. No acute abnormality in the abdomen or pelvis. Specifically,
no hepatic
abscess or cholangitis. The gallbladder is unremarkable and
there is no
evidence of biliary dilatation.
2. Normal appendix. No evidence of bowel obstruction.
CXR
EXAMINATION: CHEST (BOTH OBLIQUES ONLY)
INDICATION: ___ year old woman with fever and rash// Shallow
oblique views to
assess whether a finding in the left upper lung field on 2v was
artifiactual
or not. Shallow oblique views to assess whether a finding in
the left
upper lung field on ___ was artifiactual or not.
IMPRESSION:
Compared to chest radiographs ___.
Oblique views show that the small region of sclerosis, proximal
left first rib should not be mistaken for a lung lesion.
Lungs clear. Heart size top-normal. No pleural abnormality or
evidence of central adenopathy.
Micro largely pending
Lyme IgG-PENDING; Lyme IgM-PENDING INPATIENT
___ SEROLOGY/BLOOD RUBEOLA ANTIBODY, IgG-PENDING
INPATIENT
___ Blood (EBV) ___ VIRUS VCA-IgG
AB-PENDING; ___ VIRUS EBNA IgG AB-PENDING; ___
VIRUS VCA-IgM AB-PENDING INPATIENT
___ Blood (CMV AB) CMV IgG ANTIBODY-PENDING; CMV
IgM ANTIBODY-PENDING INPATIENT
___ SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL INPATIENT
___ SEROLOGY/BLOOD MONOSPOT-FINAL INPATIENT
___ CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
Discharge Labs
___ 06:50AM BLOOD WBC-9.6 RBC-4.01 Hgb-11.9 Hct-35.1 MCV-88
MCH-29.7 MCHC-33.9 RDW-13.7 RDWSD-44.0 Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-99 UreaN-5* Creat-0.5 Na-139
K-3.8 Cl-101 HCO3-23 AnGap-15
___ 06:50AM BLOOD ALT-77* AST-38 AlkPhos-85 TotBili-0.5
___ 06:50AM BLOOD Calcium-8.6 Phos-4.9* Mg-1.9
___ 10:15AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 10:15AM BLOOD HCV Ab-NEG
___ 10:15AM BLOOD HIV1 VL-PND
___ 03:25PM BLOOD Lactate-1.2
___ 09:19AM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND
___ 09:19AM BLOOD RUBEOLA ANTIBODY, IGM-PND
Brief Hospital Course:
___ year old ___-speaking woman with no significant PMH who
presents with three days of fever and body aches and day of
diffuse rash likely from viral process.
#SEPSIS
#RASH
#MILD TRANSAMINITIS
Presented with fever, transaminitis, and rash. Initially was
tachycardic and hypotensive. In the Emergency room she underwent
an LP which was a traumatic tap but no concern for infection.
She also had a CT abdomen and pelvis which was unremarkable. She
was supported with IVF and with this improved. Seems most
consistent with viral process. ID was consulted and recommended
rule out for measles given CHA records did not document she was
vaccinated. Measles titers were sent, tick panel, EBV, HIV viral
load which are all still pending. Hepatitis serology were sent
and are negative (HAV, HBV, HCV). With symptomatic treatment
with IVF and Tylenol she improved and the rash was lightening
with no skin breakdown. Her LFTs were improving on discharge but
were not yet back to normal. She should have these rechecked in
1 week to ensure they have returned to normal. She will need
close follow up with her PCP.
[] F/u Measles IGm IGG
[] F/u Lyme serology
[] F/u Anaplasma serology
[] F/u EBV
>30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Viral Illness
Rash
Transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after you were having a fever and rashes at
home. You underwent a procedure called lumbar puncture to test
your CSF for infection, all the tests were negative. You were
found to have low blood pressure. We did many more tests .
Infectious disease doctors were ___ and ___ this was
likely due to a viral illness. You were treated with medication
to lower your fevers and intravenous fluids. You should have
your liver function tests rechecked in one week.
It was a pleasure caring for you,
Your ___ Team
Followup Instructions:
___
|
19884729-DS-21
| 19,884,729 | 26,888,271 |
DS
| 21 |
2158-08-24 00:00:00
|
2158-08-24 20:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ hx of HTN, HLD, CHF, and gastric sleeve presenting with
elevated troponin and BNP from outpatient pulmonology
appointment.
Patient reports intermittent shortness of breath over the last
month and was referred to a pulmonologist - Dr. ___ at
___. She had been evaluating him for OSA and SOB x 1
month and he was there today for f/u. Patient reports chest
pressure yesterday evening which is new which occurred at rest
and resolved in several minutes. Had one more episode earlier
today. Reports that the pressure lasts few minutes. Nonradiating
pressure and no diaphoresis. He tells me that this chest pain is
the same as the pain he had several years ago when he was
evaluated with cath and tte and found to have cardiomyopathy and
reduced EF, but no CAD on cath in ___. Went to the
pulmonologist today and had episode in the waiting room. A
troponin and BNP were checked - handwritten note in chart states
thses were BNP 1473, Trop 0.57 (unsure troponin type). Patient
was called to the emergency department as he had elevated
troponin and BNP. Patient currently denies any chest pressure.
Denies fever, chills, cough, lower extremity pain, history of
DVT/PE, recent surgery, recent travel.
Of note, the patient reports he has had progressive SOB over the
past month. He has had worsening ___ edema, reports 25lb wt gain
in the past month and also has developed worsening orthopnea and
DOE. He takes Lasix at home and reports it was recently
increased to 40mg daily, however he does not know what his other
medications are.
In the ED, initial vitals: Afebrile 98.4, BP 157/128, HR 89, RR
24, 97%RA. Exam reportedly unremarkable. Labs notable for
unremarkable CBC, Chem 7 with BUN/Cr ___ (close to recent
baseline), BNP 4033, Trop 0.07. EKG sinus with frequent PCVs and
no evidence of ischemia. Imaging notable for pulmonary edema.
Patient was given full dose ASA and started on a heparin gtt and
admitted for further w/u.
On arrival to the floor, pt reports reports ongoing SOB but
denies any chest pain and has not had any further chest pain
since the episode at his pulmonoligsts office.
REVIEW OF SYSTEMS:
No fevers, chills, night sweats. No changes in vision or
hearing, no changes in balance. No cough. No nausea or vomiting.
No diarrhea or constipation. No dysuria or hematuria. No
hematochezia, no melena. No numbness or weakness, no focal
deficits.
Past Medical History:
1) hypertension
2) cardiomyopathy with history of congestive heart failure
(stress echocardiogram ___ noted ejection fraction of
35% an echocardiogram on ___ demonstrated ejection
fraction of 40%)
3) obstructive sleep apnea diagnosed ___ on CPAP at 15
4) history of mild asthma not on inhalers
5) vitamin D deficiency
6) hepatic steatosis by ultrasound study
7) hyperlipidemia with elevated triglycerides
8) probable type II diabetes with hemoglobin A1c of 6.2% (had
been 7.0% ___
9) chronic renal insufficiency (creatinine 1.8)
10) hyperuricemia serum uric acid level of 10.5
11) chronic tinnitus
12) history of mild CVA with lacunar infarct ___
Social History:
___
Family History:
His family history is noted for both parents living father age
___ relatively healthy; mother living age ___ with hypertension,
diabetes, renal issues and coronary artery disease; has 6
brothers 2 of them have passed on one with an MI and 6 sisters
all alive and well relatively healthy except one sister with
breast CA.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals:98.4; 174/98; 71; 18; 99% on 3L NC
wt: 101.4kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
elevated to mandible at 45deg
Lungs: Faint crackles at bilateral base, otherwise CTA
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, 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 to knees bilatearlly
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly normal. Normal gait.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T98.5 BP 146/94 HR 62, 18 98% RA
wt: 97.4 kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple
Lungs: Faint crackles at bilateral base, otherwise CTA
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis,
trace pitting edema
Skin: Without rashes or lesions
Pertinent Results:
ADMISSION LABS:
===============
___ 06:35PM D-DIMER-483
___ 06:30PM GLUCOSE-95 UREA N-26* CREAT-1.3* SODIUM-142
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16
___ 06:30PM estGFR-Using this
___ 06:30PM CK(CPK)-105
___ 06:30PM cTropnT-0.07*
___ 06:30PM CK-MB-2 proBNP-4033*
___ 06:30PM CALCIUM-9.4 PHOSPHATE-3.5 MAGNESIUM-1.9
___ 06:30PM WBC-7.1 RBC-5.31 HGB-14.2 HCT-43.4 MCV-82
MCH-26.7 MCHC-32.7 RDW-13.7 RDWSD-40.5
___ 06:30PM NEUTS-73.1* LYMPHS-16.9* MONOS-7.0 EOS-2.2
BASOS-0.4 IM ___ AbsNeut-5.20 AbsLymp-1.20 AbsMono-0.50
AbsEos-0.16 AbsBaso-0.03
___ 06:30PM PLT COUNT-188
___ 06:30PM ___ PTT-34.4 ___
DISCHARGE LABS:
===============
___ 07:54AM BLOOD WBC-6.5 RBC-5.47 Hgb-14.4 Hct-44.9 MCV-82
MCH-26.3 MCHC-32.1 RDW-13.8 RDWSD-41.0 Plt ___
___ 07:54AM BLOOD Glucose-102* UreaN-28* Creat-1.2 Na-142
K-3.9 Cl-99 HCO3-27 AnGap-20
___ 07:54AM BLOOD ALT-23 AST-18 LD(LDH)-184 AlkPhos-98
TotBili-0.6
___ 07:21AM BLOOD CK-MB-2 cTropnT-0.09*
___ 03:00PM BLOOD CK-MB-2 cTropnT-0.08*
___ 04:40AM BLOOD cTropnT-0.07*
___ 07:54AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.1
___ 08:47AM BLOOD %HbA1c-5.7 eAG-117
___ 07:21AM BLOOD Triglyc-78 HDL-38 CHOL/HD-3.1 LDLcalc-62
IMAGING:
========
___ CXR:
AP portable upright view of the chest. Overlying EKG leads are
present. The heart is markedly enlarged. Hila are congested
and there is mild pulmonary edema. No large effusions. No
pneumothorax. No convincing evidence for pneumonia. Bony
structures are intact. Mediastinal contour is normal. No free
air is seen below the right hemidiaphragm.
IMPRESSION:
Cardiomegaly, congestion and mild edema.
___ ECHO:
The left atrial volume index is moderately increased. The
estimated right atrial pressure is at least 15 mmHg. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is severely dilated. There is severe global
left ventricular hypokinesis (LVEF = ___ % visually and 23%
biplane). Systolic function of apical segments is relatively
preserved. No masses or thrombi are seen in the left ventricle.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Doppler parameters are most
consistent with Grade III/IV (severe) left ventricular diastolic
dysfunction. The right ventricular cavity is mildly dilated with
moderate 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
leaflets are structurally normal. There is no mitral valve
prolapse. An eccentric, posterolaterally directed jet of Mild to
moderate (___) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. There is
moderate pulmonary artery systolic hypertension. The
end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is no
pericardial effusion.
IMPRESSION: ___ dilated left ventricle with severe global
hypokinesis. Depressed right ventricular systolic function.
Severe diastolic dysfunction. Increased PCWP. At least moderate
pulmonary hypertension with increased RA pressure.
Compared with the prior study (images reviewed) of ___ the
left ventricle is more dilated, he right ventricle is more
hypokinetic, there is more mitral regurgitation, the pulmonary
pressures are higher.
Brief Hospital Course:
___ hx of HTN, HLD, non-ischemic HFrEF, and gastric sleeve
presented with one month of progressive DOE and leg swelling.
#Acute on chronic HFrEF:
Patient has known history of sCHF and cardiomyopathy with EF of
30% who presented with lower extremity edema and DOE. Exam
significant for JVP elevation, ___ pitting edema to knees and
nearly 25 lb weight gain. Patient's family reported he is
inconsistent with taking home medications, which could have
contributed to his acute presentation. BNP ~4000, trp .09,
normal CKMB. Patient was diuresed with IV Lasix with good effect
and maintained on heparin gtt X 48hrs. TEE showed ___
dilated left ventricle with severe global hypokinesis and severe
diastolic dysfunction (EF ___. Patient was discharged on
Lasix 40 mg BID, Spironolactone 12.5 daily, carvedilol 6.25 mg
BID, valsartan 160 mg BID.
Of note, heparin gtt was initially started because patient did
report an episode of substernal chest pressure radiating to
shoulder (at rest) which resolved after 30 min without
intervention (prior to coming to the hospital). However, patient
remained chest pain free during hospitalization with stable EKG,
downtrending troponin, and CKMB remained flat. It was felt that
trp was elevated in the setting of demand ischemia in addition
to being elevated in the setting of CKD. Heparin gtt was
discontinued and patient remained chest pain free.
#HTN
Patient was hypertensive (SBP 160-170) despite initiating his
home regimen of 160 mg of valsartan and continuing carvedilol
3.125 mg BID. Valsartan was increased to 160 mg BID and was
increased to carvdilol 3.125mg BID to 6.25 BID.
==============
CHRONIC ISSUES:
===============
#HLD - increase atorva 40 -> 80
#HTN - continue meds as above
#BPH - cont home tamsulosin, finasteride
#OSA - cont CPAP. Echo indicates pHTN. Would consider ongoing
eval of OSA as outpt.
TRANSITIONAL ISSUES:
====================
#NEW MEDICATIONS: Atorvastatin 80 mg, ASA 81 mg
#CHANGED MEDICATIONS: Valsartan was changed from 160 mg daily to
BID, and carvedilol was increased from 3.125mg BID to 6.25 BID.
Furosemide 40 mg QD was changed to BID.
[] Utility of stress test as outpatient
[] BP follow-up as outpatient as patient was SBP 140-160s
inpatient and medications were increased.
DISCHARGE WEIGHT: 97.4 kg
DISCHARGE Cr: 1.2
# Full Code
# CONTACT: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. Spironolactone 12.5 mg PO DAILY
3. Carvedilol 3.125 mg PO BID
4. Valsartan 160 mg PO DAILY
5. Tamsulosin 0.4 mg PO QHS
6. Finasteride 5 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Furosemide 40 mg PO BID
RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Valsartan 160 mg PO BID
RX *valsartan 160 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Finasteride 5 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Spironolactone 12.5 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Acute on chronic heart failure with reduced ejection fraction
SECONDARY DIAGNOSIS:
Hypertension
Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were in the hospital because you were having trouble
breathing and swelling in your legs. This is caused from your
heart being unable to pump properly.
What was done while I was in the hospital?
- You were given medicine to remove fluid from your body.
- You had imaging of your heart that showed it is not pumping
properly
What should I do now that I am going home?
- Please take your water pill (Lasix aka furosemide) exactly as
prescribed. We changed your Lasix from 40 mg daily to 40 mg
twice a day.
- Please take your medicines as prescribed. See paperwork for
changes to your medicines.
- Please weigh yourself daily. You weighed 214.7 lbs on
discharge. If your weight goes up by more than 3 lbs, please
call your doctor.
Please follow-up with your PCP and cardiologist. Your
appointments have been scheduled for you.
Thank you for allowing us to participate in your care.
- Your ___ Team
Followup Instructions:
___
|
19884788-DS-14
| 19,884,788 | 20,657,679 |
DS
| 14 |
2183-04-16 00:00:00
|
2183-04-16 11:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
lower back pain
Major Surgical or Invasive Procedure:
1. Posterior open treatment, fracture-dislocation, L2.
2. Posterior spinal instrumentation, T12-L4, segmental.
3. Posterior arthrodesis, T12-L4.
4. Iliac crest bone graft harvest, left hip.
5. Application of allograft.
History of Present Illness:
___ who was transferred here from ___ for injuries
sustained from falling off of a horse. Patient reports that she
fell from a horse earlier today, landing onto her backside. She
denies hitting her head or LOC. She noted immediate pain in her
lower back, and inability to ambulate d/t pain. She denies
having any numbness tingling in her legs. No loss of bowel or
bladder function. No saddle anesthesias. A CT scan was obtained
at ___ showing a L2 burst fracture. She was
subsequently transferred to ___ for further managment.
Past Medical History:
Bipolar disorder, hypothyroidism
Social History:
Denies tobacco, occasional ETOH. Lives with husband
Physical ___:
PHYSICAL EXAMINATION per Ortho note dated ___-
In general, the patient is in NAD, A&Ox3
Vitals:VSS
Right upper extremity:
Skin intact
Soft, non-tender arm and forearm
Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Left upper extremity:
Skin intact
Soft, non-tender arm and forearm
Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Right lower extremity:
Skin intact
Soft, non-tender thigh and leg
Full, painless AROM/PROM of hip, knee, and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Left lower extremity:
Skin intact
Soft, non-tender thigh and leg
Full, painless AROM/PROM of hip, knee, and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Spine exam:
Motor-
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory:
Sensory UE
C5 (Ax) R nl, L nl
C6 (MC) R nl, L nl
C7 (Mid finger) R nl, L nl
C8 (MACN) R nl, L nl
T1 (MBCN) R nl, L nl
Sensory ___
L2 (Groin): R nl, L nl
L3 (Leg) R nl, L nl
L4 (Knee) R nl, L nl
L5 (Grt Toe): R nl, L nl
S1 (Sm toe): R nl, L nl
S2 (Post Thigh): R nl, L nl
Perianal sensation: intact
Rectal tone: intact
Physical Exam ___-
General:NAD, Alert, Oriented times 3
Heart:RRR
Lungs:CTAB
ABd:soft,nt,nd
Extremities:wwp,2+rad,2+dp pulses,good capillary refill
___ throughout to BUE Del/EF/EE/WF/WE/Grip/IO and BLE
___
Normal Sensory throughout
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
treated medically in a Brace for several days but was limited by
severe back pain. The Orthopaedic team felt it was necessary for
her to undergo surgery for her L2 burst fracture. The patient
agreed and was taken to the Operating Room for the above
procedure. Refer to the dictated operative note for further
details. The surgery was without complication and the patient
was transferred to the PACU in a stable condition.
TEDs/pnemoboots were used for postoperative DVT prophylaxis.
Intravenous antibiotics were continued for 24hrs postop per
standard protocol.Initial postop pain was controlled with a PCA.
Diet was advanced as tolerated. The patient was transitioned to
oral pain medication when tolerating PO diet. Foley has remained
in place during hospitalization. It is recommended for her to
have a void trial once she is more ambulatory. Physical therapy
was consulted for mobilization OOB to ambulate. Hospital course
was otherwise unremarkable. On the day of discharge the patient
was afebrile with stable vital signs, comfortable on oral pain
control and tolerating a regular diet.
Medications on Admission:
Aripiprazole
Benztropine
Clonazepam
Lamotrigine
Levothyroxine
Paroxetine
Quetiapine Fumarate
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aripiprazole 5 mg PO BID home dose
3. Benztropine Mesylate 1 mg PO DAILY home dose
4. Bisacodyl 10 mg PO/PR DAILY Constipation
5. ClonazePAM 0.5 mg PO BID prn home dose
6. Diazepam ___ mg PO Q6H:PRN spasm
7. Docusate Sodium 100 mg PO BID
8. Heparin 5000 UNIT SC TID dvt prophylaxis
9. LaMOTrigine 25 mg PO DAILY home dose
10. Levothyroxine Sodium 125 mcg PO DAILY home dose
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
12. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*75 Tablet Refills:*0
13. Paroxetine 20 mg PO DAILY home dose
14. QUEtiapine Fumarate 50 mg PO QHS home dose
15. Senna 17.2 mg PO BID constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L2 burst fracture.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You have undergone the following operation: Thoraco-Lumbar
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 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.
Brace: You may 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 while lying in bed.
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___ 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.
___ 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:
-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.
-___ 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.
Treatments Frequency:
Pressure Wounds from TLSO Brace:
-Location: R side above hip
-Location: R lower back adjacent to bottom part of surgical
wound
-Location: R lower back adjacent to bottom part of surgical
wound
Factors affecting wound healing: pressure from TLSO brace
Goals of wound care: Heal wounds; prevent further breakdown;
prevent infection
Recommendations:
Would suggest that patient wear a large T-shirt underneath
Brace to help protect skin.
Topical Therapy:
Commercial wound cleanser or normal saline to cleanse wounds.
Pat the tissue dry with dry gauze.
Cover all wounds with Mepilex Border dressings
Change every 3 days
Support nutrition and hydration.
Surgical Wound- Remove the dressing in 2 days. If the incision
is draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
Followup Instructions:
___
|
19884866-DS-14
| 19,884,866 | 25,495,735 |
DS
| 14 |
2159-02-01 00:00:00
|
2159-02-01 20:01:00
|
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:
Pacemaker placement ___
EGD ___
History of Present Illness:
Mr. ___ is an ___ year old man w/ history of HTN, HLD, PAD,
dilated distal aorta, h/o syncope who presents for chest pain.
Mr. ___ reports that over the last two months he has had
episodes of seconds long sharp left sided chest pain which
radiates to his back and neck. These have increased in
frequency
over the last two weeks and then yesterday this was associated
with dizziness and diarrhea x3. The pain is not triggered when
he walks ___ minutes daily. He has not taken sildenafil or
Cialis in months, has never taken SL nitro. He denies nausea or
vomiting. He has had no reoccurrence of CP in ED or on floor.
Initially patient was placed in observation in ED for a stress
test. However, with the third EKG showing new atrial
fibrillation, decision was made for admission.
In the ED, initial vitals were
HR 40 BP 144/74 RR 14 O2 Sat 94
CXR was unremarkable.
CTA showed no evidence of aortic abnormality or PE. It did note
an esophageal hiatal hernia.
Labs revealed:
Normal CBC with exception of low platelets 130
Chem 7 with low bicarb 20, otherwise with normal Cr 1.1
Trop < 0.01
Of note, on review of his prior records, it appears that he
presented to ___ clinic in ___ with syncopal
episodes; he had three in ___. These occurred during 1) after
urinating and standing up 2) feeling dizzy when walking 3)
standing up from seated position. His cardiologist felt that his
syncopal episodes were vasovagal and an event monitor did no
reveal anything. He was not noted to have any chronotropic
incompetence given a normal peak exercise HR of 123. It was
recommended that he get a LINQ implant if his symptoms should
persist, but it appears that he did not have any further
episodes.
On the floor he confirms history as above.
REVIEW OF SYSTEMS: Positive as above.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations.
On further review of systems, denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding
at the time of surgery, myalgias, joint pains, cough,
hemoptysis,
black stools or red stools. Denies exertional buttock or calf
pain. Denies recent fevers, chills or rigors. All of the other
review of systems were negative.
Past Medical History:
HTN
HLD
PAD
dilated distal aorta
h/o syncope
Social History:
___
Family History:
Negative for premature CAD, arrhythmias, heart failure,
cardiomyopathy, sudden or unexpected death. Father had
pacemaker.
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
VS: ___ 2312 Temp: 98.2 PO BP: 157/88 HR: 63 RR: 16 O2
sat: 100% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
Telemetry: since arrival to floor in sinus rhythm with
occasional PACs, rare dropped beat no atrial fibrillation or
flutter
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: regular, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=============================
VS: afebrile, BP 130/65, HR 62
GENERAL: NAD, sitting upin bed
HEENT: AT/NC, anicteric sclera, MMM, no pill visualized in
oropharynx
NECK: supple, no LAD
CV: tachycardic, regular, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, no focal
neuro deficits
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
===================
___ 02:40PM WBC-8.0 RBC-4.60 HGB-14.4 HCT-42.6 MCV-93
MCH-31.3 MCHC-33.8 RDW-14.6 RDWSD-48.9*
___ 02:40PM NEUTS-70.6 ___ MONOS-9.8 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-5.64 AbsLymp-1.53 AbsMono-0.78
AbsEos-0.00* AbsBaso-0.01
___ 02:40PM PLT COUNT-130*
___ 02:40PM GLUCOSE-99 UREA N-16 CREAT-1.1 SODIUM-139
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-20* ANION GAP-14
___ 02:40PM cTropnT-<0.01
___ 02:40PM TSH-1.0
IMAGING/STUDIES
===================
___ CTA chest
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Patulous esophagus with moderate hiatal hernia.
3. Moderate to severe atherosclerotic disease.
4. Diffuse airway wall thickening suggests chronic bronchitis.
___ CXR
No acute cardiopulmonary abnormality.
___ TTE
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/colorDoppler. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
suboptimal image quality to assess regional left ventricular
function. The visually estimated left ventricular ejection
fraction is >=55%. Normal right ventricular cavity size with
normal free wall motion. There is a normal ascending aorta
diameter for gender. The aortic arch diameter is normal. The
aortic valve leaflets (?#) appear structurally normal.There is
no aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets appear structurally normal. There is
trivial mitral regurgitation. The tricuspid valve leaflets
appear structurally normal. There is trivial tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.IMPRESSION:
Suboptimal image quality. Normal biventricular cavity sizes,
systolic function. Normal estimated pulmonary artery systolic
pressure.
___
EGD:
Distal esophageal Schatzki ring with one spot of superficial
ulceration and hematoma, likely due to pill esophagitis. One
pill
was seen in stomach.
DISCHARGE LABS
===================
___ 08:16AM BLOOD WBC-6.7 RBC-4.47* Hgb-13.6* Hct-41.4
MCV-93 MCH-30.4 MCHC-32.9 RDW-14.4 RDWSD-48.7* Plt ___
___ 08:16AM BLOOD Plt ___
___ 08:16AM BLOOD Glucose-120* UreaN-11 Creat-1.2 Na-140
K-4.2 Cl-102 HCO3-25 AnGap-13
___ 08:16AM BLOOD Calcium-9.6 Phos-2.9 Mg-1.8
Brief Hospital Course:
Mr. ___ is an ___ male with PMH HTN, PAD,
dilated distal aorta, history of syncope who presented with
atypical chest pain. Patient was found to have paroxysmal atrial
fibrillation with sinus pauses concerning for sick sinus
syndrome.
ACUTE ISSUES
====================================
# Sick sinus syndrome
Initially the patient was mostly in sinus bradycardia. He would
periodically go into atrial fibrillation with pauses before
converting back to sinus rhythm. He was mostly asymptomatic
while in atrial fibrillation, although did develop dizziness
with the pauses when they were more frequent. He underwent
pacemaker placement on ___, and then was more consistently in
atrial fibrillation with non-sustained episodes of HR 120s. At
that time he was started on metoprolol with improvement in HR.
He was also started on apixaban 5 mg PO BID. During this
hospitlization, the patient had a TTE ___ with EF >55%. He
should follow up with device clinic in 1 week, and with Dr. ___
in ___ weeks
# Atypical chest pain: atypical, non-exertional (able to walk
~25 minutes on treadmill at home), unclear if perhaps represents
the onset of new paroxysmal atrial fibrillation, CTA reassuring
against PE/aortic dissection. ACS work-up was negative and he
had no further episodes of chest pain during admission.
# Pill esophagitis
# Schatzki ring (new this hospitalization)
On ___, patient had persistent epigastric pain after swallowing
KCl pill. There was concern the pill was lodged in his
esophagus. GI was consulted and patient had urgent EGD which
showed the pill had passed into his stomach. EGD also showed
esophageal erosion/hematoma as well as Schatzki ring. GI
recommended patient continue PPI for 8 weeks with repeat EGD in
8 weeks for possible dilation of Schatzki ring.
CHRONIC ISSUES
==================================
# HTN: Home losartan 100mg was continued this hospitalization.
#HLD: Home statin was continued during this hospitalization. The
patient was started on aspirin 81 mg daily
# PAD: Home cilostazol was continued
TRANSITIONAL ISSUES
======================================
[] Stress test was deferred this admission as patient did not
have any further episodes of chest pain. He also reported daily
exercise on treadmill walking up to 25 minutes daily. If patient
continues to have episodes of atypical chest pain, would
consider outpatient stress test.
[] Patient has follow-up with device clinic on ___.
[] Patient has follow-up with Dr. ___ on ___.
[] Patient should follow-up with GI in 8 weeks for repeat EGD to
evaluate for interval changes in esophagitis and possible
Schatzki ring dilation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
3. Docusate Sodium 100 mg PO BID
4. Atorvastatin 40 mg PO QPM
5. sildenafil 50 mg oral DAILY:PRN
6. Cilostazol 100 mg PO BID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Omeprazole 20 mg PO DAILY
9. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
3. Lidocaine Viscous 2% 15 mL PO TID:PRN for pain post EGD
RX *lidocaine HCl [Lidocaine Viscous] 2 % 15 ml three times a
day Refills:*0
4. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
5. Atorvastatin 40 mg PO QPM
6. Cilostazol 100 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
9. Hydrochlorothiazide 25 mg PO DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Losartan Potassium 100 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. sildenafil 50 mg oral DAILY:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Sick Sinus Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
Why was I here?
-You were hospitalized because of chest pain. You were found to
have an atypical heart rhythm (atrial fibrillation with pauses).
What happened to me while I was hospitalized?
- You had a pacemaker placed to prevent your heart pauses. You
were also started on new medication called metoprolol to prevent
your heart from beating too quickly.
- You had an endoscopic procedure (EGD) where a small camera
looked down your throat to see if a pill was lodged in your
throat. The EGD showed that the pill was in your stomach. It
also showed an area of your esophagus that was irritated. You
should have another EGD in 8 weeks to see if your throat has
healed.
What do I need to do when I go home?
- You should take your medications as prescribed and go to your
follow-up appointments.
We wish you the best!
Sincerely,
Your team at ___
Followup Instructions:
___
|
19885694-DS-21
| 19,885,694 | 26,958,770 |
DS
| 21 |
2198-02-26 00:00:00
|
2198-03-21 22:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
___ 05:20PM WBC-8.3 RBC-4.02* HGB-12.5* HCT-38.2* MCV-95
MCH-31.1 MCHC-32.7 RDW-14.4 RDWSD-50.0*
___ 05:20PM NEUTS-75.2* LYMPHS-13.2* MONOS-10.1 EOS-0.4*
BASOS-0.7 IM ___ AbsNeut-6.25* AbsLymp-1.10* AbsMono-0.84*
AbsEos-0.03* AbsBaso-0.06
___ 05:20PM PLT COUNT-150
___ 05:20PM GLUCOSE-108* UREA N-35* CREAT-1.6* SODIUM-142
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-26 ANION GAP-15
___ 05:20PM ALT(SGPT)-7 AST(SGOT)-29 CK(CPK)-660* ALK
PHOS-61 TOT BILI-0.8
___ 05:20PM CALCIUM-9.5 PHOSPHATE-3.6 MAGNESIUM-2.0
___ 05:20PM CK-MB-6 cTropnT-<0.01
___ 05:20PM TSH-2.6
___ 05:45PM LACTATE-2.0 CREAT-1.5*
___ 03:00PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 03:00PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG*
___ 03:00PM URINE RBC-167* WBC-47* BACTERIA-FEW*
YEAST-NONE EPI-<1 TRANS EPI-<1
___ 03:00PM URINE HYALINE-1*
DISCHARGE LABS:
___ 05:47AM BLOOD WBC-5.0 RBC-3.69* Hgb-11.4* Hct-35.2*
MCV-95 MCH-30.9 MCHC-32.4 RDW-13.9 RDWSD-49.0* Plt ___
___ 05:47AM BLOOD Glucose-97 UreaN-28* Creat-1.2 Na-140
K-4.4 Cl-104 HCO3-24 AnGap-12
MICRO:
Urine Culture
___ 3:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: STAPHYLOCOCCUS, COAGULASE
NEGATIVE. 10,000-100,000 CFU/mL.
IMAGING:
GU Ultrasound
IMPRESSION:
No focal renal or bladder mass identified. Small amount of
echogenic mobile material within the bladder could represent
blood or debris. No underlying cause for hematuria identified.
RLE Doppler US
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
R Knee XR
IMPRESSION:
No acute fracture. Severe degenerative changes of the lateral
femorotibial compartment.
Brief Hospital Course:
SUMMARY:
___ hx dementia, BPH, hypothyroid who presents with fever, foul
smelling urine, and altered mental status, found to have UA with
increased WBCs, overall presentation consistent with sepsis and
toxic metabolic encephalopathy ___omplicated by hematuria.
___ HOSPITAL COURSE:
# Sepsis
# Fever
# UTI
Presented with fever (Tmax 103.6) and hypotension (baseline SBPs
120s), with UTI as likely source. Possible pneumonia on chest
x-ray but has not had significant cough. Ucx with coag negative
staph which is not a typical urinary pathogen though with his
strongly suggestive clinical history and rapid improvement on
antibiotics, he was recommended to continue a 7d course of
Bactrim (day 1 = ___.
# Hematuria
Blood tinged urine and frank blood at urethral meatus seen on
___. Suspect trauma ___ straight cath in the ED, vs. ___ UTI.
Symptoms improved within ___. H/H stable. Would benefit from
outpatient Urology f/u for cystoscopy and CT urogram.
# Toxic metabolic encephalopathy
# Dementia
Patient is normally alert and interactive. He was lethargic at
home prior to admission. Most likely cause is infectious, with
UTI as leading diagnosis. No focal deficits to suggest stroke.
He returned to baseline with treatment as above.
# R knee edema, pain
R knee swollen. No erythema or increased warmth. Full ROM
though crepitus heard. Suspect patient may have had a fall
prior to admission and now has post-traumatic effusion. US
negative for DVT and low suspicion for infection. Family
reports long
standing history of arthritis and chronic knee pain. Treated
with Tylenol PRN
# ___ (resolved)
Cr 1.6 from baseline 1.1-1.3. Likely prerenal in setting of
sepsis. Improved s/p IVF and now back to baseline
# C3 lucency - possible underlying lesion, though could be from
osteopenia
- MRI when able
CHRONIC/STABLE PROBLEMS:
# Hypothyroidism
- continue home levothyroxine
# GERD
- continue home omeprazole
# BPH
- continue home finasteride and tamsulosin
TRANSITIONAL ISSUES:
[] Follow-up with Urology for further ___
[] MRI C spine if within goals of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Memantine 5 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Tamsulosin 0.4 mg PO QHS
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Hydrochlorothiazide 50 mg PO DAILY
9. Ranitidine 150 mg PO DAILY
Discharge Medications:
1. Ramelteon 8 mg PO QPM:PRN insomnia
RX *ramelteon 8 mg 1 tablet(s) by mouth qHS PRN Disp #*30 Tablet
Refills:*0
2. 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 #*7 Tablet Refills:*0
3. Finasteride 5 mg PO DAILY
4. Hydrochlorothiazide 50 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Memantine 5 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Ranitidine 150 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Urinary tract infection
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You came to the hospital with shaking chills, fever and foul
smelling urine. You were diagnosed with a urinary tract
infection. You improved with antibiotic treatment. Please
continue taking the antibiotic for a total 7 day course.
While you were in the hospital you were noticed to have some
blood in your urine. This could have been a complication of the
infection, or a complication from a straight catheterization
procedure done in the Emergency Room. However, we would like
you to follow-up with a Urologist for further evaluation, and
especially if this persists.
We wish you the best in your recovery!
-- Your ___ team
Followup Instructions:
___
|
19885726-DS-21
| 19,885,726 | 29,902,732 |
DS
| 21 |
2118-12-16 00:00:00
|
2118-12-19 13:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / adhesive tape
Attending: ___.
Chief Complaint:
Chronic abdominal pain
Major Surgical or Invasive Procedure:
___: Ultrasound guided drainage of a 9.4 cm left hepatic
cyst
History of Present Illness:
___ year old female with history of afib on Coumadin, SSS s/p
PPM, COPD/emphysema/interstitial pulmonary fibrosis on O2 at
night, and HTN presents as transfer from ___ with LUQ and
epigastric abdominal pain in the setting of known hepatic cysts.
The patient has had LUQ abdominal pain for about 5 weeks now
which has gotten worse over the past couple of days. She has a
difficult time explaining her pain and when it began. She has
been constipated recently and straining to have a BM. She felt
that left sided abdominal pain worsened when she was straining
to have a BM. She denies any vomiting, has +flatus, and last BM
yesterday. She does have chronic nausea and was scheduled to
have HIDA as an outpatient. She was also scheduled for rib films
due to ongoing RUQ/flank pain. No recent trauma.
She has known liver cysts and had one drained years ago. She
does not recall the situation surrounding that cyst and whether
or not she had any symptoms.
In the ED, initial vitals were: 98.7 84 181/76 18 98% RA
PE: bibasilar crackles, tender to palpation of the epigastrium
and LUQ. otherwise normal except for chronic ___ venous stasis
skin changes and dry MM.
Hepatology was consulted and recommended:
-have images uploaded and formally read by our radiologist to
better characterize cysts and other potential etiologies for
abdominal pain.
-DO NOT ASPIRATE these hepatic cysts yet. Her case will need to
be formally reviewed by hepatology, radiology, and liver surgery
for diagnosis and intervention.
-it is unlikely that she would be an appropriate surgical
candidate given her comorbidities.
-obtain outside medical records
-can admit to medicine, hepatology consult if needed.
Labs at OS___ were normal (Cr 1.0 and GFR 52, INR 2.6). She
destatted and was placed on 2 NC. Labs were significant for trop
<0.01. She received ___nd a ___ to he upper
ebdeoment.
At OSH, CT scan showed:
1. multiple hypodense liver lesions ranging from a few mm to
the largest cyst 10x9x7 cm in the lateral segment of the left
lobe previously measured at 10x8x6. It exerts mass effect in
conjunction with an adjacent splenic cyst upon the stomach,
somewhat increased from prior.
2. CBD distention to 8mm w/o etiology similar to prior
3. main pancreatic duct mildly prominent at 3-4mm in diameter
with elongated tubular cysts in the head and uncitate process of
the pancreas measuring up to 16mm in diameter, unchanged from
prior. Possibly IPMN. 4mm cystic lesion in posterior tail of
pancreas.
4. subtle induration of fat LUQ anterior to spleen, stomach and
Left upper lobe of liver. Trace fluid is seen adjacent to the
anterior periohery of LUL of liver not presents on earlier
study, no surrounding inflammatory changes.
5.normal spleen and bowel with diverticulosis no
diverticulitis.
6.hiatal hernia
On the floor, patient is sleeping comfortably. When awake she
complains of abdominal pain and slight nausea. Had normal BM
yesterday.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. No recent change in bowel or bladder
habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
Chronic, multi-oragan cystic process of liver, spleen,
pancreas, kidney
Atrial fibrillation on Coumadin
Emphysemia
Hypertension
Sinoatrial node dysfunction
Cardiomyopathy
Macular degeneration
Interstitial lung disease/pulmonary fibrosis of the lung bases
Hearing loss
Social History:
___
Family History:
noncontributory
Physical Exam:
============================
ADMISSION PHYSICAL
============================
Vital Signs: 97.9 194/96 R Lying, repeat 188/76 97 18 94 2L
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
============================
DISCHARGE PHYSICAL
============================
Vital Signs: 97.4 149/77 75 95%RA
General: Alert, oriented, no acute distress, wearing glasses
HEENT: Sclerae anicteric, hearing aids in place
Neck: JVP not elevated
CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Velcro-like crackles at the bases bilaterally
Abdomen: +BS, soft, discomfort in LUQ, epigastric area, no
rebound or guarding. small bandage in place at drainage site
which is c/d/i with no surrounding inflammation of the skin
Ext: Warm, discolored with stasis changes in lower ext, no edema
Skin: extensive plaques with thick scale on scalp.
Pertinent Results:
============================
ADMISSION LABS
============================
___ 11:00PM URINE RBC-3* WBC-<1 Bacteri-FEW Yeast-NONE
Epi-<1
___ 11:00PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 11:00PM URINE Color-Straw Appear-Clear Sp ___
___ 07:12AM BLOOD WBC-10.3* RBC-4.49 Hgb-13.1 Hct-41.2
MCV-92 MCH-29.2 MCHC-31.8* RDW-12.8 RDWSD-43.0 Plt ___
___ 07:12AM BLOOD ___ PTT-68.3* ___
___ 07:12AM BLOOD Glucose-75 UreaN-19 Creat-0.9 Na-138
K-4.5 Cl-98 HCO3-25 AnGap-20
___ 07:12AM BLOOD ALT-16 AST-25 LD(LDH)-222 AlkPhos-110*
TotBili-0.6
___ 07:12AM BLOOD Albumin-3.2* Calcium-8.6 Phos-4.4 Mg-2.0
============================
DISCHARGE LABS
============================
___ 06:25AM BLOOD ___
============================
INTERVAL LABS
============================
___ 07:15AM BLOOD Digoxin-1.5
============================
PROCEDURES
============================
___ Ultrasound guided aspiration of hepatic cyst
Corresponding to the large left hepatic cyst seen on prior CT,
there is a 9.4 cm anechoic structure within the left hepatic
lobe with internal nonvascular septations. Post aspiration
imaging demonstrates collapse of the cavity.
IMPRESSION:
Successful ultrasound-guided aspiration of a 9.4 cm left hepatic
cyst with
collapse of the cavity on post aspiration imaging. 350 cc of
dark non
purulent fluid was aspirated with a sample sent for microbiology
and cytology evaluation.
============================
CYTOLOGY
============================
Hepatic cyst fluid:
NEGATIVE FOR MALIGNANT CELLS.
-Blood and macrophages consistent with cyst contents.
-No cyst lining is present.
============================
MICRO
============================
__________________________________________________________
___ 3:26 pm FLUID,OTHER Source: Hepatic Cyst.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 7:12 am BLOOD CULTURE
Blood Culture, Routine (Pending): no growth at discharge
__________________________________________________________
___ 11:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
***TRANSITIONAL ISSUES***
#Patient has a chronic, polycystic process affecting her liver,
spleen, pancreas, and spleen of unclear etiology. ___ need
further workup and drainage procedures depending on her pain
level, goals of care.
#Please assist for follow up with Dr. ___, her GI
doctor in ___. Patient's nephew aware and will reach out
for a follow up appointment.
#CT A/P showing extensive bilateral fibrosis with honeycombing
of the lung bases. Diagnosis may need clarification.
#Patient noted to desat to 88% with ambulation, quickly
recovered with rest, may need to wear oxygen more than just at
night
#Patient is troubled by her psoriasis, consider starting
treatment
#Warfarin follow by Dr. ___ ___, currently 2mg
daily
#Digoxin level 1.5, monitor closely as outpatient may need dose
reduction
#Discharge weight: 44.32kg (euvolemic exam)
#CODE STATUS: DNR/DNI (confirmed ___ with patient)
#CONTACT: ___, nephew ___, ___
___ year old female with history of a chronic, polycystic process
affecting her liver, spleen, pancreas, and spleen of unclear
etiology, afib/SSS s/p PPM on warfarin, fibrosis/honeycombing of
the lung bases on O2 at night who presents as transfer from
___ with chronic, worsening LUQ and epigastric abdominal
pain. Abdominal imaging showed mass effect from these cysts, and
our team believed this explained her chronic abdominal pain.
On ___ she had an uncomplicated ultrasound-guided
aspiration of a 9.4 cm left hepatic cyst with collapse of the
cavity on post aspiration imaging. 350 cc of dark non purulent
fluid. Cytologic evaluation was negative for malignant cells
and no microorganisms were seen on gram stain or culture.
After the procedure her pain had improved, though not
completely. Our team believed this was most likely due to the
multiple cysts that were not drained. We spoke extensively with
the patient regarding the utility of further aspiration
procedures. We noted that is very difficult to determine which
cysts are generating her pain and that the cysts can
re-accumulate fluid. Also explained the risk of infection and
bleeding with each additional procedure. Given that her pain
was "tolerable", she elected to defer any additional procedures
at this time. We told her this can be readdressed as an
outpatient if her pain level changes.
Additionally, patient had diarrhea for ___ days after her
procedure. This was likely related to an overly aggressive
bowel regimen which was started given her presenting complaint
of constipation. She was sent home with a bowel regimen to use
as needed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Taztia XT (dilTIAZem HCl) 360 mg oral DAILY
2. bumetanide 1 mg oral DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. ALPRAZolam 0.25 mg PO TID:PRN anxiety
6. Lunesta (eszopiclone) 2 mg oral QHS:PRN
7. Warfarin 2 mg PO DAILY16
8. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
9. Livalo (pitavastatin) 2 mg oral QHS
10. digoxin 125 mcg oral DAILY
11. Ondansetron Dose is Unknown PO Q8H:PRN dyspepsia, nausea
12. Fexofenadine 180 mg PO DAILY
13. Sotalol 40 mg PO BID
14. lutein 20 mg oral DAILY
15. Bevacizumab (Avastin) unknown IV Q 8 WEEKS to left eye
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 8 hours
Disp #*30 Tablet Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Please take only if becoming constipation.
RX *polyethylene glycol 3350 [Gavilax] 17 gram/dose 17g
powder(s) by mouth every day Refills:*0
3. Psyllium Powder 1 PKT PO TID constipation
RX *psyllium husk (aspartame) [___] 3.4 gram/5.8 gram 1
powder(s) by mouth three times daily with 8oz of water
Refills:*0
4. ALPRAZolam 0.25 mg PO TID:PRN anxiety
5. Bevacizumab (Avastin) unknown IV Q 8 WEEKS to left eye
6. bumetanide 1 mg oral DAILY
7. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
8. Digoxin 125 mcg oral DAILY
9. Fexofenadine 180 mg PO DAILY
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Livalo (pitavastatin) 2 mg oral QHS
12. Lunesta (eszopiclone) 2 mg oral QHS:PRN
13. lutein 20 mg oral DAILY
14. Omeprazole 20 mg PO DAILY
15. Sotalol 40 mg PO BID
16. Taztia XT (dilTIAZem HCl) 360 mg oral DAILY
17. Warfarin 2 mg PO DAILY16
18.Outpatient Lab Work
INR
ICD10: ___
___
Fax results: Dr. ___ ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Chronic, multi-organ polycystic process of
unclear etiology.
Secondary diagnosis: atrial fibrillation, fibrotic lung disease,
psoriasis, cardiomyopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
======================================
Why did you come to the hospital?
======================================
-You were having abdominal pain.
======================================
What was done for you at the hospital?
======================================
-An imaging study of your belly showed many large fluid
collections known as "cysts". They were located in various
organs including your liver, spleen, kidney, and pancreas. Some
of these cysts were pressing on your stomach, and our team
believes this is the source of your pain and lack of appetite.
-We drained one of these large liver cysts and your symptoms
improved, though did not completely resolve.
=================================================
What needs to happen when you leave the hospital?
=================================================
-Follow up with your primary care doctor
-___ up with our liver team
-Have your INR checked on ___
Followup Instructions:
___
|
19885929-DS-7
| 19,885,929 | 24,702,155 |
DS
| 7 |
2139-01-01 00:00:00
|
2139-01-06 16:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Egg / Food Allergies
Attending: ___.
Chief Complaint:
Fever, malaise, dysuria and foul smelling urine
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ presenting with fever, chills and malaise for 1 week in the
setting of urinary urgency and foul odor.
1 week ago she noticed increased urinary frequency and foul
smelling urine. She denies vaginal bleeding or discharge. These
symptoms are typical for her UTIs so she started drinking
cranberry juice. This ususally helps with her symptoms. However,
some days after she felt "kidney pains" and started to have
fevers. Measured temperatures at home were 102. She endorsed
chills and shaking episodes alongside the fevers. Fevers
generally happen in the morning. 4 days ago she became acutely
weak. She had to take baby steps at home becasue any other level
of exertion caused her pain in her joints and pain all over her
body. She has fibromyalgia at baseline and was worried that her
UTI was causing a flare of her fibromyalgia. She treated her
pain and fever with aleve and tylenol. yesterdya, the weakness
became so profound that she was hardly able to take a few steps
without becoming fatigued. This is when she decided to come to
the ED. While in the ED she endorsed nause and vomiting. She
also endorsed chills, fevers and sweats.
She has not been sick otherwise. She had visitors from ___
several weeks ago and one of them was "sick". She is from ___
and travels to ___ on a weekly basis. No other travel
outside the ___ in the past months. She has not been to ___
___. She denies contact with any animals. Denies any new
recent medications. No insect bites or tick exposure that she is
aware of. She states that she was admitted a few months ago for
leg cellulitis and was treated with antibiotics at that time.
She doesnt think the infection ever resolved and is worried this
illness could be from that leftover infection.
On admission to the ED,
Pain with urination and foul smelling. Pain in ___ flanks.
Describes history of kidney infections with "comas".
Has been taking ___ ASA/day. Alleve only started past few days.
endorsing a dry cough since yesterday, consistent with her
asthma.
Fluids: 1L NS
Drips: 1g IV tylenol, 1g IV ceftriaxone
In the ED, initial vitals were: T: 96.8 P: 112 BP: 164/90 RR: 18
Sat: 99% RA. She had 1 reported fever of 101.5. She received
Fluids: 1L NS, 1g IV tylenol, and 1g IV ceftriaxone
Labs were notable for:
- AST 55
- WBC 2.6, Absolute Lymp 0.73
- Hgb 13.4
- Plt 186
- Lactate:1.6
Patient was given:
Omeprazole 20 mg PO DAILY
CeftriaXONE 1 gm IV Q24H
Ketorolac 30 mg IV ONCE
Acetaminophen 1000 mg PO x3
Ibuprofen 600 mg PO ONCE
IV 1000 mL NS Bolus 1000 ml
Consults: None
On the floor, she states that she is feeling much better. She
denies HA, vision changes, SOB, CP. She endorses stable
abdominal pain, although the dysuria and foul smelling urine
went away this AM. She has not had a bowel movement in several
days. Endorses ___ lbs weight loss recently (unclear over what
time period). She only takes some of her medications on a daily
basis because she does not like the way they make her feel. She
endorses tooth pain, she was supposed to have a root canal but
has not done this yet.
Review of systems:
(+) Per HPI
(-) Denies current fever, chills, night sweats, recent weight
loss or gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies diarrhea, constipation.
Past Medical History:
PAST MEDICAL HISTORY:
ASTHMA
CHRONIC LOW BACK PAIN/DJD
DEPRESSED MOOD
HYPERTENSION
ELEVATED BLOOD SUGAR
FIBROIDS
FIBROMYALGIA
GERD
HYPERLIPIDEMIA
IT BAND SYNDROME
OBESITY
VERTIGO
FOOD ALLERGIES
?TRANSIENT ISCHEMIC ATTACK
?PTSD
CARPAL TUNNEL SYNDROME
CEREBROVASCULAR DISEASE
NONADHERENCE
HIGH ED UTILIZATION
Social History:
___
Family History:
FAMILY HISTORY: No family history of auto-immune disease to her
knowledge. Positive family history of diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals:98.9, 116/60, 74, 18, 100RA
General: Alert, oriented, no acute distress, wearing hat, speaks
slowly,
HEENT: Sclera midly injected and mildly icteric, MMM, oropharynx
clear, poor dentiion, no purulence of abscess pockets, EOMI,
PERRL, no sinus tenderness, tenderness to palpation overlying
bilaterl cheeks
Neck: Supple, JVP not elevated, non-tender small submandibular
LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, mild tenderness to palpation over suprpublic
area, non-distended but obese, bowel sounds present, no
organomegaly, no rebound or guarding
+CVA tenderness bilaterally
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
lower extremity pitting edema and at ankles. Skin at ankles
without warmth, erythema, or skin breakdown.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM
Vitals: T: 98.6 BP:101/62 P:62 R:18 O2:96% RA
General: Alert, oriented, no acute distress
HEENT: MMM. Oral cavity with many missing teeth but no areas of
erythema/inflammation. Tenderness to palpation over maxillary
sinuses
Neck: Supple, JVP not elevated, tender and mobile 1-2 cm
submandibular/submental LAD
CV: Regular rate and rhythm, normal S1 + S2, grade II/VI
systolic murmur best heard at R/LUSB, no rubs or gallops
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: Soft, non-distended but obese, RUQ soreness to
palpation (improved from yesterday), bowel sounds present, no
organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
lower extremity pitting edema to the ankles. Skin at ankles
without warmth, erythema, or skin breakdown.
Neuro: CNII-XII intact, grossly non-focal, gait deferred.
Pertinent Results:
ADMISSION LABS
___ 06:03PM URINE RBC-7* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-3
___ 06:03PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
___ 09:20PM WBC-2.6*# RBC-4.84 HGB-13.4 HCT-40.9 MCV-85
MCH-27.7 MCHC-32.8 RDW-13.8 RDWSD-42.7
___ 09:20PM NEUTS-63 BANDS-3 ___ MONOS-6 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-1.72 AbsLymp-0.73*
AbsMono-0.16* AbsEos-0.00* AbsBaso-0.00*
___ 09:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 09:20PM ALT(SGPT)-18 AST(SGOT)-55* ALK PHOS-82 TOT
BILI-0.3
___ 09:20PM GLUCOSE-97 UREA N-15 CREAT-1.1 SODIUM-135
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15
PERTINENT LABS DURING ADMISSION
___ 06:35AM BLOOD WBC-2.6* RBC-4.76 Hgb-12.9 Hct-40.6
MCV-85 MCH-27.1 MCHC-31.8* RDW-14.1 RDWSD-43.8 Plt ___
___ 06:35AM BLOOD Neuts-29* Bands-0 ___ Monos-12
Eos-0 Baso-0 Atyps-7* ___ Myelos-0 AbsNeut-0.75*
AbsLymp-1.53 AbsMono-0.31 AbsEos-0.00* AbsBaso-0.00*
___ 10:55AM BLOOD HAV Ab-NEGATIVE IgM HAV-NEGATIVE
___ 12:39AM BLOOD HIV Ab-Negative
___ 10:55AM BLOOD HCV Ab-NEGATIVE
HCV Viral load: not detected
HIV ___: Negative
HIV viral load: Not detected
EBV: IgG positive, IgM negative
MONOSPOT: Negative
CMV: IgG positive, IgM negative
Lyme: IgG/IgM negative
Anaplasma: IgG/IgM negative
DISCHARGE LABS
___ 06:05AM BLOOD WBC-7.6 RBC-4.47 Hgb-12.1 Hct-39.1 MCV-88
MCH-27.1 MCHC-30.9* RDW-14.6 RDWSD-46.7* Plt ___
___ 06:05AM BLOOD Neuts-34 Bands-2 ___ Monos-9 Eos-1
Baso-0 ___ Metas-1* Myelos-0 AbsNeut-2.74 AbsLymp-4.03*
AbsMono-0.68 AbsEos-0.08 AbsBaso-0.00*
___ 06:05AM BLOOD Glucose-89 UreaN-15 Creat-0.9 Na-138
K-5.0 Cl-103 HCO3-29 AnGap-11
___ 06:05AM BLOOD ALT-239* AST-144* LD(LDH)-337* AlkPhos-74
TotBili-0.2
___ 06:05AM BLOOD Calcium-9.9 Phos-4.1 Mg-2.___bdomen
1. No evidence of colitis.
2. Right renal hypodensity is small, but measuring Hounsfield
units greater than that typically seen for a a simple cyst.
RECOMMENDATION(S): Followup nonurgent renal ultrasound to
evaluate right
kidney hypodensity.
NOTIFICATION: The recommendation for nonurgent renal ultrasound
was discussed by Dr. ___ with Dr. ___ on the
telephone on ___ at approximately 18:00.
CT Sinus/Maxillary/Mandibular
1. Periapical lucency about the left lateral maxillary incisor,
and multiple dental caries, for which dedicated dental
examination is recommended.
2. Chronic inflammatory changes of the sphenoid sinus on the
right, the
possibility of fungal colonization is a consideration.
3. Prominent submental, submandibular, and cervical lymph nodes
are likely
reactive.
RUQ Ultrasound
Large gallbladder stone without evidence of cholecystitis.
Brief Hospital Course:
___ year old F with PMHx of Fibromyalgia, frequent UTIs, Asthma,
GERD, and migraines who presents with 1 week fevers 102,
malaise, 10lb weight subject weight loss, urinary
urgency/frequency, and foul smelling urine, found to have
leukopenia on blood work in the ED.
ACTIVE ISSUES
# Neutropenia. Patient presented with leukopenia of 2.6 on
admission, down from baseline of ___ from values dating back to
___, with normal differential. Her absolute lymphocyte count
was 730 and ANC was 750. She was placed on neutropenic
precautions, but was not started on coverage for neutropenia
given that she was aferbile and stable on the floor.
Subsequently ___ trended up with ___ trending down to a nadir of
410. Viral workup including HIV, EBV, CMV, Lyme, and
Anaplasmosis were all negative. Concern for drug-induced;
however patient was unfortunately unable to give a clear history
of what medications she usually takes at home and whether she
had been taking anything new or unusual recently. ___
subsequently uptrended again prior to discharge. Heme/onc were
consulted and reviewed peripheral smear. They felt initial
insult causing leukopenia was likely viral, with subsequent
neutropenia possibly caused by ceftriaxone or clindamycin which
were started as described below. Given improvement in counts
patient was discharged home with heme/onc followup.
# Fever. Patient presented with fever in the setting of
leukopenia. Given symptoms of dysuira and foul smelling urine
she received 1x dose of Ceftriaxone in the ED to cover for
possible UTI. UA was negative, urine culture was negative, and
symptoms resolved. CTX was stopped. Given complaints of tooth
pain and sinus pressure a CT sinus/mandible was done which
revealed multiple dental caries (no abscess) and signs of
chronic sinus inflammation. Clindamycin was started for possible
dental infection; however this was also subsequently stopped in
the absence of a clear infectious source. Patient remained
afebrile throughout admission.
# Oral pain. Pt described significant oral pain on admission,
indication mucosal tenderness, without discreet lesions or
masses appreciated. The pain fluctuated in intensity. CT
head/sinus did not reveal dental abscess. Pt was seen by dental
consult service, who recommended tooth extraction, to be done
either as inpatient or in follow up after discharge. Pt's
preference was to pursue this treatment as an outpatient;
contact details were provided for low cost dental clinic.
# Transaminitis. Although LFTs normal on admission patient
subsequently developed hepatocellular pattern liver injury with
AST/ALT peaking around 300, LDH 551. RUQ was notable only for
nonobstructive cholelithiasis. Hepatitis panel was unremarkable.
Transaminitis thought likely secondary to initial viral insult
versus medications (as above for neutropenia). LFTs trended down
prior to discharge and will be followed by PCP.
# Vertigo/Migraines: Patient endorsed some instability with
walking, orthostatic vital signs normal. Did not reported
migraines in house. Meclizine continued.
# Asthma. Continued home flovent and asthma
# GERD. Continued home omeprazole
# Fibromyalgia. She does not take any pain medications at home
for this.
# Hyperlipidemia. She was not taking prescribed atorvastatin.
This was not restarted while inpatient.
TRANSITIONAL ISSUES
# Transaminitis- Repeat LFTs ___.
# Multiple Dental Caries- Will need dedicated dental
examination. Patient was given information about Dental School
low cost options.
# Chronic Sinus Inflammation- ___ need ENT referral for
definitive treatment.
# Cholelithiasis- Recommend considering elective cholecystectomy
for management of gallstones.
# Studies: Recommend non-urgent renal ultrasound to evaluate
right kidney hypodensity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. Meclizine 12.5 mg PO Q8H:PRN dizziness
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Albuterol Sulfate (Extended Release) 90 mcg PO Q6H:PRN SOB
6. Topiramate (Topamax) 50 mg PO 2X/WEEK PRN headache
7. Omeprazole 20 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Omeprazole 20 mg PO DAILY
3. Meclizine 12.5 mg PO Q8H:PRN dizziness
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Albuterol Sulfate (Extended Release) 90 mcg PO Q6H:PRN SOB
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Losartan Potassium 25 mg PO DAILY
9. Topiramate (Topamax) 50 mg PO 2X/WEEK PRN headache
10. Outpatient Lab Work
Please draw CBC with diff and liver panel on ___ and fax to
Dr. ___ at ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Dignosis
Fever of unknown origin
Secondary Diagnosis
Neutropenia
Transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. Briefly, you were hosptialized with fevers and found
to have a low white blood cell count. You were treated with
antibiotics and a search for a source of infection was not very
revealing. A CT scan of your sinuses and teeth showed possible
chronic sinus inflammation and multiple dental erosions, which
will need evaluation by a dentist. Your white blood cell count
initially dropped during your stay but then rose to normal
again. Your liver enzymes increased and then began to go back
down again. We tested you for multiple infections, including
viruses and Lyme disease, that could explain these findings, and
this was all negative. You were seen by a hematologist who
agreed this was most likely caused by an infection or a
medication, and would like to see you in 6 weeks.
Please go to the lab on ___ to have blood drawn and
faxed to Dr. ___. Please follow up with your appointments
including primary care, hematology/oncology, and make a dental
appointment if possible.
It was a pleasure taking care of you during your stay.
- Your ___ Team
Followup Instructions:
___
|
19886408-DS-6
| 19,886,408 | 28,518,899 |
DS
| 6 |
2114-12-28 00:00:00
|
2114-12-28 16:21:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Iodinated Contrast- Oral and IV Dye / Omnipaque
Attending: ___
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
___ - Left craniotomy for tumor resection
History of Present Illness:
___ is a ___ year old female with no past medical
history who was transferred intubated from OSH after witnessed
seizure. Per reports, the patient woke confused with right arm
shaking. Her husband called EMS, who found her confused and
postictal. Her mental status did not clear and she had a
witnessed GTC in the ambulance en route to OSH. NCHCT was
completed and significant for small left temporoparietal brain
lesion. She was transferred to ___ for further evaluation.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
ON ADMISSION
============
O: T: 98.2 BP: 128/90 HR: 110 R: 20 O2Sats:
100%intubated
Gen: Intubated female lying on stretcher, no evidence of trauma
HEENT: Pupils: PERRL sluggish
Neuro: Eye opening to deep noxious. Pupils 3mm-2mm, sluggishly
reactive. Not following commands. Moving all extremities
spontaneously, no focal deficits.
ON DISCHARGE:
=============
She is awake, alert, and cooperative with the exam. She is
oriented to self, ___ with choices, and ___. PERRL,
EOMI. Face symmetric, tongue midline. No pronator drift. She
moves all extremities with ___ strength. Sensation is intact to
light touch throughout. Incision is clean, dry, and intact with
staples.
Pertinent Results:
Please see OMR for relevant findings.
Brief Hospital Course:
___ is a ___ year old female who was transferred from
OSH intubated after 2 witnessed seizures. She arrived intubated
and was extubated in the Emergency Department. MRI brain
revealed a ring-enhancing left temporal mass.
#Brain lesion with cerebral edema
She was admitted to the ___ for close neurological monitoring.
She was started on Dexamethasone for cerebral edema and Keppra
for seizure prophylaxis. She underwent CT torso, which was
negative for metastatic disease. On ___, she underwent left
craniotomy for tumor resection. The procedure was uncomplicated.
For further procedure details, please see separately dictated
operative report by Dr. ___. She was extubated in operating
room and transported to the PACU for recovery. Once stable, she
was transferred back to the ___. Post-operative MRI
demonstrated expected surgical changes and no residual tumor.
She had word finding difficulty post-operatively, which was
expected. On day of discharge, her pain was well controlled with
oral medications. She was tolerating a diet and ambulating
independently. Her vital signs were stable and she was afebrile.
She was discharged to home in a stable condition.
#Bradycardia
Patient was found to be bradycardic during her admission with
heartrate in the ___, sometimes dipping into the ___. EKG was
obtained and medicine was consulted. Patient remained
asymptomatic. After evaluation medicine determined that this is
a normal physiologic bradycardia for the patient and no further
workup was necessary.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every six hours as needed for pain Disp #*60
Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Dexamethasone 2 mg PO Q12H Duration: 1 Dose
This is dose # 3 of 4 tapered doses
4. Dexamethasone 1 mg PO DAILY Duration: 1 Dose
This is dose # 4 of 4 tapered doses
RX *dexamethasone 1 mg ___ tablet(s) by mouth every 12 hours
Disp #*3 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO BID
Take until steroid course is completed
RX *famotidine 20 mg 1 tablet(s) by mouth every 12 hours Disp
#*3 Tablet Refills:*0
7. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth every 12 hours
Disp #*60 Tablet Refills:*1
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four hours as
needed for pain Disp #*60 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 17.2 mg PO QHS:PRN Constipation - First Line
11. levonorgestrel-ethinyl estrad 0.15-0.03 mg oral NOON
Discharge Disposition:
Home
Discharge Diagnosis:
Brain lesion
Cerebral edema
Bradycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions:
Surgery
- You underwent surgery to remove a brain lesion from your
brain.
- Please keep your incision dry until your staples are removed.
- You may shower at this time but keep your incision dry.
- It is best to keep your incision open to air but it is ok to
cover it when outside.
- 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 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 have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
- You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
- You may experience headaches and incisional pain.
- You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
- You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
- Feeling more tired or restlessness is 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.
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:
___
|
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