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19886569-DS-7 | 19,886,569 | 26,818,429 | DS | 7 | 2131-02-26 00:00:00 | 2131-02-28 11:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
**History somewhat limited upon interview given post-ictal
state,
most history obtained through ___ records**
Ms. ___ is a ___ year old woman wiht known history of epilepsy
and
recurrent skin infections who presents with increased seizure
activity. Typically Ms. ___ has seizures consisting of eye
blinking or head dropping that occur without loss of
consciouness
several times per day and rarely has convulsive seizures. Over
the last 24 hours she has had 4 convulsive events prompting
evaluation in the ED.
Over the last week she has had cough and vomiting, which she
says
has been occuring a few times per day. She denies any fever or
diarrhea. She has not missed any doses of medication and denies
vomiting any of her medication as well. She had been having her
usual frequency of blinking epsiodes (few per day) and last
night
on the evening of ___ she had a generalized tonic clonic
seizure and was seen at ___. She was discharged
after workup was unremarkable but again this morning had an
event
at 7:45 am that lasted 5 minutes and occurred while getting her
daughter ready for daycare. Dr. ___ was aware of the
ED
visit and seizures and advised prn ativan and a dose increase in
her lamictal from 850mg to 900mg. She was advised to take the
ativan once this afternoon and again around 8pm if she was not
feeling too sleepy. When her aunt had gone to pick up the
perscription for ativan, she returned home to find ___
seizing in the bathroom. At that time the decision was made to
bring her into the ED for further evaluation. She was seen at
___ again, received her evening meds and 1mg
ativan
PO and was transferred here.
Upon arrival to our ED, she had another generalized tonic clonic
seizure that lasted <1 minute. She was post-ictal afterwards but
began to regain consciousness and become more alert.
She was last admitted to the epilepsy service in ___ when she
had increasing seizure frequency in the setting of transitioning
from Tegretol to Lamictal. She was admitted and placed on EEG
which showed no specific electrographic events
concerning for seizure although the patient noted having events
consistent with her typical seizures - eye blinking for less
than one minute which resolved without loss of consciousness or
post-ictal confusion / lethargy. Her lamictal XR was increased
to
800mg daily and she continued on Zonisamide at 400mg daily.
To review her prior epilepsy history, she has had seizures since
___. At that point they were generalized convulsions that would
occur at night. She was started on Tegretol and developed more
subtle events of eye blinking sometimes with speech arrest or
slurred speech. She sometimes has events of just slurred speech.
These more subtle events sometimes can progress to loss of
consciousness.
Per recent notes, currently, her semiologies are:
- bilateral eye blinking with speech arrest
- slurred speech
- head bobbing, groaning and stuttering and speech arrest
- generalized convulsions.
She has previously been on Tegretol XR and was also on
Neurontin
and Keppra both of which were discontinued (neurontin-
ineffective, keppra-irritability). She is currently on Lamictal
and Zonegran.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, she complains of vomiting and
cough. The pt denies recent fever or chills. No night sweats or
recent weight loss or gain. Denies shortness of breath. Denies
chest pain or tightness, palpitations. Denies diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
Epilepsy
Ovarian Cyst
?OSA
recurrent MRSA infections
acute interstitial nephritis secondary to Vanco
Social History:
___
Family History:
- Diabetes
- Hypertension
Physical Exam:
ADMISSION EXAMINATION:
Vitals: T:98.8 P:92 R: 18 BP:119/61 SaO2: 100RA
General: asleep but easily arouseable, NAD
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds,
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history in
limited fashion given post-ictal state. Speaking in short
answers
but normal prosody, no paraphasic errors. 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.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: deferred given level of arousal
********************
DISCHARGE EXAMINATION:
Pt more awake and cooperative; still with flat affect. Otherwise
unchanged.
Pertinent Results:
ADMISSION LABS:
___ 08:45PM BLOOD WBC-15.6*# RBC-4.60 Hgb-12.2 Hct-38.2
MCV-83 MCH-26.5* MCHC-31.9 RDW-14.3 Plt ___
___ 08:45PM BLOOD Neuts-84.4* Lymphs-12.5* Monos-2.6
Eos-0.4 Baso-0.2
___ 08:45PM BLOOD ___ PTT-30.7 ___
___ 08:45PM BLOOD Glucose-92 UreaN-14 Creat-0.9 Na-137
K-4.8 Cl-107 HCO3-18* AnGap-17
___ 04:40AM BLOOD ALT-23 AST-18 LD(LDH)-135 AlkPhos-72
___ 08:45PM BLOOD Calcium-8.7 Phos-3.2 Mg-2.3
TOX SCREEN:
___ 08:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:23AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
URINALYSIS:
___ 09:23AM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:23AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 09:23AM URINE RBC-4* WBC-19* Bacteri-NONE Yeast-NONE
Epi-15
___ 12:00AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 12:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM
___ 12:00AM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
IMAGING:
___ CXR: No acute intrathoracic process.
___ EEG: This is an abnormal continuous video EEG telemetry
due to interictal discharges seen with right frontal or
bifrontal predominance, more pronounced with sleep. No
pushbutton activations and no seizures.
Brief Hospital Course:
Ms. ___ is a ___ yo RH woman with history of epilepsy and
recurrent MRSA infection who presented with increased frequency
of convulsive seizures at home in setting of systemic illness
with nausea/vomiting. She was started on standing lorazepam
bridge, in addition to recently increased doses of lamotrigine
(increased by Dr. ___ prior to admission) and
monitored on EEG without further clinical or electrographic
events. She was seen by social work who recommended that she be
evaluated by psychiatry given her depressive symptoms. She was
seen by psychiatry and was cleared for home, though patient
declined further psychiatric treatment. She was discharged home
with slow lorazepam taper over 1 week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LaMICtal XR *NF* (lamoTRIgine) 900 mg Oral daily
2. Zonisamide 400 mg PO QPM
3. FoLIC Acid 4 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. FoLIC Acid 4 mg PO DAILY
2. LaMICtal XR *NF* (lamoTRIgine) 900 mg Oral daily
3. Zonisamide 400 mg PO QPM
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Lorazepam 0.5 mg PO Q 8H
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth every 8 hours
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: epilepsy, depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because of the
cluster of convulsives seizures you had at home in setting of
recent illness (cough/vomiting).
You were checked for influenza, which was negative. Other
sources of infections were checked and showed possible urinary
traction, which was treated with antibiotics.
You were started on ___ to break the cluster of
seizures and you remained seizure-free. EEG was done and did not
show any seizures. You will need to be on a slow ativan taper at
this time.
Because of your mood, you were seen by social work who
recommended psychiatric evaluation. They psychiatrist recommend
that outpatient treatment.
Followup Instructions:
___
|
19886569-DS-8 | 19,886,569 | 26,866,665 | DS | 8 | 2131-09-15 00:00:00 | 2131-10-11 17:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ right handed female with a history of
epilepsy, multiple MRSA-cultured skin abscesses who presents
today with persistent auras resulting in atypical episode of
loss
of tone and fall without headstrike or neck trauma. The patient
notes having multiple episodes of her typical aura today which
manifests as "feeling like sounds reverberate for a period of
time" which terminate with eyelid fluttering. However, today
the
episodes waxed and waned over the course of 1400hrs to 1830hrs
as
well as included the sensation that she was "tingling all over".
The patient also reported attempting to contact ___
for an Ativan prescription to arrest the aura, however, at
1830hrs, she reported losing all tone, not awareness, and
collapsing to the ground for a few seconds ___ sec) without any
loss of awareness. No episode of post-ictal fatigue, weakness,
or other sequelae were remarkable; however, the patient today
noted feeling some fatigue approximately 2.5 hours status post
the event. She denies any recent trauma, illness, or
non-compliance with medication. Of note, she reportedly had
been
scheduled for LTM admission on ___. Per conversation with
Dr. ___ epileptologist, the decision was made to
admit to expedite her study.
Seizure history per my prior note as in OMR and per patient
report:
She has had seizures since age ___. The description of events at
that time were night-time episodes of generalized convulsions
with loss of consciousness. At one point, she had a cluster of
six events and was started on carbamazepine. She subsequently
developed more subtle events with right eye blinking, sometimes
progressing to speech arrest. At times, she might also just have
slurred speech. Rarely, she might have progression of these
episodes to generalized convulsions with loss of consciousness.
Her blinking episodes now affect both sides, and she has mostly
"head bobbing" episodes. Her usual events now are described as
bilateral eyelid twitching upon awakening, usually lasting
seconds to a minute, and head bobbing or dipping with stuttering
groan without impaired consciousness, limb movements, or
post-ictal lethargy / confusion.
Past Medical History:
Epilepsy
Ovarian Cyst
?OSA
recurrent MRSA infections
acute interstitial nephritis secondary to Vanco
Social History:
___
Family History:
- Diabetes
- Hypertension
Physical Exam:
ADMISSION:
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Able to read without difficulty. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Attentive, with good knowledge of current events.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 3mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, pinprick in all
distributions, and ___ strength noted bilateral in masseter
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, and is equal ___ strength
bilaterally as evidenced by tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 1 2 2 1
R 2 1 2 2 1
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
DISCHARGE EXAM
Normal neurologic exam - Mental status alert awake and oriented,
attention intact able to recite months of year backwards in
under 10 seconds. Cranial nerves were intact with smooth
saccades and no nystagmus. No asterixis, and no dysdiadokinesia.
Strength was ___ throughout and her sensation was intact.
Pertinent Results:
___ 06:00AM BLOOD ALT-26 AST-23 LD(LDH)-162 AlkPhos-83
TotBili-0.5
___ 06:00AM BLOOD Albumin-3.8 Calcium-8.9 Phos-3.5 Mg-2.2
___ 06:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MRI brain w and w/out contrast
No evidence of acute intracranial process, abnormal enhancement,
hemorrhage or
structural abnormality.
SPECT
Ictal - not interpretable due to motion artifact
inter-ictal - IMPRESSION: No obvious focal perfusion
abnormality identified on this
interictal study.
EEG - IMPRESSION: This is an abnormal continuous EMU monitoring
study with the
presence of occasional right frontotemporal spikes and six
electrographic
seizures followed by a generalized post ictal slowing. This is
suggestive of
a highly epileptogenic cortex with a right frontal foci.
Additionally, there
are occasional two to three second bursts of fast activity with
higher voltage
over the right hemisphere which can, at times, be seen in
patients with a
cortical malformation but in themselves are non-specific.
Compared to prior
days' recording, there was an increase in epleptiform activity
and
electrographic seizures.
Brief Hospital Course:
Ms. ___ was admitted to the epilepsy monitoring unit earlier
than previously planned (she was scheduled for monitoring for
pre-epilepsy surgery evaluation) for seizure. She had multiple
events after her medications were tapered off. Unfortunately,
however, her ictal SPECT was not readable.
#SEIZURE - She was placed on EEG monitoring ___, and her
Lamictal XR 800mg daily was tapered to 0 by ___. Over this
period of time, she had multiple episodes of eye fluttering with
no EEG correlate. On ___, her Zonegran was discontinued. On ___
and ___, patient underwent ictal and inter-ictal SPECT, however,
the ictal spect was not readable secondary to motion artifact.
The ictal SPECT was normal with no perfusion abnormalities. MRI
with and without contrast was normal. Her background EEG showed
right frontotemporal spikes. Over the next several days, she had
multiple generalized seizures, which were characterized on EEG
by a secondarily generalizing partial seizure beginning in the
right frontotemporal region with a 1.5Hz spike and wave pattern.
Clinically, these were characterized by facial twitching,
followed by bilaterally eye fluttering and bilateral clonic arm
and leg movements. Due to this, she was loaded with dilantin,
and her home medications were restarted, which stopped her
seizures.
New medications added during this admission include dilantin. No
other medication changes were made.
OUSTANDING ISSUES
- Taper dilantin
- Pre-surgical planning with SPECT unsuccessful - she may
require invasive EEG monitoring
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LaMICtal XR *NF* (lamoTRIgine) 800 mg Oral QHS
2. Zonisamide 400 mg PO QPM
3. FoLIC Acid 4 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 4 mg PO DAILY
2. Zonisamide 400 mg PO QPM
3. LaMICtal XR (lamoTRIgine) 800 mg ORAL QHS
4. Phenytoin Sodium Extended 300 mg PO HS
RX *phenytoin sodium extended 300 mg 1 capsule(s) by mouth at
bedtime Disp #*30 Capsule Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental state: slightly tired but awake alert and oriented
Ambulatory Status: independent
Neuro exam: non-focal
Discharge Instructions:
Dear Ms. ___,
You were admitted to the epilepsy monitoring unit for EEG
monitoring to further characterize your seizures for
pre-surgical evaluation. After stopping your lamictal, you had
multiple events which we were able to see on EEG, on the right
side of your brain. After this, we started you on dilantin, and
restarted your lamictal, at which point your generalized
seizures stopped. You will follow up with epilepsy to make a
plan from here, which will likely include invasive EEG
electrodes.
NEW MEDICATIONS
Dilantin 300mg extended release every evening.
Please continue to take your other medications as prescribed
Followup Instructions:
___
|
19886573-DS-4 | 19,886,573 | 25,916,071 | DS | 4 | 2120-05-31 00:00:00 | 2120-05-31 15:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ no relevant PMH s/p fall out of bed at 0200 on morning of
presentation. Transferred from OSH with LUQ and L chest wall
pain found to have splenic laceration and left sided rib
fracture. No dizziness or LOC. Having pain in L chest wall
with deep breathing and movement.
Past Medical History:
PMH: hyperlipidemia, hypertension, GERD
PSH: hysterectomy, appendectomy, breast reduction, incisional
hernia repair
Social History:
___
Family History:
Noncontributory.
Physical Exam:
Admission Physical Exam:
VS P 99 BP 112/57 sO2 99%
HEENT: PERRL, EOMI.
Neck: Supple, no LAD.
CV: RRR, no m/r/g.
Resp: Lungs CTAB, no w/r/r. Chest wall tenderness to palpation.
over the L side.
Abd: Soft, TTP in LUQ, mildly distended. No guarding.
Skin: No rashes; some bruising over L chest/abdomen.
Ext: 2+ peripheral pulses b/l.
Neuro: CN II-XII intact, sensation/motor strength grossly
intact.
Discharge Physical Exam:
Tm 99.1 Tc 98.2 P 84 BP 140/86 R 15 sO2 94% 2L
Gen: Caucasian female sitting up in bed in NAD, appears
comfortable.
HEENT: PERRL, EOMI. Moist mucous membranes.
Neck: Supple, no LAD.
CV: RRR, no m/r/g.
Resp: Lungs CTAB, no w/r/r. Mild chest wall tenderness,
resolving ecchymosis.
Abd: Soft, NTND. Bowel sounds present.
Skin: No rashes or lesions.
Ext: WWP, no c/c/e.
Neuro: CN II-XII intact. Sensation/motor strength grossly
intact.
Pertinent Results:
___ 11:30AM BLOOD Glucose-111* UreaN-22* Creat-0.7 Na-146*
K-4.3 Cl-109* HCO3-26 AnGap-15
___ 11:30AM BLOOD WBC-12.5* RBC-3.86* Hgb-11.6* Hct-36.0
MCV-93 MCH-30.2 MCHC-32.4 RDW-13.1 Plt ___
___ 05:50PM BLOOD Hct-33.2*
___ 01:50AM BLOOD WBC-10.2 RBC-3.45* Hgb-10.3* Hct-32.4*
MCV-94 MCH-30.0 MCHC-31.9 RDW-13.3 Plt ___
___ 08:55AM BLOOD Hct-28.7*
___ 03:59PM BLOOD Hct-29.0*
___ 06:50AM BLOOD WBC-7.3 RBC-2.91* Hgb-9.0* Hct-27.1*
MCV-93 MCH-30.8 MCHC-33.1 RDW-13.1 Plt ___
___ 08:45PM BLOOD WBC-7.9 RBC-2.90* Hgb-9.0* Hct-27.0*
MCV-93 MCH-30.9 MCHC-33.2 RDW-12.8 Plt ___
___ 05:40AM BLOOD WBC-7.7 RBC-3.01* Hgb-9.0* Hct-28.0*
MCV-93 MCH-29.8 MCHC-32.0 RDW-13.2 Plt ___
___ 06:50AM BLOOD Glucose-94 UreaN-14 Creat-0.6 Na-139
K-3.9 Cl-104 HCO3-28 AnGap-11
Brief Hospital Course:
Ms. ___ was admitted to the General Surgery service at
___ for observation and management of left-sided rib fractures
and a splenic laceration with hemoperitoneum. She underwent a CT
of the abdomen and pelvis which showed stable hemoperitoneum in
comparison with outside hospital imaging; a large splenic
laceration; fractures of left ___ ribs; and fractures of the
L2-3 transverse processes. The patient remained hemodynamically
stable while in the ICU and was transferred to the floor after
24 hours. She underwent aggressive pulmonay toilet and incentive
spirometry. She had adequate urine output. Serial hematocrits
were obtained and as follows: 33.2 ->32.4 -> 28.7-> 29.0->
27.1-> 27.0-> 28.0. Her pain was well-controlled with a
combination of oxycodone and lidocaine patch. Her diet was
advanced to regular which she tolerated. On HD#4 she was
discharged home in good condition with follow-up planned in two
weeks' time.
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H
RX *acetaminophen 500 mg 1 tablet(s) by mouth every six (6)
hours Disp #*28 Tablet Refills:*0
2. Atenolol 50 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Gabapentin 600 mg PO BID
5. Lidocaine 5% Patch 1 PTCH TD QPM (___) pain
6. Omeprazole 40 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Please do not drive while taking this medication.
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Splenic laceration
L ___ rib fractures
L2-3 lumbar transverse process fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to the General Surgery (___) service at ___
for an injury to your spleen and multiple rib fractures. Here
are some instructions for your post-hospital course:
Your liver/spleen injury will heal in time. It is important that
you do not participate in any contact sports or any other
activity for the next 6 weeks that may cause injury to your
abdominal region.
Avoid aspirin producs, NSAID's such as Advil, Motrin, Ibuprofen,
Naprosyn, or Coumadin for at least ___ weeks unless otherwise
directed as these can cause bleeding internally.
You should go to the nearest Emergency department if you
suddenly feel dizzy or lightheaded, as if you are going to pass
out. These are signs that you may be having internal bleeding
from your liver/spleen injury.
You also sustained rib fractures which can cause severe pain and
subsequently cause you to take shallow breaths because of the
pain. You should take your pain medicine as 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.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Narcotic pain medication can cause constipation. Therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
Followup Instructions:
___
|
19886688-DS-20 | 19,886,688 | 20,633,117 | DS | 20 | 2126-12-27 00:00:00 | 2126-12-29 21:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Lower back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yom with history of HTN who presents with
acute on chronic low back pain. Patient reports history of low
back pain for 3 months which originally began after a few days
of heavy lifting at a ___ job. He reports that this same
pain has worsened over the past two days without any clear
precipitating factor. Patient noticed he had difficulty walking
down stairs after smoking a joint of marijuana. He describes the
pain as sharp and radiates from midline down back of right leg.
He states was involving left leg the day prior to admission.
Patient reports that his whole right leg is numb and tingling
which has been intermittent for past 3 months with back pain and
frequently switches legs. Patient denies taking any medications
for pain at home, but does report compliance with his
antihypertensive medications. He denies any fevers, trauma, IV
drug use, bowel/bladder incontinence, weakness or saddle
anesthesia.
Past Medical History:
1. Hypertension
2. L knee ACL injury
Social History:
___
Family History:
Father with prostate cancer (still living), mother with CAD s/p
3-vessel CABG.
Physical Exam:
Admission:
Vitals: 97.6 159/120 HR 75 sat 100% on RA
Gen: rolling around on bed with exaggerated response to pain
Neck: supple
HEENT: clear oropharynx
Pulm: CTAB
CV: NR, RR, no murmur
Abd: NT, ND, soft
Back: no point tenderness, no overlying skin changes, no masses
Ext: no peripheral edema
Neuro: sensation intact bilaterally in low ext, ___ strength in
dorsoflexion of feet, moves all extremities well, CN's intact,
mental status normal, ambulation not assessed due to pain
Skin: no lesions noted
Psych: possibly histrionic type behavior
Discharge:
Vitals: afebrile 98 ___ HR ___ sat 98-100% on
RA
Gen: rolling around on bed with exaggerated response to pain
Neck: supple
HEENT: clear oropharynx
Pulm: CTAB
CV: NR, RR, no murmur
Abd: NT, ND, soft
Back: no point tenderness, no overlying skin changes, no masses
Ext: toes are warm, good pulses in feet, no peripheral edema
Neuro: sensation intact bilaterally in low ext, ___ strength in
dorsoflexion of feet, moves all extremities well, CN's intact,
mental status normal, ambulation not assessed due to pain
Skin: no lesions noted
Psych: possibly histrionic type behavior
Pertinent Results:
___ 08:45AM BLOOD WBC-7.6 RBC-4.77 Hgb-14.8 Hct-40.8 MCV-85
MCH-30.9 MCHC-36.2* RDW-12.9 Plt ___
___ 07:55AM BLOOD Glucose-136* UreaN-10 Creat-1.1 Na-137
K-3.4 Cl-99 HCO3-27 AnGap-14
___ 08:45AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.8
Lumbosacral Xray: IMPRESSION:
Partial lumbarization of S1. No acute fracture or dislocation.
Lower Extremity ABI: IMPRESSION: No evidence of any peripheral
vascular disease at rest in either lower extremity.
Brief Hospital Course:
Mr. ___ is a ___ yom with history of HTN who presented with
acute on chronic low back pain most consistent with
musculoskeletal etiology.
# Low Back Pain: Likely acute on chronic musculoskeletal back
pain. Patient had no red flags on exam or history. Differential
diagnosis includes herniated disc or spinal stenosis. Less
likely would be fracture, epidural abscess, aortic/iliac
dissection, or neoplasm. Lumbosacral Xray normal.
-continue ___ as outpatient
-Ibuprofen 800mg q8h
-Acetaminophen 1,000mg po q8h
-Diazepam 2mg po q8h:prn muscle spasm
-Oxycodone ___ po q4h:prn back pain
-will follow up with Ortho Spine clinic
# Toe Pain, Right ___: Unclear and slightly inconsistent
reporting of cold/numb sensation in left foot. Physical exam
unremarkable. Unlikely vascular etiology, but does not fit with
musculoskeletal back pain. Blood pressure equal in lower ext on
___. Negative ABI of lower extremities
-follow up right toe pain as outpatient
# Hypertension
-continued home Amlodipine 10mg po daily
-continued home Labetaolol 200mg po BID
# CODE: Full-confirmed
# CONTACT: ___ (friend, ___ call) ___
HCP is his father- ___ ___
### ___ ISSUES:
-follow up low back pain and right toe pain as outpatient
-continue ___ as outpatient
-will follow up with Ortho Spine clinic
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 200 mg PO BID
2. Amlodipine 10 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Labetalol 200 mg PO BID
3. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth every 8 hours PRN Disp #*250 Tablet
Refills:*1
4. Diazepam 2 mg PO Q8H:PRN back pain
RX *diazepam 2 mg 1 tablet(s) by mouth every 8 hours as need
Disp #*20 Tablet Refills:*0
5. Ibuprofen 800 mg PO Q8H
RX *ibuprofen 800 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN back pain
do not drive or drink alcohol with this medication.
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed
Disp #*25 Tablet Refills:*0
7. Outpatient Physical Therapy
Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Lower back pain
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 came to the hospital for worsening lower back pain radiating
down your right leg. Because you have been having chronic back
pain for 3 months, we performed an x-ray of your lower spine,
which was normal. You likely have a mechanical cause of your
back pain, which could be a herniated disc. Your pain was
reduced with a combination of oxycodone, ibuprofen, and
acetaminophen. We recommend that you follow up with the spine
clinic for further management of your back pain as an
outpatient. Please keep the appointments listed below.
Followup Instructions:
___
|
19886772-DS-12 | 19,886,772 | 29,520,585 | DS | 12 | 2119-07-10 00:00:00 | 2119-07-10 18:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa / carbamazepine
Attending: ___.
Chief Complaint:
hypotension, headaches
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with PMH of thyroid
disease (not on meds), remote cervical cancer, panic attacks,
anxiety, depression, history of alcoholism in the past and some
type of viral meningitis in ___, GERD, presenting to ED from
clinic found to be hypotensive I/s/o poor PO intake d/t
increased
shock-like headaches, which are longstanding.
Initially at urgent care visit at ___ today in setting of severe
head discomfort and inability to function secondary to this pain
(described below). Her BP in clinic ranged from 77-90/50-60
prompting ED visit. Neuro exam was nonfocal. Pt was very anxious
and tearful.
Re headaches: describes 2 types of pain, shock like pains which
occur in head/neck mostly but can sometimes now occur throughout
body. Last half a second. Also has a sharp, constant, worsening
headache x6-7 weeks. Now feeling it on both sides of head. No
changes in vision. Does endorse hearing loss and tinnitus on
right side. This pain is new. Has had episodes in the past of
worsened headaches that lasted for ___ weeks and went away but
the duration of this headache is new. Extensive neurologic Hx is
detailed below per neuro note. No weakness. No falls. Some
fuzziness/confusion but this is more related to decreased energy
I/s/o poor PO intake (see below). No fevers, chills. Has had
longstanding occasional nightsweats but none more than usual
recently. No seizure-like activity, LOC, incontinence.
Re lightheadedness/hypotension: occurring past couple of days.
No
food x3 days. Minimal liquid, solids. No n/v. Generalized lwo
energy without focal weakness. GI and neuro SX detailed above
and
below.
Re anorexia: Describes lack of desire to eat. Mood not more
depressed than usual. No dysphagia/odynophagia, choking,
regurgitation. Rare GERD sx but none recently. Occasional loose
stools in the past week, now resolving. Does note dental pain.
Has had numerous caries. No dental contact ___ years.
Re ___: pt denies Hx of this prior. No recent tick exposure,
rash. Does live in woods. Has remote tick bites.
Neurology outpatient note reviewed and summarized as follows:
Had an unremarkable MRI/MRA in ___. Saw neurology in ___
with very in depth documentation. Pain at that point described
as
originating in cervical area, occurring dozens of times in
several minute spurts. Had a Hx of meningitis in ___, unclear
etiology despite LP. Has had a c-spine surgery, although it was
apparently not until after meningitis that this started. Pt
reportedly had a venous thrombus at the time of meningitis. Had
"spontaneous dural leak confirmed by CT myelogram" but derived
no
benefit froma blood patch. There was a question of whether some
intracranial hypotension contributed, as pain was significantly
relieved in reverse ___ position. Pt at that time on
vicodin; had not responded to carbamazepine. Also has tried
lamotrigine, Neurontin, lidocaine, amitriptyline, Tylenol,
motrin. Reported having had some relief with vicodin.
Also has seen pain clinic, last note from ___: headaches ___
years. Pt struggling with ADLs. Note she has also tried
accupuncutre, TPI, chiropractor. pain thought to be myofascial
Reported in notes to have seen rheum, with a Dx of fibromyalgia,
but no notes in OMR. Per pt, she disagreed with this Dx as a
'catchall' and did not continue relationship. Dr was located in
___.
Multiple medications (gabapentin, lamotrigine, carbamazepine,
amitriptyline, venlafaxine, bupropion) have either caused
significant side effects or have been ineffective.
In ED
VS
Labs: wbc 11, hb 12.5, plt 146, INR 1.5; no chemistry obtained;
UA
EKG noted to have brady to 44
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
thyroid disease (not on meds), remote cervical cancer, panic
attacks, anxiety, depression, history of alcoholism in the past
and some type of viral meningitis in ___, GERD
Social History:
___
Family History:
Diabetes, heart disease, glaucoma in the mother who is ___.
Father was an alcoholic. Brother passed at ___ from hardening of
the arteries due to drug and alcohol use, another brother with
diabetes drug and alcohol abuse and a fourth brother atrial
fibrillation as well. Daughter passed at ___ months of age
from a fire, has a daughter who is ___, grandmother with heart
disease.
Physical Exam:
Admission Physical Exam:
========================
VITALS: Afebrile and vital signs reviewed, SBP 110-110s in ED
(b/l is the same), HR 48 on arrival
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. Grossly
decreased hearing in Rt vs the left ear
CV: Heart regular but brady, 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, ___ UE and ___, CN2-12 intact;
sensation to light touch grossly intact throughout
PSYCH: pleasant, appropriate affect
Discharge Physical Exam:
========================
VITALS: see Eflowsheets
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.
neck: full ROM, able to flex/extend no signs of meningismus
CV: Heart regular but brady, 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, ___ UE and ___, CN2-12 intact;
sensation to light touch grossly intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission Labs:
===============
___ 06:25AM BLOOD WBC-7.5 RBC-3.74* Hgb-11.9 Hct-36.1
MCV-97 MCH-31.8 MCHC-33.0 RDW-12.3 RDWSD-43.0 Plt ___
___ 05:55AM BLOOD WBC-8.3 RBC-3.76* Hgb-11.8 Hct-36.0
MCV-96 MCH-31.4 MCHC-32.8 RDW-12.3 RDWSD-43.5 Plt ___
___ 06:59PM BLOOD WBC-11.2* RBC-3.85* Hgb-12.5 Hct-37.7
MCV-98 MCH-32.5* MCHC-33.2 RDW-12.3 RDWSD-44.4 Plt ___
___ 06:59PM BLOOD Neuts-52.4 ___ Monos-9.0 Eos-0.9*
Baso-0.5 Im ___ AbsNeut-5.85 AbsLymp-4.12* AbsMono-1.00*
AbsEos-0.10 AbsBaso-0.06
___ 07:41PM BLOOD ___ PTT-36.5 ___
___ 05:55AM BLOOD Glucose-97 UreaN-14 Creat-0.7 Na-145
K-4.1 Cl-106 HCO3-29 AnGap-10
___ 05:55AM BLOOD ALT-14 CK(CPK)-57 AlkPhos-57 TotBili-0.4
___ 05:55AM BLOOD Lipase-52
___ 05:55AM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:55AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.1
___ 05:55AM BLOOD TSH-1.8
___ 05:55AM BLOOD Cortsol-8.7
___ 07:47PM BLOOD Lactate-0.6
Imaging:
========
CXR:
IMPRESSION:
No acute intrathoracic process.
Brain MRI:
IMPRESSION:
1. No acute intracranial abnormality or evidence of intracranial
hypotension.
Micro data:
___ GPCs, GNR
Discharge Labs:
===============
___ 05:21AM BLOOD WBC-6.9 RBC-3.57* Hgb-11.5 Hct-34.7
MCV-97 MCH-32.2* MCHC-33.1 RDW-12.5 RDWSD-44.6 Plt ___
___ 05:21AM BLOOD Glucose-81 UreaN-13 Creat-0.7 Na-146
K-3.8 Cl-107 HCO3-27 AnGap-12
___ 05:21AM BLOOD Calcium-8.2* Phos-4.6* Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ female with the past medical
history of thyroid disease, remote cervical cancer, panic
attacks with anx/depression, history of alcoholism, viral
meningitis ___, GERD who presented with hypotension, nausea,
and acute on chronic headaches found to have polymicrobial
bacteremia.
# Concern for polymicrobial blood steam infection: blood
cultures from ___ grew CONS in one set, Pantoea in one bottle
only. Additional set of blood cultures were ___ were negative.
Additional culture from ___ (prior to antibiotic therapy
initiation) was also negative. After cultures returned positive
she was started on IV ceftriaxone. In terms of symptoms of
possible infection, she had no localizing symptoms other than
headache. She did have hypotension as below, but this may have
been due to volume depletion. She was seen by the infectious
disease team who felt that her positive cultures were a
contaminant. They recommended discontinuation of antibiotics.
She was advised to return to the emergency room if she developed
fever, dizziness, or any other concerning symptoms at home.
# Hypotension: developed hypotension with systolics ___. She
was likely volume depleted from anorexia secondary to headaches.
TSH and cortisol were within normal limits. Due to concern for
sepsis as the etiology of hypotension given positive blood
cultures, she was also treated with antibiotics as above. These
were discontinued after cultures were felt to be a contaminant.
She had no further hypotension during her hospital course.
# Sinus bradycardia: presented with sinus bradycardia to the ___
of unclear etiology. There was no evidence of AV block. TSH was
normal. Her outpatient heart rates usually ranged in the ___
with occasional values in the ___. Heart rates were in the
___ range on the day prior to discharge.
# Headaches:
# Chronic pain:
Described shock-like headaches as well as a more recent
progressively which are unchanged from chronic pain persisting
since encephalitis diagnosis years ago. There were no focal
deficits apart from possible decreased hearing in right ear.
There were no signs of meningitis or encephalitis. Neurology was
consulted and recommended MRI which was normal and also
recommended Topamax for headaches as follows:
- Topiramate 25mg PO qHS x 5 days
-> increase to 50mg PO qHS x 1 week
-> increase to 75mg PO qHS x 1 week
-> increase to 100mg PO qHS = goal dose
She was provided with home pain regimen equivalent - could not
receive vicodin here as she would receive too much acetaminophen
(we have only ___. She was treated with oxycodone as needed
and home vicodin was restarted at time of discharge.
CHRONIC/STABLE PROBLEMS:
# Depression/anxiety: continued home Ativan, paroxetine,
clonidine
> 30 minutes spent on discharge coordination and planning
Transitional Issues:
- started on topiramate with plan to uptitrate dose to 100mg:
-> topiramate 25mg QHS X 5 days (completed while
hospitalized)
-> topiramate 50mg PO at bedtime x 1 week
-> increase to 75mg PO at bedtime x 1 week (start on ___
-> increase to 100mg PO at bedtime = goal dose (start on
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CloniDINE 0.1-0.2 mg PO BID:PRN anxiety
2. Omeprazole 20 mg PO DAILY
3. Diazepam 5 mg PO Q12H:PRN pain, brain shocks, anxiety
4. HYDROcodone-acetaminophen ___ mg oral Q6H:PRN pain
5. Ibuprofen 600 mg PO Q8H:PRN pain
6. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
7. PARoxetine 30 mg PO DAILY
8. Calcium Carbonate 1000 mg PO DAILY
9. ipratropium bromide 42 mcg (0.06 %) nasal TID
Discharge Medications:
1. Topiramate (Topamax) 50 mg PO QHS
increase to 75mg on ___, then increase to 100mg on ___
RX *topiramate 50 mg 1 tablet(s) by mouth at bedtime Disp #*32
Tablet Refills:*0
2. Calcium Carbonate 1000 mg PO DAILY
3. CloniDINE 0.1-0.2 mg PO BID:PRN anxiety
4. Diazepam 5 mg PO Q12H:PRN pain, brain shocks, anxiety
5. GenTeal Tears (dxtrn-hpm-gly) (artificial
tear(dxtrn-hpm-gly)) 0.1-0.3-0.2 % ophthalmic (eye) QID:PRN
6. HYDROcodone-acetaminophen ___ mg oral Q6H:PRN pain
7. Ibuprofen 600 mg PO Q8H:PRN pain
8. ipratropium bromide 42 mcg (0.06 %) nasal TID
9. Omeprazole 20 mg PO DAILY
10. PARoxetine 30 mg PO DAILY
11. urea 10 % topical DAILY:PRN
12. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic headache
Hypotension
Bradycardia
Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for evaluation of low blood pressure, low
heart rate, and headaches. For your headaches, you were
evaluated by the neurology team who recommended the initiation
of Topamax for pain and an MRI that was normal. Please see below
for the Topamax dosing instructions.
Topiramate 50mg PO at bedtime x 1 week
-> increase to 75mg PO at bedtime x 1 week (start on ___
-> increase to 100mg PO at bedtime = goal dose (start on
___
You were also found to have a bacteria in your blood. You were
seen by the infectious disease team who thought that this was
likely due to contamination of your blood cultures. They did not
feel that you had any signs of a true infection.
If you develop fevers, dizziness, or any other concerning
symptoms, please call your primary doctor or return to the
emergency room.
It was a pleasure taking care of you and we are happy that
you're feeling better!
Followup Instructions:
___
|
19887057-DS-5 | 19,887,057 | 21,690,920 | DS | 5 | 2149-08-11 00:00:00 | 2149-08-11 18:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / cefaclor / clindamycin / Levaquin / sulfamethoxazole /
Biaxin / Augmentin / Cephalosporins
Attending: ___.
Chief Complaint:
Diarrhea, Falls, Increased Weakess
Major Surgical or Invasive Procedure:
Lumbar Puncture ___
History of Present Illness:
Ms. ___ is a ___ female with history of
muscular ___ disease and stage IV
Hodgkin lymphoma on clinical trial ___ (nivolumab + ABVD,
last
dose on ___ complicated by recent admission for diarrhea due
to proctocolitis thought to be viral in etiology who presents
with diarrhea.
She started having sudden watery non-bloody greenish diarrhea
about 4 times/hour with incontinence on the ___ prior to
admission. She is also having nausea without any episode of
emesis. She notes intermittent abdominal cramping. She also had
a
fall on ___ morning. She was sitting on her walker and
attempting to stand up when she notes that she felt very weak
and
her knees buckled. She slid onto the ground and landed on her
bottom. She denies head strike and LOC. She denies preceding
shortness of breath, chest pain, palpitations, dizziness, and
seizure activity. She does note that she urinated in her pants
while on the ground but denies incontinence. Her daughter was
home and helped her off the floor.
She was seen at ___ ED the day prior to admission.
Labs were unremarkable. She was afebrile. She had a CXR which
showed no acute findings. She had CT Abdomen/Pelvis which did
not
show any acute abdominal process. She received dilaudid 0.5mg
IV,
Zofran 4mg IV, and 1L NS. She was discharged home with
prescriptions for Zofran and Percocet. At home she was able to
tolerate some food and went to bed.
She awoke the morning of admission and had not more episodes of
watery non-bloody diarrhea. She took a shower. Given the
continued diarrhea, she called her outpatient Oncologist who
referred her to the ED.
She denies any recent travel. She denies sick contacts. She
denies any raw or undercooked food/seafood. She has several pets
at home including a hamster, three cats, and fish. She notes
that
about 1 month ago her daughter pulled ___ tick off of her
neck. She denies any associated rashes.
Of note, patient had brief admission ___ for diarrhea
with
imaging finding of procto-colitis that was thought to be viral
in
origin, patient treated with PO metronidazole with resolution by
the time of discharge. Stool studies were negative.
In the ED, initial vitals were: 98.7 82 126/63 18 100% RA. Labs
were notable for WBC 5.6, H/H 10.5/32.1, Plt 151, INR 1.0, Na
134, K 3.4, BUN/Cr ___, lactate 1.0, and UA negative. Pelvis
x-ray was negative for fracture. She had blood and urine
cultures. Patient was given morphine 2mg IV x 2 and Zofran 4mg
IV. She did not have any further episodes of diarrhea while in
the ED. Prior to transfer vitals were: 98.3 72 131/60 16 96% RA.
On arrival to the floor, patient reports ___ bilateral
shoulder
blade pain for the past two week and bilateral neck pain for the
past one week. Her pain on her tail bone is not severe. Her
abdominal cramps are improving. She notes chills and nights
sweats but no fevers. She feels very weak. She also notes
headache. She denies dizziness/lightheadedness, shortness of
breath, cough, hemoptysis, chest pain, palpitations, vomiting,
hematemesis, hematochezia/melena, dysuria, hematuria, and new
rashes.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
--___, the patient had trouble obtaining her thyroid
medication due to unclear reasons and ended up missing many
doses. She then had a lot of anger issues, cutting up pictures
of her family and basically could not take care of herself at
that time. She was hospitalized and sectioned to ___
___;
details are of that hospitalization is unclear. Per report from
her 2 daughters and the patient, her thyroid medication was
restarted and she stabilized.
--___: and she started to have very high fevers to
105.9,,
106, almost on a nightly basis and was rigoring. This actually
continued through ___ and ___ and ___ it does not appear
they
sought medical care during this time.
--___: her family tells me her next presentation to
healthcare was at an ER when they were down in ___
___.
She ended up getting discharged from the ER for fevers of
unclear
etiology at this point.
--___: she was admitted to ___ and diagnosed
with Lyme disease. She says she was treated with vancomycin and
doxycycline at this time and she was scanned and found to have
diffuse lymphadenopathy. A lymph node was biopsied at this time
it was inconclusive. She has followup with outpatient
hematologist at ___, Dr. ___ had a bone marrow
biopsy done that was also inconclusive.
--Late ___ or early ___: she continued to have
fevers and had worsening symptoms including gagging, nausea,
constipation and had severe night sweats as well where she was
waking up soaked with sweat. Shewent to ___ and
was admitted. At ___, she had the following
workup
done: She had a PET scan done, on ___, which showed
findings consistent with malignant lymphoma with extensive
cervical right hilar, mediastinal, bilateral lower lobe
peribronchial, right internal mammary, porta hepatis, periaortic
and bilateral iliac lymphadenopathy. She had two lung nodules
that showed significant increased glucose at the right lung base
and left lower lobe superior segment. She also had a possible
lymphoma deposit in the right hepatic lobe, segment VIII and
multiple tumors are present in the spleen. She had a right
anterior T5 metastatic bone tumor present as well. She had an
echocardiogram done that showed a normal EF. Additionally, she
had a supraclavicular lymph node excisional biopsy. She had
actually three biopsy. She had cervical lymph node 2 and 4R
lymph node. The pathology revealed classical Hodgkin's lymphoma
with mixed cellularity. She was seen by an oncologist locally,
who referred her here for further care.
--Initial heme/onc evaluation: Patient offered clinical trial
___, Cohort D: Phase 2 Study of Nivolumab (___) in
newly diagnosed, previously untreated classical Hodgkin Lymphoma
(cHL) subjects
--___: C1D1 Nivolumab on trial ___: C2D1 Nivolumab
--___: C3D1 Nivolumab
--___: Seen in ___ area for diarrhea, received IVF. Stool
studies could not be obtained as symptoms resolved.
--___: C4D1 Nivolumab
--___: C1D1 Nivo + AD
--___: C1D15 Nivo + AD
--___: C2D1 Nivo + AD
--___: C2D15 Nivo + AD
--___ to ___: Admitted for influenza, discharged with 28 day
course of influenza.
--___: Cycle 3 day 1 Nivo + AD. Scans with continued
response overall. There is low level FDG uptake in the
bilateral
axillary and inguinal inguinal nodes are unchanged. There is
also new focal FDG avidity within the T7 vertebral body that did
not have a CT correlate.
--___: C3D15 Nivo + AD
--___: C4D1 Nivo + AD
--___: C4D15 Nivo + AD
--___: C5D1 Nivo + AD
--___: C5D13 Nivo + AD
--___: C6D1 Nivo + AD
PAST MEDICAL HISTORY:
-Muscular dystrophy, ___ since age ___ that was
diagnosed. Unclear as to which genotype she has.
-thyroidectomy for unclear reasons with subsequent
hypothyroidism
that was in ___.
-Anxiety, depression
Social History:
___
Family History:
Her mother had lung and cervical cancer, father had lung cancer.
Her daughter has ___ syndrome, tubulointerstitial nephritis
and uveitis.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T98.3 BP126/76 HR81 RR18 94%Ra
GENERAL: Friendly, anxious, engaging, NAD.
HEENT: Anicteric, PERRL, MMM, OP clear.
CARDIAC: Regular rate and rhythm, normal heart sounds, no
murmurs, rubs or gallops.
LUNG: CTABL, no m/r/g
ABD: Non-distended, normal bowel sounds, soft, non-tender. No
guarding.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: A&Ox3. Decreases lower extremity strength (4+/5 bilat)
and
sensation at baseline per patient.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema or tenderness to
palpation.
DISCHARGE PHYSICAL EXAM:
VS: T98.0 BP99/63 HR81 RR18 96%Ra
GENERAL: NAD distress, cheerful, eating bagel.
HEENT: Anicteric, MMM, OP clear.
CARDIAC: RRR, no murmurs, rubs or gallops.
LUNG: CTABL
ABD: Non-distended, normal bowel sounds, soft, non-tender. No
guarding.
EXT: Warm, well perfused. No lower extremity edema. NEURO:
A&Ox3.
Decreases lower extremity strength (4+/5 bilat) and
sensation at baseline per patient.
SKIN: erythematous area on sacrum with skin breakdown. LP site
w/o erythema or exudate.
ACCESS: Right chest wall port
Pertinent Results:
ADMISSION LABS:
================
___ 12:47PM BLOOD WBC-5.6 RBC-3.45* Hgb-10.5* Hct-32.1*
MCV-93 MCH-30.4 MCHC-32.7 RDW-14.6 RDWSD-49.5* Plt ___
___ 12:47PM BLOOD Neuts-71.6* Lymphs-18.6* Monos-7.7
Eos-1.3 Baso-0.4 Im ___ AbsNeut-3.98 AbsLymp-1.03*
AbsMono-0.43 AbsEos-0.07 AbsBaso-0.02
___ 12:47PM BLOOD Glucose-118* UreaN-8 Creat-0.3* Na-143
K-3.4 Cl-110* HCO3-20* AnGap-13
___ 12:47PM BLOOD ALT-6 AST-12 AlkPhos-51 TotBili-<0.2
___ 12:47PM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.2 Mg-1.7
___ 06:51AM BLOOD calTIBC-246* VitB12-516 Ferritn-59
TRF-189*
___ 12:47PM BLOOD TSH-0.37
___ 05:47AM BLOOD T4-6.7 Free T4-1.4
___ 06:51AM BLOOD CRP-1.6
___ 12:58PM BLOOD Lactate-1.0
PERTINENT INTERVAL LABS:
========================
___ 04:31AM BLOOD CK(CPK)-19*
___ 04:31AM BLOOD ACETYLCHOLINE RECEPTOR MODULATING
ANTIBODY-PND
___ 04:31AM BLOOD ACETYLCHOLINE RECEPTOR ANTIBODY-NEG
___ 04:31AM BLOOD ALDOLASE-PND
___ 07:23AM BLOOD SED RATE-2
___ 04:51PM CEREBROSPINAL FLUID (CSF) TNC-2 RBC-1 Polys-1
___ Monos-15 Other-2
___ 04:51PM CEREBROSPINAL FLUID (CSF) TotProt-110*
Glucose-67
DISCHARGE LABS:
===============
___ 06:03AM BLOOD WBC-3.8* RBC-3.67* Hgb-11.1* Hct-34.5
MCV-94 MCH-30.2 MCHC-32.2 RDW-14.7 RDWSD-51.1* Plt ___
___ 06:03AM BLOOD Glucose-104* UreaN-12 Creat-0.5 Na-139
K-4.7 Cl-98 HCO3-30 AnGap-11
___ 06:03AM BLOOD Calcium-9.5 Phos-4.6* Mg-1.7
MICROBIOLOGY:
=============
__________________________________________________________
___ 5:31 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
__________________________________________________________
___ 12:47 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
=========
RENAL U.S. Study Date of ___ 5:16 ___
No cystic lesions are seen in the left kidney. Small septated
cyst right
kidney.
MR ___ W/O CONTRAST Study Date of ___ 7:38 ___
1. There is diffuse thickening and abnormal enhancement of the
cervical and thoracic ventral and dorsal nerve roots as well as
of the cauda equina and lumbar peripheral nerves. Overall the
findings are compatible with given history of
___. However, given the patient's history of
stage IV lymphoma, lymphomas involvement should be excluded.
2. No definite cord signal abnormality is identified. There is
no evidence of high-grade spinal canal or neural foraminal
narrowing.
3. Multiple nonenhancing T2 hypointense cystic lesions in the
left kidney
measuring up to 1 cm, likely representing hemorrhagic cysts.
This could be further evaluated with ultrasound.
4. Bilateral dependent atelectasis of the lung bases. Clinical
correlation for more confluent focus in the right lung base for
superimposed consolidation.
5. Additional findings as described above.
EMG ___
Abnormal, limited study. Based on the studies performed, there
is no
electrophysiologic evidence for myopathic process. Incidentally,
the findings are suggestive of a generalized sensorimotor
polyneuropathy that was incompletely characterized by the
present study.
Brief Hospital Course:
Ms. ___ is a ___ female with history of
muscular ___ disease and stage IV
Hodgkin lymphoma on clinical trial ___ (nivolumab + ABVD,
last dose on ___, recent history of proctocolitis,
presenting with reported diarrhea, falls, and proximal ___
weakness.
===ACUTE ISSUES===
#Fall
#Proximal, bilateral lower extremity weakness
#Muscular dystrophy
___:
Neurology was consulted given patient's report of lower
extremity weakness and falls. Likely the cause of her reported
increase in falls at home and need for help w ADLs. No head
strike or other concerning symptoms. Pelvic x-ray without
fracture. MRI spine with diffuse enhancement of nerve roots, EMG
limited in scope but not indicative of myopathy. B12 and CK
normal. Acetylcholinesterase antibodies pending. Lumbar puncture
___ to r/o CNS spread of lymphoma was negative on prelim
path. CSF w high protein thought likely to be from known CMT.
Most likely cause of weakness thought to be worsening CMT.
Discharge to rehab to improve functional status and safety at
home with non-urgent outpatient neuro f/u.
#Report of Diarrhea: Patient did not have any episodes of
diarrhea during hospitalization. Stool studies were not sent.
#Small septated cyst right kidney: Incidentally noted left renal
cysts on MRI, followed up with U/S, one cyst noted on the right.
Should have Renal phase MRI for further evaluation done as
outpatient.
===CHRONIC ISSUES===
#Stage IV Hodgkin Lymphoma: On clinical trial ___ (nivolumab
+ ABVD). Completed last dose of chemotherapy on ___. Has
staging studies planned for ___.
#Chronic Pain: Patient now also with neck and shoulder pain.
Continued home MS ___ 15mg q12h and oxycodone. Patient's home
PRN oxycodone was increased to Q4H:PRN for increased neck pain.
#Hypothyroidism s/p thyroidectomy: Continue home synthroid,
thyroid studies reassuring
#Anemia: Secondary to malignancy. No evidence of active
bleeding. H/H stable throughout hospitalization.
===TRANSITIONAL ISSUES===
-___ final LP pathology reports
-___ final Aldolase and Acetylcholine Receptor Modulating
Antibody
-Needs Renal phase MRI for further evaluation as outpatient to
further evaluate R sided septate cyst.
-Staging CTs scheduled for ___.
-Patient's home PRN oxycodone was increased to Q4H:PRN for
increased neck pain.
-Patient should call outpatient neurologist within 1 month to
schedule appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Morphine SR (MS ___ 15 mg PO Q12H
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild
5. Ondansetron 4 mg PO BID:PRN nausea/vomiting
6. Ibuprofen 400-600 mg PO Q8H:PRN Pain - Mild
7. LORazepam 0.5 mg PO BID:PRN anxiety/nausea
8. Prochlorperazine 10 mg PO Q6H:PRN nuasea/vomiting
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Polyethylene Glycol 17 g PO DAILY
3. Senna 8.6 mg PO BID:PRN constipation
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Mild
hold for oversedation, RR<12
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4H:PRN Disp #*5 Tablet
Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. Ibuprofen 400-600 mg PO Q8H:PRN Pain - Mild
7. Levothyroxine Sodium 150 mcg PO DAILY
8. LORazepam 0.5 mg PO BID:PRN anxiety/nausea
9. Morphine SR (MS ___ 15 mg PO Q12H
10. Ondansetron 4 mg PO BID:PRN nausea/vomiting
11. Prochlorperazine 10 mg PO Q6H:PRN nuasea/vomiting
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Fall
#Proximal, bilateral lower extremity weakness
#Muscular dystrophy
___
#Stage IV Hodgkin Lymphoma
#Hypothyroidism s/p thyroidectomy
#Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you had diarrhea,
increased weakness, and falls at home.
You did not have any diarrhea in the hospital.
Your weakness was evaluated by the neurologists, who think it is
probably from your ___ disease. Your tests from
your lumbar puncture suggest that it is very unlikely that your
symptoms are from lymphoma, which is excellent news.
You are going to rehab to gain strength and will have an
appointment with your neurologist to follow-up. Please see below
for all of your medications and follow-up appointments.
We wish you the best in your recovery,
___ Oncology Team
Followup Instructions:
___
|
19887262-DS-8 | 19,887,262 | 27,243,050 | DS | 8 | 2176-05-26 00:00:00 | 2176-05-31 17:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain for 4 days with an inability
to tolerate anything PO
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ h/o dementia, Afib and DVT/PE (w/ IVC filter), on
Coumadin, p/w abd pain, n/v, txf from ___ w/ SBO and NSTEMI.
Ms. ___ has been having abd pain for 4 days with an
inability
to tolerate anything PO. In addition, she had a fall yesterday
___, but patient's daughter was able to help her to the
ground
so she had no head strike or suffer any trauma.
An EKG was obtained which showed Afib, a HR of 127, left axis
deviation, and no ST elevations or depression. At bedside, she
denies any chest pain or abd pain. She does not appear septic
and
endorses no Sx. However, her last bowel movement was 2 days ago
and she has not passed any gas during that time with minimal
appetite. Ms. ___ denies fevers, chills, nausea, vomiting,
diarrhea, or nay neuro Sx.
A CT scan shows a small bowel obstruction with abrupt transition
in the left lower quadrant with significant distention in the
stomach and multiple air-fluid levels.
Past Medical History:
PMH: anxiety, dementia, DVT (with IVC filter), HLD, HTN, ovarian
cancer, PE
PSH: C-section, hernia repair with mesh, hysterectomy
Social History:
___
Family History:
NC
Physical Exam:
Admission:
Gen: AAO x 3. in NAD, very alert.
HEENT: EOMI
Lungs: CTAB
CV: Sinus tach. no m/r/g
Abd: Soft, ND. Distended. No masses palpated.
Neuro: Grossly intact
Extrem: mild edema in b/l lower extremities. no cyanosis or
clubbing.
Neuro: Grossly intact
Discharge:
Gen: AAO x 3. in NAD, very alert.
HEENT: EOMI
Lungs: CTAB
CV: Sinus tach. no m/r/g
Abd: Soft, non-tender, non-distended. No masses palpated.
Neuro: Grossly intact
Extrem: mild edema in b/l lower extremities. no cyanosis or
clubbing.
Neuro: Grossly intact
Pertinent Results:
___ 05:28AM BLOOD WBC-7.7 RBC-3.22* Hgb-10.5* Hct-33.0*
MCV-103* MCH-32.6* MCHC-31.8* RDW-13.6 RDWSD-51.2* Plt ___
___ 06:55AM BLOOD WBC-7.1 RBC-3.07* Hgb-10.0* Hct-31.7*
MCV-103* MCH-32.6* MCHC-31.5* RDW-13.9 RDWSD-53.5* Plt ___
___ 08:00AM BLOOD WBC-4.8 RBC-3.19* Hgb-10.4* Hct-32.3*
MCV-101* MCH-32.6* MCHC-32.2 RDW-13.9 RDWSD-51.1* Plt ___
___ 01:45AM BLOOD WBC-4.2 RBC-4.35 Hgb-14.5 Hct-43.1
MCV-99* MCH-33.3* MCHC-33.6 RDW-14.0 RDWSD-51.4* Plt ___
___ 06:26PM BLOOD WBC-4.3 RBC-4.26 Hgb-14.0 Hct-41.0 MCV-96
MCH-32.9* MCHC-34.1 RDW-13.8 RDWSD-48.8* Plt ___
___ 06:26PM BLOOD Neuts-43 Bands-27* ___ Monos-10
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-3.01 AbsLymp-0.86*
AbsMono-0.43 AbsEos-0.00* AbsBaso-0.00*
___ 05:28AM BLOOD Plt ___
___ 07:38AM BLOOD ___ PTT-30.3 ___
___ 06:55AM BLOOD Plt ___
___ 06:55AM BLOOD ___ PTT-42.4* ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD ___ PTT-37.5* ___
___ 01:45AM BLOOD Plt ___
___ 01:45AM BLOOD ___ PTT-29.5 ___
___ 06:26PM BLOOD Plt Smr-NORMAL Plt ___
___ 06:26PM BLOOD ___ PTT-25.7 ___
___ 05:28AM BLOOD Glucose-101* UreaN-12 Creat-0.8 Na-143
K-3.7 Cl-103 HCO3-29 AnGap-11
___ 03:15PM BLOOD Glucose-100 UreaN-22* Creat-0.9 Na-144
K-3.9 Cl-101 HCO3-34* AnGap-9*
___ 06:55AM BLOOD Glucose-108* UreaN-28* Creat-1.0 Na-143
K-3.8 Cl-100 HCO3-34* AnGap-9*
___ 08:00AM BLOOD Glucose-119* UreaN-40* Creat-1.6* Na-140
K-3.5 Cl-95* HCO3-34* AnGap-11
___ 03:30PM BLOOD Glucose-123* UreaN-41* Creat-2.0* Na-141
K-3.3* Cl-95* HCO3-34* AnGap-12
___ 08:34AM BLOOD Glucose-128* UreaN-46* Creat-2.4* Na-142
K-3.5 Cl-92* HCO3-36* AnGap-14
___ 01:45AM BLOOD Glucose-185* UreaN-43* Creat-2.2* Na-143
K-4.0 Cl-92* HCO3-35* AnGap-16
___ 06:26PM BLOOD Glucose-164* UreaN-35* Creat-2.0* Na-140
K-4.2 Cl-94* HCO3-26 AnGap-20*
___ 06:26PM BLOOD CK(CPK)-78
___ 08:34AM BLOOD CK-MB-5 cTropnT-0.05*
___ 01:45AM BLOOD CK-MB-8 cTropnT-0.05*
___ 06:26PM BLOOD cTropnT-0.04*
___ 06:26PM BLOOD CK-MB-4
___ 05:28AM BLOOD Calcium-8.5 Phos-2.0* Mg-2.1
___ 03:15PM BLOOD Calcium-8.6 Phos-2.8 Mg-2.5
___ 06:55AM BLOOD Calcium-8.7 Phos-1.7* Mg-2.8*
___ 08:00AM BLOOD Calcium-8.3* Phos-2.6* Mg-3.1*
___ 03:30PM BLOOD Calcium-7.9* Phos-2.9 Mg-3.6*
___ 08:34AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.7
___ 01:45AM BLOOD Calcium-9.7 Phos-5.0* Mg-1.9
___ 09:23AM BLOOD ___ pO2-30* pCO2-65* pH-7.43
calTCO2-45* Base XS-15 Comment-PERIPHERAL
___ 02:04AM BLOOD Type-ART pO2-66* pCO2-48* pH-7.48*
calTCO2-37* Base XS-10
___ 09:23AM BLOOD Lactate-1.7
___ 09:14PM BLOOD Lactate-2.8*
___ portable KUB:
Contrast extends from dilated small bowel into colon.
Brief Hospital Course:
Ms. ___ was admitted to ___
with abdominal pain and the inability to tolerate any substances
by mouth on ___. She also suffered a fall without head trauma
on ___. An EKG was obtained which showed atrial fibrillation.
A CT scan demonstrated a small bowel obstruction. She was placed
on bowel rest, given intravenous fluids, and given pain
medication as needed. She was medically cleared and discharged
on ___.
___ Warfarin resumed, reg diet, HLIV, R shoulder limited-
Xray chronic ___
___ BMx1, UA-UTI, DC'ed foley, O2 sat high ___
Advair. FENa 0.2, vit k
___ Gastrograffin KUB- contrast in colon, BM +. DC'd NGT,
adv to clears
___ Trigger for low BP & tachy- 1L bolus given. 5 IV metop
x 3. 10 dilt.
___ txf to TSICU for low SBP & Afib RVR
___ admit to ACS. NPO, IVF, NGT.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol Inhaler 1 PUFF IH Q6H SOB
3. Aspirin 81 mg PO DAILY
4. Metoprolol Tartrate 75 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
SBO and atrial fibrillation
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 ___ with
abdominal pain and the inability to tolerate any substances by
mouth on ___. You also suffered a fall without head trauma on
___. An EKG was obtained which showed atrial fibrillation. A
CT scan demonstrated a small bowel obstruction. You were placed
on bowel rest, given intravenous fluids, and given pain
medication as needed. You are recovering well and are now ready
for discharge.
Please follow the instructions below to continue your recovery:
Please continue taking your Coumadin/warfarin.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
|
19887349-DS-16 | 19,887,349 | 26,179,448 | DS | 16 | 2176-05-14 00:00:00 | 2176-05-16 21:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
glipizide
Attending: ___
Chief Complaint:
Vulvar abscess
Major Surgical or Invasive Procedure:
vulvar wound debridement, delayed primary closure
History of Present Illness:
Ms. ___ is a ___ female with T2DM, HTN, hypothyroidism,
POD#9 from an anterior and right radical hemi vulvectomy for at
least 1b SCC of the vulva, who was admitted for a vulvar
abscess. She reported pain, swelling and redness of her vulva at
that time of presentation on ___. On evaluation, patient
endorsed noticing worsening vulvar discharge and horrible smell
from the genital area on POD4. She was seen by a family member
who is an ___ who recommended she present to the ER for further
evaluation.
Past Medical History:
OB: G4P___
- SVD x3
- SAB x1
GYN:
- LMP: menopause at ___ yo, denies h/o hormone replacement
therapy
- Sexually active: denies
- STIs: denies
- Contraception: n/a
- Pap: ___, wnl per patient
- h/o endometriosis, fibroids, cysts: denies
PMH:
- T2DM, checks ___ once a week, ~170
- HLD (hyperlipidemia)
- HTN (hypertension)
- Hypothyroid
PSH:
- Appendectomy (open) age ___. Not ruptured
- D&C
- Anterior and right radical hemi vulvectomy
ALL:
- glipizide, rash
Social History:
___
Family History:
Denies family history of GYN cancer, sister with breast cancer
diagnosed ___, alive, No colon cancer.
Physical Exam:
PREOPERATIVE PHYSCIAL EXAM:
General: NAD, uncomfortable, slow to move, non-toxic appearing
CV: RRR
Resp: mild crackles lower to middle posterior lobe bilaterally
Abd: soft, non-tender, non-distended
Ext: non-tender, no edema
Pelvic: 4 x 2 cm lesion with purulent exudate along the right
labia minorum to perineum ___ o'clock position), severely
tender, induration along the 11 o'clock position,
non-erythematous, minimally tender, clitoral incision with scant
purulence with stiches intact, declined speculum exam and
therefore unable to examine visually or palpate vagina
PHYSICAL EXAM ON DISCHARGE:
PE: Comfortable, resting in bed
CV: RRR, no murmurs, rubs, or gallops
Pulm: CTAB, no wheezes or crackles
Abd: soft, non distended, non tender, no rebound or guarding.
GU: R vulvar region w/ minimal erythematous, sutures in place
with dermabond overlying incision, stool in surrounding area No
fluctuance, or induration.
Ext: warm and well perfused, pneumoboots in place
Pertinent Results:
___ 06:22AM BLOOD WBC-10.8* RBC-3.98 Hgb-11.9 Hct-35.4
MCV-89 MCH-29.9 MCHC-33.6 RDW-13.6 RDWSD-44.3 Plt ___
___ 06:00PM BLOOD WBC-17.9*# RBC-4.81 Hgb-14.2 Hct-41.6
MCV-87 MCH-29.5 MCHC-34.1 RDW-12.7 RDWSD-40.4 Plt ___
___ 06:05AM BLOOD Neuts-59.3 ___ Monos-8.6 Eos-3.7
Baso-0.8 Im ___ AbsNeut-6.83* AbsLymp-3.10 AbsMono-0.99*
AbsEos-0.42 AbsBaso-0.09*
___ 06:00PM BLOOD Neuts-74.1* Lymphs-16.7* Monos-6.7
Eos-1.2 Baso-0.4 Im ___ AbsNeut-13.22* AbsLymp-2.98
AbsMono-1.20* AbsEos-0.21 AbsBaso-0.08
___ 11:25AM BLOOD ___ PTT-28.1 ___
___ 06:22AM BLOOD Glucose-160* UreaN-10 Creat-0.9 Na-143
K-3.9 Cl-97 HCO3-25 AnGap-21*
___ 06:00PM BLOOD Glucose-252* UreaN-27* Creat-0.6 Na-136
K-3.8 Cl-93* HCO3-24 AnGap-19*
___ 11:25AM BLOOD ALT-12 AST-10 CK(CPK)-18*
___ 06:22AM BLOOD Calcium-9.1 Phos-4.5 Mg-2.0
___ 02:58AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.4*
___ tissue, debridgement
Right vulvar debridement:
Benign fibroadipose tissue with acute and chronic inflammation,
granulation tissue, and fat necrosis.
___- CT pelvis w/contrast
1. The patient is post-operative day 9 from anterior and right
radical
hemi-vulvectomy.
2. 4.1 x 2.3 cm area of fluid and multiple foci of gas without a
definite rim,
concerning for phlegmon or developing abscess in the
subcutaneous space
inferior to the mons pubis and superior to the right labia.
This does not
represent a drainable fluid collection.
___- Tissue: Vulva, biospy
Right vulvar skin bridge, excision:
- Skin and subcutis with changes consistent with prior surgical
site, mixed acute and chronic inflammatory cell infiltrate, and
focal fat necrosis.
___- Dx chest portable PICC
Right PICC line tip is at the level of lower SVC. Heart size
and mediastinum
are stable. Lungs are clear. There is no pleural effusion or
pneumothorax.
Brief Hospital Course:
Ms. ___ was admitted to the gynecologic oncology service
after she was found to have a severe vulvar abscess on post op
day #9 status post anterior and right radical hemi vulvectomy on
___.
*) Right vulvar abscess:
Ms. ___ was admitted on ___. On admission, she underwent an
exam under anesthesia and vulvar debridement for a vulvar wound
abscess. Intraoperative finidings included a 12 x 8cm necrotic
vulvectomy wound bed extending under skin edges 4-5 cm
superiorly to symphysis. A 4 x 3 cm separate necrotic ulcer
extending 2-3 cm inferiorly and 4 cm superiorly/laterally and
connecting to the larger wound defect with overlying ___ll visible necrotic tissue was debrided and packed with
moistened Kerlix packing. Rectum and urethra appeared intact and
uninvolved. A foley was also placed. ID was consulted and she
was subsequently started on broad spectrum antibiotics of
vancomycin, clindamycin, and zosyn. On HD1, she was taken back
to the OR for an exam under anesthesia, wound exploration, and
vulvar debridement. Intraoperative findings included a large
right-sided vulvar defect tracking superiorly towards mons and
right inguinal ligament, urethra and anus in tact. Patient
remained afebrile and stable with pain well controlled with
dilaudid PCA. On HD2, she underwent her third wound debridement
at which time a wound vac was placed. Her antibiotic regimen was
also narrowed at which time vancomycin and clindamycin were
discontinued and she was continued on zosyn. On HD4, she
underwent her fourth wound debridement and a wound vac changed.
A PICC line was also placed. On HD5, her tissue and wound
cultures resulted and her antibiotics were further changed from
zosyn to IV ceftriaxone and PO flagyl. On HD7, she underwent a
delayed primary closure done by Dr. ___ with intraoperative
findings as follows: Clean wound with 100% granulation. No
purulence. Remaining tissue appears viable. 15 cm in length. A
JP drain was placed. Patient recovered well and continued to be
afebrile with vital signs stable. On HD10, her foley was removed
and she was able to void spontaneously. Her incision continued
to heal well with minimal erythema but with out induration or
fluctuance. On HD11 her JP was removed with out issues. She was
able to ambulate independently, voiding spontaneously,
tolerating a regular diet with out nausea or vomiting. She was
discharged home with ___ services to continue her course of IV
ceftriaxone and PO flagyl until ___.
*) Hypertension
Ms. ___ was continued on her home medication for chronic
hypertension (lisinopril-hydrochlorothiazide ___ mg tablet
daily). Initially her blood pressure was stable however on HD3
and 4 she began having sustained elevated blood pressures to the
180s/90s. She required spot doses of IV hydralazine ranging from
___. Her medication were uptitrated to the maximum dose of
lisinopril and hydrochlorothiazide. She was also started on
labetalol for further control of her blood pressures. On the day
of discharge, she was stable with baseline blood pressures, with
outpatient follow up with her PCP, ___ further
titrating of her hypertension regimen.
*) Loose stools: On HD4 she began having loose stools with stool
incontinence. Patient endorsed a baseline of episodes of stool
incontinence, however, given repeated episodes in the setting of
antibiotic use, a c-diff was obtained. On HD5, the c-diff
resulted as negative. She was placed on stool bulkers. Her wound
was cleaned after every bowel movement to assure the incision
was clean, dry and intact. Her loose stools and incontinence
improved throughout her hospital stay.
*) T2DM: Ms. ___ was placed on an insulin sliding scale with
her home dose of glargine. Her measured blood glucose were
elevated through her admission and thus her insulin sliding
scale was up-titrated to achieve glycemic control. She was
discharged with follow up with Dr. ___ further diabetes
management.
*) Hypothyroidism/ HLD: patient continued on home regimen of
levothyroxine and simvastatin
Patient was discharged home in stable conditioned with ___
health services for aid with IV antibiotics as well as follow up
with Dr. ___, Dr. ___ Dr. ___.
Medications on Admission:
Levothyroxine Sodium 125 mcg PO/NG DAILY
Simvastatin 20 mg PO/NG QPM
Glimepiride 4mg tablet BID
metformin 1,000mg tablet BID
linagliptin 5mg tablet qd
Lisinopril-HCTZ ___ tablet daily
Insulin glargine 20 units PRN
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Do not take more than 4000mg in 24 hours.
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*50 Tablet Refills:*1
2. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 1 package IV
every 24 hours Disp #*8 Intravenous Bag Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN constipation
hold for loose stools.
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
4. Labetalol 100 mg PO BID
RX *labetalol 100 mg 1 tablet(s) by mouth every 12 hours Disp
#*60 Tablet Refills:*0
5. LOPERamide 2 mg PO QID:PRN diarrhea
6. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*24 Tablet Refills:*0
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
do not drink alcohol or drive when on narcotics. ___ make you
drowsy.
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20
Tablet Refills:*0
8. Hydrochlorothiazide 50 mg PO DAILY
RX *hydrochlorothiazide 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
9. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
10. Levothyroxine Sodium 125 mcg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
vulvar wound abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecologic oncology service after
presenting with a wound abscess and undergoing the procedures
listed below. You have recovered well after your procedure, and
the team feels that you are safe to be discharged home. Please
follow these instructions:
* Take your medications as prescribed. We recommend you take
non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first
few days post-operatively, and use the narcotic as needed. As
you start to feel better and need less medication, you should
decrease/stop the narcotic first.
* Take a stool softener to prevent constipation. You were
prescribed Colace. If you continue to feel constipated and have
not had a bowel movement within 48hrs of leaving the hospital
you can take a gentle laxative such as milk of magnesium.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (tylenol) in 24
hrs.
WOUND CARE:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* please use ___ bottle to clean the vulva with warm water
after each time you use the bathroom and pat dry afterwards
* Please use ___ baths ___ times a day starting two days after
surgery to help keep the area clean. please pat dry afterwards.
* Use ice packs on the vulva for ___ days after surgery to help
with the swelling.
* Take Colace stool softener ___ times daily and senna once a
day to help keep your stool soft and prevent constipation and
straining. ___ hold for loose stool.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19887608-DS-4 | 19,887,608 | 20,888,673 | DS | 4 | 2140-09-14 00:00:00 | 2140-09-14 18:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
Left hip hemiarthroplasty ___, Dr. ___
History of Present Illness:
___ w/ dementia, HTN, admitted s/p unwitnessed fall with L
femoral neck fracture.
Patient has advanced dementia with psychotic symptoms and
behavioral disturbance, but is ambulatory at baseline. She had
an unwitnessed fall at ___ in
___ the night prior to presentation.
She was taken to ___, where a CTH/Cspine/Torso showed an
isolated L femoral neck fracture. She was transferred to ___
for surgical management. Of note, patient does have a MOLST
signed by her in ___ stating that she is DNR/I.
Past Medical History:
Dementia with behavioral disturbances and psychotic symptoms
Hypertension
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: AVSS
General: Elderly female, delirious, AOx0, in no acute distress.
Left lower extremity:
- Skin intact
- No deformity, edema, ecchymosis, erythema, induration
- Tender over lateral hip
- Soft, non-tender thigh and leg
- Full, painless ROM at knee and ankle
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
DISCHARGE PHYSICAL EXAM:
========================
VITALS:
24 HR Data (last updated ___ @ 703)
Temp: 97 (Tm 98.4), BP: 140/79 (140-178/70-79), HR: 91
(85-91), RR: 20 (___), O2 sat: 94% (91-95), O2 delivery: RA
GENERAL: Elderly woman in NAD. Sitting upright in
chair
NEURO: AAOx0. Alert and interactive, but rambling
HEENT: NCAT. EOMI. MMM.
CARDIAC: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs,
or gallops.
PULMONARY: CTAB anteriorly
ABDOMEN: Soft, non-tender, non-distended. No rebound.
EXTREMITIES: Warm, well perfused, non-edematous.
SKIN: No significant rashes.
PSYCH: generally calm and pleasant. Occasionally agitated and
even combative when she feels threatened. Compulsively
straightens bedclothes and moves in repetitive stereotyped
fashion when in any distress.
Pertinent Results:
ADMISSION LABS:
===============
___ 08:35AM BLOOD WBC-11.9* RBC-4.06 Hgb-11.7 Hct-36.8
MCV-91 MCH-28.8 MCHC-31.8* RDW-15.1 RDWSD-50.4* Plt ___
___ 08:35AM BLOOD Neuts-83.7* Lymphs-5.2* Monos-10.1
Eos-0.0* Baso-0.3 Im ___ AbsNeut-9.92* AbsLymp-0.62*
AbsMono-1.20* AbsEos-0.00* AbsBaso-0.03
___ 08:35AM BLOOD ___ PTT-27.3 ___
___ 08:35AM BLOOD Glucose-145* UreaN-13 Creat-1.1 Na-141
K-4.0 Cl-103 HCO3-23 AnGap-15
___ 07:40AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.7
DISCHARGE LABS:
===============
___ 08:00AM BLOOD WBC-9.0 RBC-3.14* Hgb-9.2* Hct-28.3*
MCV-90 MCH-29.3 MCHC-32.5 RDW-16.8* RDWSD-53.6* Plt ___
___ 06:10AM BLOOD ___ PTT-27.0 ___
___ 08:00AM BLOOD Glucose-99 UreaN-8 Creat-0.6 Na-146 K-3.5
Cl-105 HCO3-29 AnGap-12
___ 08:00AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.8
STUDIES:
========
DX PELVIS & FEMUR ___
Acute left femoral neck fracture. No additional fractures.
HIP 1 VIEW ___
Left hip hemiarthroplasty, in overall anatomic alignment.
CT HEAD W/O CONTRAST
No acute intracranial process.
HIP (UNILAT 2 VIEW) W/P
1. No evidence of hardware related complications.
2. Mild degenerative changes of the right hip and moderate
degenerative
changes of the lumbar spine.
Brief Hospital Course:
___ woman with history of dementia and psychosis with
delusions who presented with following fall with left femoral
neck fracture s/p left hemiarthroplasty, with hospital course
complicated by UTI, pneumonia, and toxic-metabolic
encephalopathy.
ACUTE ISSUES:
=============
# LEFT FEMORAL NECK FRACTURE S/P LEFT HEMIARTHROPLASTY
The patient presented to the emergency department and was
evaluated by the orthopaedic surgery team. The patient was found
to have an isolated displaced left femoral neck fracture and was
admitted to the orthopaedic surgery service. The patient was
taken to the operating room on ___ for left hip
hemiarthroplasty, which the patient tolerated well. 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 in the form of enoxaparin 40 mg
sc daily per routine. She should continue enoxaparin for 4 weeks
(until ___.
# URINARY TRACT INFECTION
# PNEUMONIA
# TOXIC-METABOLIC ENCEPHALOPATHY
She developed worsening mental status, hypoxia, and increased
respiratory secretions on ___. Her chest x-ray showed evidence
of a left lower lobe consolidation concerning for pneumonia. She
also had a UA with pyuria and bacteriuria. Her Foley was pulled
on ___. Her urine culture grew pansensitive E. coli. She was
started on ceftriaxone on ___. This was broadened to
vanc/ceftazidime on ___ given concurrent likely
hospital-acquired pneumonia. Her mental status and respiratory
symptoms improved significantly on this regimen.
Vancomycin was discontinued on ___ given a negative MRSA swab.
The following day, ceftazidime was discontinued and she was
transitioned to oral Augmentin. Unfortunately her mental status
then deteriorated again and she was unable to tolerate p.o.'s.
While she did not have any pulmonary symptoms that would be
particularly suggestive of a partially-treated PNA, the
worsening of her encephalopathy seemed to correlate with switch
from an antipseudomonal cephalosporin to PO Augmentin, so we
re-initiated cefepime on ___. Almost like magic her
encephalopathy cleared again after two days of treatment. She
completed five more days of cefepime in house and will take two
days of PO Levaquin at discharge to complete a seven-day
re-treatment course for HAP, presumably caused by pseudomonas or
an ESBL gram-negative organism.
# DYSPHAGIA
After recovering her mental status, she was recommended for
nectar thick liquids and puree solids. Ongoing discussions with
family regarding GOC. In terms of her PO
intake, they would like to optimize her quality of life even if
there is a risk of aspiration. Thus, she was upgraded to regular
diet as tolerated to aid in nutrition.
# URINARY RETENTION
She developed urinary retention postoperatively and failed
multiple trials of void initially. She required multiple
straight catheterizations. At discharge she is again voiding
spontaneously.
# HYPERTENSION
Primarily appears to be driven by agitation with concurrent
tachycardia that coincides with behavioral disturbances. She was
not given antihypertensives due to her labile blood pressures.
# ANEMIA
Likely acute blood loss from hip surgery. Hemoglobin was stable
at discharge.
# DEMENTIA
# PSYCHOSIS / DELUSIONS
She was continued on her home risperidone, lamotrigine, and
citalopram while able to take p.o. medications.
# ACUTE KIDNEY INJURY
Suspect prerenal in setting of acute infection and recent
operation. Improved following IV fluids.
# GOALS OF CARE
The patient has advanced dementia and declining quality of life
in the setting of psychiatric disturbance secondary to her
dementia. It was also appreciated on this admission that she
tolerates serious illness and prolonged hospitalization poorly,
given her poor cognitive reserve and tendency to profound
delirium.
Goals of care were discussed with family and they wish to
transition her to a more comfort-directed plan of care. Their
preference is to forgo interventions that decrease quality of
life in the name of safety or longevity (i.e. texture modified
diet) and for her not to return to the hospital unless needed
for comfort.
TRANSITIONAL ISSUES:
====================
[ ] Please continue lovenox injections until ___.
[ ] Please continue Levaquin for pneumonia until ___.
CODE: DNR/DNI, do not hospitalize unless required for comfort
HCP: ___ (son) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. RisperiDONE 0.5 mg PO QAM
2. LamoTRIgine 75 mg PO BID
3. Citalopram 20 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Enoxaparin Sodium 30 mg SC Q12H
End date ___.
3. Levofloxacin 500 mg PO Q24H Duration: 2 Days
4. Ramelteon 8 mg PO QHS
5. Citalopram 20 mg PO DAILY
6. LamoTRIgine 75 mg PO BID
7. RisperiDONE 0.5 mg PO QAM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left displaced femoral neck fracture
Pneumonia
Acute kidney injury
Toxic metabolic encephalopathy
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure being involved in your care.
Your hospitalized for a hip fracture and you had surgery.
You also developed pneumonia while in the hospital and were
treated with antibiotics.
Your family decided that it would be within your wishes to stay
out of the hospital if you were ever to become sick again. Thus,
you were discharged on hospice.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing and range of motion as tolerated to the left
lower extremity.
ANTICOAGULATION:
- Please take enoxaparin (Lovenox) 40 mg injection once daily
for 4 weeks to help decrease the risk of developing a blood
clot.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
|
19887933-DS-18 | 19,887,933 | 28,099,240 | DS | 18 | 2128-12-25 00:00:00 | 2128-12-26 11:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fevers and abdominal distension
Major Surgical or Invasive Procedure:
Paracentesis (multiple)
EGD (___)
Colonoscopy (___)
History of Present Illness:
___ yo M hx of Hep C, EtOH, liver cirrhosis presenting with
increasing abdominal distension, abdominal pain, nausea, low
grade fevers x 3 days. He also had an 3 episodes of black stools
1 week ago, however stools are now yellow. Since yesterday he
has also had dyspnea, light headedness and dizziness.
In the ED intial vitals were: 7 99.9 102 117/49 16 100%. Tmax
101.7 in ED. Exam was notable for Jaudnice, icteric sclera, RRR,
CTAB, no asterixis, +ascites, TTP RUQ and RLQ. He had 2 # 18 g
pivs R & L placed. Ceftriaxone and Pantoprazole 40mg were given
IV. His repeat Hct fell from 24.2 to 21.9. He was guaiac
negative. ED attempted paracentesis w US , no aspirate. He went
up to BR several times, weak but ok on feet with short
distances. Abd feels better after BMs.
Past Medical History:
- HCV and alcoholic cirrhosis
- Caput medusae
- Asymptomatic gallstones
- Osteoarthritis
- Polyarthralgias
- Chonic lower back pain
Social History:
___
___ History:
No history of liver disease.
Physical Exam:
ADMISSION EXAM
Vitals- 99.3 106/59 85 18 97 ra
General- Alert, oriented, no acute distress
HEENT- Sclera icteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- distended, +ve fluid thrill, BS+ve
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- ___ intact, motor function grossly normal
DISCHARGE EXAM
Vitals: 98.3, 81, 100/54, 20, 100% RA
General: AAOx3, NAD
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes/rales/rhonchi
CV: RRR, nl S1/S2, systolic murmur that is old per patient
Abdomen: Soft, ___, distended, normoactive bowel sounds
GU: Deferred
Ext: Warm, ___, no cyanosis/clubbing/edema, 2+ pulses
Neuro: CN ___ grossly intact
Skin: No jaundice, caput medusae, no stigmata of endocarditis
Pertinent Results:
ADMISSION LABS
___ 09:10PM BLOOD ___
___ Plt ___
___ 09:10PM BLOOD ___
___
___ 10:58PM BLOOD ___ ___
___ 09:10PM BLOOD ___
___
___ 09:10PM BLOOD ___
___
___ 09:10PM BLOOD ___
___ 10:22PM BLOOD ___
___ 09:10PM URINE ___ Sp ___
___ 09:10PM URINE ___
___
___ 09:10PM URINE ___ Epi-<1
PERTINENT LABS
___ 06:20AM BLOOD ___
___ 09:54AM ASCITES ___
___
___ 09:54AM ASCITES ___ THAN
___ 10:30AM ASCITES ___
___
___ 10:30AM ASCITES ___ THAN
DISCHARGE LABS
___ 09:05AM BLOOD ___
___ Plt ___
___ 09:05AM BLOOD ___ ___
___ 09:05AM BLOOD ___
___
___ 09:05AM BLOOD ___
___ 09:05AM BLOOD ___
MICROBIOLOGY
___ 10:17 ___ BLOOD CULTURE ___ bottles)
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
VIRIDANS STREPTOCOCCI. further identification on request.
FINAL SENSITIVITIES. Sensitivity testing performed by
Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
CEFTRIAXONE----------- S
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
PENICILLIN G---------- 0.5 I
VANCOMYCIN------------ <=1 S
All other blood, urine, peritoneal cultures were NEGATIVE or
PENDING at time of discharge.
IMAGING
CT colonography (___): There is adequate distention of the
cecum, ascending colon, and transverse colon to the splenic
flexure, rectum and distal sigmoid colon between the supine
upright scan. The patient was unable to retain sufficient
volume of gas for successful insufflation of the descending
colon. There are no mass lesions or polyps larger than 1 cm in
the portion of the colon which is insufflated. The large and
dilated recannalized umbilical vein is pressing on and indenting
the ___ colon anteriorly. There are multiple splenic,
gastric, and ___ varices seen. No evidence of active
extravasation of contrast to account for melena.
TTE (___): The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF = 70%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. There is no valvular
aortic stenosis. The increased transaortic velocity is likely
related to high cardiac output. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion. IMPRESSION: no vegetations seen.
Colonoscopy (___): Normal mucosa in the rectum, sigmoid colon,
descending colon, transverse colon and distal ascending colon.
The cecum was not visualized. There was no obvious source of
bleeding in the remainder of the examined colon. The cecum was
not reached secondary to difficult anatomy and patient
intolerance of further scope advancement. Otherwise normal
colonoscopy to proximal ascending colon.
EGD (___): Grade 1 varices at the gastroesophageal junction
that did not have stigmata of recent hemmorhage. There was no
clear source for the anemia or dark stools seen on this exam.
Abnormal mucosa in the stomach. Normal mucosa in the whole
duodenum. Otherwise normal EGD to third part of the duodenum
RUQ US (___): Cirrhosis with sequelae of chronic portal venous
hypertension. Reversal of flow in the portal vein branches is
suggestive of severe portal hypertension. Moderate ascites. An
amenable spot was marked by the radiology resident in the left
flank for paracentesis. Splenomegaly.
CXR (___): Increased density at the left lung base concerning
for pneumonia with fluid layering in the left major fissure.
Brief Hospital Course:
___ yo M with PMH of HCV and alcoholic cirrhosis presenting with
abdominal pain, distension, and fevers for 3 days.
ACTIVE ISSUES
# Spontaneous bacterial peritonitis: Patient had been with
worsening abdominal distension and fevers for 3 days concerning
for SBP. Paracentesis was unsuccessful despite a good fluid
pocket in ED. Patient was started on empiric ceftriaxone and
albumin per the SBP protocol. Repeat paracentesis on ___
revealed 1200 WB Cs and 67% PMNS consistent with SBP. Had a LVP
with 2 L removal on ___ which showed downtrend in counts with
antibiotics. Blood culture grew Strep viridans as below for
which vancomycin was added. This was subsequently discontinued
as S. viridans was found to be sensitive to ceftriaxone. Patient
completed 5 day course for SBP but was continued on ceftriaxone
given bacteremia. He was given a prescription for prophylactic
Bactrim to fill after he completes course of ceftriaxone.
# Strep viridans bacteremia: Blood cultures grew S. viridans for
which vancomycin was added to ceftriaxone. Source unclear.
Patient denied any recent dental work and has not used IV drugs
in over a decade. Exam significant for a murmur which is old per
patient. Subacute infectious endocarditis seemed most likely for
which he underwent TTE on ___. This revealed no vegetations.
Further evaluation with ___ was discussed with Cardiology and
they felt that patient's TTE was sufficient to rule out
endocarditis. ID was consulted regarding source identification
and duration of antibiotics. Their impression was that S.
viridans was most likely from a GI source as it is a GI
colonizer. Recommended at 3 week course of antibiotics.
Sensitivities revealed S. viridans was sensitive to ceftriaxone
for which vancomycin was discontinued. A PICC was placed for
outpatient antibiotic therapy and patient was discharged to
complete a 3 week course of antibiotics.
# Melena: Patient with dark stools recently. Recent Hct 21.9
with baseline in 40's. Most recent EGD in ___ remarkable for
grade I esophageal varices and portal hypertensive gastropathy.
Patient received 1 unit RBC on ___. Hct bumped appropriately.
EGD on ___ remarkable only for grade I esophageal varices with
no stigmata of recent bleeding. Subsequent colonoscopy did not
reveal any bleeding but cecum could not be visualized. For this
reason, patient underwent CT colonography which again showed no
active source of bleeding. Patient was managed with pantoprazole
IV Q12H while in hospital and he was discharged on twice daily
dosing. Would benefit from further evaluation with capsule
endoscopy as outpatient.
CHRONIC ISSUES
# Cirrhosis: Due to HCV and alcohol. Has stopped drinking for
past 18 months. Patient has no history of HE or SBP. He has
grade I esophageal varices. MELD 17. Not on transplant list but
would like to be considered. Continued home Lasix and
spironolactone. Increased doses of diuretics on day of discharge
due to worsening ascites. Patient underwent a large volume
paracentesis removing 2 L while in hospital. He was not very
distended on discharge but will likely need another LVP in the
near future. Has ___ for transplant evaluation scheduled.
# Depression: Stable. Continued home regimen.
TRANSITIONAL ISSUES
- Discharged to complete a 3 week course of ceftriaxone via PICC
- ___ services to help with infusions
- Labs to be followed by OP AT. Check CBC, electrolytes, BUN/Cr,
ALT, AST.
- Patient would like to be evaluated for transplant
- Consider capsule endoscopy to evaluate reported black stools
as above
- ___ with PCP scheduled
- ___ with Liver Clinic for transplant evaluation pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aripiprazole 10 mg PO DAILY
2. Quetiapine Fumarate 200 mg PO DAILY
3. Venlafaxine XR 75 mg PO EVERY OTHER DAY
4. Spironolactone 50 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. etodolac 400 mg oral tid pain
7. Sildenafil 100 mg PO DAILY
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 2 mg IV Q24H Disp #*16 Vial Refills:*0
2. Aripiprazole 10 mg PO DAILY
3. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*1
4. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*1
5. Venlafaxine XR 37.5 mg PO EVERY OTHER DAY
6. etodolac 400 mg ORAL TID pain
7. Sildenafil 100 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth twice a day Disp #*60 Tablet Refills:*1
9. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
Please start AFTER you finish ceftriaxone.
RX ___ 800 ___ mg 1 tablet(s) by
mouth DAILY Disp #*30 Tablet Refills:*1
10. QUEtiapine Fumarate 200 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Spontaneous bacterial peritonitis
- Streptococcus viridans bacteremia
Secondary diagnosis: HCV and alcoholic cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you while you were a patient at
___. You came to us with
increasing abdominal pain and distension. This was found to be
due to an infection in your abdomen. You were treated for this
with antibiotics which resulted in improvement in your symptoms.
You were also found to have an infection in your blood. You will
need to continue IV antibiotics for the next ___ days. Because of
this we placed a PICC line in your arm. A visiting nurse ___
help you infuse the antibiotics after you go home. After you
finish these antibiotics please start taking Bactrim tablets
once a day.
Please be sure to take all of your medications as listed below.
Please keep all of your ___ appointments.
Followup Instructions:
___
|
19887950-DS-14 | 19,887,950 | 26,297,591 | DS | 14 | 2162-06-05 00:00:00 | 2162-06-05 21:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Flagyl
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ TAH-BSO
___ Exploratory laparotomy, jejunal resection, left in
discontinuity with abthera, ventral hernia repair
History of Present Illness:
___ with menorrhagia ___ uterine fibroids s/p TLH-BS on ___
with OB/Gyn admitted from OSH with nausea, vomiting and CT
concerning for SBO for which ACS is consulted. She underwent
surgery on ___ and reports feeling nauseous and having
persistent emesis since that night. She called the office for
Zofran, which she took without any relief. She presented to
___ on ___ where CT showed dilated loops of small
bowel concerning for SBO with likely transition point in the
pelvis. She was admitted to ___ on ___ and has yet to have
return of bowel function despite bowel rest. Denies fevers,
chills, chest pain, SOB, dysuria, hematuria.
Past Medical History:
PMH:
-iron deficiency anemia
-fibroids, menorrhagia, AUB
PSH:
-HSC, D&C
-TAH-BSO ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
HR 74 BP127/75 RR18 Sat99% on RA
Gen: uncomfortable appearing
CV: RRR
Pulm: breathing comfortably on RA
Abd: softly distended, nontender to palpation (recently
medicated
with morphine in ED), no rebound or guarding, laparoscopic
incisions healing well
SSE: deferred
SVE: deferred
DISCHARGE PHYSICAL EXAM:
Physical Exam:
Gen: [x] NAD, [x] AAOx3
CV: [x] RRR, [] murmur
Resp: [x] breaths unlabored, [x] CTAB, [] wheezing, [] rales
Abdomen: [x] soft, [] distended, [] tender, [] rebound/guarding
Wound: [x] incisions clean, dry, intact, wound vac holding
suction, JP with serosang/purulent drainage, ___ drain with
purulent drainage
Ext: [x] warm, [] tender, [] edema
Pertinent Results:
IMAGING:
TTE: ___:
The left atrial volume index is normal. There is normal left
ventricular wall thickness with a normal cavity size. Overall
left ventricular systolic function is normal. However, the
posterior wall appears hypokinetic. Other focal wall motion
abnormalities cannot be excluded with certainty. The visually
estimated left ventricular ejection fraction is 60%. The right
ventricle was not well seen with uninterpretable free wall
motion assessment. The aortic sinus diameter is normal for
gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal. The aortic valve leaflets (3)
appear structurally normal. There is no aortic valve stenosis.
There is no aortic regurgitation. The mitral valve leaflets are
mildly thickened with no mitral valve prolapse. There is trivial
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. There is moderate [2+] tricuspid
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
CT ___
IMPRESSION:
1. There is an organized/walled-off collection in the left
abdomen which is
increased in size compared to prior. This collection is
amenable to
percutaneous drainage.
2. There is no extravasation of oral contrast from the small
bowel.
3. Pigtail catheter is seen in the perisplenic collection, this
collection is
decreased in size compared to prior imaging.
4. Hypoenhancement of the left kidney compared to the right with
associated
small peripheral wedge-shaped hypodensity (suspected infarct)
suggests left
renal vascular compromise. The left renal artery and vein
appears grossly
patent. No hydronephrosis. Nephrology/urology consult advised
5. Bilateral lower lung zone airspace opacification/pneumonia
with small
left-sided pleural effusion appears fairly similar compared to
prior.
Labs
___ 05:42AM BLOOD ___-15.9* RBC-2.93* Hgb-7.1* Hct-22.5*
MCV-77* MCH-24.2* MCHC-31.6* RDW-25.1* RDWSD-67.2* Plt ___
___ 12:30AM BLOOD WBC-10.0 RBC-3.95 Hgb-9.0* Hct-30.1*
MCV-76* MCH-22.8* MCHC-29.9* RDW-17.8* RDWSD-49.3* Plt ___
___ 04:24AM BLOOD Neuts-73.4* Lymphs-9.5* Monos-9.6 Eos-2.5
Baso-0.4 Im ___ AbsNeut-13.26* AbsLymp-1.71 AbsMono-1.73*
AbsEos-0.45 AbsBaso-0.08
___ 12:30AM BLOOD Neuts-69.4 ___ Monos-10.3
Eos-0.1* Baso-0.2 Im ___ AbsNeut-6.92* AbsLymp-1.95
AbsMono-1.03* AbsEos-0.01* AbsBaso-0.02
___ 01:39AM BLOOD Hypochr-2+* Anisocy-2+* Poiklo-1+*
Macrocy-1+* Microcy-1+* Polychr-1+* Target-3+* Schisto-1+*
Fragmen-1+*
___ 01:38AM BLOOD Hypochr-2+* Anisocy-2+* Poiklo-2+*
Macrocy-1+* Microcy-1+* Polychr-1+* Target-2+* Schisto-1+* Tear
Dr-2+* Fragmen-1+*
___ 05:42AM BLOOD Plt ___
___ 01:39AM BLOOD Plt Smr-VERY HIGH* Plt ___
___ 12:30AM BLOOD Plt ___
___ 05:42AM BLOOD Glucose-118* UreaN-17 Creat-0.8 Na-135
K-4.9 Cl-99 HCO3-24 AnGap-12
___ 04:59AM BLOOD Glucose-113* UreaN-16 Creat-0.8 Na-133*
K-4.7 Cl-99 HCO3-22 AnGap-12
___ 06:50AM BLOOD Glucose-115* UreaN-11 Creat-0.7 Na-137
K-3.3* Cl-102 HCO3-24 AnGap-11
___ 12:30AM BLOOD Glucose-122* UreaN-16 Creat-0.7 Na-139
K-4.1 Cl-105 HCO3-22 AnGap-12
___ 05:42AM BLOOD CK(CPK)-40
___ 06:03PM BLOOD CK(CPK)-434*
___ 04:59AM BLOOD Lipase-261*
___ 03:59AM BLOOD cTropnT-<0.01
___ 06:03PM BLOOD CK-MB-7 cTropnT-<0.01
___ 05:42AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.2
___ 04:59AM BLOOD Calcium-8.0* Phos-2.8 Mg-1.9
___ 04:24AM BLOOD Albumin-2.4* Calcium-8.2* Phos-2.8 Mg-2.1
___ 06:50AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0
___ 12:30AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0
___ 01:20AM BLOOD Triglyc-298*
___ 01:38AM BLOOD Triglyc-857*
___ 08:01PM BLOOD Vanco-16.9
___ 05:59AM BLOOD Vanco-18.6
___ 07:11PM BLOOD Vanco-22.9*
___ 02:17AM BLOOD Type-CENTRAL VE pO2-32* pCO2-41 pH-7.45
calTCO2-29 Base XS-3
___ 02:30AM BLOOD ___ pO2-93 pCO2-40 pH-7.49*
calTCO2-31* Base XS-6 Comment-GREEN TOP
___ 02:17AM BLOOD freeCa-1.29
___ 10:34PM BLOOD freeCa-1.07*
Brief Hospital Course:
Ms. ___ is a ___ year old female who was transferred to ___
___ on ___ with a small bowel
obstruction s/p TAH-BSO on ___. She was initially
admitted to the OB-Gyn service for nonoperative management of
her SBO with bowel rest. The patient's symptoms did not improve
and she developed worsening sepsis. ACS was consulted on
hospital day 1 in this setting, due to concern for intra
abdominal source of infection. Review of the patient's OSH
imaging revealed that her bowel obstruction was secondary to an
incarcerated port site hernia. In this setting, she was taken to
the operating room with ACS that evening and underwent an
exploratory laparotomy, jejunal resection left in discontinuity
with an open abdomen, abthera placement, and repair of her port
site hernia. Of note, she was found to have a small bowel
perforation and this segment of bowel was resected, however the
incarcerated bowel appeared healthy For additional details of
the procedure, please see the surgeon's operative note. The
patient remained intubated post operatively and on pressors, and
she was brought to the ICU for hemodynamic and respiratory
support. The remainder of her hospital course is described below
by system:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a fentanyl
drip. She was then transitioned to an oral pain regimen once
extubated and tolerating a diet.
CV: Post operatively, the patient was resuscitated with
crystalloid and colloid, titrated to achieve goal urine output >
0.5cc/kg/hr. Her lactate peaked at 5.9 but downtrended with
resuscitation and decreasing pressor requirements. She was
eventually weaned off of pressors on ___.
Pulmonary: The patient had an increasing ventilatory requirement
post operatively, likely in the setting of volume overload. She
required a PEEP as high as 16, which was gradually weaned as her
volume status improved. She was extubated. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression and management of
post-operative ileus. She was maintained on TPN given high
gastric outputs from ___ until ___. Her diet was then
advanced sequentially to a regular diet, which was well
tolerated. Patient's intake and output were closely monitored.
She was diuresed with a lasix drip and then with lasix boluses
as tolerated. During her ICU course she was noted to have a
multifactorial acute kidney injury due to hypotension requiring
pressors and aggressive diuresis, which had been initiated due
to her volume overloaded status.
ID: The patient's fever curves were closely watched for signs of
infection. She was febrile at multiple points in her ICU course
and was cultured multiple times with the only pertinent positive
being a sputum culture from ___ growing sparse yeast.
HEME: The patient's blood counts were closely watched for signs
of bleeding. She was transfused 1u pRBCs on ___ for an H/H
6.9/21.7 in the setting of ongoing pressor requirement, and she
responded appropriately. She was also transfused 1u pRBCs on
___ for anemia with appropriate response.
On ___ she was called out to the floor. She was started on a
clear liquid diet and IV Reglan. She reported mild nausea which
was treated with IV Zofran and her oxygen saturation was 95-97%
on RA. On ___ we removed the staples from her incision, she
continued on full TPN due to minimal PO intake. On ___ skin
dehiscence was found when inspecting her wound, fascia was found
to be intact and wet to dry dressing were applied twice a day.
On ___ it was decided that a wound VAC would be placed in the
wound. Due to increase in PO intake, TPN was switched to half
dosage. Her WBC had an elevation to 20.9, urine culture was
sent, CXR and blood cultures along with C diff stool PCR were
sent. A CT abdomen and pelvis was also sent to rule out any
collections. CT showed a organized walled off collection in the
left abdomen along with left renal infarct.
On ___ she was seen by interventional radiology and 280cc of
pus were drained and a pigtail catheter was left in place. Due
to CT finding of renal infarct a renal US was performed and
showed no thrombosis of the renal vein or stenosis, TPN was
d/c'd and she was tolerating regular diet. On ___ ID saw the
patient and recommended continue IV cefepime. On ___ final
culture from fluid collection grew Enterococcus and she was
switched to IV meropenem. on ___ her C diff was found to be
negative, she increased ambulation and was on a regular diet.
She worked with physical therapy.
On ___ her first wound VAC change was performed, wound looked
pink and appropriately healing. Infectious disease saw her for
final recommendations and suggest switching to
Daptomycin/Ertapenem 24 hours before discharge to see if patient
tolerated regimen as well as baseline laboratory values.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. She is going home with ___
services to help her with her IV antibiotic treatment along with
VAC wound change every 3 days.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
Please take aspirin until your follow up appointment
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*20 Tablet
Refills:*0
2. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
RX *bisacodyl [Bisac-Evac] 10 mg 1 suppository(s) rectally at
bedtime Disp #*5 Suppository Refills:*0
3. Daptomycin 350 mg IV Q24H
RX *daptomycin 350 mg 1 q24h Disp #*28 Vial Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
5. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
RX *ertapenem 1 gram 1 q24h Disp #*28 Vial Refills:*0
6. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate
RX *oxycodone 5 mg/5 mL 5 ml by mouth every four (4) hours
Refills:*0
7. Ramelteon 8 mg PO QHS:PRN sleep
Should be given 30 minutes before bedtime
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
8. Ferrous Sulfate 325 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Small-bowel obstruction with port
site hernia with jejunal perforation x 2.
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 ___ and
underwent a diagnostic laparoscopy with conversion to
exploratory laparotomy, repair of incarcerated incisional
hernia, jejunal resection followed by an
abdominal washout, small intestine anastomosis and abdominal
closure.
You are recovering well and are now ready for discharge. Please
follow the instructions below to continue your recovery:
ACTIVITY:
-Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
-You may climb stairs.
-You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
-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.
-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" for a couple of 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 might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
-You 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 BOWELS:
-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.
-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. o 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 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.
Warm regards,
Your ___ Surgery Team
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
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.
Followup Instructions:
___
|
19888315-DS-22 | 19,888,315 | 28,965,100 | DS | 22 | 2201-03-25 00:00:00 | 2201-03-25 16:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Mirapex / aloe ___ / Vitamin D3
Attending: ___
Chief Complaint:
Global Aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old left handed male with a history of ?
epilepsy and a-fib c/b strokes now presenting with recurrent
aphasia.
The patient's neurologic history is long and nebulous. When he
and his wife married ___ years ago, he had several episodes of
brief LOC that were thought to reflect seizure. His wife is not
sure what was done for w/u. He was maintained on PHT for many
years without LOC (had a spell when was off PHT briefly). He
also has a history of atrial fibrillation and is anticoagulated.
He has a number of strokes that have been seen on prior imaging,
possibly a mix of small vessel and embolic.
His recent neurologic history began in ___. Please
refer to discharge summary for full details. In brief, on
___ pt had ~90 minutes of slurred speech and diminished
output (said "no" to most questions). Stroke w/u showed chronic
R basal ganglia nd L lacunar strokes without any acute lesions.
He was started on a statin (LDL 115). Immediately after
discharge, he had new aphasia, inability to read, R face droop,
RUE weakness. He was transferred back to ___ and admitted
from ___. cvEEG showed slowing over the right
hemisphere but no seizures or epileptiform discharges. LEV was
increased from 500mg to 750mg BID.
In the interim, speech has been normal per wife and he has not
had any episodes of LOC. Recently he has had a chest cold,
coughing but without fevers/chills; this has been improving. He
was last seen normal at approximately 10:30 this morning by his
wife. She called him for lunch at 12:30 and when he came to eat
his sandwich (which he did without choking or coughing), he was
trying to tell his wife something but his speech was non-fluent
and unintelligible. She calls EMS and he was brought to ___
___. There, ___ reportedly 7 (speech only with a normal
motor exam; telestroke with a Dr. ___ ___.
Creatinine 0.9 at OSH. CXR was clear. ___ was without acute
process and he was sent here for further evaluation.
On arrival here 0 98.5 66 126/70 12 96%. The examination was
essentially unchanged, revealing a global aphasia but no other
abnormalities. CTA head/neck & C- were unchanged compared to
priors (loss of right V4, numerous bilateral hypodensities).
Repeat INR was 3. Basic labs were WNL.
Past Medical History:
1. Paroxysmal atrial fibrillation, on Coumadin.
2. History of left lacunar stroke.
3. History of diminished dorsalis pedis pulses.
4. Hyperlipidemia.
5. OSA, on CPAP.
6. History of prior stroke.
7. Seizure disorder.
8. Neuropathy.
9. Restless legs.
10. Depression.
11. Gait instability.
12. Urinary incontinence.
13. Varicose veins.
14. Chronic ___ otitis media.
15. History of skin cancer.
16. Sensorineural hearing loss.
Social History:
___
Family History:
Mother died of "bone cancer". Father died from an aneurysm. Only
child. No biologic children.
Physical Exam:
Admission Physical Examination:
98.5 66 126/70 12 96%
Gen: NAD NT ND
HEENT: NC/AT no ptosis
Neck: restricted ROM bidirectionally
Card: Irregularly irregular, faint sounds
Pulmonary: Wheezes throughout, moving air well
Abdomen: Soft NT ND
Extrem: Venous stasis, hairless shins - bilaterally
Neurologic
- MS: Awake, alert. Says own name, but cannot say date or
location. Speech is non-fluent and on initial exam, cannot name
objects on the stroke card (makes noises). Produces both
syllables and occasional inappropriate words (e.g. at end of
exam
when I re-examined his speech, called all of the stroke card
objects a "blanket"). He can write his name, but no more (when
asked where he lives writes 12 tophert A ___. Cannot repeat.
Simple midline commands are sometimes understood but no others.
Cannot read. No apparent neglect.
- CN: PERRL, difficult to assess visual fields but appears to
respond to stimulus on both sides. Full horizontal eye
movements.
Face seems symmetric to pin based on grimace. Activates face
equally. Hearing grossly intact. Tongue and palate midline.
Shrug
full.
- Motor: No drift. Full strength save for ? 4 range IOs (vs not
being able to understand what I want him to do). Toes start
slightly up, ? withdrawal vs Babinski R, left seems mute. No
___.
- Sensory: I can pantomime enough of the exam to discern that
he
does not extinguish to double (with eyes closed, points to
left/right/both when I touched his legs) and is sensitive to
pain
on both sides. More sophisticated exam difficult given speech;
could not tell if there was any difference to pin on both sides
and we could not do hallux proprioception. Romberg deferred
given
patient size and chronic gait imbalance ___ years.
- Reflexes: Attenuated throughout save brisk patellars and
absent L ankle jerk.
- Cerebellar: Smooth heel/shin and no obvious tremor or ataxia
grabbing for my hand. No truncal ataxia at edge of bed with arms
crossed, eyes closed, feet off of ground.
- Gait: Somewhat wide base, unsteady on his own - sat him back
down quickly (confirmed chronicity of gait imbalance with wife).
========================
Discharge Physical Exam:
Gen: NAD
HEENT: NC/AT, no ptosis, moist mucus membranes
Neck: Restricted ROM bidirectionally
Card: Irregularly irregular, faint sounds
Pulmonary: Comfortable on room air
Abdomen: Soft, nondistended, nontender
Extrem: Venous stasis with skin discoloration bilaterally
Neurologic
MS: Awake, alert and oriented to person, place and date. Speech
is fluent but still a little slow. Naming intact. Able to
read. No neglect. Repetition intact. Able to follow both
appendicular and axial commands. Some difficulty with multistep
commands.
CN: PERRL, blinks to threat bilaterally. Full horizontal eye
movements.
Face is symmetric at rest and with activation. Hearing grossly
intact. Tongue and palate midline. Shrug full.
Motor: No drift. Full strength throughout.
Sensory: Intact to light touch bilaterally
Reflexes: Attenuated throughout save brisk patellars and
absent L ankle jerk.
Cerebellar: No dysmetria. No truncal ataxia.
Pertinent Results:
___ 05:25AM BLOOD WBC-5.1 RBC-4.31* Hgb-13.7* Hct-38.4*
MCV-89 MCH-31.8 MCHC-35.7* RDW-13.1 Plt ___
___ 05:25AM BLOOD Neuts-61.4 ___ Monos-9.0 Eos-3.0
Baso-0.3
___ 05:10AM BLOOD ___ PTT-42.2* ___
___ 05:10AM BLOOD UreaN-24* Creat-0.9
___ 11:30AM BLOOD Glucose-83 UreaN-16 Creat-0.9 Na-140
K-4.0 Cl-105 HCO3-28 AnGap-11
___ 11:30AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1
___ 04:09PM BLOOD Glucose-111* Na-139 K-4.2 Cl-102
calHCO3-28
MRI:
1. Small 6 mm acute to subacute infarct of the left temporal
lobe. No
associated mass effect.
2. Numerous chronic infarcts of the cerebral white matter,
bilateral basal
ganglia, and thalami. Severe chronic microangiopathy.
3. Moderate generalized parenchymal volume loss.
4. Asymmetric enlargement of the right temporal horn, although
this appears to
be due to adjacent temporal lobe volume loss rather than
specifically volume
loss of the right hippocampus.
5. Occlusion of the V4 segment of the right vertebral artery,
unchanged from
CTA on ___.
EEG:
This telemetry captured no pushbutton activations. It showed a
slow background throughout, indicative of a widespread
encephalopathy.
Medications, metabolic discharges, and infection are among the
most common causes. In addition, there was prominent delta
slowing broadly over the left hemisphere, suggestive of an
additional subcortical dysfunction there. Minimal slowing was
evident on the right. There were no epileptiform features or
electrographic seizures.
This telemetry captured one pushbutton activation for an episode
of confusion. There was no electrographic correlate. Otherwise,
it showed
prominent delta slowing over the left hemisphere suggestive of
focal cerebral dysfunction. In addition, the background was slow
and disorganized throughout suggestive of a widespread
encephalopathy which is non-specific with regard to etiology.
There were no epileptiform features or electrographic seizures.
CT Head and Neck:
1. No evidence for acute intracranial abnormalities on
noncontrast head CT.
Nondiagnostic CT perfusion study due to technical factors.
2. Multiple chronic infarcts are again seen in the right
thalamus, left
caudate, and left lentiform nucleus/corona radiata/external
capsule.
3. No flow-limiting arterial stenosis in the neck.
4. Unchanged atherosclerotic occlusion of the distal V4 segment
of the non
dominant right vertebral artery.
5. Bronchiectasis in the visualized upper lungs with apparent
new bronchial
wall thickening compared to ___, which may represent
superimposed
infectious/inflammatory process versus technical differences.
Clinical
correlation is recommended.
6. Severe cervical spinal stenosis, previously assessed by MRI
in ___.
Brief Hospital Course:
Mr. ___ is an ___ year old left handed man who presented with
isolated global aphasia similar to a prior MRI-negative episode
in ___ thought to be seizure vs stroke.
Initially, given the exam and the identical nature of his
current aphasia to an MRI-negative spell in ___, seizure
was higher consideration than stroke. However, EEG showed no
epileptiform activity. It showed left greater than right
slowing. Previous EEG showed right greater than left slowing.
However, due to the clinical suspicion for seizure, whether of
unknown etiology or secondary to stroke, we have increased his
Keppra 1000mg BID. Although the initial CT was negative, an MRI
showed a small posterior insular cortex. His stroke risk
factors have been assessed. He is currnetly on Atorvastatin
40mg qday. His last LDL was 66. He has afib and is currently
on Coumadin 2mg with theurapeutic INRs. His INR on discharge
was 3.1. His INR will continue to be trended by his primary
care doctor. We were going to obtain an Echo since his last
Echo was ___, however, the result will not change management.
He will follow up with his outpatient Neurologist.
In regards to pulmonary, Mr. ___ had some wheezing on inital
exam that improved throughout the hospital course. He had a CTA
that showed bronchiectasis visualized in the upper lungs with
apparent new bronchial wall thickening compared to ___, which may represent superimposed infectious/inflammatory
process. Mr. ___ did endorse a recent viral illness.
Additionally, Mr. ___ was found to have pancytopenia of unknown
etiology. The pancytopenia improved over the course of the
hospitalization. He will follow up with his outpatient primary
care doctor.
Medications on Admission:
1. Warfarin 2 mg PO DAILY16
2. LeVETiracetam 750 mg PO BID
3. Citalopram 20 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Metoprolol succinate 25 mg PO QAM
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Atorvastatin 40 mg PO QPM
3. Citalopram 20 mg PO DAILY
4. LeVETiracetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Warfarin 2 mg PO DAILY16
7. Outpatient Physical Therapy
Please evaluate and treat.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subacute to Acute Stroke
History of prior strokes
Seizures
Atrial Fibrillation
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ___ Inpaitient Neurology Service for
an episode of being unable to speak correctly. You had a
similar episode in ___. At that time, the MRI of your
brain was negative for stroke. However, this time, your MRI
showed a stroke in the left side of your brain in a part called
the temporal lobe. We have continued your blood thiner,
Coumadin, to help prevent further strokes. We have also
continued your cholesterol lowering medication, Atorvastatin.
We have also increased your seizure medication because we are
unsure if your previous episode was a seizure and if you had a
seizure preciptated by a stroke this time. Due to the
possibility of seizures, do not drive for the next 6 months.
Please follow up with your primary care doctor and your
neurologist.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19888347-DS-10 | 19,888,347 | 25,162,606 | DS | 10 | 2147-02-20 00:00:00 | 2147-02-21 06:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ceftriaxone / seasonal allergies / morphine
Attending: ___.
Major Surgical or Invasive Procedure:
PRBC transfusion (2 units) ___
ERCP
attach
Pertinent Results:
ADMISSION LABS:
___ 09:13PM BLOOD WBC-18.0* RBC-2.22* Hgb-6.9* Hct-21.6*
MCV-97 MCH-31.1 MCHC-31.9* RDW-18.6* RDWSD-65.0* Plt ___
___ 09:13PM BLOOD Neuts-58 Bands-1 ___ Monos-9 Eos-0*
Baso-0 NRBC-1.2* AbsNeut-10.62* AbsLymp-5.76* AbsMono-1.62*
AbsEos-0.00* AbsBaso-0.00*
___ 09:13PM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-2+*
Ovalocy-2+* Target-1+* RBC Mor-SLIDE REVI Stomato-1+*
___ 09:13PM BLOOD Glucose-90 UreaN-6 Creat-0.3* Na-135
K-3.8 Cl-101 HCO3-27 AnGap-7*
___ 09:13PM BLOOD ALT-52* AST-54* AlkPhos-70 TotBili-2.6*
DirBili-0.5* IndBili-2.1
___ 09:13PM BLOOD Lipase-24
___ 09:13PM BLOOD Albumin-3.9
___ 09:25PM BLOOD Lactate-0.8
DISCHARGE LABS:
___ 03:00AM BLOOD WBC-14.4* RBC-3.37* Hgb-10.4* Hct-32.8*
MCV-97 MCH-30.9 MCHC-31.7* RDW-22.2* RDWSD-74.3* Plt ___
___ 03:00AM BLOOD ___ PTT-39.5* ___
___ 08:40AM BLOOD Ret Aut-18.6* Abs Ret-0.53*
___ 03:00AM BLOOD Glucose-86 UreaN-3* Creat-0.4 Na-139
K-4.4 Cl-100 HCO3-21* AnGap-18
___ 03:00AM BLOOD ALT-49* AST-60* AlkPhos-60 TotBili-2.7*
DirBili-0.6* IndBili-2.1
___ 03:00AM BLOOD Calcium-8.3* Phos-4.2 Mg-1.8
IMAGING:
___ Chest X-ray
Moderate cardiomegaly. No evidence of pneumonia.
___ MRCP
1. Evidence of severe iron deposition in the liver, spleen bone
marrow,
pancreas, and adrenals, likely due to chronic transfusions in
the setting of
sickle cell disease.
2. Splenomegaly, measuring up to 20 cm, with numerous rounded
lesions within
the spleen measuring up to 3.9 cm which are of differing T2
signal
hyperintensities and enhancement, possibly representing focal
areas of
extramedullary hematopoiesis. No evidence of splenic infarct.
3. Numerous prominent periportal, aortocaval, and periaortic
lymph nodes in
the upper abdomen with severe hypoattenuation compatible with
iron deposition,
the may be a form of extramedullary hematopoiesis.
4. Cholelithiasis without evidence of acute cholecystitis.
5. Dilation of the common bile duct up to 8 mm with either
multiple adjacent
tiny adherent stones or a larger stone measuring up to 9 mm
within the distal
common bile duct. No significant intrahepatic biliary duct
dilatation.
Brief Hospital Course:
___ is a ___ female with hx of asthma, sickle
cell disease (hemoglobin SS) c/b CVA on chronic transfusion
protocol. with residual R sided weakness transferred for concern
of biliary dilation and splenomegaly/infarct on CT after
initially presenting to them with lower back pain.
TRANSITIONAL ISSUES:
[ ] Given significant e/o iron overload, would re-consider
frequent transfusions, ongoing discussions with patient about
Hydrea. Will defer discussions to patient's hematologist.
[ ] CBD dilation and cholelithiasis: CCY recommended ___. Pt
declined CCY here
[ ] if CCY to move forward, will need goal Hgb of 10
[ ] patient needs pap smear (has not had one previously), would
do w/ PCP or GYN ___
ACUTE/ACTIVE PROBLEMS:
# Acute Pain Crisis:
# Hemoglobin SS Disease:
# Chronic Iron Overload:
Presented initially with acute pain, mostly located in low back.
No e/o acute chest. Treated with IV fluids, pain and nausea
medications with improvement in pain symptoms. Patient typically
follows with ___ Dr. ___ at ___. Due to history
of CVA, she gets blood transfusions every 2 weeks with goal to
keep hemoglobin >8, but ideally ___ with <30% Hgb SS. She was
due for scheduled transfusion on ___, therefore received this
while she was admitted. MRCP to evaluate biliary tree dilatation
and splenic lesions on ___ noted that lymphadenopathy and
splenic abnormalities both likely due to iron deposition from
overload and extramedullary hematopoiesis. Continued home
deferasirox for iron overload. Pain control on discharge with
Tylenol and dilaudid to taper. PMP reviewed, with stool
softeners
# CBD dilation:
# Choledocholithiasis:
CT abdomen from ___ noted progressed intrahepatic biliary
dilatation (compared to CT from ___. Note that Partners ___
from ___ did not show any biliary dilation. MRCP at ___
confirmed 8mm CBD dilation and distal CBD stone(s). ERCP team
consulted. Underwent ERCP on ___ with sphincterotomy and
removal of stones/sludge. ACS consulted for consideration of
cholecystectomy. Heme was consulted as well for perioperative
recommendations. She was transfused to Hgb of 10 with plan for
add on CCY. However, after logistical delays the patient
declined CCY here. Risks and benefits were discussed in detail
and patient expressed good understanding and accepted risks of
delay.
- she will coordinate CCY in outpatient setting ___ with her
outpatient providers
# ___:
# Upper respiratory infection:
Patient with complaints of cough and sore throat. Received
notification from ___ that throat swab from when she was
there returned positive for group A strep. Patient treated with
IM penicillin G injection on ___. Also likely with URI given
cough/runny nose (not characteristic of strep) and sick contacts
(mom w/ URI).
# Vulvovaginitis/candidiasis
Had vaginal speculum exam on ___ which showed thick white
discharge but no lesions. Swabs neg GC/Chlamydia, + yeast.
started on miconazole cream
CHRONIC/STABLE PROBLEMS:
# Asthma: Continued home fluticasone.
# CODE STATUS = FULL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Aspirin 81 mg PO DAILY
3. deferasirox 360 mg oral DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
RX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe
RX *hydromorphone 4 mg 1 tablet(s) by mouth ___ times per day
Disp #*30 Tablet Refills:*0
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 ml by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. deferasirox 360 mg oral QID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. FoLIC Acid 1 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Choledocholithiasis with obstruction
Sickle cell anemia
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 abdominal pain. You were
found to have gallstones in your bile duct. These were
successfully removed with ERCP procedure. We considered surgery
to remove your gallbladder and gave you blood transfusion.
You have decided to delay your surgery and schedule this after
discharge. As we discussed, we recommended surgery this
hospitalization and this decision to leave now is against
medical advice.
Please follow up ___ with your PCP and hematologist to see a
surgeon to discuss removal of your gallbladder and any
transfusion you may need beforehand.
Please take all medication as prescribed. Do not drive or drink
alcohol with opioids.
Followup Instructions:
___
|
19888426-DS-8 | 19,888,426 | 27,937,540 | DS | 8 | 2150-03-19 00:00:00 | 2150-03-21 16:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypertensive urgency, headaches
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old ___ man PMH of HTN, HLD, DM,
presents today as referral for HTN, HA from urgent care.
Mr. ___ reports that 3 days ago, he noted high HTN at home
which he checked as head some chest tightness, nausea without
vomiting. This morning at 4:00 am, pt woke up with headache ___
that improved to ___ with over the counter excedrin. He has no
visual changes no new numbness or weakness. Denies fevers, SOB,
belly pain, urinary or bowel symptoms. Pt takes lisinopril 40mg
daily, chlorthalidone 25mdaily, carvedilol 25mg BID and has not
missed any doses of these medications. However he has bene
prescribed spironolactone as well which he stopped as he thought
it perhaps had been worsening his headaches.
Regarding chest pain: he has intermittent daytime chest
heaviness that lasts anywhere from minutes to hours, it is not
associated with activity such as his often daily walks of up to
five miles. He had an unremarkable exercise stress test with
echo
in ___.
In the ED:
- Initial vitals: T: 97.2 HR: 58 BP: 232/87 RR: 16 SO2: 99%
RA
- EKG: Sinus bradycardia, normal rhythm, normal intervals, no ST
segment changes
- Labs/studies notable for:
WBC: 4.9 Hgb: 12.9 Plt: 169
Na: 137 Cl: 101 BUN: 17
K: 4.2HCO3: 27 Crt: 1.0
___: 12.7 PTT: 27.3 INR: 1.2
Trop-T: <0.01
CT HEAD: no acute process
CXR: no acute process
- Patient was going to be given IV labetalol when blood pressure
recheck showed reduction in MAP to 105
On the floor, he was asymptomatic, headline has resolved, no
chest
pain or tightness, no focal weakness or loss of sensation.
REVIEW OF SYSTEMS:
Positive per HPI otherwise ten system reviewed and negative.
Past Medical History:
- Hypertension
- Dyslipidemia
- Diabetes mellitus type II
Social History:
___
Family History:
His mother had CHF and hypertension. His father had cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.5 PO 218 / 110 R Manual Sitting 56 17 95 RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, 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: 24 HR Data (last updated ___ @ 814)
Temp: 97.6 (Tm 98.4), BP: 184/86 (137-198/67-86), HR: 50
(48-56), RR: 18 (___), O2 sat: 99% (95-99), O2 delivery: RA
GENERAL: NAD, sitting upright on edge of bed
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, 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 or clubbing. trace edema in R ___.
MSK: Full ROM in all extremities. Pain with passive and active
abduction of the L shoulder but full ROM. Negative empty can
test
and lift off test.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, CN II-XII intact, strength ___ throughout all
extremities, sensation intact bilaterally.
DERM: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
=============
___ 04:26PM cTropnT-<0.01
___ 04:26PM GLUCOSE-136* UREA N-17 CREAT-1.0 SODIUM-137
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-27 ANION GAP-9*
___ 04:26PM WBC-4.9 RBC-4.48* HGB-12.9* HCT-39.6* MCV-88
MCH-28.8 MCHC-32.6 RDW-13.0 RDWSD-41.7
IMAGING:
=======
CT HEAD W/O CONTRASTStudy Date of ___ 8:48 ___
There is no intra-axial or extra-axial hemorrhage, edema, shift
of normally
midline structures, or evidence of acute major vascular
territorial
infarction. Prominence of ventricles and sulci likely reflect
age related
involutional changes. Complete opacification of the bilateral
maxillary
sinuses which contain hyperdense material, possibly representing
blood
products, inspissated secretions, difficult to exclude fungal
colonization.
Mild opacification of the right ethmoidal air cells and right
frontal sinus.
Mastoid air cells are clear as are the middle ear cavities. The
bony
calvarium is intact.
IMPRESSION:
1. No acute intracranial process.
2. Complete opacification of the maxillary sinuses which
contain hyperdense
material, differential includes blood products, inspissated
material versus
fungal colonization.
CHEST (PA & LAT)Study Date of ___ 9:14 ___
No acute intrathoracic process.
DISCHARGE LABS:
=============
___ 06:32AM BLOOD WBC-5.4 RBC-4.45* Hgb-12.9* Hct-38.8*
MCV-87 MCH-29.0 MCHC-33.2 RDW-12.8 RDWSD-40.7 Plt ___
___ 07:49AM BLOOD Glucose-169* UreaN-20 Creat-1.1 Na-133*
K-4.4 Cl-93* HCO3-27 AnGap-13
Brief Hospital Course:
Mr. ___ is a ___ year old ___ man PMH of HTN, HLD, DM,
presented for HTN and HA from urgent care. He was started on
eplerenone BID and nifedipine at bedtime (given elevated blood
pressures in the evening). He did receive intermittent doses of
nitropaste when SBP>200. BP was better controlled by time of
discharge with SBPs 160s-180s/60s-80s consistently.
ACUTE ISSUES:
====================
# Hypertension:
Patient presented with BP 232/87, no evidence of end organ
disease. He takes carvedilol, lisinopril, and chlorthalidone at
home. He was prescribed spironolactone but self discontinued in
___ due to headaches. He checks his blood pressure at
home irregularly and reports that this degree of hypertension is
new. Goal MAP reduction of 25% in first hour happened
spontaneously in the ED. Target BP ___. He notes having
been on amlodipine in the past with insufficient improvement.
Eplerenone was started BID, but still required nitropaste
intermittently for acutely elevated symptomatic hypertension
(SBP > 220). Eplerenone can take up to 4 weeks to see the full
antihypertensive effect, so nifedipine was started given higher
evening blood pressures. Because the higher BPs were mostly in
the evening the lisinopril dose was split and administered BID.
BP was better controlled by time of discharge with SBPs
160s-180s/60s-80s consistently. Renin and aldosterone labs were
pending on discharge.
# Chest Pain:
Recent stress echo was negative for ischemia with adequate
workload. Trop negative x2 without EKG changes c/f ischemia.
HEART score 4 meriting admission with low ___ score of 85
(0.5% in hospital death). Resolved prior to discharge.
# Headaches:
Chronic and tolerable per patient, with intact neurological
exam and negative CT head. Most likely chronic tension headache.
He was given Tylenol 1 gram TID and counseled to avoid NSAIDs as
outpatient.
CHRONIC ISSUES:
=======================
# L shoulder Pain:
Patient with L shoulder pain with passive and active abduction,
chronic and intermittent in nature. He was given acetaminophen 1
gram TID and lidocaine patch QAM.
# Type 2 Diabetes. Treated with ISS while inpatient with holding
of home oral medications. Will restart home oral diabetic
medications
TRANSITIONAL ISSUES:
=======================
[ ] Eplerenone 50mg BID started ___, can take up to 4 weeks
to see full antihypertensive effect. Nifedipine 30mg ER started
to decrease blood pressure more rapidly in the interim. It can
be discontinued if eplerenone effect is sufficient.
[ ] Would benefit from follow-up in outpatient ___ clinic
[ ] f/up renin and aldosterone lab results, pending results may
need endocrine follow up.
[ ] consider outpatient sleep study to assess for OSA
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. CARVedilol 25 mg PO BID
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. SITagliptin 100 mg oral DAILY
5. Atorvastatin 20 mg PO QPM
6. Multivitamins 1 TAB PO DAILY
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
8. Aspirin 81 mg PO DAILY
9. GlipiZIDE XL 20 mg PO DAILY
10. Chlorthalidone 25 mg PO DAILY
Discharge Medications:
1. Eplerenone 50 mg PO Q12H
RX *eplerenone 50 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
2. NIFEdipine (Extended Release) 30 mg PO QPM
RX *nifedipine 30 mg 1 tablet(s) by mouth qPM Disp #*30 Tablet
Refills:*0
3. CARVedilol 25 mg PO Q12H
4. Lisinopril 20 mg PO Q12H
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. Chlorthalidone 25 mg PO DAILY
8. GlipiZIDE XL 20 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
12. SITagliptin 100 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
Hypertensive Urgency
Chest Pain
Headaches
SECONDARY DIAGNOSES:
==================
Type 2 Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had high blood pressure in the 200s/80s and were referred
from Urgent Care.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given medications to lower your blood pressure.
- We started a new blood pressure medication called eplerenone.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19889187-DS-21 | 19,889,187 | 24,863,608 | DS | 21 | 2129-01-12 00:00:00 | 2129-01-12 14:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Morphine / Valium / Codeine
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with known history of
hypertension on atenolol and lisinopril at home. She reports
that
at 3am this morning (12 hours ago appx) she was awaked from
sleep
acutely due to severe, sudden central chest and back pain. She
reported that the pain radiated from her chest to her back. She
denies any previous history of similar symptoms or
exacerbating/alleviating symptoms. She did note that today she
had multiple bouts of NBNB emesis and loose stools and this
precluded her from taking her normal medications. She was
evaluated initially for these complaints at ___ where she
underwent CTA CAP which identified a Type B dissection extending
distally from the takeoff of the left subclavian and terminating
prior to the celiac artery. She was reportedly given a dose of
toradol while at ___ and following this experienced no
further chest or back pain.
At present, she denies chest or back pain, nausea, or vomiting.
She reports that at present she is totally asymptomatic. She
also
denies any pain in the abdomen or in the extremities. On arrival
in the ___ ED her SBP was 180-190 but is now ___ on esmolol and
nicardipine gtt.
Past Medical History:
R hip in ___ after fall from standing height
GERD
HTN
COPD
Asthma
Gout
___ esophagus
Social History:
___
Family History:
Her husband and 2 daughters have MS, 1 daughter with
polymyositis. No endocrinopathies
Physical Exam:
DISCHARGE PHYSICAL EXAM:
Vitals: 24 HR Data (last updated ___ @ 734)
Temp: 98.2 (Tm 98.2), BP: 130/74 (115-147/61-75), HR: 56
(56-79), RR: 18 (___), O2 sat: 92% (92-96), O2 delivery: Ra,
Wt: 154.9 lb/70.26 kg
Gen: NAD, A&Ox3
Card: RRR
Pulm:no respiratory distress
Abd: Soft, non-tender, non-distended
Ext: 1+ ___ edema, warm well-perfused
Pertinent Results:
___ 12:21AM GLUCOSE-110* UREA N-13 CREAT-0.7 SODIUM-140
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-28 ANION GAP-11
___ 04:03AM ___ PTT-26.7 ___
___ 04:03AM PLT COUNT-230
___ 04:03AM CALCIUM-8.6 PHOSPHATE-3.0 MAGNESIUM-1.9
___ 04:03AM CALCIUM-8.6 PHOSPHATE-3.0 MAGNESIUM-1.9
___ 12:21AM cTropnT-<0.01
___ 12:21AM estGFR-Using this
___ 12:21AM WBC-12.5* RBC-4.14 HGB-11.7 HCT-36.1 MCV-87
MCH-28.3 MCHC-32.4 RDW-14.6 RDWSD-46.9*
___ 12:44AM BLOOD WBC-15.0* RBC-3.48* Hgb-9.7* Hct-31.0*
MCV-89 MCH-27.9 MCHC-31.3* RDW-14.6 RDWSD-47.2* Plt ___
___ 05:44AM BLOOD Glucose-97 UreaN-20 Creat-0.6 Na-140
K-4.6 Cl-98 HCO3-26 AnGap-16
ECHO ___
Preserved biventricular systolic function. Increased left
ventricular filling pressure.
Mild mitral regurgitation. Mild to moderate tricuspid
regurgitation. Mild pulmonary hypertension.
Carotids Doppler US ___
Less than 40% stenosis of the internal carotid arteries
bilaterally.
CTA ___
Stable dissection per radiology report - official report ___
Brief Hospital Course:
Ms. ___ was on ___ transferred from ___ with a CTA
finding of type B dissection. She was admitted to our intensive
care unit for continuous blood pressure monitoring and
intravenous blood pressure medications. At the admission
vascular medicine was consulted to help with blood pressure
management. She was initially managed on iv medication and later
transitioned to oral medications. Patient was on ___ in
stable conditions transferred to the floor. During the
hospitalization patient underwent ECHO and carotid arteries
imaging - see the reports above. During the hospitalization the
pain was well controlled, patient tolerating diet. Before
discharge patient underwent CTA which showed stable findings and
she was cleared for home on the new blood pressure medications
per vascular medicine recommendation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. PredniSONE 10 mg PO DAILY
4. Celecoxib 100 mg oral QHS:PRN Pain
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Ipratropium Bromide Neb 1 NEB IH BID
7. Esomeprazole 20 mg Other DAILY
8. Brovana (arformoterol) 15 mcg/2 mL inhalation BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
Please do not exceed 3 g a day.
2. Aspirin 81 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
RX *chlorthalidone 25 mg 1 tablet(s) by mouth daily Disp #*20
Tablet Refills:*0
4. Diltiazem 360 mg PO DAILY hypertension
RX *diltiazem HCl 360 mg 1 tablet(s) by mouth daily Disp #*20
Tablet Refills:*0
5. Metoprolol Succinate XL 200 mg PO DAILY hypertension
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth daily Disp
#*20 Tablet Refills:*0
6. NIFEdipine (Extended Release) 30 mg PO DAILY
RX *nifedipine 30 mg 1 tablet(s) by mouth daily Disp #*20 Tablet
Refills:*0
7. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*20 Tablet
Refills:*0
8. Brovana (arformoterol) 15 mcg/2 mL inhalation BID
9. Celecoxib 100 mg oral QHS:PRN Pain
10. Esomeprazole 20 mg Other DAILY
11. Ipratropium Bromide Neb 1 NEB IH BID
12. Multivitamins W/minerals 1 TAB PO DAILY
13. PredniSONE 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
acute Type B aortic dissection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___.
You were admitted to ___ for severe abdominal pain which was
proven to be acute type B aortic dissection. You were admitted
for close monitoring and management of your blood pressure. You
recovered well, with good blood pressure and you are now ready
to be discharge. Please read the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new or worsening abdominal or 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 driving or operating heavy machinery while taking pain
medications.
Please call our vascular surgery office (___) to
schedule an follow up appointment. Follow up appointment with
vascular medicine clinic will be scheduled as well (dr. ___.
You are being discharge with visiting nurse to measure your
blood pressure at home.
Best wishes,
Your ___ Vascular Surgery team.
Followup Instructions:
___
|
19889247-DS-7 | 19,889,247 | 22,579,998 | DS | 7 | 2166-09-21 00:00:00 | 2166-09-22 09:16:00 |
Name: ___ ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ history of bronchiectasis with restrictive ventilatory
deficit on prior PFTs, atopy, prior tobacco abuse that presents
with acute onset of shortness of breath and cough.
Pt reports cough for the last month w/ sx worsening over the
past week. He states that about a month ago, he had the onset of
a cold with a persistent cough. He also felt like he was having
throat issues from ? post-nasal drip with coughing fits.
He was producing a good amount of sputum that was mostly
colorless/white with occasional tinge of yellow in amount of
___ cc phelgm daily for about ___ weeks. He tried multiple
home
remedies (he used to have an acapella flutter valve but has not
used this) including a z-pak (some improvement in symptoms
initially), mucinex, zyrtec for ? allergies starting over this
weekend. He initially thought that he was getting better but
then had coughing "come and go." He also noted wheezing and
tried
albuterol inhaler without much benefit. He primarily feels that
this has been an upper airway issue.
This weekend, he started to notice that he was more short of
breath and was continuing to cough. He came to work at ___
today and was very short of breath and was referred to the ED
for
ongoing management.
In ___, he has similar complaints although his coughing episode
was not that bad.
Additionally, he does endorse a history of allergy/atopy,
post-nasal drip. He denies fever/chills/weight loss although has
felt "sweaty" in the past day or so. He has noted an increased
HR
attributable to albuterol usage. He also has had episodes of PND
with awakening to cough. He denies any recent sick contacts,
GERD/aspiration events.
He presented to the ___ ER. Initial VS were:07:38 0 96.0 125
149/72 24 97%. In the ED, several tests were performed:
- ABG ___
- D-Dimer: 297
- Na 139 K 5.2 Cl 100 HCO3 24 BUN 19 Cr 1.2 Glc 145
- Trop-T: <0.01
- proBNP: 166
- WBC 8 Hgb 15.9 Plt 310
He was given albuterol/ipratropium and methylprednisolone 125 mg
IV x 1. 1L IVF. Later, he was given Bactrim DS, guaifenesin, and
fluticasone per pulm rec.
A CTA Chest was negative for pulmonary embolism. There were
multiple sub-4 mm RUL pulmonary nodules in addition to a region
of nonspecific GGO in the LLL.
Review of Systems: positive as per HPI. of note, ___ BRBPR, ___
melena. a full ten point review
of systems is otherwise negative.
Past Medical History:
- Bronchiectasis, followed by Pulmonary clinic.
- h/o Positive PPD ___ yrs)
- Atopy
- Serous Retinopathy (OS) - idiopathic. s/p laser treatment
Social History:
___
Family History:
Non-contributory for Pulmonary disease
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T:98.1 BP:121/69 P:112 R:20 O2:97RA
Gen: NAD, non-toxic
HEENT: PERRL, EOMI, oropharynx clear, neck supple
CV: tachycardiac, JVP 8 cm H2O
Pulm: There is wheeze over the trachea. The lungs have decent
air
movement bilaterally with ___ obvious focality. There was
scattered wheeze and occasional rhonci.
Prolonged examination results in mild respiratory distress.
Abd: non-tender, hypoactive bowel sound, non-distended. ___ HSM
Ext: ___ c/c/e
Skin: ___ rashes
Neuro: AAOx3, CN II-XII grossly in tact, strength ___
throughout. normal gait.
.
DISCHARGE PHYSICAL EXAM
Vitals: 98.2 104/62 81 18 99RA
Gen: NAD, non-toxic
HEENT: PERRL, EOMI, oropharynx clear, neck supple
CV: tachycardiac, JVP 8 cm H2O
Pulm: good airway entry b/l, prolonged expiratory phase w/
diffuse wheeze. ___ crackles.
Abd: non-tender, hypoactive bowel sound, non-distended. ___ HSM
Ext: ___ c/c/e
Skin: ___ rashes
Neuro: AAOx3, CN II-XII grossly in tact, strength ___
throughout. normal gait.
Pertinent Results:
ADMISSION LABS
==============
___ 08:05AM BLOOD WBC-8.0 RBC-4.97 Hgb-15.9 Hct-48.4 MCV-98
MCH-32.1* MCHC-32.9 RDW-13.3 Plt ___
___ 08:05AM BLOOD Neuts-82.1* Lymphs-10.0* Monos-5.3
Eos-1.9 Baso-0.8
___ 07:45AM BLOOD ___ PTT-29.9 ___
___ 08:05AM BLOOD Glucose-145* UreaN-19 Creat-1.2 Na-139
K-5.2* Cl-100 HCO3-24 AnGap-20
___ 08:05AM BLOOD cTropnT-<0.01 proBNP-166
___ 02:15PM BLOOD cTropnT-<0.01
___ 07:45AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.1
___ 08:05AM BLOOD D-Dimer-297
.
DISCHARGE LABS
==============
___ 07:45AM BLOOD WBC-9.3 RBC-4.30* Hgb-13.9* Hct-41.1
MCV-96 MCH-32.4* MCHC-33.9 RDW-13.3 Plt ___
___ 07:45AM BLOOD Glucose-103* UreaN-24* Creat-1.3* Na-140
K-4.2 Cl-105 HCO3-26 AnGap-13
.
MICROBIOLOGY LABS
___ SPUTUM GRAM STAIN-PENDING; RESPIRATORY
CULTURE-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
.
IMAGING
=======
CTA CHEST W&W/O C&RECON
Final Report
HISTORY: Shortness breath and cough. Evaluate for pulmonary
embolism.
TECHNIQUE: Axial helical MDCT images were obtained from the
suprasternal
notch to the upper abdomen without contrast and low-dose
radiation at first,
followed by an early arterial phase scanning after 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.
DLP: 304.12
COMPARISON: Comparison is made to CT torso dated ___.
FINDINGS:
CT THORAX: The airways are patent to the subsegmental level.
There is ___
mediastinal, hilar, or axillary lymph node enlargement by CT
size criteria.
Diffuse coronary calcifications are seen. Heart, pericardium,
and great
vessels are within normal limits. ___ hiatal hernia or any other
esophageal
abnormality is present.
Lung windows redemonstrate multiple pulmonary nodules within the
right upper
lobe measuring up to 4 mm (3:38, 39, 64, and 88), all of which
are stable in
size as compared to the most recent prior examination. Regions
of nonspecific
ground-glass airspace opacification are noted within the right
apex and mid
left lower lobe (3:147), and may represent an area of infection
versus
inflammation. Diffuse bronchial wall thickening and mucous
plugging is
compatible with an inflammatory airway process. ___ pleural
effusion or
pneumothorax is present.
CTA THORAX: The aorta and main thoracic vessels are well
opacified. The
aorta contains diffuse atherosclerotic calcifications and
demonstrates normal
caliber throughout the thorax without intramural hematoma or
dissection. The
pulmonary arteries are opacified to the segmental level. There
is ___ filling
defect to suggest pulmonary embolism.
BONES: ___ focal osseous lesions concerning for malignancy are
seen.
Although this study is not designed for assessment of
intra-abdominal
structures, limited views demonstrate mild thickening of the
bilateral adrenal
glands, stable since the prior examination. The visualized solid
organs and
stomach are otherwise unremarkable.
IMPRESSION:
1. ___ evidence of pulmonary embolism.
2. Regions of nonspecific ground-glass opacity with the RUL and
LLL, which
may reflect infection.
3. Diffuse bronchial wall thickening and bilateral mucous
plugging. Findings
likely represent an inflammatory airway process such as COPD or
asthma.
4. Multiple sub-4 mm right upper lobe pulmonary nodules, stable
as compared
to the prior examination. ___ further follow up is required for
these nodules.
Brief Hospital Course:
___ history of bronchiectasis, atopy, prior remote tobacco use
that presents with acute onset of shortness of breath and cough
likely consistent with a bronchiectasis flare +/- early
superimposed pneumonia based on GGO on chest CT vs less likely
hypersensitivity reaction.
# Bronchiectasis flare - pt presents w/ increased sputum
production subacute worsening SOB x ___s acute
worsening SOB and cough x 1 day. afebrile in the ED.
Presentation consistent withi a bronchiectasis flare +/- early
superimposed PNA per CT. also consider allergic bronchopulmonary
aspergillosis. Alt etiology such as acute MI, VTE, acute aortic
syndrome have been r/o'd in the ED. Troponin negative x 2. CTA
with ___ evidence of PE or aortic pathology. pt treated with
methylprednisone, inhalers and bactrim in the ED per pulmonology
recommendations. Bactrim was chosen given that he failed z-pack
as an outpatient and that previous culture had grown gram
positive organisms (staph coverage). His respiratory status
further improved with saline nebulizers, acapella flutter valve,
guaifenesin, lorataine, fluticasone, and albuterol inhaler. He
remained afebrile with ___ systemic signs of infection and ___
leukocytosis. On day of discharge, pt was breathing comfortably
on room air with O2 sat > 98%. Pt was also able to maintain good
ambulatory sats (O2 > 95%). Pt was discharged to complete a
total of 5 day course of 40mg PO prednisone, as well as 10 days
of doxycycline (chosen for gram positive coverage as well as
atypical coverage). Pt was able to provide a sputum culture,
which will need PCP follow up to adjust abx therapy as
appropriate. Pt was also given scripts for inhalers on discharge
to be used as needed.
# Abnormal chest CT with GGO - concerning for early superimposed
PNA per CT. also consider allergic bronchopulmonary
aspergillosis. pt afebrile w/ ___ leukocytosis on admission. Pt
was treatd with bactrim DS BID based on previous sputum culture
with gram positive organism. pt remained stable with ___
systemic signs of infection. He was discharged to complete 10
day course of doxcycline (gram + and atypical coverage). blood
culture ___ growth to date on day of discharge.
# Tachycardia - pt presented w/ HR of 110s-120s in the ED. most
likely ___ frequent albuterol usage w/ combination of dyspnea.
pt did not meet SIRS criteria (___) and is maintaining good BP.
EKG sinus tachycardia with PVCs, and tall P on lead II. ___ signs
of bleeding on exam. PE and aortic etiologies r/o'd per CTA.
His tachycardia resolved (HR of ___ on day of discharge) with
spacing out of albuterol and ___ further intervention.
## Transitional issues
- please f/u on sputum culture results and modify abx rx prn
- if sx persists after treated for possible infection cause, may
benefit from allergy referral
- will need repeat thoracic imaging in 4 weeks
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H
RX *albuterol ___ puff inhaled every 6 hours Disp #*2 Unit
Refills:*1
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
RX *fluticasone [Flovent HFA] 110 mcg/actuation 2 puffs inhaled
twice a day Disp #*2 Unit Refills:*1
3. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL ___ ml by mouth every 6 hours Disp
#*1 Bottle Refills:*0
4. Loratadine 10 mg PO DAILY
RX *loratadine 10 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
5. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*8 Tablet
Refills:*0
6. Sodium Chloride Nasal ___ SPRY NU TID
RX *sodium chloride [Saline Nasal Mist] 0.65 % ___ Spray
intranasally three times a day Disp #*2 Unit Refills:*1
7. Aspirin 81 mg PO DAILY
8. Doxycycline Hyclate 100 mg PO Q12H Duration: 10 Days
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Bronchiectasis
Possible superimposed LLL pneumonia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Dr. ___,
___ has been our pleasure to take care of you. You were admitted
for dyspnea, which was most consistent with a bronchiectasis
flare with a possible superimposed pnuemonia. We treated you
with steroid, antibiotics as well as inhalers. You responded to
treatment well with improved breathing. Please continue to take
prednisone for a total of 5 days and antibiotics (doxycycline)
for the next ___ days, as well as inhalers to help optimize your
breathing. We have also set up follow-up appointments for you
(please see below).
Followup Instructions:
___
|
19889659-DS-12 | 19,889,659 | 29,856,140 | DS | 12 | 2130-06-14 00:00:00 | 2130-06-16 19:17:00 |
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:
___ with hx of ___, sacroilitis, submucosal fibroids p/w 14
days of abdominal pain, nausea, and decreased appetite. Patient
notes that this feels just like one of her ___ flare. The
pain started 2 weeks ago after eating fried chicken at ___.
She notes that she usually stays away from fried foods as they
tend to trigger her flares. The pain is dull, intense, ___
constant and it wraps around to her lower back. She denies
bloody diarrhea, mucous. She has never had fistulas or abscesses
and notes her GI tells her she has a very mild ___. Patient
notes Tylenol has helped somewhat with her pain. Hes las BM was
yesterday and it was normal, no diarrhea, melena, bright red
blood, mucous, fat. Patient has been having ___ bowel movements
per day (her normal). Has had nausea and decreased PO intake for
about 2 weeks, also normal for her flares. In the ED she had
chest pain last a few minutes, which she notes felt like her
usual GERD pain. Denies pedal edema, PND, orthopnea, DOE.
Patient has a history of CNIII s/p LEEP, fibroids (one was
resected about ___ years). Notes that she has regular menstrual
periods about once per month last ___ days. LMP ___. Condoms
for contraception. Patient is sexually active. No irregular
bleeding, no abnormal vaginal discharge, no dyspareunia. Patient
denies fevers, chills, sweats, weight loss (except for 5lbs as
she has been dieting with her fiancé). Patient denies dysuria,
malodorous urine, hematuria.
In the ED, VS- 98.0 97 136/87 18 100RA. Exam significant for
mild TTP inferior to umbilicus. Labs significant for UCG
(negative), unremarkable chem and cbc. Studies including CXR,
KUB, CT Abd were negative for acute pathology. Patient treated
with IV Ondansetron 4mg, IVF 1000cc NS, IV Morphine 2mg x 2, IV
Morphine 4mg.
On arrival to the floor: vitals 98.9 119/75 89 98% RA.
Patient endorses abdominal pain in lower quadrants, more
midline.
Past Medical History:
___ ileocolitis
Sacroilitis
CIN III
Vertigo
Generalized Anxiety Disorder
Iron Deficiency
Migraine
Pre-diabetes
Obesity
Lateral malleolar fracture (left)
Closed fracture of posterior malleolus
PAST GYN HISTORY:
Submucosal Fibroids
Gonorrhea
Chlamydia
Pelvic Inflammatory Disease
Vulvovaginitis
Herpes
Chronic nipple discharge/galactorrhea and pain
Abortion
PAST SURGICAL HISTORY
LEEP
Myomyectomy
Social History:
___
Family History:
Three siblings. Two sisters, one brother. One sister lupus,
other sister molar pregnancy/uterine cancer/mets to lung.
Physical Exam:
ADMISSION EXAM
=================
Vital Signs: 98.9 119/75 89 12 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: +striae, soft, non-distended, mild tenderness to
palpation over lower mid-abdomen, 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, normal gait.
DISCHARGE EXAM
=================
Vital Signs: 98.9 ___ 12 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: +striae, soft, non-distended, mild tenderness to
palpation over lower mid-abdomen, 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, normal gait.
Pertinent Results:
ADMISSION EXAM
==================
___ 06:55AM NEUTS-61.6 ___ MONOS-7.6 EOS-2.0
BASOS-0.9 IM ___ AbsNeut-4.08 AbsLymp-1.83 AbsMono-0.50
AbsEos-0.13 AbsBaso-0.06
___ 06:55AM WBC-6.6 RBC-4.49 HGB-11.3 HCT-35.5 MCV-79*
MCH-25.2* MCHC-31.8* RDW-17.6* RDWSD-49.8*
___ 06:55AM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-1.9
___ 06:55AM LIPASE-27
___ 06:55AM ALT(SGPT)-17 AST(SGOT)-21 ALK PHOS-84
___ 06:55AM GLUCOSE-107* UREA N-16 CREAT-0.9 SODIUM-137
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-23 ANION GAP-14
IMAGES/STUDIES
=================
Pelvis Ultrasound ___:
FINDINGS:
The uterus is retroverted. The uterus is enlarged measuring 9.3
x 5.2 x 5.7
cm. There are multiple masses consistent with fibroids. The
largest fibroid is located in the fundus on the right and
measures 2.5 x 2.9 x 2.4 cm, similar to recent CT. The
endometrium is distorted by fibroids, but where seen measures 4
mm.
The ovaries are normal. There is a trace amount of free fluid.
IMPRESSION:
Fibroid uterus with normal ovaries.
CT Abdomen/Pelvis ___:
IMPRESSION:
1. No bowel obstruction or bowel wall thickening. No findings
to suggest an acute ___ flare. Normal appendix.
2. Fibroid uterus, similar in appearance to prior. One fibroid
appears to
involve the endometrial cavity (submucosal) versus less likely
representing a polyp; stable in appearance since ___.
Findings could be further assessed on outpatient pelvic
ultrasound if clinical symptoms referable to this.
3. Right corpus luteum.
4. Again seen bilateral sacroiliitis.
DISCHARGE LABS
===================
___ 07:07AM BLOOD WBC-4.4 RBC-4.52 Hgb-11.3 Hct-35.7
MCV-79* MCH-25.0* MCHC-31.7* RDW-17.2* RDWSD-49.0* Plt ___
___ 07:07AM BLOOD Glucose-90 UreaN-11 Creat-0.9 Na-136
K-4.2 Cl-103 HCO3-25 AnGap-12
___ 07:07AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.8
___ 07:07AM BLOOD CRP-18.8*
___ 07:07AM BLOOD SED RATE-29H
Brief Hospital Course:
___ with hx of ___, sacroilitis, submucosal fibroids p/w 14
days of abdominal pain, nausea, and decreased appetite,
concerning for ___ flare, although CT abdomen not suggestive
of active inflammation.
# Abdominal pain: Pt presented with two weeks of abdominal pain,
mainly in her mid lower abdomen, which she notes is similar to
her previous ___ flare. She also notes she has bilateral
groin and back pain, which often come with her flares. Patient
was tolerating PO. The pain is in the setting of a known trigger
of eating fried/greasy foods. Patient has flares about two -
three times per year. ___ flare is a potential cause for her
abdominal pain. However, there were no CT findings to suggest
acute ___ flare. Of note, in ___, pt had elevated ESR (26)
and CRP (9.5) in the setting of similar episode of abdominal
pain and normal CT abdomen. Gynecological diagnoses are also on
differential, including fibroids, PID (pt has been tx for
gonorrhea and chlamydia in the past), ovarian cysts,
endometriosis. Patient has hx of 1.9cm left ovarian cyst on CT
___, however his cyst was not seen on this admission's CT.
Patient also has known submucosal fibroids and a history of
cervical fibroid that was resected. Endometriosis pain could be
lower abdominal, however expect pain to be cyclical with
menstruation. Ectopic pregnancy less likely due to negative HCG
in ED. Interestingly, pt's pain is improved with BMs, which
could be suggestive of IBS. Viral or bacterial gastroenteritis
less likely given chronicity and lack of fevers, diarrhea,
vomiting. Patient did travel to ___ in ___, however had been
in her normal state of health up until 2 weeks ago.
Interestingly, patient has a history of sacroilitis and
arthralgias which in combination with her IBD, could be
consistent with spondyloarthropathy. On this admission, her CRP
was 18.8, and ESR 29, which are both elevated. Pelvic ultrasound
showed known uterine fibroids, no ovarian masses. Her abdominal
pain is of unclear etiology. Patient discharged with close
follow up with GI and PCP. Patient interested in second opinion
about her ___ diagnosis.
# GERD: Patient endorses increased GERD symptoms especially
during her ___ flare. She endorsed heartburn while in the ED
and chest discomfort. EKG without ischemic changes. Increased
Pantoprazole to Q12H (at home she takes Q24H, and increases to
Q12H when it worsens) and offered tums for immediate relief.
TRANSITIONAL ISSUES
====================
[ ] Patient was encouraged to start a pain diary, as this could
be helpful to better understand your pain and symptoms.
[ ] Patient meets criteria for IBS, this diagnosis should be
considered.
[ ] Follow up with GI, OB-GYN.
[ ] CONTACT: Sister, HCP: ___ ___
[ ] Full code, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q12H
2. Mesalamine Enema 4 gm PR QHS:PRN mucous BM
3. Mesalamine 1500 mg PO DAILY
4. Cyanocobalamin 100 mcg PO DAILY
5. Vitamin B Complex 1 CAP PO DAILY
6. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Cyanocobalamin 100 mcg PO DAILY
2. Mesalamine 1500 mg PO DAILY
3. Mesalamine Enema 4 gm PR QHS:PRN mucous BM
4. Multivitamins 1 TAB PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. Vitamin B Complex 1 CAP PO DAILY
7. Acetaminophen 1000 mg PO Q8H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=====================
Abdominal pain
Fibroids
SECONDARY DIAGNOSIS
=====================
___ ileocolitis
Sacroilitis
CIN III
Vertigo
Generalized Anxiety Disorder
Iron Deficiency
Migraine
Pre-diabetes
Obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure to care for you at ___. You came to us for
abdominal pain. We checked lab work and your inflammatory
markers were slightly elevated, however the CT imaging of your
abdomen was not suggestive of active inflammation. We also did a
pelvic ultrasound which showed: normal ovaries, however multiple
fibroids - which could certainly cause abdominal/groin pain.
Given that you were eating and drinking and that your pain was
slightly improving, your primary team felt that you were safe to
be discharged home.
Avoid greasy foods if indeed this triggers abdominal pain. We
encourage you to start a pain diary, as this could be helpful to
better understand your pain and symptoms.
Please follow up with your PCP and also with the GI doctor for ___
second opinion about your abdominal complaints.
Please bring a copy of this work sheet to your outpatient
appointments.
Take care. We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19889694-DS-46 | 19,889,694 | 28,067,210 | DS | 46 | 2171-03-30 00:00:00 | 2171-03-31 15:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zosyn / Penicillins / Sulfa (Sulfonamide Antibiotics) / Iodine /
Vancomycin / Zofran / Morphine / Fentanyl / Midazolam /
shellfish derived
Attending: ___
Chief Complaint:
Right-sided chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with past medical history of SLE, renal
transplant, prior DVT no longer on anticoagulation who presents
with right-sided pleuritic chest pain after coming back from
___ a few days ago. She states that she has developed the
chest pain in her sleep, and it is worsened with deep
inspiration. At rest, she is not dyspneic and has no radiation
of the pain to her arms, jaw, or associated with diaphoresis or
nausea she has a significant family cardiac history, diabetes,
but does have hypertension and hyperlipidemia. She has been
taking all her medications as prescribed. She denies any URI
symptoms, cough, back pain, abdominal pain, nausea, vomiting or
diarrhea, urinary symptoms, rashes, or paresthesias. She denies
any leg swelling, cancer diagnosis, recent surgery, being
bedridden, or on estrogen.
In the ED:
Initial vital signs were notable for: 97 87 120/86 18 99% RA.
Vitals remained stable in ED.
Exam notable for:
Con: alert, oriented and in no acute distress
HEENT: NCAT. PERRLA, no icterus or injection bilaterally. EOMI.
No erythema or exudate in posterior pharynx; uvula midline; MMM.
Neck: neck veins flat with full ROM
LAD: no cervical LAD
Resp: Breathing comfortably on RA. No incr WOB, CTAB with no
crackles or wheezes.
CV: RRR. Normal S1/S2. NMRG. 2+ radial and DP pulses bilateral.
Abd: Soft, Nontender, Nondistended with no organomegaly; no
rebound tenderness or guarding.
MSK: ___ without edema bilaterally
Skin: No rash, Warm and dry, No petechiae
Neuro: AOx3, speech fluent, no obvious facial asymmetry, moves
all 4 ext to command.
Psych: Normal mentation
Labs were notable for: Cr 1.5, serum K 5.9, whole blood K 5.5,
WBC 6.4, trop negative.
Studies performed include: CXR unremarkable. EKG w/ ? S1Q3T3,
but
stable from prior EKGs, no ischemic ST-T wave changes
Bilateral lower extremity US:
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
Patient was given:
___ 18:18 IV Heparin 1350 units/hr
___ 19:39 IH Albuterol 0.083% Neb
___ 21:03 PO/NG Acyclovir 400 mg
___ 21:03 PO/NG Metoprolol Tartrate 50 mg
___ 21:03 PO Tacrolimus 4 mg
___ 21:03 PO/NG Acetaminophen 650 mg
Consults: none
Upon arrival to the floor, patient states her pain is currently
well controlled but gets worse with deep breaths or if she lies
flat. Additionally states that she feels as though her lupus has
been more active since the beginning of the ___. Has been
getting join pains, rashes for the last few months. Endorses
history of plural/pericardial effusions, BOOP related to SLE in
past. Denies ever being diagnoses with pleuritis, tamponade in
past.
Past Medical History:
1. Lupus
2. Prior DVT, not currently on anticoagulation
3. Renal transplant in ___
4. Hypertension.
5. Depression.
6. Sjogren syndrome - ___
7. BOOP - ___
8. Inflammatory arthropathy
9. Orthostatic hypotension - ___
Social History:
___
Family History:
Mother Living ___ DIABETES MELLITUS, ASTHENIA, OBESITY
Father Living ___ BIPOLAR DISORDER
Sister Living 34 LUPUS
Physical Exam:
ADMISSION EXAM:
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection. MMM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
DISCHARGE EXAM:
24 HR Data (last updated ___ @ 1139)
Temp: 98.3 (Tm 98.6), BP: 116/81 (103-133/71-94), HR: 86
(76-86),
RR: 18, O2 sat: 95% (95-100), O2 delivery: Ra, Wt: 261.68
lb/118.7 kg (amb sat 100% on RA on ___
Gen: sitting comfortably in bed in NAD
HEENT: PERRL, EOMI, OP clear
CV: RRR, nl S1, S2, no m/r/g, no friction rub appreciated, JVP
flat
Chest: CTAB, mild TTP over sternum, no R-sided lateral chest
wall
tenderness w/palpation
Abd: obese, + BS, soft, NT, ND
MSK: lower ext warm without edema; joints without evidence of
effusions or arthritis
Neuro: AOx3, CN II-XII intact, ___ strength all extremities,
sensation grossly intact throughout, gait not tested
Psych: pleasant, appropriate affect
Pertinent Results:
CBC:
___ 04:20PM BLOOD WBC-6.4 RBC-4.00 Hgb-10.3* Hct-32.7*
MCV-82 MCH-25.8* MCHC-31.5* RDW-14.8 RDWSD-44.1 Plt ___
___ 08:20AM BLOOD WBC-7.7 RBC-3.76* Hgb-9.5* Hct-30.8*
MCV-82 MCH-25.3* MCHC-30.8* RDW-14.8 RDWSD-44.7 Plt ___
___ 10:05AM BLOOD WBC-7.7 RBC-4.04 Hgb-10.4* Hct-32.9*
MCV-81* MCH-25.7* MCHC-31.6* RDW-14.8 RDWSD-43.6 Plt ___
BMP:
___ 04:20PM BLOOD Glucose-95 UreaN-20 Creat-1.5* Na-138
K-5.9* Cl-103 HCO3-23 AnGap-12
___ 08:20AM BLOOD Glucose-90 UreaN-27* Creat-1.5* Na-140
K-4.5 Cl-104 HCO3-23 AnGap-13
___ 10:05AM BLOOD Glucose-121* UreaN-25* Creat-1.6* Na-137
K-4.7 Cl-103 HCO3-22 AnGap-12
___ 04:20PM BLOOD cTropnT-<0.01
___ 08:20AM BLOOD TSH-4.5*
___ 08:20AM BLOOD T4-7.7
___ 08:20AM BLOOD CRP-16.1*
___ 08:20AM BLOOD C3-155 C4-45*
___ 08:20AM BLOOD CRP-16.1* dsDNA-NEGATIVE
___ 08:20AM BLOOD tacroFK-7.1
___ 10:05AM BLOOD tacroFK-6.2
EKG (___):
NSR at 83 bpm, nl axis, PR 161, QRS 87, QTC 362, Q in III,
otherwise no ST changes
CXR ___:
PA and lateral views of the chest provided. Suture material is
noted in the right midlung as on prior. The lungs are clear
bilaterally. No focal
consolidation, large effusion, pneumothorax. Cardiomediastinal
silhouette is stable. Bony structures are intact. No free air
below the right
hemidiaphragm.
LENIs ___:
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
V/Q scan ___:
FINDINGS: Ventilation images demonstrate no focal ventilation
defects.
Perfusion images demonstrate no perfusion defects.
Chest x-ray shows no acute cardiopulmonary process.
In comparison, prior lung scan dated ___ showed normal
perfusion (no
ventilation data available as patient was unable to adequately
inhale tracer aerosol).
IMPRESSION: 1. No evidence of pulmonary embolism
Brief Hospital Course:
___ woman with past medical history of SLE (on
plaquenil), Sjogren's syndrome, Lupus nephritis s/p DDRT ___
(on
tac/pred) w/chronic allograft dysfunction (b/l Cr 1.4-1.6),
remote pericarditis, prior DVT no longer on anticoagulation,
recent admission for lightheadedness (___) p/w R-sided
pleuritic chest pain and DOE, likely MSK in etiology and
resolving at discharge.
# Dyspnea on exertion:
# Pleuritic chest pain:
Patient presented with R-sided pleuritic chest pain and DOE
after
recent flight from ___. Onset after plane travel concerning
for PE, but CTA could not be obtained due to a contrast allergy.
She was empirically anticoagulated with heparin in the ED and
admitted. B/l LENIs and V/Q scan were negative, and heparin was
discontinued. CXR without evidence of PNA, and EKG/negative
biomarkers argue against ACS or pericarditis. Low suspicion for
pleuritis secondary to SLE given absence of active joint disease
and normal complement levels and dsDNA. Suspect that her pain is
likely MSK given reproducible tenderness on exam, improving at
the time of discharge. Dsypnea had resolved by the time of
discharge, and ambulatory sats were 100% on RA. She will f/u
with
her PCP ___ ___.
# ESRD s/p DDRT ___:
# Chronic allograft nephropathy:
Cr 1.5 on admission (baseline 1.3-1.5). She was followed by the
renal transplant team while in-house. Tacrolimus levels were
therapeutic. At the transplant team's suggestion, home OTC
melatonin was discontinued on discharge given potential for
interaction with tacrolimus. She was discharged on home
prednisone 5mg daily and tacrolimus 4mg q12h, as well as her
home
acyclovir ppx. F/u in the ___ is scheduled for
___.
# SLE:
# Sjogren's:
Patient has a hx of SLE and Sjogren's, for which she is followed
by rheumatology. There was low suspicion for active
rheumatologic
disease despite mildly elevated CRP of 16. Complement levels and
dsDNA were normal. She was discharged on her home plaquenil and
prednisone and will f/u with rheumatology on ___.
# Borderline microcytic anemia:
Hgb 10.3 on admission, stable at 10.4 on discharge. Baseline
appears to be ___. No e/o active bleeding. Further w/u
deferred
to outpatient setting.
# Hypertension: continued home metoprolol
# Depression/Anxiety: continued home lorazepam QHS, mitrazipine,
ziprasidone, prazosin
# Metabolic acidosis: continued NaHCO3
TRANSITIONAL ISSUES:
[] F/u ESR pending at discharge
[] Avoid melatonin given potential for immunomodulation with
tacrolimus (per renal transplant team)
[] further w/u of ongoing microcytic anemia (stable this
admission)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Hydroxychloroquine Sulfate 200 mg PO BID
3. LORazepam 1 mg PO QHS
4. Metoprolol Tartrate 50 mg PO BID
5. Mirtazapine 30 mg PO QHS
6. Prazosin 1 mg PO QHS
7. PredniSONE 5 mg PO DAILY
8. Sodium Bicarbonate 650 mg PO BID
9. Tacrolimus 4 mg PO Q12H
10. Vitamin D 1000 UNIT PO DAILY
11. ZIPRASidone Hydrochloride 80 mg PO QHS
12. Clindamycin 600 mg PO ASDIR prior to dental procedures
13. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
14. ___ ___ UNIT PO Q4H:PRN thrush
15. melatonin 10 mg oral QHS
16. biotin 1 mg oral DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. biotin 1 mg oral DAILY
3. Clindamycin 600 mg PO ASDIR prior to dental procedures
4. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 Duration: 1 Dose
5. Hydroxychloroquine Sulfate 200 mg PO BID
6. LORazepam 1 mg PO QHS
7. Metoprolol Tartrate 50 mg PO BID
8. Mirtazapine 30 mg PO QHS
9. ___ ___ UNIT PO Q4H:PRN thrush
10. Prazosin 1 mg PO QHS
11. PredniSONE 5 mg PO DAILY
12. Sodium Bicarbonate 650 mg PO BID
13. Tacrolimus 4 mg PO Q12H
14. Vitamin D 1000 UNIT PO DAILY
15. ZIPRASidone Hydrochloride 80 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Costochondritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital with chest pain that
worsened with breathing.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were started on blood thinners because of concern for a
blood clot in your lungs.
- Your lungs were scanned to evaluate for a blood clot in the
lungs. The scan was negative so the blood thinner was stopped.
- You also got blood work to evaluate for whether lupus could be
causing your chest pain.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please note all of your medication changes below, as well as
your upcoming doctor appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19889694-DS-48 | 19,889,694 | 26,986,243 | DS | 48 | 2172-06-12 00:00:00 | 2172-06-14 17:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zosyn / Penicillins / Sulfa (Sulfonamide Antibiotics) / Iodine /
Vancomycin / Morphine / Fentanyl / Midazolam
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
================
___ 12:58AM ___ PTT-31.3 ___
___ 12:58AM PLT COUNT-253
___ 12:58AM NEUTS-69.7 ___ MONOS-5.7 EOS-2.3
BASOS-0.4 IM ___ AbsNeut-5.86 AbsLymp-1.81 AbsMono-0.48
AbsEos-0.19 AbsBaso-0.03
___ 12:58AM WBC-8.4 RBC-4.04 HGB-10.1* HCT-33.5* MCV-83
MCH-25.0* MCHC-30.1* RDW-14.7 RDWSD-44.5
___ 12:58AM cTropnT-<0.01
___ 12:58AM estGFR-Using this
___ 12:58AM GLUCOSE-124* UREA N-27* CREAT-1.7* SODIUM-135
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-20* ANION GAP-13
___ 04:50PM PLT COUNT-273
___ 04:50PM WBC-7.6 RBC-4.31 HGB-10.7* HCT-35.5 MCV-82
MCH-24.8* MCHC-30.1* RDW-14.8 RDWSD-44.7
___ 04:50PM tacroFK-6.1
___ 04:50PM CALCIUM-9.8 PHOSPHATE-3.0 MAGNESIUM-1.8
___ 04:50PM GLUCOSE-110* UREA N-24* CREAT-1.6* SODIUM-138
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-21* ANION GAP-14
___ 11:07PM PTT-150*
DISCHARGE LABS:
===============
___ 09:40AM BLOOD WBC-7.7 RBC-3.89* Hgb-9.7* Hct-31.7*
MCV-82 MCH-24.9* MCHC-30.6* RDW-14.8 RDWSD-43.7 Plt ___
___ 09:40AM BLOOD Plt ___
___ 09:40AM BLOOD ___ PTT-72.9* ___
___ 09:40AM BLOOD Glucose-97 UreaN-28* Creat-1.5* Na-134*
K-4.3 Cl-101 HCO3-22 AnGap-11
___ 09:40AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.6
IMAGING:
========
___ VQ Scan
FINDINGS: No defects noted on the ventilation or perfusion
images.
Chest x-ray shows globular enlargement of the cardiac
silhouette.
IMPRESSION: Normal VQ scan.
___ B/l LENIs
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left
lower extremity
veins. Limited assessment of the right posterior tibial and
peroneal veins.
2. Dampening of the right common femoral vein waveform may
reflect persistence
of proximal deep vein thrombosis.
3. Partially occlusive superficial venous thrombophlebitis in
the right
posterior calf at the site of pain.
___ CXR
IMPRESSION:
In comparison with the study of ___, there again is
globular enlargement
of the cardiac silhouette. Scatter radiation related to the
size of the
patient somewhat obscures detail, but no appreciable vascular
congestion is
seen. No pleural effusion or acute focal pneumonia.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=====================
Ms. ___ is a ___ year old woman with a history of SLE
complicated by lupus nephritis s/p DDRT ___ now with allograft
CKD (baseline Cr 1.4-1.7), provoked DVTs now off anticoagulation
since ___, HTN, and Sjogren's syndrome who presented to the
ED with pleuritic chest pain concerning for PE, now determined
to be less likely given normal V/Q scan.
While in the hospital, Ms. ___ was closely monitored for her
chest pain and breathing status. During this admission, she had
continuous symptomatic improvement of chest pain and had oxygen
saturation >95% on room air. She was started on heparin drip
given concern of PE. She underwent bilateral lower extremity
ultrasounds that demonstrated no new DVTs. Chest x-ray did not
demonstrate any pneumonia, pulmonary edema, or pleural
effusions. There was persistent globular enlargement of the
cardiac silhouette that has been stable since ___. V/Q scan
demonstrated normal ventilation and perfusion with low
likelihood of PE. Given symptomatic improvement with low concern
for PE, she was taken off of anticoagulation and was deemed
ready for discharge with close outpatient follow-up.
TRANSITIONAL ISSUES
===================
[ ] Patient may require long term anticoagulation given history
of provoked DVTs and hypercoagulable state in the setting of
SLE. Her outpatient hematologist (Dr. ___ has been notified
of her admission. Of note, patient desiring pregnancy and would
like to stay off of warfarin (which has been her anticoagulant
in the past given CKD).
[ ] Globular enlargement of cardiac silhouette again seen on
chest x-ray this admission. Stable since ___ but may require
outpatient work-up with echocardiogram.
ACUTE ISSUES
============
#Pleuritic chest pain
Patient with history of two provoked DVT ___ and ___ in
the setting of refusing heparin prophylaxis while inpatient had
presented with pleuritic chest pain. Recent cessation of
warfarin in ___ after 6 months of anticoagulation. Given
history of DVTs, patient was admitted for V/Q scan with concern
for PE. CTA was contraindicated given CKD. However, bilateral
LENIs ruled out new DVT (but possible residual proximal DVTs
unable to be seen on ultrasound) and CXR and V/Q scan indicated
low probability of PE. Patient had been started on heparin drip
which was discontinued after normal V/Q scan. Etiology of chest
pain remains unclear but given low suspicion for PE and patient
symptomatically improving and without acute shortness of breath,
tachycardia or desaturations, patient was deemed ready for
discharge home with close follow up.
CHRONIC ISSUES
==============
# Immunosuppression
# ESRD due to lupus nephritis, s/p DDRT
Patient's renal function at baseline with creatinine at 1.5 on
discharge. The transplant renal team assessed the patient during
this admission and the patient was deemed to be stable. Her home
medications were continued and tacrolimus levels were monitored.
She was not exposed to any contrast.
#Lupus: Patient continued on home hydroxychloroquine
#Anxiety: Patient continued on home Ativan and trazodone
#Depression: Patient continued on home ziprasidone and
mirtazapine
#Hypertention: Patient continued on home metoprolol
#Sleep Apnea: Patient reports no longer using CPAP at home.
Patient was not on CPAP during this admission.
# CODE: Presumed FULL
# CONTACT: sister ___ ___ Boyfriend ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Ferrous Sulfate 325 mg PO DAILY
3. Hydroxychloroquine Sulfate 200 mg PO BID
4. LORazepam 1 mg PO QHS
5. Metoprolol Tartrate 50 mg PO BID
6. Mirtazapine 30 mg PO QHS
7. PredniSONE 5 mg PO DAILY
8. Sodium Bicarbonate 650 mg PO BID
9. TraZODone 25 mg PO QHS:PRN insomnia
10. Vitamin D 1000 UNIT PO DAILY
11. ZIPRASidone Hydrochloride 60 mg PO QHS
12. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
13. Multivitamins 1 TAB PO DAILY
14. Tacrolimus 4 mg PO Q12H
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
3. Ferrous Sulfate 325 mg PO DAILY
4. Hydroxychloroquine Sulfate 200 mg PO BID
5. LORazepam 1 mg PO QHS
6. Metoprolol Tartrate 50 mg PO BID
7. Mirtazapine 30 mg PO QHS
8. Multivitamins 1 TAB PO DAILY
9. PredniSONE 5 mg PO DAILY
10. Sodium Bicarbonate 650 mg PO BID
11. Tacrolimus 4 mg PO Q12H
12. TraZODone 25 mg PO QHS:PRN insomnia
13. Vitamin D 1000 UNIT PO DAILY
14. ZIPRASidone Hydrochloride 60 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Pleuritic chest pain
SECONDARY DIAGNOSIS
===================
SLE complicated by lupus nephritis s/p DRRT ___ with allograft
CKD
Prior provoked DVT not currently on anticoagulation
HTN
Depression
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were admitted to the hospital because you were having
chest pain that was worse with breathing. We were concerned
that this was due to a blood clot in your lungs (called a
pulmonary embolus) and you were admitted for further evaluation
of the possible blood clot.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- While you were in the hospital, your breathing and heart were
closely monitored. Your chest pain improved and you were
breathing comfortably on room air.
- You were started on a heparin drip (an anticoagulant) in the
setting of concern for a blood clot in your lungs. The heparin
drip was stopped after imaging showed you likely did not have a
blood clot.
- You had several types of imaging of your chest including a
chest x-ray and a ventilation-perfusion scan (V/Q Scan) that
helped us determine that it was unlikely you had a pulmonary
embolus.
- You also had an ultrasound of your lower extremities and there
were no new blood clots in your legs.
- You were seen by the kidney transplant team and they helped in
making medical decisions in the setting of your transplanted
kidney. They determined that your kidney function had not
changed and no changes were made to your home medications.
- Your symptoms improved and breathing remained stable and were
deemed ready for discharge home.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all of your medications and follow up
with your doctors at your ___ appointments.
- Weigh yourself every morning, call your doctor if weight goes
up more than 3 lbs.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19890030-DS-12 | 19,890,030 | 26,070,834 | DS | 12 | 2178-09-13 00:00:00 | 2178-09-13 13:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___ - Emergency aortic valve replacement with a 23 mm ___
___ tricuspid tissue valve for endocarditis.
History of Present Illness:
Ms. ___ is a ___ woman with no significant past
medical history. She was visiting her son and developed sudden
dyspnea at rest. She was asleep in a guest room when she
developed sudden onset shortness of breath. A first aid was
called for respiratory distress, and the patient was tachypneic
and tachycardiac and found to have an oxygen saturation of 76%
on room air. Her husband noted that she had a non-productive
cough that night before going to bed. She smokes, but she denied
any other past medical history. She denies chest pain, but
stated that she could not catch her breath. She denied fever and
stated that she felt well prior to this. She was transported to
the ED and received a nonrebreather.
Of note, she was recently treated at ___ for lyme
meningitis ___ weeks ago. She initially presented with about 3
weeks of neck pain per the family which progressed to retrograde
memory loss and altered mental status. An LP was done at the OSH
which showed signs of lyme infection (+ IgM) in CSF. She also
had a head CT which was reportedly negative. Per records, she
was treated with Vancomycin, Rocephin and acyclovir.
Additionally, the family noted that Mrs. ___ had been under
extreme stress lately, as her son is in the MICU for strep
anginosis.
In the ED she was placed on Bipap and diuresed, but ultimately
required intubation for respiratory support. CTA of chest was
negative for pulmonary embolism. There was moderate pulmonary
edema with bilateral mild to moderate pleural effusions.
She received nebulizers and 60 mg fuorsemide, upon intubation
she became hypotensive with a blood pressure of 77/49.
Norepinephrine was initiated for pressure support.
Echocardiogram overnight demonstrated an estimated ejection
fraction of 40-45% with significant aortic insufficiency and
mild mitral regurgitation. She required additional drips for
pressure support. She was referred to cardiac surgery.
Past Medical History:
Viral Meningitis
Hepatitis
Anemia
Thrombocytosis
Hypoalbuminemia
Social History:
___
Family History:
Siblings - diabetes
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
================================
VS: T 98.2 HR 109 BP 119/46 RR O2Sat: 100% on vent
General: intubated, sedated
HEENT: pupils minimally reactive
Neck: supple, JVD difficult to assess
CV: tachycardic, regular rhythm, III/VI diastolic murmur heard
over most of the precordium
Lungs: course breath sounds anteriorly
Abdomen: soft, non-tneder, non-distended, normoactive BS
GU: Foley in place draining clear yellow urine
Ext: no ___ edema
Neuro:
Skin: warm proximally, cool distally in feet and hands
PULSES: 2+ ___
Pertinent Results:
STUDIES:
=============
CT HEAD W/O CONTRAST ___:
No evidence for acute intracranial abnormalities.
TEE ___:
The study was performed in the CCU with the patient intubated,
on a mechanical ventilator, and sedated on a IV fentanyl drip.
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
___ or the RA/RAA. Good (>20 cm/s) ___ ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mildly depressed LVEF. [Intrinsic LV systolic
function likely depressed given the severity of valvular
regurgitation.]
RIGHT VENTRICLE: RV function depressed.
AORTA: Simple atheroma in aortic arch. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Moderate-sized vegetation on aortic
valve. No aortic valve abscess. Moderate to severe (3+) AR.
MITRAL VALVE: Normal mitral valve leaflets. No mass or
vegetation on mitral valve. Moderate (2+) MR.
___ VALVE: Normal tricuspid valve leaflets. No mass or
vegetation on tricuspid valve. Mild to moderate [___] TR.
Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Informed consent was obtained. A TEE was
performed in the location listed above. I certify I was present
in compliance with ___ regulations. The patient was monitored
by a nurse in ___ throughout the procedure. The patient
was sedated for the TEE. Medications and dosages are listed
above (see Test Information section). Local anesthesia was
provided by benzocaine topical spray. No glycopyrrolate was
administered. No TEE related complications. Resting tachycardia
(HR>100bpm). Results were personally reviewed with the MD caring
for the patient. Left pleural effusion.
Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular systolic
function is mildly depressed (LVEF= 40 %). [Intrinsic function
is likely more depressed given the severity of aortic
regurgitation.] Overall right ventricular systolic function is
depressed. There are simple atheroma in the aortic arch and
descending thoracic aorta. The aortic valve leaflets are
thickened with a 1.0x0.8 mm focal relatively "fixed" echodensity
on the non-coronary cusp of the aortic valve and a second 0.6cm
long highly mobile echodensity on the aortic side of the same
leaflet (clip 47) as well as diastolic fluttering of the right
coronary leaflet . There appears to be diastolic prolapse of the
non-coronary leaflet into the LVOT. No aortic root abscess is
seen. Moderate to severe (3+) aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Moderate (2+)
mitral regurgitation is seen. No mass or vegetation is seen on
the mitral valve, tricuspid valve, or pulmonic valve. There is
at least moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Diffuse and focal thickening of the aortic valve
leaflets c/w vegetations (?chronic vs. acute) with partial
leaflet flail. No aortic root abscess. Moderate to severe aortic
regurgitation. Moderate mitral regurgitation. Global
biventricular systolic dysfunction. Simple atheroma in the
descending aorta and aortic arch.
TEE ___:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is severely depressed
(LVEF= 20 - 25 %). with moderate global free wall hypokinesis.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. There is a probable
vegetation on the aortic valve's non-coronary cusp. There is no
aortic valve stenosis. Severe (4+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is no pericardial effusion.
___ 07:25AM BLOOD WBC-8.7 RBC-3.53* Hgb-10.4* Hct-33.5*
MCV-95 MCH-29.5 MCHC-31.1 RDW-15.4 Plt ___
___ 06:42PM BLOOD Neuts-94.4* Lymphs-2.4* Monos-2.5 Eos-0.2
Baso-0.5
___ 07:25AM BLOOD Glucose-77 UreaN-8 Creat-0.7 Na-139 K-3.7
Cl-101 HCO3-29 AnGap-13
___ 04:28AM BLOOD ALT-28 AST-48* LD(LDH)-403* AlkPhos-85
Amylase-30 TotBili-0.5
Brief Hospital Course:
___ continued with medical management and was diuresed
with a Lasix drip. She was eventually extubated however, within
___ hours she again became hypoxic requiring intermittent
bipap and IV lasix bolus concerning for continued flash
pulmonary edema. She was subsequently re-intubation. She
developed recurrent fevers and leukocytosis concerning for
infection of unknown source. She was initially started on broad
spectrum antibiotic coverage including vancomycin and cefipime.
She developed diarrhea and c. diff was positive. She was started
on oral Vancomycin and broad spectrum coverage was discontinued.
She had persistent waxing and waning altered mental status
throughout hospital course initially concerning for possible
meningitis given recent history of viral meningitis at outside
hospital. ID was consulted to evaluate for possible residual
lyme meningitis though felt that this had resolved. Head CT
demonstrated no evidence of acute bleed or mass. Her altered
mental status was thought to be secondary to delirium in
hospital setting and delirium precautions taken.
On ___, she decompensated and became acutely short of breath
and profoundly
hypotensive. Cardiac surgery was consulted for consideration of
emergent surgical intervention. She underwent a cardiac
catheterization which demonstrated no significant coronary
artery disease. She was taken emergently to the operating room
and underwent emergency aortic valve replacement with a 23 mm
___ tricuspid tissue valve for endocarditis. Please see
operative note for full details. She tolerated the procedure and
was transferred to the CVICU in stable condition for recovery
and invasive monitoring.
She weaned from sedation, awoke neurologically intact and was
extubated on POD 1. She was weaned from inotropic and
vasopressor support. Beta blocker was initiated and she was
diuresed toward her preoperative weight. She remained
hemodynamically stable and was transferred to the telemetry
floor for further recovery. She was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on post-operative day six she was
ambulating freely, the wound was healing, and pain was
controlled with oral analgesics. She was noticed to have slight
serous drainage from the sternal pole without erthema or a
sternal click. This wound should be washed daily and patted dry
and otherwise kept as dry as possible. She was discharged to
___ in good condition with appropriate follow up
instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Amiodarone 400 mg PO DAILY
take 400mg daily for one week, then decrease to 200mg daily
ongoing
3. Aspirin EC 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Bisacodyl ___AILY:PRN constipation
6. Metoprolol Tartrate 25 mg PO BID
7. Ciprofloxacin HCl 500 mg PO Q12H
8. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
9. Vancomycin Oral Liquid ___ mg PO Q6H
take Vancomycin while on IV antibiotics
10. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
11. Gentamicin 60 mg IV Q12H
Projected end date ___
12. Ampicillin-Sulbactam 3 g IV Q6H
Projected end date ___
13. Heparin 5000 UNIT SC TID
14. Furosemide 40 mg PO DAILY Duration: 10 Days
please titrate per exam
15. Potassium Chloride 40 mEq PO DAILY Duration: 10 Days
16. Outpatient Lab Work
WEEKLY: CBC with differential, Gent trough level, LFT's ESR/CRP
TWICE WEEKLY: BUN/Cr
PLEASE FAX LAB RESULTS WITH ATTN: ___ CLINIC - FAX:
___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aortic Insufficieny
C. Diff
Endocarditis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema. Slight serous
sternal drainage at the lower pole with no erythema, sternum
stable.
1+ ___ edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
19890202-DS-3 | 19,890,202 | 27,867,603 | DS | 3 | 2144-08-14 00:00:00 | 2144-08-14 19:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Lumbar puncture ___
History of Present Illness:
___ is a ___ year-old female, pmh of anxiety and adhd, who
presents with altered mental status. She is unable to provide a
history, so it is gathered from her boyfriend ___ )
and ___ notes. For the past ___ days, She was having flu-like
symptoms, such as soreness, chills, subjective fevers, nausea
(no
emesis) and bad body aches. Yesterday, they woke up to go to
clinic (both in optometry school). Since she was feeling sick,
he
offered to write an email to her preceptor. Then, she suddenly
began speaking gibberish, but it seemed to him that she thought
she sounded fine. She also had difficultly getting into her
computer, and It took her ___ times to type password into
computer. He is not sure how long the gibberish lasted or if it
resolved, as he went to clinic and She stayed home. This was the
last he saw her. When he came to ___, it looked all the same
(such that she didn't clean up a bowl of soup), but her wallet
and keys were gone.
Per ___ notes, she was found mute in a ___ restaurant, so EMS
was called. In intial psychiatry consult, "Per RN, when
patient
arrived to the ED she remained nonverbal and made only minimal
eye contact she was clutching at clothes and acting afraid or
paranoid. When asked if she speaks ___ , pt nodded, yes."
The
Psychiatry team was concerned for catatonia and recommended a
medical workup. They also reached out for collateral information
from aunt, boyfriend and OSH psychiatrists. Briefly, Aunt's
reported her parents divorced one year prior, denied family
history of psychiatric conditions. Her OSH psychiatrist (Dr
___, ___, has seen her only twice), but
notes (per psychiatry note) " no serious mood problems, no
psychosis, never hospitalized for psych, no h/o self injury; did
report a trauma history - father abusive - no known PTSD". He
prescribed Adderall for adhd and buspar for "low level anxiety".
On my visit, she does not speak. Per further discussion with her
boyfriend, ___, he does not believe she has had a psychiatric
break. He denies depression, anxiety. He notes school as a
stressor for her, and he has never met her parents (planned for
this ___). He denies any events concerning for seizure or any
abnormal movements of her hands/mouth. He denied mood swings,
but
notes she does seem more irritable (which he attributed to
school). Of note, she has received a total of 3 doses of 1 mg IV
Ativan in past 24 hours in ED as recommended by Pysch for
catatonia, but it is unclear if she has had improvement.
Past Medical History:
Anxiety
Attention deficit hyperactivity disorder (ADHD), combined type
De Quervain's tenosynovitis
Social History:
___
Family History:
No psychiatric or neurological illnesses.
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: Minimal right NLFF. Activates symmetrically.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 1
R 2 2 2 1 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
ADMISSION LABS:
___ 06:15PM BLOOD WBC-2.9* RBC-4.57 Hgb-13.8 Hct-40.3
MCV-88 MCH-30.2 MCHC-34.2 RDW-11.9 RDWSD-38.3 Plt ___
___ 06:15PM BLOOD Neuts-52 Bands-0 ___ Monos-5 Eos-0
Baso-1 ___ Myelos-0 AbsNeut-1.51* AbsLymp-1.22
AbsMono-0.15* AbsEos-0.00* AbsBaso-0.03
___ 06:15PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 06:40AM BLOOD ___
___ 06:15PM BLOOD Glucose-84 UreaN-18 Creat-0.8 Na-136
K-4.2 Cl-101 HCO3-21* AnGap-18
___ 05:05AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.1
___ 06:15PM BLOOD TSH-0.71
___ 06:15PM BLOOD HCG-<5
___ 06:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DIAGNOSTIC LABS:
___ 06:40AM BLOOD calTIBC-312 Ferritn-287* TRF-240
___ 06:20AM BLOOD HIV Ab-Negative
___ 05:35AM BLOOD ALT-2503* AST-1728* LD(LDH)-402*
AlkPhos-64 TotBili-2.5*
___ 06:40AM BLOOD ALT-1665* AST-744* LD(LDH)-226 AlkPhos-66
TotBili-1.6*
___ 04:04AM BLOOD ALT-1283* AST-420* AlkPhos-64 TotBili-1.1
DISCHARGE LABS:
___ 04:30AM BLOOD WBC-3.6* RBC-3.49* Hgb-10.4* Hct-30.7*
MCV-88 MCH-29.8 MCHC-33.9 RDW-12.0 RDWSD-38.6 Plt ___
___ 04:30AM BLOOD Glucose-90 UreaN-5* Creat-0.5 Na-140
K-3.4 Cl-106 HCO3-25 AnGap-12
___ 04:30AM BLOOD Calcium-7.9* Phos-3.3 Mg-1.7
___ 04:30AM BLOOD ALT-987* AST-213* AlkPhos-62 TotBili-1.1
CSF STUDIES:
___ 09:15AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 09:15AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 09:15AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-POS* oxycodn-NEG mthdone-NEG
___ 01:00PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 Polys-10
___ Monos-44 ___ Macroph-4
___ 01:00PM CEREBROSPINAL FLUID (CSF) TotProt-142*
Glucose-45
___ 01:00PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-negative
___ 06:30PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-1* Polys-0
___ Macroph-16
___ 06:30PM CEREBROSPINAL FLUID (CSF) TotProt-92*
Glucose-73
___ 06:30PM CEREBROSPINAL FLUID (CSF) MULTIPLE SCLEROSIS
(MS) PROFILE-negative
___ 06:30PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-negative
___ 06:30PM CEREBROSPINAL FLUID (CSF) VARICELLA DNA
(PCR)-negative
IMAGING:
Noncontrast head CT ___
IMPRESSION:
No evidence for acute intracranial abnormalities.
Chest XR ___
IMPRESSION:
Heart size and mediastinum are stable. Lungs are clear. There
is no pleural effusion or pneumothorax.
MRI head w/wo contrast ___
IMPRESSION:
1. Mild motion artifact requiring use of BLADE acquisition
technique.
2. Questionable diffuse mild thickening of the cortical gray
matter and
indistinct gray-white interface seen only on the T2 and FLAIR
sequences and appearing normal on the correlate T1 sequences,
therefore likely due to motion and BLADE acquisition technique.
Given the clinical setting, however an early encephalitis is not
entirely excluded. Consider follow-up imaging if clinically
warranted.
3. No acute infarct, hemorrhage, or mass.
Pelvic ultrasound ___
IMPRESSION:
Normal pelvic ultrasound.
Liver ultrasound ___
IMPRESSION:
1. Unremarkable right upper quadrant ultrasound.
2. Partially imaged bilateral pleural effusions.
Brief Hospital Course:
# Neurology
Patient was admitted to Neurology for altered mental status and
mutism; found on CSF studies to have elevated protein to 142
without CSF pleocytosis. Overall clinical presentation was
concerning for HSV encephalitis. She was started on acyclovir
IV. EEG showed left temporal slowing and discharges (but no
seizures), and MRI showed question of cortical edema vs
artifact. She was also started on keppra 750mg BID. Her
presentation improved significantly and by day 3 of
hospitalization her mental status was back to baseline. CSF was
sent for oligoclonal bands (which were negative) and autoimmune
antibody mediated encephalitis panels, which were sent to ___
and pending at time of discharge. Although HSV PCR was negative
x2 and there was no other revealing positive culture result, it
was thought that given her positive response to treatment and
abnormal MRI brain showing cortical edema, that it was prudent
to treat empirically for HSV encephalitis, however the diagnosis
remains unclear.
# ID
Patient was started on acyclovir IV empirically for concern for
HSV encephalitis. Her HIV, RPR, Lyme serologies, and CSF
bacterial culture were all negative. ID was consulted and also
made other recommendations for microbial serologic testing but
recommended only to continue acyclovir and not to start empiric
coverage for bacterial meningitis (see other pending studies
below). She developed a rash over right forehead which was
vesicular; this was scraped and sent for skin culture. There
were no other cranial nerve findings. She was discharged with
plan for 3 week course of acyclovir with labs to monitor for
renal function and plan to follow up with ID.
# GI/Abd
Upon improvement of her mental status, patient had severe nausea
and vomiting. LFTs were taken and showed acute elevation to ALT
2500 and AST 1700. Viral hepatitis serologies were ordered- on
discharge, HBsAg was negative, HBaAb borderline, and hep A
pending. Abdominal ultrasound was performed which was negative
for structural anatomic changes. LFTs were monitored and
decreased. GI was consulted and recommended further evaluation
for autoimmune-mediated and infiltrative hepatitides with
anti-smooth muscle Ab, AMA, and iron studies. She was discharged
with plan to monitor liver function as an outpatient and to
follow up with Hepatology.
Transitional issues:
[ ] F/U ID studies: anaplasma, ehrlichia, EBV PCR, skin scraping
for herpes virus
[ ] F/U CSF studies: autoimmune encephalitis panel, arbovirus
and ___ encephalitis panel
[ ] F/U hepatitis C ab, AMA, anti-sm muscle Ab
[ ] Patient will be contacted to follow up with Neurology, ID,
and Hepatology (unable to be arranged prior to discharge because
of holiday weekend).
[ ] Discussed with patient the possibility of infectious vs
autoimmune mediated etiology of her symptoms, which is still yet
unclear. Gave strict instructions to patient and her family to
follow up immediately with Neurology if symptoms return for
consideration of alternate diagnoses and need for empiric
treatment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lutera (28) (levonorgestrel-ethinyl estrad) 0.1-20 mg-mcg
oral DAILY
2. HydrOXYzine 25 mg PO QHS:PRN insomnia
3. Amphetamine-Dextroamphetamine 10 mg PO BID
Discharge Medications:
1. Acyclovir 500 mg IV Q8H
RX *acyclovir sodium 500 mg 500 mg IV every 8 hours Disp #*48
Vial Refills:*0
2. LevETIRAcetam 750 mg PO BID
RX *levetiracetam [Keppra] 750 mg 1 tablet(s) by mouth twice
daily Disp #*60 Tablet Refills:*3
3. Amphetamine-Dextroamphetamine 10 mg PO BID
4. HydrOXYzine 25 mg PO QHS:PRN insomnia
5. Lutera (28) (levonorgestrel-ethinyl estrad) 0.1-20 mg-mcg
oral DAILY
6. Outpatient Lab Work
ICD-9: 070
Please check CBC, basic metabolic panel, ALT, AST, LDH, total
bili, alk phos before or on ___, and fax results to:
Dr. ___ at ___.
7. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours as
needed Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute encephalitis, likely viral
Acute hepatitis, likely viral
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 acute change in your
mental status. We performed extensive evaluation including a
brain MRI and EEG, which were abnormal and suggestive of
possible infection which may have been irritating your brain
activity. We started you on antiviral medication as well as an
anti-seizure medication, and you displayed some improvement.
We performed a lumbar puncture, a procedure in which we
extracted cerebrospinal fluid, and the findings were suggestive
of either viral infection or another cause of inflammation. Some
of the tests we sent will take a long time to return. In the
meantime, we will continue to treat you for a viral encephalitis
with IV medications for a total of a 3 week course.
If you develop similar symptoms in the future or any other acute
neurologic deficit (listed below), please seek emergency care
immediately and notify your providers of this recent admission.
It is possible that you may have another underlying process that
requires further evaluation and treatment if this occurs in the
future.
You will follow up in clinic with Neurology, Infectious
Diseases, and Hepatology, which will be arranged within the next
week. It was a pleasure taking care of you. We wish you the
best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19890361-DS-11 | 19,890,361 | 29,599,221 | DS | 11 | 2168-05-24 00:00:00 | 2168-05-25 07:28:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lethargy, leukocytosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with ___ disease, morbid obesity, afib (not on
anticoag), presenting with altered mental status. Patient
himself has no complaints and does not report feeling confused.
Of note, patient was recently admitted to ___ in ___ for leg
weakness. ASA started for afib, as patient not deemed to be
candidate for coumadin due to fall risk. MRI ruled out stroke.
Weakness thought to be ___ deconditioning, ___ disease,
and ___ edema. Mirapex was increased from BID to TID at that
time. He was discharged to rehab.
In the ___, labs significant for WBC of 44, N90. He was
sent to ___ for hematology eval given severity of leukocytosis
(WBC 9 one week ago).
In the ___ ___, initial vs were: 99.2 88 111/67 20 97%RA. Labs
were remarkable for WBC 35.2 with N92, Cr 1.3. lactate 1.5.
Patient was found to have extensive right lower extremity
erythema and induration. Also with left lower extremity
erythema, seems more consistent with stasis changes. Patient was
given Vanc 1g IV and clindamycin 900mg IV x1 for presumed
cellulitis.
Vitals on transfer: 99 99 111/67 27 96%
On the floor, patient awake and alert. Reports chronic venous
stasis and leg swelling, but recently worsening and with
increasing redness in the R. leg but no pain.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
___ Disease
lymphedema
venous insufficiency
h/o recurrent cellulitis
Afib
HTN
elevated PSA; cancer workup unable to be pursued; recent bone
scan negtaive
Social History:
___
Family History:
Unknown
Physical Exam:
EXAM ON ADMISSION
Vitals: 99.1 99.1 100-130s/70s 80-90s ___ 97RA
General: Morbidly obese gentleman lying on back in bed, taking
shallow breaths, but not in respiratory distress; very pleasant
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, unable to evaluate JVP ___ habitus, no LAD
Lungs: Clear to auscultation bilaterally with distant breath
sounds; no wheezes, rales, ronchi
CV: irregularly irregular, normal rate, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended obese abdomen; bowel
sounds present; increased tympany over epigastric region with
some mild tenderness to deep palpation; no rebound tenderness or
guarding, no organomegaly; mild erythema in intertriginous
folds; large well-healed surgical scar of RUQ at site of prior
open cholecystectomy; periumbilical well-healed surgical scar at
site of prior cellulitis (per HCP) and hernia repair
Ext: 3+ pitting edema to the knee bilaterally. BLE with brawny
venous stasis changes including thickened skin, RLE with
erythema, warmth, but no tenderness or crepitus to palpation,
area of erythema demarcated; RLE warm to touch around
nonerythematous areas of knee and medial thigh
Neuro: AOx3, CNII-XII intact, UE strength intact; patient unable
to lift LEs off bed; patient not ambulated
DISCHARGE: same as above except:
Ext: 2+ pitting edema to knee bilaterally. Equal warmth in BLE
on skin touch. Improving erythema, receding from marked borders
in RLE. Patches of erythema still present on RLE.
Pertinent Results:
___ 07:30PM BLOOD WBC-35.2* RBC-5.05 Hgb-14.9 Hct-44.5
MCV-88 MCH-29.5 MCHC-33.4 RDW-14.5 Plt ___
___ 07:30PM BLOOD Neuts-92.3* Lymphs-4.2* Monos-3.1 Eos-0.2
Baso-0.2
___ 07:35AM BLOOD WBC-23.4* RBC-4.66 Hgb-13.8* Hct-40.8
MCV-88 MCH-29.5 MCHC-33.7 RDW-14.6 Plt ___
___ 07:00AM BLOOD WBC-11.6*# RBC-4.73 Hgb-13.7* Hct-42.2
MCV-89 MCH-28.9 MCHC-32.4 RDW-14.6 Plt ___
___ 06:25AM BLOOD WBC-9.6 RBC-4.70 Hgb-13.8* Hct-42.3
MCV-90 MCH-29.4 MCHC-32.7 RDW-14.3 Plt ___
___ 07:30PM BLOOD Glucose-106* UreaN-23* Creat-1.3* Na-139
K-3.6 Cl-104 HCO3-23 AnGap-16
___ 07:35AM BLOOD Glucose-100 UreaN-21* Creat-1.0 Na-138
K-3.5 Cl-104 HCO3-23 AnGap-15
___ 07:00AM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-139
K-3.6 Cl-106 HCO3-23 AnGap-14
___ 06:25AM BLOOD Glucose-86 UreaN-15 Creat-0.8 Na-140
K-4.0 Cl-108 HCO3-22 AnGap-14
BCx: NGTD
CXR:
1. TECHNICALLY LIMITED STUDY WITHOUT CLEAR EVIDENCE OF ACUTE
CARDIOPULMONARY ABNORMALITIES.
2. WIDENED APPEARANCE OF THE UPPER MEDIASTINUM COULD BE RELATED
TO TECHNICAL ARTIFACT, DISTENDED VENOUS STRUCTURES OR
LIPOMATOSIS, BUT OTHER PATHOLOGY CANNOT BE EXCLUDED. IF
CLINICALLY WARRANTED, THIS COULD BE FURTHER EVALUATED BY CTA OF
THE CHEST.
Right Leg xray:
Soft tissue swelling without subcutaneous gas or underlying
osseous
abnormality. Degenerative changes at the knee.
Left leg xray:
Soft tissue swelling of the calf without radiopaque foreign body
or
subcutaneous gas.
CT head:
1. No acute intracranial process.
2. Given mild asymmetry in the nasopharynx with fullness on the
left and secondary left mastoid and middle ear opacification,
direct visualization should be performed to exclude underlying
lesion.
Discharge Labs:
___ 08:30AM BLOOD WBC-9.5 RBC-4.83 Hgb-14.1 Hct-43.1 MCV-89
MCH-29.3 MCHC-32.8 RDW-14.2 Plt ___
___ 08:30AM BLOOD Glucose-113* UreaN-16 Creat-0.8 Na-141
K-4.1 Cl-108 HCO3-22 AnGap-15
___ 2:58 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).
Brief Hospital Course:
___ y/o M with h/o ___ disease, afib, presents with
reported lethargy and severe leukocytosis, likely in the setting
of cellulitis.
# Cellulitis: Patient with chronic venous stasis in bilateral
lower extremities, but also with superimposed erythema,
tenderness and induration in the right lower extremity
consistent with cellulitis. Xrays do not show air, so low
concern for necrotizing fasciitis. Patient's leukocytosis,
though remarkably high, likely explained by this cellulitis
given history of 1) acuity of WBC increase from 9 to 44 in one
week, 2) decrease in WBC with vanc/clinda. He was transitioned
from vancomycin/clindamycin to Bactrim/Keflex on hospital day #4
and will complete a 2 week course of antibiotics total. He is
encouraged to continue good skin care with moisturizing lotion
and consider follow up in ___ clinic. Symptoms much
improved at time of discharge.
# Diarrhea: Pt. reported 4 BMs on day prior to discharge. C.
diff was ordered but he had no additional stools prior to
discharge. If diarrhea persists, would have low threshold to
send C. diff given clindamycin use this admission.
# Leukocytosis: Patient with severe leukocytosis to 44 at OSH,
35 here. Differential with 92N, no atypicals, anemia, or
thrombocytopenia concerning for heme malignancy. More likely,
left shift suggest infectious etiology. Treat cellulitis as
above. Ddx also includes C. diff, unclear last antibiotic
course, but has been treated for cellulitis in the past. CXR and
UA at ___ are unremarkable. Head CT with nasopharynx with
fullness on the left and secondary left mastoid and middle ear
opacification, which can be another source of infection, though
patient is asymptomatic. WBC improved with cellulitis tx.
# Altered mental status: AOx3 at baseline, per HCP. Patient
appears to be at baseline today. What was observed by ___
could be progression of ___ dementia vs altered mental
status from infection. CT head without acute intracranial
pathology. MS remained at baseline per family.
# Afib: Normal rate. Unclear etiology. CHADS2=1. Continued ASA
325, diltiazem for rate control.
# CODE: DNR/DNI
# CONTACT: ___ (Sister/HCP) ___
Of note, there was some mention on admission CT of "mild
asymmetry in the nasopharynx with fullness on the left and
secondary left mastoid and middle ear opacification." This can
be investigated further if patient continues to feel unwell.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mirapex *NF* (pramipexole) 0.125 mg Oral TID
2. Carbidopa-Levodopa (___) 1.5 TAB PO TID
3. Topiramate (Topamax) 25 mg PO BID
4. Aspirin 325 mg PO DAILY
5. Diltiazem Extended-Release 360 mg PO DAILY
6. Furosemide 60 mg PO DAILY
7. Senna 1 TAB PO BID:PRN constipation
8. Multivitamins 1 TAB PO DAILY
9. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
10. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
11. Fleet Enema ___AILY:PRN constipation
12. Milk of Magnesia 30 mL PO Frequency is Unknown
13. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Aspirin 325 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Carbidopa-Levodopa (___) 1.5 TAB PO TID
6. Diltiazem Extended-Release 360 mg PO DAILY
7. Fleet Enema ___AILY:PRN constipation
8. Milk of Magnesia 30 mL PO Q6H:PRN constipation
9. Multivitamins 1 TAB PO DAILY
10. Senna 1 TAB PO BID:PRN constipation
11. Topiramate (Topamax) 25 mg PO BID
12. Mirapex *NF* (pramipexole) 0.125 mg Oral TID
13. Furosemide 60 mg PO DAILY
14. Cephalexin 500 mg PO Q6H Duration: 10 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*38 Capsule Refills:*0
15. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 10 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice a day Disp #*38 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cellulitis
Discharge Condition:
Mental Status: Sometimes confused - at baseline.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ___ from an outside hospital because
of lethargy and an increased white blood cell count. There are
many reasons to have an increased white blood cell count,
including infection. On physical exam, you were found to have
an area on your right leg that was warm and red and concerning
for skin infection, or cellulitis. You were started on
intravenous antibiotics, which helped the rash go away. Prior
to discharge, you were transitioned to oral antibiotics.
It is important you continue taking the full course of this
antibiotic, even if you feel better. Please take these
antibiotics, in addition to the rest of your medications as
written below. Please follow up with your doctors at the
___ listed below, or reschedule as needed.
It was a pleasure caring for you!
Followup Instructions:
___
|
19890665-DS-7 | 19,890,665 | 20,028,733 | DS | 7 | 2118-10-13 00:00:00 | 2118-10-14 06:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of asthma, GERD, and
depression who presents with abdominal pain. The patient reports
that she has been having abd pain x 2 months, sharp epigastric
pain post-prandially which usually resolves in ___ minutes,
non-radiating. Yesterday, she had similar type of pain, though
more severe than usual, and it lasted throughout day with
increasing severity. She had two episodes of NBNB emesis. Pt
also endorses anorexia; she last ate yesterday evening. She
denies fevers or chills. Had two BMs yesterday, brown in color,
soft. Denies black stools but does report some blood on toilet
paper today for the first time. Denies dysuria, foul-smelling
urine, urinary urgency or frequency. Does not have menses due
to being on Depo shot.
In the ED intial vitals were: 97.9 98 128/66 16 100%. Received
hydromorphone 1mg IV x 3 for pain. VS on transfer: 97 80 100/60
15 95% RA.
On the floor, VS 97.6 102/52 66 18 100% RA. Pt is
uncomfortable appearing.
Review of Systems:
Gen: Feels really hot, measured temp at home and did not have
fever. No chills.
HEENT: +HA, +rhinorrhea. No sore throat.
Pulm: No cough, no SOB
CV: No CP
GI: As per HPI
GU: No dysuria, foul-smelling urine, urinary urgency or
frequency
MSK: Has pain on the opposite side of whichever side she sleeps
on
Skin: No rash
Heme: No LAD, no abnormal bruising/bleeding.
Neuro: +dizziness, light-headedness
Past Medical History:
GERD
Asthma
Depression
ADHD
h/o Gonorrhea and Chlamydia a couple months ago, finished abx
course
Recent concussion and right wrist splint (no fracture) after
altercation
Social History:
___
Family History:
Seizures
HTN
Depression
Thyroid disease
ADD (brother)
Heart attack
Cancer, does not know what type
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 97.6 102/52 66 18 100% RA
General- Alert, oriented, mild distress
HEENT- Sclera anicteric, no conjunctival pallor, MMM
Neck- Supple, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- Soft, non-distended, bowel sounds present, tender to
palpation of epigastrium and RUQ, ___ sign, no
organomegaly
DRE - poorly tolerated, tight sphincter tone. Scant speck of
stool available to guaiac, which was negative.
Ext- Warm, well perfused, no edema
Neuro- Face symmetric, speech fluent, alert, oriented. B/l grip
strength, elbow flex/ext weak, symmetric, limited by effort
DISCHARGE PHYSICAL EXAM:
Vitals- 98.3 94/47 68 18 99% RA
Tmax 98.5 SBP 88-94 HR ___
I/O 240 PO, ___ IV / BRP (24H)
I/O 0, 0 / 600+ (since MN)
General- Awake, alert, oriented, calm
HEENT- Sclera anicteric, MMM
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- Soft, non-distended, bowel sounds present, tender to
light palpation of RUQ, +voluntary guarding, no organomegaly
Ext- Warm, well perfused, no edema
Neuro- Face symmetric, speech fluent, alert, oriented. Able to
flex and extend b/l ankles though does so with significant
coaching, able to flex b/l knees and hips slowly. Decreased
light touch sensation on feet and reports no light touch
sensation on ankles. B/l patellar DTRs symmetric.
Pertinent Results:
ADMISSION LABS
___ 11:30PM GLUCOSE-87 UREA N-11 CREAT-0.7 SODIUM-139
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15
___ 11:30PM ALT(SGPT)-10 AST(SGOT)-20 ALK PHOS-51 TOT
BILI-0.2
___ 11:30PM LIPASE-24
___ 11:30PM ALBUMIN-4.4 CALCIUM-9.3 PHOSPHATE-4.9*
MAGNESIUM-2.2
___ 11:30PM WBC-7.3 RBC-4.75 HGB-13.5 HCT-41.9 MCV-88
MCH-28.5 MCHC-32.3 RDW-12.8
___ 11:30PM NEUTS-44.9* LYMPHS-46.0* MONOS-4.5 EOS-2.8
BASOS-1.8
___ 11:30PM PLT COUNT-252
___ 10:30PM URINE UCG-NEGATIVE
___ 10:30PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 10:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-LG
___ 10:30PM URINE RBC-7* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-11
___ 10:30PM URINE AMORPH-OCC
___ 10:30PM URINE MUCOUS-FEW
INTERIM LABS
DISCHARGE LABS
___ 05:00AM BLOOD WBC-5.4 RBC-4.18* Hgb-12.0 Hct-37.2
MCV-89 MCH-28.7 MCHC-32.3 RDW-12.6 Plt ___
___ 05:00AM BLOOD Glucose-78 UreaN-10 Creat-0.7 Na-141
K-4.0 Cl-107 HCO3-24 AnGap-14
___ 05:00AM BLOOD ALT-9 AST-18 AlkPhos-42 TotBili-0.3
___ 05:00AM BLOOD Calcium-8.5 Phos-4.7* Mg-2.1
MICROBIOLOGY
URINE CULTURE (Final ___: NO GROWTH.
___ 12:11 am URINE Source: ___.
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Pending):
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Pending):
IMAGING/STUDIES
RUQ US ___
The liver is normal in echotexture without focal lesions. The
pancreas is homogeneous in echotexture and without evidence of
pancreatic duct
dilation. There is no evidence of intrahepatic or extrahepatic
biliary duct
dilation. The common bile duct measures ___ile
duct is seen
extending from its origin to the pancreatic head and contains no
stones. The
gallbladder is unremarkable without evidence of wall thickening
or stones.
The visualized portions of the aorta and IVC appear normal. The
portal vein
is patent and demonstrates normal hepatopetal flow. The pancreas
appears
normal.
IMPRESSION: No evidence of cholecystitis, cholelithiasis or
choledocholithiasis. Normal right upper quadrant ultrasound.
CT abd/pelvis without contrast ___
The lung bases are clear. The heart size is normal.
Without the administration of IV contrast, evaluation of the
solid organs is
limited. The liver, gallbladder, pancreas, spleen, adrenal
glands and kidneys
appear normal. There is no evidence of hydronephrosis or
stones.
The small and large bowel are unremarkable without evidence of
obstruction.
The appendix is visualized in the right lower quadrant and
appears normal.
The bladder and uterus appear normal. There is no free air,
free fluid or
lymphadenopathy.
OSSEOUS STRUCTURES: There are no concerning osteoblastic or
osteolytic
lesions.
IMPRESSION: No renal stones or hydronephrosis. No other
findings to explain
the patient's abdominal pain.
CXR (PA/lateral) ___
Frontal and lateral views of the chest. Normal heart, lungs,
pleural and mediastinal surfaces.
IMPRESSION: Normal chest radiograph.
Brief Hospital Course:
___ F h/o GERD, asthma and depression p/w epigastric and RUQ
abdominal pain and NBNB emesis.
ACTIVE DIAGNOSES
# RUQ/epigastric abdominal pain and emesis: Differential
diagnosis included viral gastroenteritis (especially in light of
lymphocytic predominance) or functional abdominal pain. Pain
could be exacerbated by GERD; patient does not take home med for
GERD despite history of it. Differential also included peptic
ulcer disease; scant speck of stool was guaiac negative. CT
abd/pelvis, RUQ US, and LFTs were unremarkable, decreasing
suspicion for other etiologies such as: cholecystitis,
pancreatitis (lipase normal), cholangitis. Chlamydia and
Gonorrhea tests were pending at time of discharge. HCG was
negative, excluding ectopic pregnancy. Functional abdominal pain
was the major consideration given lack of abnormalities on labs
and imaging as well as recent psychosocial stressors (namely a
recent altercation with her child's father and the mother of his
other children). Pt was afebrile with stable vital signs.
Abdomen was exquisitely tender to palpation with voluntary
guarding when exam done with patient's attention but when
palpated with stethoscope while talking to the patient she
showed no tenderness.
She was given some IV fluids given anorexia and poor PO intake.
She was ordered for oxycodone PRN pain, pantoprazole,
ondansetron, and maalox/diphenhydramine/lidocaine. She was seen
by Social Work although was not very interactive with the social
worker. She reported feeling safe at home and did not feel
endangered by her children's father. She was discharged with
prescriptions for acetaminophen, ondansetron and pantoprazole.
CHRONIC DIAGNOSES
# Depression: No apparent exacerbation of chronic disease.
Denied SI/HI. Continued citalopram 10mg PO daily and bupropion
150mg PO daily, both of which pt usually takes on non-work days
due to associated drowsiness. ___ consider changing bupropion
to everyday dosing, as it would not be expected to cause
drowsiness.
# Asthma: Pt had non-labored breathing on RA. She was ordered
for albuterol/ipratropium nebs q 6 hrs PRN dyspnea.
# GERD: Pt does not take medicine for GERD at home. Started
pantoprazole as described above.
# ADHD: Pt not on medication at home.
TRANSITIONAL ISSUES
*Follow up with primary care doctor as necessary
*Patient takes citalopram and bupropion on non-work days due to
sedation. Depression would be better treated by stable
antidepressant regimen. Suggest trial of different regimen to
optimize treatment of depression as an outpatient.
*If pt continues to have problems with abdominal pain in the
future, EGD to assess for peptic ulcer diseasec could be
considered.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 10 mg PO DAILY:PRN non-work days
2. BuPROPion (Sustained Release) 150 mg PO QAM PRN non-work days
3. OxycoDONE (Immediate Release) 5 mg PO Q ___ HRS PRN pain
4. Albuterol Inhaler Dose is Unknown IH PRN dyspnea
5. ZyrTEC (cetirizine) Dose is Unknown oral PRN allergies
6. MedroxyPROGESTERone Acetate Dose is Unknown IM Frequency is
Unknown
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
RX *acetaminophen 325 mg ___ tablet(s) by mouth q 6 hrs Disp
#*60 Tablet Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth q 8 hrs
Disp #*30 Tablet Refills:*0
3. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth daily Disp #*30 Tablet Refills:*0
4. Albuterol Inhaler ___ PUFF IH PRN dyspnea
5. Citalopram 10 mg PO DAILY:PRN non-work days
6. MedroxyPROGESTERone Acetate 0 mg IM Frequency is Unknown
7. ZyrTEC (cetirizine) ___ mg ORAL DAILY:PRN allergies
8. BuPROPion (Sustained Release) 150 mg PO QAM PRN non-work days
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses: Functional abdominal pain versus viral
gastroenteritis
Secondary diagnoses: Gastroesophageal reflux disease, depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care at ___
___. As you know, you came to the hospital
due to abdominal pain. A variety of radiographic images and
blood work was done and revealed no abnormalities to explain
your pain. It was suspected that your abdominal pain may have
been due to a viral gastroenteritis or possibly triggered by
recent stressors. You were given medications for pain and
nausea, as well as intravenous fluids due to your lack of
appetite and poor intake of food and drink. Please see the
attached medication list for changes to your home regimen.
Followup Instructions:
___
|
19890770-DS-9 | 19,890,770 | 27,645,357 | DS | 9 | 2185-08-07 00:00:00 | 2185-08-07 11:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma: MVC:
R medial/lat/inferior orbital fx
R scapular fx
R 4,5,6 post rib fx
Major Surgical or Invasive Procedure:
repair of laceration right eyebrow
staples to laceration right side head
History of Present Illness:
HPI: ___ female who was brought in by medics light. The
patient states that she was rear ended and had head trauma with
loss of consciousness. They saw the police told her they state
that she was a hitfrom the rear at a high speed. The car spun
around multiple times and this is likely when she hit her head
and lost consciousness. Firefighters were called to the scene
and
there was a prolonged extrication time. It is unclear if her car
was drivable however the patient thinks that it was not. The
patient states that when she was extricated she was immediately
called and boarded. The patient complained of pain in her head
in
her right shoulder as well as the ribs bilaterally.
.
The patient currently at this time is to complaining of a
headache as well as rib pain and right shoulder pain. The
patient
denies any loss of sensation. The patient denies any loss of
strength. She does state that it does hurt to move her shoulder.
She states that this is limiting her range of motion. Otherwise
the patient denies any other symptoms including fevers, chills,
nausea, vomiting, and diarrhea. the patient denies any
paresthesias.
.
Past Medical History:
none
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION: ___
HR: 80 BP: 127/72 Resp: 20 O(2)Sat: 100 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles
intact, Pupils round and reactive to light, anisocoria R>L,
abrasions to face, full visual fields
Oropharynx within normal limits, no c spine tenderness,
stepoff or crepitus, blood R nares, no septal hematoma, no
malocclusion
Chest: Clear to auscultation, pain to R chest wall on
palpation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema, + pulses, FROM
Skin: multiple abrasions
Neuro: Speech fluent, GCS15
Psych: Normal mood, Normal mentation
___: No petechiae
Pertinent Results:
___ 05:03AM BLOOD WBC-16.6* RBC-4.08* Hgb-11.8* Hct-35.6*
MCV-87 MCH-29.0 MCHC-33.2 RDW-12.8 Plt ___
___ 12:54PM BLOOD WBC-17.8* RBC-4.65 Hgb-13.5 Hct-39.6
MCV-85 MCH-29.0 MCHC-34.0 RDW-12.7 Plt ___
___ 05:03AM BLOOD Plt ___
___ 12:54PM BLOOD Plt ___
___ 12:54PM BLOOD ___ PTT-27.0 ___
___ 05:03AM BLOOD Glucose-114* UreaN-13 Creat-0.5 Na-136
K-3.7 Cl-102 HCO3-25 AnGap-13
___ 12:54PM BLOOD UreaN-12 Creat-0.7
___ 12:54PM BLOOD Lipase-18
___ 05:03AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.7
___ 12:57PM BLOOD Glucose-130* Lactate-3.2* Na-137 K-3.5
Cl-102 calHCO3-23
___: chest x-ray:
IMPRESSION: Probable bibasilar atelectasis. Multiple radiopaque
foreign
bodies projecting over the left upper abdomen and left
hemithorax, which could represent retained foreign bodies or be
external to the patient, and clinical correlation is advised.
___: cat scan of the head:
IMPRESSION:
1. Two left parietal subgaleal scalp hematomas and a small right
parietal
soft tissue laceration.
2. No acute intracranial hemorrhage or mass effect.
3. Fractures of the right orbit better characterized on
concurrent CT of the sinus
___: cat scan of the chest:
IMPRESSION:
1. Fracture of the right scapula with mild distraction near the
base of the coracoid process.
2. Non-displaced fractures of the lateral aspects of the right
fourth, fifth and sixth ribs.
3. No acute traumatic injury in the abdomen or pelvis.
___: cat scan of the c-spine:
IMPRESSION: No fracture or subluxation of the cervical spine.
___: cat scan of the sinus:
Minimally displaced fractures of the right medial, lateral and
inferior
orbital walls without herniation or entrapment of the inferior
rectus muscle. Globes intact. Small amount of blood in the right
anterior ethmoid air cells and right maxillary sinus.
___: x-ray of the shoulder:
IMPRESSION: Known minimally displaced fracture of the right
scapula is
redemonstrated. Known right fourth, fifth, and sixth ribs are
better seen on prior CT. No dislocation.
___: x-ray of the femur:
IMPRESSION: No acute fracture or dislocation
___: chest x-ray:
pending
___: chest x-ray:
pending
Brief Hospital Course:
___ year old female admitted to the acute care service afer being
involved in a MVC. Med-flighted in from scene. Upon admission,
she was made NPO, given intravenous fluids, and underwent
radiographic imaging. She was found to have fractures of the
lateral aspects of the right ___, and 6th ribs. She was
also reported to have a right scapular fracture with mild
distraction near the base of the coracoid. She also sustained
right medial/lat/inferior orbital fracture. Because of her
injuries, she was seen by Orthopedics for the right coracoid
fracture. This was determined to be non-operative and a sling
was recommended for comfort. Plastics was consulted to provide
input into the management of her rigth orbital fracture. She was
reported to have a non-displaced orbital fracture which was
non-operative and sinus precautions were recommended. She did
require suturing of a laceration above her right brow.
Her rib pain was controlled with intravenous analgesia and on HD
#2 converted to oral agents. She has maintained on room air with
an oxygen saturation of 96% on room air and has been encouraged
to use the incentive spirometer. She was introduced to clear
liquids with progression to a regular diet. Her foley catheter
was discontinued on HD #2 and she voided without difficulty.
Her vital signs are stable and she is afebrile. Because of her
questionable loss of consciousness, she was evaluated by
occupational therapy to determine the need for outpatient
cognitive evaluation. Physical therapy was consulted to
instruct patient in the ongoing management of the right scapula
fracture and provided instruction in ROM exercises.
She is preparing for discharge home and has been instructed to
follow-up with Orthopedics, Plastics, and the Acute Care
Service. She will need to have her staples removed by the Acute
Care Service and her sutures removed by the plastic surgery
service in outpatient follow up. She should also work with
outpatient ___ to restore full range of motion in her
shoulder.
Medications on Admission:
none
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for diarrhea.
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
4. Outpatient Occupational Therapy
fracture of right coracoid process of scapula.
Rx: evaluate and treat ___ per week for ___ weeks. AROM/active
assisted ROM/PROM od shoulder as tolerated. advance as
tolerated. ROMAT to all other joints of RUE.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: MVC
R medial/lat/inferior orbital fx
R scapular fx
R 4,5,6 post rib fx
right brow laceration (sutured)
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 were involved in a
motor vehicle accident. You received rib, facial, and a scapula
fracture. You had a laceration to your right eyelid and
required suturing by the Plastic service. Your pain medicine
was converted to an oral agent. You are now preparing for
discharge home with the following instructions:
* Your injury caused right sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory 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 ).
You also sustained a right orbital wall fracture, please follow
these instructions:
Because of the close relationship between the upper back teeth
and the sinus, a communication between the sinus and the mouth
sometimes results from surgery. This condition has occurred in
your case, which often heals slowly and with difficulty. Certain
precautions will assist healing and we ask that you faithfully
follow these instructions:
1. Take the prescribed medications as directed.
2. Do not forcefully spit for several days.
3. Do not smoke for several days.
4. Do not use straws for several days.
5. Do not forcefully blow your nose for at least 2 weeks, even
though your sinus may feel stuffy or there may be some nasal
drainage.
6. Try not to sneeze; it will cause undesired sinus pressure. If
you must sneeze, keep your mouth open.
Followup Instructions:
___
|
19890784-DS-28 | 19,890,784 | 21,503,447 | DS | 28 | 2131-08-14 00:00:00 | 2131-08-14 23:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Percodan / Lidocaine / Ultram / adhesive tape /
Neosporin Scar Solution / Levofloxacin
Attending: ___.
Chief Complaint:
Cellulitis/Right foot ulcer
Major Surgical or Invasive Procedure:
___ Bedside Debridement of Right Foot
History of Present Illness:
___ with PMHx of chronic gait instability and venous stasis
ulcers followed in ___ clinic who presents with worsening
ulceration and pain over right heel x3 days. Patient reports
noting new skin lesion over her right heel severl days ago. She
has since had increasing difficulty ambulating and pain over the
area. On day of admission, the lesion 'opened up' and began
draining purulent, foul smelling discharge. She reportedly
slipped off her bed (no headstrike or LOC), and was brought to
___ ED by EMT after she was unable to get back in bed.
There, she was found to have profound leukocytosis, significant
wounds ___ venous stasis on both lower extremities. Started on
Vanc 1250mg IV on arrival. Transferred to ___ ED on ___ for
further management.
In the ED, initial vital signs were: pain ___, T 98.8, HR 92,
BP 134/83, R 20, SpO2 99%/RA. Labs showed: leukocytosis (31, N
94%), Hgb 8.8, platelets 441. Nl Chem 7 and lacate. LFT's
notable for ALP 167 and LDH 307. UA negative. NCHCT and C-spine
CT were unremarkable. Right foot CXR showed no evidence of
osteomyelitis. CT Abdomen/Pelvis showed right leg enlargement
c/w venous stasis, 4.3 cm rim enhancing collection in mid left
thigh (?hematomoa), right inguinal nodes, and ? colitis. Patient
was started on Vancomycin, Zosyn, and Flaygl. She was also given
haloperidol 5 mg and lorazepam 2 mg. Consults were placed to
vascular surgery as well as plastic surgery. Vascular surgery
felt that given size of wounds, would be better served by
plastic surgery; that and the patients pulses were intact.
Plastic surgery examined the patient and felt that the wounds
were improved since last clinic visit, although would recommend
amputation. VS prior to transfer were T 97.8, HR 82, BP 128/77,
RR 18, O2 100%.
Upon arrival to the floor, patient endorses pain along lateral 3
toes on both feet, her R heel and left anterior shin, where she
is having skin breakdown. Also notes sharp abdominal pain around
umbilical region that comes and goes, worse when she bares down.
Otherwise, she denies fevers or chills. No SOB or CP. No cough.
No N/V/D. She is somewhat constipated. Remainder of ROS is
unremarkable.
Past Medical History:
Heart murmur, arthritis, thyroid disease, obesity, reflux,
chronic pain syndrome, gastric bypass, spinal fusion, hiatal
hernia, appendectomy, multiple finger surgeries.
Social History:
___
Family History:
Mother with carotid stenosis, deceased from stroke
Physical Exam:
==ADMISSION PHYSICAL EXAM==
VS: T 98.1, BP 136/60, HR 86, RR 18, O2 100%RA
GENERAL: Chronically ill appearing woman in mild distress
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, OP with sore over
left posterior soft palate and mild blood. Sore over lip with
crusting skin.
NECK: Nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Crackles at bases bilaterally, nonlabored appearing
ABDOMEN: Scaphoid, nondistended, +BS, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Bilaterally edematous. She has a left lower shin
wound 9x11cm with fibrinous material, some pink granulation
tissue underneath, and clear serous drainage. Right heel with
~2cm cratering ulcer with pink granulation tissue underneath,
foul smell with small amount of purulence.
NEURO: AAOx3, moving all extremities, symmetric face/tongue,
PERLL, EOMI, CN III-XII intact
==DISCHARGE PHYSICAL EXAM==
VS: T 98.4, BP 111/70, HR 69, RR 18, O2 99% RA
GENERAL: NAD, eating breakfast, interactive
HEENT: Non-scarring alopecia. Tooth #9 chipped, no oral lesions.
LUNGS: CTAB, poor respiratory effort
HEART: RRR S1 and S2, HSM loudest @ RUSB with radiation to the
axilla
ABDOMEN: BS+, soft, ND, NT.
EXTREMITIES: WWP, trace edema. 2+ DP pulses. Significant BLE
brawny changes. On BUEs are scattered white atrophic macules
with superficial erosion and overlying hemorrhagic crust. L shin
with 9x9cm irregularly shaped, well-demarcated ulcer with clean
granulated base with some fibrinous debris and some areas of
maceration and necrosis, minimal drainage, without surrounding
erythema. R heel with deep 3x3cm ulcer with necrotic/fibrinous
base, grey prurulence, but no surrounding erythema. R
dorsolateral foot with 3cm superficial erosion with overlying
crust. Plantar aspect of the third toe is a circular ulcer. R
hip and R medial calf with an atrophic patch.
NEURO: A&Ox3
Pertinent Results:
==ADMISSION LABS==
___ 02:55PM BLOOD WBC-31.0*# RBC-3.11* Hgb-8.8* Hct-28.1*
MCV-90 MCH-28.3 MCHC-31.3* RDW-15.9* RDWSD-53.1* Plt ___
___ 02:55PM BLOOD Neuts-94.2* Lymphs-2.0* Monos-2.1*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-29.25*# AbsLymp-0.61*
AbsMono-0.66 AbsEos-0.05 AbsBaso-0.06
___:55PM BLOOD Glucose-82 UreaN-20 Creat-1.1 Na-136
K-3.8 Cl-100 HCO3-24 AnGap-16
___ 02:55PM BLOOD ALT-25 AST-30 LD(LDH)-307* AlkPhos-167*
TotBili-0.3
___ 02:55PM BLOOD Lipase-29
___ 02:55PM BLOOD Albumin-2.8*
___ 07:40AM BLOOD CRP-142.9*
___ 02:58PM BLOOD Lactate-1.0
___ 07:40AM BLOOD SED RATE-126
==DISCHARGE LABS==
___ 08:16AM BLOOD WBC-6.8 RBC-2.70* Hgb-7.5* Hct-25.7*
MCV-95 MCH-27.8 MCHC-29.2* RDW-17.6* RDWSD-59.7* Plt ___
___ 08:16AM BLOOD Neuts-84* Bands-0 Lymphs-7* Monos-5 Eos-3
Baso-0 ___ Metas-1* Myelos-0 AbsNeut-5.71 AbsLymp-0.48*
AbsMono-0.34 AbsEos-0.20 AbsBaso-0.00*
___ 08:16AM BLOOD Plt Smr-NORMAL Plt ___
___ 08:16AM BLOOD Glucose-111* UreaN-17 Creat-1.0 Na-138
K-3.9 Cl-107 HCO3-26 AnGap-9
___ 08:16AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0
==IMAGING==
MRI Right Foot With and Without Contrast ___
IMPRESSION: Large ulcer and subcutaneous soft tissue defect
along the posteroinferior aspect of the heel, with the ulcer
extending to the surface of the calcaneus.
Trace edema and enhancement in the subcortical bone along the
posteroinferior calcaneus. This is non-specific and is most
suggestive of reactive changes, secondary to adjoining soft
tissue inflammation/infection. Within this area, a tiny (6 mm)
marrow focus adjacent to the inferior calcaneal spur
demonstrates low T1 signal and the possibility of a tiny focus
of osteomyelitis in this location cannot be entirely excluded.
No other evidence of osteomyelitis.
Degenerative change, edema, and thickening of the proximal
plantar fascia. The possibility of an intra substance tear in
the proximal portion of the lateral band of the plantar fascia
cannot be excluded. Severe atrophy of the abductor digiti
minimi muscle is noted.
Extensive subcutaneous soft tissue edema with enhancement. The
differential includes cellulitis. No focal abscess identified.
Midfoot osteoarthritis.
Diffuse non-specific muscle edema.
Mild posterior tibialis tendinosis and trace tenosynovitis of
several tendons. No tendon tear.
Left Thigh US ___
Left lateral thigh hematoma with removal of 5 cc sanguinous
fluid, sent to microbiology.
Bilateral ___ US ___
1. No evidence of deep venous thrombosis in the right or left
lower extremity veins, though the right peroneal veins could not
be well visualized.
2. Two hypoechoic collections along the distal left anterior
thigh and distal left lateral thigh measuring up to 4.7 cm,
likely hematomas.
Right foot xray ___
Ulceration overlying the heel. No radiographic evidence of
osteomyelitis.
Left Tib/Fib Xray ___
No radiographic evidence of osteomyelitis.
CT Abd/Pelvis ___
1. Somewhat limited exam secondary to lack of intra-abdominal
fat, without definite acute intra-abdominal process.
2. Apparent wall thickening of the ascending colon potentially
due to
underdistention noting that colitis is not entirely excluded.
3. Asymmetric enlargement of the right leg relative to the left.
This likely reflects known chronic venous stasis. However if
there is concern for venous occlusion, ultrasound study may be
obtained.
4. 4.3 cm rim enhancing collection in the midleft thigh, which
may represent an organizing hematoma, although superimposed
infection cannot be excluded.
5. Severe atherosclerotic disease.
6. Multiple enlarged right inguinal lymph nodes.
7. Cholelithiasis without acute cholecystitis.
CT Head Noncontrast ___
No acute intracranial process.
CT C-spine Noncontract ___
Degenerative and postoperative changes without fracture or new
malalignment.
Brief Hospital Course:
___ with PVD and chronic non-healing ___ venous stasis ulcers
followed by vascular/plastics admitted for worsening R calcaneal
ulceration with fall at home in the setting of leukocytosis, now
s/p debridement on ___ and 7-day course (___) of broad
spectrum IV abx (vanc/cef/flagyl).
# Sepsis: Patient presented on admission with leukocytosis with
suspected source (right heel) vs urinary source (UCx
+klebsiella). The rest of her infectious workup was negative.
She completed a 7-day course of empiric vancomycin, cefepime,
and metronidazole on ___ with resolution of her
leukocytosis.
# Cellulitis: Patient presented with a right calcaneal ulcer
that was frankly infected with surrounding cellulitis in the
setting of a leukocytosis to 22 on arrival and her ESR and CRP
were both elevated. She was empirically started on vancomycin,
cefepime, and metronidazole. MRI showed a questionable focus of
osteomyelitis in the right calcaneous. The podiatry team was
consulted and patient underwent bedside debridement of the right
heel on ___. Given no clinically apparent osteomyelitis on
debridement and only small focus of possible osteomyelitis on
MRI, pt treated for skin and soft tissue infection with a 7 day
antibiotic course, from ___. ID recommended
discontinuing antibiotic therapy unless patient is febrile or
develops new cellulitis. On ___, patient had discussion with
team with plan to be discharged to rehab.
# UTI: Patient presented with positive urine culture growing
Klebsiella in the setting of leukocytosis, which resolved
following completion of a 7-day course of broad spectrum
antibiotics with vancomycin/cefepime/metronidazole, and on
discharge was asymptomatic.
# Left anterior shin ulcer: The patient had a left anterior shin
ulcer that had been present for ___ years per her report. She
had been followed by vascular surgery for this issue. In the
hospital, the dermatology consult service was consulted and felt
that she would benefit from a biopsy. The patient, however, did
not wish to have a biopsy done during this hospitalization.
This issue was deferred to outpatient follow up. The patient
was advised that she could call ___ Dermatology to schedule a
clinic appointment.
# Oral Health: #9 chipped and several mandibular teeth chipped
on presentation. Tooth fractures had been present for weeks per
pt's son. Pt was very uncomfortable, said difficult to eat
(however did eat most of her food in the hospital), and she was
concerned about having her dentition addressed in the hospital.
A Panorex scan was ordered. The scan showed multiple broken
down teeth, periapical radiolucencies, and cloudy maxillary
sinuses. A dental consult was deferred given the lack of acute
dental issue. The patient was advised to consult with a dentist
soon after discharge.
# Left thigh hematoma. The pt had a left thigh mass that was
rim enhancing on CT imaging. She had an ultrasound guided
biopsy that showed that the mass was a hematoma. Cultures of
the aspirate were negative.
# Anemia: Her hemoglobin and hematocrit was near recent
baseline. Iron studies were sent. Her anemia was likely due
both to chronic inflammation and iron deficiency.
# Hyperlipidemia: Contined home simvastatin.
# History of TIA: Continued ASA/simvastatin.
# Hypothyroidism: Continued home synthroid .
# Psych: Continued home medications.
# Hypertension: Continued home atenolol.
=====================
TRANSITIONAL ISSUES:
=====================
-Left anterior shin ulcer should have a skin biopsy per
dermatology consultation service. Pt can call ___ Dermatology
at ___ to schedule a clinic appointment.
-Pt has fractured #9 and several mandibular teeth and requires
dental follow up to discuss treatment
-Follow up with podiatry as scheduled
-Code: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
3. Furosemide 40 mg PO BID
4. Gabapentin 400 mg PO DAILY
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Nortriptyline 50 mg PO QHS
7. Potassium Chloride 20 mEq PO TID
8. Ranitidine (Liquid) 150 mg PO BID
9. Sertraline 50 mg PO DAILY
10. Simvastatin 40 mg PO QPM
11. Sucralfate 1 gm PO BID
12. Atenolol 25 mg PO DAILY
13. Nabumetone 750 mg PO BID
14. Diazepam 5 mg PO QAM
15. Diazepam 10 mg PO QHS
16. HYDROcodone-acetaminophen 7.5-325 mg ORAL Q4H:PRN pain
17. Collagenase Ointment 1 Appl TP DAILY
18. Protopic (tacrolimus) 0.1 % topical DAILY:PRN lip lesion
19. Acetaminophen 1000 mg PO Q8H:PRN pain
20. Docusate Sodium 100 mg PO BID
21. Milk of Magnesia 15 mL PO DAILY:PRN indigestion
22. Senna 8.6 mg PO BID:PRN constipation
23. Multivitamins 1 TAB PO DAILY
24. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Collagenase Ointment 1 Appl TP DAILY
4. Diazepam 5 mg PO QAM
5. Multivitamins 1 TAB PO DAILY
6. Milk of Magnesia 15 mL PO DAILY:PRN indigestion
7. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
8. Acetaminophen 1000 mg PO Q8H:PRN pain
9. Sucralfate 1 gm PO BID
10. Simvastatin 40 mg PO QPM
11. Sertraline 50 mg PO DAILY
12. Senna 8.6 mg PO BID:PRN constipation
13. Levothyroxine Sodium 112 mcg PO DAILY
14. Ranitidine (Liquid) 150 mg PO BID
15. Furosemide 40 mg PO BID
16. HYDROcodone-acetaminophen 7.5-325 mg ORAL Q4H:PRN pain
RX *hydrocodone-acetaminophen 7.5 mg-325 mg 1 tablet(s) by mouth
every four (4) hours Disp #*60 Tablet Refills:*0
17. Nortriptyline 50 mg PO QHS
18. Gabapentin 400 mg PO DAILY
19. Diazepam 10 mg PO QHS
20. Docusate Sodium 100 mg PO BID
21. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
22. Potassium Chloride 20 mEq PO TID
23. Protopic (tacrolimus) 0.1 % topical DAILY:PRN lip lesion
24. Miconazole 2% Cream 1 Appl TP BID Duration: 6 Weeks
please apply to web spaces
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Sepsis
Cellulitis
Urinary tract infection
Secondary Diagnoses:
Left leg ulcer
Venous stasis
Depression
Anemia
Hyperlipidemia
Poor Dentition
Protein malnutrition
Demand cardiac ischemia
Chronic kidney disease
Anemia
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 of you at the ___. You were admitted
to the hospital because of an infected wound on your right heel.
You received intravenous antibiotics and you had a bedside
wound debridement to remove the infected material. You
completed your antibiotics in the hospital. You should follow
up with podiatry in the coming weeks. They will call you with
an appointment time. You should also follow up with your
primary care physician, ___, and plastic surgeon as
scheduled. We also recommend that you see a dentist to discuss
the management of your teeth. Finally, you should see a
dermatologist to have a skin biopsy of your left leg wound. If
you would like to be seen in the Department of Dermatology at
___, you can call ___ to schedule a clinic
appointment. If you begin to feel ill, have a fever, or have
more pain or redness in your right leg, please return to the
hospital.
Thank you for allowing us to participate in your care.
Sincerely,
-- Your ___ Team
Followup Instructions:
___
|
19890872-DS-20 | 19,890,872 | 21,308,291 | DS | 20 | 2190-07-20 00:00:00 | 2190-08-19 06:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
___: cardiac catheterization
History of Present Illness:
Ms. ___ is a ___ year old female with a past medical history
significant for rheumatoid arthritis, polymyalgia rheumatica,
peptic ulcer disease, ischemic colitis, HTN and severe aortic
stenosis who presented to ___ with acute onset
dyspnea and was found to be hypoxic, now transferred to ___
for further management of new onset CHF.
Per patient, her AS was first discovered at ___
approximately ___ years ago when she underwent cardiac cath and
was found to have normal coronaries but a "bad valve" and was
told that she has severe aortic stenosis. She states that she
has been asymptomatic since then until approximately 1 month ago
when she began having worsening dyspnea on exertion, however per
her family they have noticed a decline in her energy and
gradually increasing shortness of breath over the past ___ years
since her diagnosis.
She was told at the time of discovery that she needed aortic
valve replacement surgery, however, at the time she did not want
to have surgery performed as she was concerned about the risks
of the procedure. She has not had any follow up with cardiology
or CTS since, however patient was scheduled for an appointment
with cardiac surgery here tomorrow and thus requested to be
transferred here for further evaulation and treatment.
The current episode began she attempted to go to sleep but
before being able to lay down she experienced acute onset
shortness of breath and wheezing, prompting her husband to call
an ambulance. Per report, EMS found the patient to be tachypneic
at 46 breaths per minute and hypoxic to the ___, as well as
hypertensive to the 200s systolic. She was brought to ___
___ where she received IV lasix diuresis and CPAP with much
symptomatic improvement.
Of note, patient reports that she was recently hospitalized
approximately 2 months ago for an episode of ischemic coliits at
which point all of her cardiac medications were stopped
(amlodipine, lisinopril).
Patient was brought to the ___ ED where CXR was significant
for bilateral infiltrates in hilar distribution suggestive of
acute pulmonary edema and she received an additional 40 IV lasix
x1 and was admitted to the heart failure service.
On the floor, she remains much improved. No current SOB at rest.
She denies fever, chills, cough, unintentional weight loss,
dysuria/change in urinary frequency, change in urine output,
syncope, lower extremity swelling, wheezing, reflux, or
abdominal pain. No syncope, chest pain, or palpitations. No
recent increase in salty food intake or fluid intake, or recent
illnesses or sick contacts.
Past Medical History:
-HTN
-Rheumatoid arthritis
-Polymyalgia rheumatica
-Severe aortic stenosis
-Ischemic colitis
-Peptic ulcer disease
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: T 98.3, HR 92, BP 143/75, RR 18, O2 sat 98% 2L
Weight: 76.5 kg
General: comfortable, no acute distress
HEENT: NC/AT, MMM
Neck: supple, JVP non-elevated
CV: ___ crescendo-decrescendo murmur heard best at the RUSB
that
radiates to the carotids, +S4
Lungs: bilateral crackles to mid-lung fields, regular
respiratory rate and effort
Abdomen: soft, non-distended, nontender, bowel sounds present
GU: no foley
Ext: warm and well perfused, no ___ edema
Neuro: alert and oriented x3, no gross neurologic deficits
Skin: no rashes
PULSES: 2+ bilaterally
DISCHARGE PHYSICAL EXAM
=======================
VS: T 98.3, hr 73, BP 125/46, RR 18, 02 sat 96% on RA
Weight: 75.3 <-- 74.7 <--75.1 <-- 75.4 <-- 76.5 kg
General: pleasant, comfortable, no acute distress
HEENT: NC/AT, MMM
Neck: supple, JVP non-elevated
CV: ___ crescendo-decrescendo murmur heard best at the RUSB
that
radiates to the carotids, +S4
Lungs: sparse bibasilar crackles, regular respiratory rate and
effort
Abdomen: soft, non-distended, nontender, bowel sounds present
GU: no foley
Ext: warm and well perfused, no ___ edema
Neuro: alert and oriented x3, no gross neurologic deficits
Skin: no rashes
PULSES: 2+ bilaterally
Pertinent Results:
ADMISSION LABS
==============
___ 08:15AM BLOOD WBC-11.3* RBC-4.33 Hgb-13.0 Hct-40.3
MCV-93 MCH-30.1 MCHC-32.4 RDW-14.0 Plt ___
___ 08:15AM BLOOD Neuts-81.8* Lymphs-10.7* Monos-6.3
Eos-0.5 Baso-0.7
___ 08:15AM BLOOD Plt ___
___ 08:15AM BLOOD Glucose-144* UreaN-20 Creat-0.9 Na-139
K-4.7 Cl-104 HCO3-22 AnGap-18
___ 04:40PM BLOOD Glucose-114* UreaN-21* Creat-1.2* Na-143
K-4.2 Cl-102 HCO3-26 AnGap-19
___ 08:15AM BLOOD CK(CPK)-98
___ 04:40PM BLOOD CK(CPK)-126
___ 08:15AM BLOOD CK-MB-8
___ 08:15AM BLOOD cTropnT-0.12*
___ 04:40PM BLOOD CK-MB-8 cTropnT-0.12*
___ 08:15AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.0
___ 04:40PM BLOOD Calcium-10.1 Mg-2.1
___ 08:26AM BLOOD Lactate-2.0
DISCHARGE LABS
==============
___ 06:40AM BLOOD WBC-8.3 RBC-3.93* Hgb-11.8* Hct-36.5
MCV-93 MCH-30.0 MCHC-32.3 RDW-13.7 Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-119* UreaN-26* Creat-1.0 Na-138
K-4.7 Cl-103 HCO3-26 AnGap-14
___ 06:40AM BLOOD ALT-30 AST-24 LD(LDH)-220 AlkPhos-66
TotBili-0.4
___ 06:40AM BLOOD Albumin-4.1 Calcium-9.4 Phos-3.7 Mg-2.4
___ 06:40AM BLOOD %HbA1c-5.7 eAG-117
STUDIES
=======
___ CXR: Vascular congestion and interstitial markings
compatible with interstitial edema. Obscuration of bilateral
costophrenic angles compatible with pleural effusions, although
component of atelectasis or focal consolidation cannot be
excluded.
___ TTE: Mild symmetric left ventricular hypertrophy with
preserved biventricular cavity size and mild global hypokinesis.
Elevated E/e'. Severe aortic stenosis. Mild aortic
regurgitation. Mild pulmonary hypertension. Mild aortic
dilatation.
___ PRE-OP Cardiac catheterization: Coronary angiography:
right dominant
LMCA: normal
LAD: minimal irregularities
LCX: 60% mid
RCA: minimal irregularities
Assessment & Recommendations
1. Moderate mid LCX lesion with no other significant CAD
___ PRE-OP CAROTID US:
Right ICA with <40% stenosis.
Left ICA with <40% stenosis.
___ PRE-OP CXR: Resolved pulmonary edema.
There is residual minimal vascular congestion
Stable cardiomegaly
Brief Hospital Course:
___ with HTN severe AS p/w acute pulmonary edema and associated
hypertensive urgency. Her sxs were c/w flash pulmonary
edema/acute dHF likely secondary to both HTN and severe AS,
resolved entirely with diuresis. She was evaluted by cardiac
surgery and plan for aortic valve replacement in the near
future. Cardiac cath, TTE, carotid US and CXR done as part of
pre-op work-up.
ACTIVE ISSUES
=============
# Flash pulmonary edema/acute diastolic heart failure: likely
secondary to HTN and severe AS. Patient had been off blood
pressure meds for at least 2 months with SBP ranging from
150-180 mmHg at home. This is her first presentation of CHF. At
baseline she has DOE and dizziness with exertion. CXR consistent
with pulmonary edema and patient's acute onset symptoms also
support flash pulmonary edema. Suspicion for pneumonia is low
giving lack of fever, leukocytosis, focal infiltrate or cough.
TTE notable for mild symmetric LV hypertrophy with preserved
biventricular cavity size and mild global hypokinesis. Elevated
E/e', severe AS, mild AR, mild pulmonary HTN and aortic
dilatation. Gently diuresed patient as likely not much total
volume overload, now pt appears euvolemic and aiming for net
even. CXR on day of discharge confirmed resolution of pulmonary
edema. She is being discharged on PO Lasix, imdur for afterload
reduction, and a beta blocker as well as ASA 81 and a statin.
# Aortic stenosis: patient with known severe AS, was recommended
to have surgery in the past but then lost to follow-up. She did
have appointment with cardiac surgery set-up for outpatient
basis, however now evaluated in house. She had a cardiac
catheterization and carotid US prior to discharge as part of
pre-op evaluation. There are multiple outstanding transitional
issues regarding her upcoming surgery, which are detailed below.
# HTN: patient with a history of HTN has been off
anti-hypertensives. On presentation to OSH she was quite
hypertensive (220/120) however in ED here she had a hypotensive
episode after receiving nitro paste from the OSH. Has been
normotensive here. And was slowly started on imdur and
metoprolol which have been well-tolerated, and patient is being
discharged on these new medications.
# Troponinemia: patient with elevated troponin at OSH, elevated
to 0.12 here. EKG with TWIs only. No chest pain. Likely
represents CHF exacerbation rather than NSTEMI.
CHRONIC ISSUES
==============
# Rheumatoid arthritis/PMR: patient on Humira injections q2
weeks outpatient, recently seen in ___ clinic here however her
provider has since left the ___ system and patient is unsure
of who her knew rheumatologist will be. ___ will need to be
stopped prior to surgery, however details of the length of lead
time and post-procedure time before restarting as well as any
other alternate interventions which may be needed in the interim
are unclear. Her PCP has been made aware and an email has been
sent to ___ clinic NP. For now, pt has been asked to
hold her dose as surgery may be scheduled as early as next week.
# Leg cramping: pt states that she has leg cramps at baseline at
home which resolve with her walking or drinking tonic water with
quinine. Pt had leg cramps on admission, resolved with movement.
TRANSITIONAL ISSUES
===================
-We are unsure of her surgery date so pt will call Dr. ___
office on ___ to check in
-She will call her dentist on ___ to get Dental Clearance
form faxed to Dr. ___
-She may need to hold humira pre-op, we have asked her not to
take today's dose and wait until she is contacted on ___ for
further instructions
-She is being discharged on PO lasix, other new meds include ASA
81, statin, imdur, beta blocker
-Email has been sent to Dr. ___ NP, and PCP
regarding these transitional issues
-Team also touched base with Dr. ___ regarding these
issues which need close follow-up
-Pt desires cardiology f/u at ___, team will try to make her
an appointment on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Humira (adalimumab) 40 mg/0.8 mL subcutaneous q2weeks
2. Cyanocobalamin Dose is Unknown IM/SC Frequency is Unknown
Discharge Medications:
1. Cyanocobalamin 0 mcg IM/SC AS DIRECTED
2. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
5. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
6. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
-Flash pulmonary edema
SECONDARY DIAGNOSES
===================
-Aortic stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were transferred to ___ from an outside hospital after you
had fluid build up around the lungs. This is a form of heart
failure related to your aortic valve stenosis.
While here, we helped remove the fluid with IV and then oral
diuretic medications. You were also seen by the Cardiac Surgery
team who recommended aortic valve replacement. Prior to
discharge, you had an echocardiogram, ultrasound of your carotid
arteries, a cardiac catheterization, as well as a pre-operative
chest X-RAY.
Now that these tests have been completed and you are not having
any more difficulty breathing, you are being discharged to home.
We are not sure of your exact surgery date yet, but it may be as
early as this coming week. Please call Dr. ___ office at
___ on ___ to find out more details. You also need
to call your dentist's office on ___ to have them fax a
Dental Clearance that clears you for Aortic Valve Replacement to
Dr. ___. The fax number is ___ ATTN:
___.
You may not be able to take your Humira before the surgery.
While we are working out the details of this, please DO NOT take
your dose tonight. You will be contacted on ___ with further
instructions.
Dr. ___ like you to have his personal cell phone number
in case you have any issues, his number is ___.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
19890943-DS-8 | 19,890,943 | 21,035,868 | DS | 8 | 2186-08-14 00:00:00 | 2186-08-14 19:30:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Thoracocentesis on ___ yielded 2.2L of serosanguinous
fluid. Lab analysis showed WBCs and exudative-type fluid.
History of Present Illness:
Mr. ___ is a ___ male with a history of sleep apnea and
hypoxic episodes related to panic attacks, who presents with
several weeks of worsening shortness of breath. His medical
history is significant for multiple recent admissions for
pericarditis/pericardial effusions which developed about 6mo
following a myocardial infarction in ___. Most recently he
presented with atrial fibrillation and pericardial effusion
___ at an OSH, then was transferred to ___. He
underwent transthoracic echo which showed early diastolic
collapse, increased IVC pressures, right atrial and right
ventricular collapse and circumferential effusion. The
pericardial effusion was drained of >1L of bloody fluid. He has
been taking ASA 325mg and colchicine for presumed idiopathic
pericarditis. He was discharged ___ and a follow-up echo
on ___ showed improvement of the pericardial effusion and
a LVEF of >55%.
Since ___ the patient has experienced worsening shortness of
breath, feeling increasingly short of breath if he lies flat and
with walking. He does report a cough that he felt improved
following pericardiocentesis, but now has increased again. These
symptoms prompted an outpatient chest x-ray and echo this
morning. A small circumferential pericardial effusion without
evidence of tamponade was demonstrated on echo; however a
significant left-sided pleural effusion was seen on chest x-ray.
He reports no variation in symptoms with exertion or significant
chest pain to suggest ischemic disease at this time. He has not
been using any oxygen at home and has not been checking his O2
sats. He has not been using his CPAP. He is feeling very
fatigued but denies any symptoms of viral illness (no
rhinorrhea, fever, chills, etc). He reports ___ edema, L>R.
In the ED, initial vitals: 96.9 71 137/70 16 92%.
CXR showed interval development of a large left pleural
effusion.
Past Medical History:
- Pericarditis with pericardial effusions
- Non-Q-wave myocardial infarction in ___ in ___
s/p catheterization without evidence of CAD per PCP's note
- Panic attacks with hypoxia
- Morbid obesity
- Sleep apnea
- Hypothyroid
- Gout
- GERD
Social History:
___
Family History:
Mother with MI in ___, ulcle with MI in ___, father died of
colon CA. No family history of arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Physical Exam on Admission:
VS - Temp 98.2F, BP 129/69, HR 59, R 18, O2-sat 96% 2L NC
GENERAL - NAD, comfortable, fatigued
HEENT - NC/AT, EOMI, sclerae anicteric, MMM
NECK - supple, JVP difficult to assess
HEART - RRR, nl S1-S2, no MRG
LUNGS - good air movement on R and L upper lung fields, crackles
over L lower lung fields with decreased air movement, no
accessory muscle use, +cough
ABDOMEN - obese, soft/NT/ND
EXTREMITIES - WWP, 1+ radial pulses, pedal pulses difficult to
appreciate, ___ non-pitting edema to ankles, LLE +cyanotic
discoloration and venous dilation
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, moving all extremities
Physical Exam on Discharge:
VS - Temp 97.4F, BP 118/68, HR 59, R 20, O2-sat 96% 2L NC
GENERAL - NAD, comfortable
HEENT - NC/AT, EOMI, sclerae anicteric, MMM
NECK - supple, JVP difficult to assess
HEART - RRR, nl S1-S2, no MRG
LUNGS - good air movement throughout lungs with deep
inspiration, no accessory muscle use
ABDOMEN - obese, soft/NT/ND
EXTREMITIES - WWP, 1+ radial pulses, pedal pulses difficult to
appreciate, ___ non-pitting edema to ankles, LLE +cyanotic
discoloration and venous dilation
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, moving all extremities
Pertinent Results:
Labs on Admission ___:
BLOOD WBC-7.0 RBC-4.61 Hgb-12.5* Hct-39.1* MCV-85 MCH-27.1
MCHC-32.0 RDW-14.6 Plt ___
BLOOD Glucose-91 UreaN-8 Creat-1.0 Na-144 K-3.8 Cl-101 HCO3-35*
AnGap-12
Pleural Fluid Analysis ___:
PLEURAL WBC-1525* Hct,Fl-2.5* Polys-1* Lymphs-49* Monos-4*
Eos-45* Other-1*
PLEURAL TotProt-5.6 Glucose-85 LD(LDH)-547 Amylase-22
Albumin-3.5 Cholest-95 Triglyc-47
Serum Labs for comparison ___:
BLOOD TotProt-6.7 Albumin-4.1 Globuln-2.6 Calcium-8.9 Phos-4.4
Mg-2.4
BLOOD LD(LDH)-236
Labs on Day of Discharge ___:
BLOOD WBC-8.0 RBC-4.66 Hgb-12.6* Hct-39.8* MCV-85 MCH-26.9*
MCHC-31.5 RDW-14.7 Plt ___
BLOOD Glucose-100 UreaN-10 Creat-0.8 Na-139 K-4.2 Cl-96 HCO3-32
AnGap-15
___ Chest Radiograph:
Interval development of a large left pleural effusion. If there
is history of
recent trauma, hemothorax should be considered. Other causes
include
infection or malignancy and malignancy, but the latter is less
likely given
the short interval time of development.
___ CT Chest w/o Contrast:
Obviously chronic mild-to-moderate left pleural effusion with
rounded atelectasis in the left lower lobe. No evidence of
parenchymal or
pleural pathology that could explain the origin of the effusion.
Incomplete inspiration and non-characteristic appearance of the
remaining
lung, including non-characteristic areas of scarring in the
subpleural parts
of the left upper lobe.
Small thymic remnant. Minimal coronary calcifications. No
enlarged hilar and
mediastinal lymph nodes. Borderline size of the heart without
evidence of
fluid overload.
___ Chest Radiograph:
Stable cardiac silhouette. Increasing left moderate to large
pleural effusion
with associated atelectasis.
Brief Hospital Course:
Mr. ___ is a ___ male with a recent history of pericardial
effusion who presented with shortness of breath and hypoxia
likely secondary to a new L pleural effusion.
# Pleural effusion: Mr. ___ presented with a new, large L
pleural effusion which has developed since his last CXR
___ and is likely contributing to his increasing SOB over
this same time period. The effusion was tapped for 2.2L of
serosanguinous fluid on ___, with 1500 WBC, a low hct and
exudative features. Most likely causes for the development of
this exudative effusion in a ___ in the context of mild
eosinophilia include malignancy, rheumatologic causes or
infection, which are also all on the differential for his
recurrent pericarditis (see below). Follow-up chest CT as above
suggested no obvious cause for the effusion. If cytological
analysis and culture of the pleural fluid do not yield an
obvious diagnosis, it may be useful to consider a rheumatologic
work-up as outpatient. RF and ___ on this admission WNL. Fluid
negative for malignant cells, and flow cytometry not consistent
with malignancy.
# Pericarditis: Mr. ___ has had recurrent pericarditis for the
past several months, with 1L of bloody pericardial fluid drained
in ___. Fluid analysis at that time showed no evidence of
malignancy and no obvious infections or rheumatologic causes of
pericarditis were identified. He has been taking colchicine and
ASA as an outpatient. Echo ___ identified only a small
circumferential pericardial effusion with some evidence of
debris. No signs of pericarditis on EKG on admission. He was
continued on his colchicine and ASA during admission. Again it
may be useful to consider rheumatologic work-up as outpatient.
# Non-Q-wave myocardial infarction in ___ without evidence of
CAD on cath. Normal sinus rhtyhm on EKG on admission, no
clinical suggestion of myocardial infarction during admission.
# Afib in the context of pericardial effusion in ___. Patient
in sinus rhythm on admission. Patient was continued on
metoprolol 25mg QDay.
# Sleep apnea for which the patient has home CPAP, which he
doesn't use. Bicarb on admission only slightly elevated at 35.
Transitional Issues:
1. f/u with IP in approximately 1 week to assess need for
further thoracentesis or intervention
2. f/u pending studies, including pleural fluid culture
3. Consider Rheum referral
4. continue outpt w/u of his pleural effusion as indicated
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin (Buffered) 325 mg PO DAILY
3. Colchicine 0.6 mg PO BID
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
hold for SBP < 100 or HR < 60
6. Simvastatin 20 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Docusate Sodium 100 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin (Buffered) 325 mg PO DAILY
3. Colchicine 0.6 mg PO BID
4. Docusate Sodium 100 mg PO DAILY
5. Levothyroxine Sodium 150 mcg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Simvastatin 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left pleural effusion, etiology unclear.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
for a large amount of fluid on your left lung. For this, you had
a thoracentesis, which is a procedure where fluid is removed
from the lung. A chest xray showed some fluid re-accumulation,
so you may need another procedure in the near future. If you
develop shortness of breath
No changes were made to your medications
Followup Instructions:
___
|
19890966-DS-20 | 19,890,966 | 24,100,578 | DS | 20 | 2136-11-06 00:00:00 | 2136-12-29 15:58:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Left sided numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year old woman with a past medical
history of left thalamic infarct (2 weeks ago) with residual
right sided numbness, hypertension, and tobacco dependence (~35
pack year history, quit ___ years ago) who presents to the ___
ED ___ with new left sided numbness.
Regarding her prior stroke, this occurred ___ while she was at
a
wedding in ___. She had been eating unhealthy
foods and drinking alcohol and she awoke on ___, the day
following the wedding, with the sensation that her right arm was
numb. She initially thought she had "slept funny" on her right
arm but then noted that her entire right side was numb. She was
brought to the hospital where she was diagnosed with a left
thalamic infarct. Her SBP was found to be in the 200s upon
presentation to the hospital. Stroke was attributed to small
vessel disease. Pt was started on metoprolol and aspirin 81 mg
daily. She stated that she had a normal carotid ultrasound and
echocardiogram. She denied any diagnosis of hyperlipidemia or
diabetes mellitus.
Since the stroke, she has felt well. She was referred by her PCP
to ___ with Dr. ___. Dr. ___ risk factor
reduction and referred pt for a TSH, hemoglobin A1c, and lipid
panel (not checked yet). She has continued to experience
right-sided numbness which has been gradually improving.
On day prior to current ED presentation, pt felt numb in her
bilateral ___ and ___ digits. This spread up the medial arm to
the elbow and she attributed this sensation to typing at work.
On
AM of presentation, upon waking, pt noted that her entire left
hemibody felt numb. She was concerned she was having a second
stroke so came to the ED immediately. She never had similar
symptoms prior on her left side.
Past Medical History:
Hypertension
Left thalamic infarct (___)
Herpes zoster (left face) complicated by neuralgia
No history of diabetes or hyperlipidemia
Social History:
___
Family History:
Mother: Heart disease (CABG, valve replacement)
Father: HTN, gout
Aunt: DM
No history of stroke or blood clot in family.
Physical Exam:
########Admission Exam########
Vitals: T: 96.2 HR: 66 BP: 164/60 RR: 15 SaO2: 97% RA
General: NAD, pleasant
HEENT: NCAT, no oropharyngeal lesions, neck supple, no carotid
bruit
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Attention to examiner easily maintained. Recalls a
coherent
history. Able to recite months of year backwards. Speech is
fluent with full sentences, intact repetition, and intact verbal
comprehension. Content of speech demonstrates intact naming
(high
and low frequency) and no paraphasias. Normal prosody. No
dysarthria. No apraxia. No evidence of hemineglect. No
left-right
agnosia.
- Cranial Nerves - PERRL 3->2 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.
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 - Decreased sensation to light touch and pinprick
bilaterally with loss of sensation greater on the left than the
right. Pt estimated about a 85% sensory loss on the left and 90%
sensory loss on the right (the sensory loss on the right is
baseline since pt's prior stroke). Sensation intact to
proprioception bilaterally at the level of the great toe and the
thumb.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response extensor on the left and flexor on the right.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Normal initiation. Narrow base. Normal stride length
and
arm swing. Stable without sway. Negative Romberg.
Discharge Exam
The only notable change is that patient reports return of normal
sensation on the Left side of her hemibody. Otherwise
unchanged.
Pertinent Results:
___ 05:51AM BLOOD WBC-6.8 RBC-4.08* Hgb-12.9 Hct-38.8
MCV-95 MCH-31.5 MCHC-33.1 RDW-12.6 Plt ___
___ 09:13AM BLOOD Neuts-52.5 ___ Monos-4.6 Eos-4.2*
Baso-0.9
___ 05:51AM BLOOD Glucose-100 UreaN-15 Creat-0.6 Na-141
K-4.8 Cl-107 HCO3-25 AnGap-14
___ 09:13AM BLOOD ALT-25 AST-23 AlkPhos-75 TotBili-0.3
___ 09:13AM BLOOD Lipase-41
___ 09:13AM BLOOD cTropnT-<0.01
___ 09:13AM BLOOD Albumin-4.7 Calcium-9.6 Phos-3.5 Mg-2.1
___ 05:51AM BLOOD Triglyc-194* HDL-44 CHOL/HD-4.9
LDLcalc-132*
___ 09:13AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK W&W/O
CONTRAST ___: IMPRESSION:
1. No evidence of acute infarction. Chronic infarctions in the
left thalamus and right coronal radiata.
2. T2/FLAIR signal hyperintensity in the periventricular,
subcortical, and deep white matter which is nonspecific but may
be seen in the setting of chronic small vessel ischemic disease.
3. No significant aneurysm or vascular malformation. No evidence
of focal
flow-limiting stenosis or vascular occlusion.
CT Head w/o Contrast ___: IMPRESSION:
No evidence for acute intracranial abnormalities. Supratentorial
white matter hypodensities are nonspecific, but compatible with
sequela of chronic small vessel ischemic disease, demyelination,
or inflammation. Please correlate clinically. MRI with
intravenous contrast may be of value, if clinically warranted.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a past medical history
of left thalamic infarct (2 weeks ago) with residual right-sided
numbness, hypertension, and history of tobacco use (~35 pack
year history, quit ___ years ago) who presented to the ___ ED
___ with new left-sided numbness.
# Left Hemibody Sensory Change
Her neurologic examination was notable for sensory loss
bilaterally (as pt has known residual sensory deficits from her
prior stroke on the right) with new sensory loss on the left
that is worse compared to the right. Non-contrast head CT and
initial labs were unremarkable. After she was admitted, Ms.
___ had an MRI/A head and neck which showed no evidence of
acute infarction. Chronic infarctions in the left thalamus and
right coronal radiata were noted, along with T2/FLAIR signal
hyperintensity in the periventricular, subcortical, and deep
white matter which likely represent chronic small vessel
ischemic disease. On the MRA, no significant aneurysm or
vascular malformation, and there was no evidence of focal
flow-limiting stenosis or vascular occlusion.
Clinically her new left-sided numbness improved significantly
over a 24 hour period after admission.
Upon checking her chronic stroke risk factors, her LDL was
elevated at 132 and so she was started on atorvastatin 40mg qd.
HBA1c was still pending on discharge.
We recommend increasing aspirin to 325 mg daily. He blood
pressure was elevated up to systolics in 170s and did not appear
to have any effect from metoprol. So, started lisinopril 10mg qd
and discontinued metoprolol.
She should follow up in stroke clinic with Dr. ___ he
is the established Neurologist for Mrs. ___.
Medications on Admission:
Metoprolol 25 BID
Aspirin 80 mg daily
Proventil PRN
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*6
3. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*6
Discharge Disposition:
Home
Discharge Diagnosis:
TIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with symptoms of numbness on
the left side of your body. While in the hospital, you had a CT
of your head performed, which did not show any evidence of a new
stroke. You also had an MRI of your head and neck, which also
showed no evidence of a new stroke or any narrowing of the blood
vessels in your head or neck. We did find that your cholesterol
is high, so we have started you on a medicine called
atorvastatin. Also, your blood pressure was quite high, so we
started you on a medicine called lisinopril.
We have made the following changes to your medications:
START
atorvastatin 40mg daily
lisinopril 10mg daily
INCREASE
aspirin to 325mg daily
STOP
metoprolol
You should follow up with Dr. ___ in stroke
clinic. Please call ___ to schedule. Please bring
copies of your echocardiogram and carotid ultrasound reports.
We wish you the best.
Followup Instructions:
___
|
19890966-DS-21 | 19,890,966 | 21,589,441 | DS | 21 | 2136-12-30 00:00:00 | 2137-01-03 14:11:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
left hemibody numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old right-handed former smoker with
a history of herpes zoster (left V2?), HTN, HLD, and left
thalamic infarct (___) with residual right-sided numbness who
presents with left hemibody numbness.
Ms. ___ was last well on ___ when she was in ___ for
a wedding and she awoke with right hemibody numbness and was
diagnosed with a left thalamic infarct in the setting of SBPs to
the 200s. Her stroke was felt to be in the setting of small
vessel disease and she was started on metoprolol and aspirin
81mg. Per her report, the work-up included a normal
echocardiogram and carotid ultrasound. While her right hemibody
numbness has improved, she still noted 80-90% sensory on the
right-side compared to the left.
Upon return to ___, she was seen by Dr. ___ in neurology
clinic for stroke risk factor stratification (TSH, A1c 5.5, LDL
132).
She was doing well until ___, when she developed left hemibody
numbness that started in her left dorsal hand and medial forearm
and entire left hemibody, lasting less than 24 hours. She was
admitted to ___ overnight for MRI/A showed only chronic left
thalamic and right corona infarctions and evidence of SVID. Her
ASA was increased to 325, atorvastatin 40mg daily was started
for
LDL 132 and her metoprolol was switched to lisinopril for better
BP control. She has continued on these meds and her PCP
increased lisinopril to 40mg this week.
Since hospital discharge, she has had intermittent numbness of
both arms that was disproportionate to her right hemibody
numbness at times. Duration of these episodes is unclear, but
she did feel that sometimes her left hand would get numb after
gripping items.
This morning, she awoke with new, more severe left hemibody
numbness (face, trunk, arm, leg) that she had not experienced
since the prior hospital admission. When she checked her
sensation, she felt "things switched" and "now the left side is
the numb side." She does endorse significant amount of stress
yesterday to meet an IRB deadline at her work. She was working
feverishly until midnight. She guessed that her blood pressure
was quite high. She also brings up that she had shingles in the
past on the left face and mid torso, but this numbness was very
different and not painful.
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 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. Denies
myalgias, arthralgias, or rash.
Past Medical History:
- Hypertension
- Left thalamic infarct (___)
- Herpes zoster (left ear, face, left torso) complicated by
neuralgia
- No history of diabetes or hyperlipidemia
- right shoulder dislocation x 2
- Recent admission in ___, for TIA evaluation, with
negative MRI
Social History:
___
Family History:
Mother: Heart disease (CABG, valve replacement)
Father: HTN, gout
Aunt: DM
No history of stroke or blood clot in family.
Physical Exam:
PHYSICAL EXAMINATION
Vitals: 98.1 95 ___ 18 97 RA
General: NAD
HEENT: NCAT, no lesions in the ear canals, 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:
Awake, alert, oriented x 3. Able to relate 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. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline and appendicular commands.
- Cranial Nerves - PERRL 4->2 brisk. VF full to number counting.
EOMI, no nystagmus. Right hemiface is 90-100% of what is felt at
mid sternum. Left hemiface is 80-90% of normal. There is slight
right NLFF, 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.
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 - She reports right hemibody is 90-100% normal to
light
touch and pin whereas left hemibody is 80-90% normal. "normal"
is what is felt at midline sternal area. No deficits to
temperature or vibration. No exinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response upgoing bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Normal initiation. Narrow base. Normal stride length
and
arm swing. Stable without sway. Negative Romberg.
===========================
Discharge exam:
She is afebrile, BP 134/65, PR 66 RR 14
she is awake, alert and oriented x3,fluent speech, intavct
repitition and comprehension.
CN exam: normal exam except for mildly diminish pin prick over
the right face.
No focal weakness in motor exam.
Sensory exam: mildly diminished pin prick ssensation over the
right side of the body, left side is backm to normal.
She is able to walk without difficulty and coordination exam is
intact
Pertinent Results:
URINE COLOR-Straw APPEAR-Clear SP ___
URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-MOD
URINE RBC-<1 WBC-4 BACTERIA-FEW YEAST-NONE EPI-2 TRANS EPI-<1
URINE MUCOUS-RARE
K+-5.1 GLUCOSE-123* UREA N-9 CREAT-0.6 SODIUM-137
POTASSIUM-6.4* CHLORIDE-101 TOTAL CO2-25 ANION GAP-17
ALT(SGPT)-24 AST(SGOT)-61* ALK PHOS-58 TOT BILI-0.4
LIPASE-37
ALBUMIN-4.6 CALCIUM-10.0 PHOSPHATE-4.4 MAGNESIUM-2.1
CHOLEST-218*
TRIGLYCER-195*
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
WBC-6.9 RBC-4.47 HGB-14.7 HCT-40.9 MCV-92 MCH-32.8*
MCHC-35.9* RDW-13.3
NEUTS-58.1 ___ MONOS-3.7 EOS-3.2 BASOS-0.6
PLT COUNT-174
___ PTT-28.2 ___
=====================================================
MRI
No acute intracranial process. No evidence of acute infarction
or hemorrhage.
Chronic left thalamic and right coronal radiata unchanged.
======================
Neck MRI
Mild cervical spine degenerative changes, as described above,
with mild right neural foramen narrowing at C3-4, C4-5, and
C5-6. No evidence of spinal canal stenosis or abnormal cord
signal.
=========================
___
No evidence of acute intracranial process.
Brief Hospital Course:
After performed ___ in the emergency room, did not show any
visible abnormal finding, Ms ___ was admitted to neurology
stroke service for overnight observation and MRI of the head.
The symptoms improved after 4 hours and she was back to her
baseline.
The patient was seen in the morning , with her neurological exam
at her baseline.
___ MRI did not show any abnormal finding in the DWI, FlAIR or
gradiant ECHO.
As she was found to have mildly hyperactive reflexes, with
upgoing toes, MRI of the neck was requested.
MRI of the neck did show mild degenerative disease but without
cord compression.
The patient was discharged home at her baseline without any new
focal sensory finding.
On the day of discharge she was awake, alert and oriented x3,
without focal finding in the cranial nerve, sensory or motor
exam.
Performed UA did not revealed any infection.
We did not changed any of her medication and she was discharged
home without any complication.
Medications on Admission:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Lisinopril 40 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Lisinopril 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1. Transient Left hemisensory loss concerning for TIA( transient
ischemic attack).
2. Hyperlipidemia.
3. Hypertension.
4. History of prior ischemic infarction.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
The patient is awake, alert, oriented x3, with fluent speech,
and intact comprehension.
No weakness was discovered in the exam and sensory exam is back
to baseline: residual decreased sensation over the right
hemibody, normal on the left side.
Discharge Instructions:
Dear Ms ___, you have been admitted here with numbness in
your left side concerning for stroke.
Performed MRI of your brain did not show that you have any new
infarction. We also performed MRI of your neck which did not
show any significant finding and in the simple words your MRI of
the head and neck did not show any new abnormality.
We did not change any of your medications and did not add any
medication.
Your symptoms resolved spontanously without any medication or
intervention.
Please take your medication as instructed.
Followup Instructions:
___
|
19891107-DS-20 | 19,891,107 | 26,303,115 | DS | 20 | 2131-07-12 00:00:00 | 2131-07-14 13:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
___: Intubation
___: 1. L2 bilateral hemilaminectomy.
2. L3 laminectomy.
3. L4 revision bilateral hemilaminotomy.
4. L5 far lateral decompression.
5. S1 laminectomy.
6. Incision and debridement, deep lumbar abscess.
7. Deep bone biopsy.
___: Extubation
History of Present Illness:
Mr. ___ is a ___ year-old man with a history of HTN and
chronic back pain who presented to OSH with acute on chronic
back pain, received a CTA and found a possible aortic dissection
and admitted to the MICU for aggressive BP control.
Patient reports that his back pain started 2 days prior to
presentation. He notes that he has chronic back pain and walks
with a walker at home, has been taking oxycodone chronically. He
reports that he missed his last two days of Oxycodone and now
presents with acutely worsening back pain. He presented to
___ who evaluated him, noted no fevers or loss of
neuro function and so monitored him for pain control and planned
for DC. Since his pain continued to be poorly controlled
decision made to move towards CTA him for possible dissection
given history of hypertension. CTA was a poor study though
appeared to have possible decending thoracic aortic dissection
so was transferred to ___. He was treated with Nitroprusside
and Esmolol drip for BP control.
Of note the patient reports his baseline back pain is sharp,
stabbing pain in the middle of his back. Pain he is now
experiencing is still localized to mid back though now is a dull
pain ___ on pain scale.
In the ED, initial vitals: 101.8 89 123/68 26 100% on RA. Labs
were remarkable for WBC 12.9. Hct was 36.8 from unknown
baseline. Imaging studies showed MRI without definite epidural
abscess. Vascular surgery was consulted, who reviewed the films
with radiology. They felt that there did not appear to be a
dissection on the CT performed at ___, but given the
suboptimal quality of the scan, the patient's story, his fever,
and his body habitus, that he should be admitted for BP control
and antibiotics. He was continued on Esmolol drip for tight BP
control. Vascular surgery recommended continuing Esmolol drip
with goal BP 90-130s with plan to repeat CTA in the AM. In the
ED he developed a fever to 102 without clear source at this spo
was cultured and MRI spine completed to eval for epidural
abscess.
On transfer, vitals were: 81 126/68 94% Nasal Cannula
On arrival to the MICU, patient is lethargic and minimally
cooperative with exam. Answering questions in short sentences,
keeping eyes closed during exam and uncooperative with neuro
exam. He appers hemodynamically stable with SBP at goal target.
Patient denies difficulty with gait, difficulty with motor
weakness, no loss of bowerl or bladder function
Past Medical History:
- HTN
- Chronic LBP
Social History:
___
Family History:
- No history of dissection or heart disease, doesnt know many
family members
Physical ___:
MICU admission exam
Vitals- Afebrile, 96/48 76 12 94%RA W: >180kg ___ pain, dry
weight 186.6
General- Appears comfortable, no acute distress, speaking
softly, eyes closed and intermittently sleeping during exam.
Minimally cooperative
HEENT- Dry MM
Neck- Large neck, obstructive airway
CV- RRR, S1S2 clear and of good quality, no MRG
Lungs- Anterior exam due to habitus and patient inability to sit
up, CTAB moving air well and symmetrically
Abdomen- Morbidly obese, soft, NT, ND, NABS throughout
GU- No foley
Ext- Bilateral ___, chronic venous stasis changes and woody
edema. Dry flaking skin and tinea pedis. Sensory function intact
with downgoing babinski and normal sensation. Reflexes difficult
to appreciate and are hypoactive. Motor function difficult to
appreciate as patient not cooperative saying his back pain is
too severe. Not ___ off bed. Patient declined rectal
exam
Neuro- AOx3, motor and sensory exam as above
Discharge exam
VS: T98.5 HR89 BP132/58 RR20 98%RA
173lb on ___
General: Alert, oriented, obese male
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: full neck, unable to assess JVP, trachea midline
Lungs: coarse rhonchi throughout anteriorly, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, distant haert sounds secondary to body habitus
Abdomen: soft, obese, tenderness to palpation of entire left
side abdomen, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
Back: staples in place along lower spine with no
erythema/exudate noted, tenderness to palpation along staples
most notable in S1
Ext: Warm, well perfused, 2+ DP and radial pulses, thickened dry
skin at BLE
Neuro: CN II-XII grossly intact
GU: No foley in place
Pertinent Results:
Admission Labs:
___ 07:00PM BLOOD WBC-12.9* RBC-4.45* Hgb-11.8* Hct-36.8*
MCV-83 MCH-26.6* MCHC-32.1 RDW-15.1 Plt ___
___ 07:00PM BLOOD Neuts-80.6* Lymphs-12.1* Monos-5.8
Eos-1.3 Baso-0.2
___ 07:50PM BLOOD ___ PTT-30.6 ___
___ 07:00PM BLOOD Glucose-91 UreaN-15 Creat-1.0 Na-134
K-4.4 Cl-100 HCO3-23 AnGap-15
___ 07:13PM BLOOD Lactate-1.4
Reports:
DVT u/s ___
IMPRESSION:
1. Left popliteal deep vein thrombosis. The left peroneal
veins were not visualized and extension into these vessels
cannot be excluded.
2. Limited evaluation of the right lower extremity, however, no
right deep vein thrombosis was visualized.
CXR ___
The patient was extubated in the meantime interval with removal
of the NG
tube. The right PICC line tip is at the level of mid SVC.
Heart size and mediastinum are stable. There is interval
improvement of bibasilar
consolidations with no evidence of new consolidation to suggest
interval
development of ventilation-acquired pneumonia.
MRI Spine ___
Study limited due to lack of intravenous contrast, but there is
no evidence abscess. There is soft tissue and interspinous
ligamentous STIR
hyperintensity at L3-L4, and L4-L5 levels. There is also fluid
within the
bilateral L4-L5 facet joints. Findings could relate to
degenerate changes and possible ligamentous injury, however
without intravenous contrast difficult to completely exclude an
infectious process. There is no definite fluid collection
identified. There is no evidence of discitis osteomyelitis. To
address the ongoing concern of possible infection, we recommend
a repeat study that includes post contrast T1 weighted imaging
only. There is no need to repeat the T2 or STIR imaging.
Lumbar spondylosis, worst at the L4-L5 level where there is a
severe spinal canal narrowing. Also multilevel lumbar spine
neural foraminal narrowing as described above.
Mild cervical and thoracic spondylosis as described above.
CTA Torso ___
No evidence of aortic dissection, aortic aneurysm, or acute
aortic pathology.
CXR ___
FINDINGS: The heart size is upper limits of normal. There is
mild prominence of interstitial markings without overt pulmonary
edema. No definite consolidation is seen. There are no
pneumothoraces. Bony structures are grossly intact.
Knee XRay ___
FINDINGS: There is a right total knee arthroplasty. There are
no signs for hardware-related complications. No periprosthetic
lucencies or fractures are seen. There is no bony destruction.
There is soft tissue swelling about the knee. Lateral view is
suboptimal for evaluation of joint effusion.
MRI T, L, and S spine ___:
Abnormal enhancement surrounding involving the left L5 lamina,
spinous process and facet joint with extension into the left
aspect of the spinal canal where there are two small epidural
collections. Abnormal enhancement surrounds the lumbar thecal
sac and extends superiorly to the mid thoracic spine. This may
represent infectious or inflammatory myositis with small
paraspinal abscesses and an epidural component.
MRI L spine ___:
Increase in size of the epidural abscess and epidural
enhancement since the previous study. Postoperative changes are
seen but there continues to be a small amount of fluid
collection in the posterior soft tissues at that level with
increased fluid in the f left acet joints at L4-5 level. Other
findings as described above.
___ TEE:
The left atrium is dilated. No atrial septal defect is seen by
2D or color Doppler. Overall left ventricular systolic function
is normal (LVEF>55%). The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 37 cm from the incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve. No aortic
valve abscess is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. No mitral valve abscess is seen.
There is no abscess of the tricuspid valve. No vegetation/mass
is seen on the pulmonic valve.
IMPRESSION: No evidence of endocarditis. Normal left ventricular
systolic function.
Micro:
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
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. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ ___
11:30AM.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
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
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 11:55 am TISSUE INTRASPINAL MASS.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Discharge Labs:
___ 05:32AM BLOOD WBC-9.4 RBC-3.55* Hgb-9.3* Hct-30.3*
MCV-86 MCH-26.1* MCHC-30.6* RDW-18.3* Plt ___
___ 05:32AM BLOOD Neuts-65.1 ___ Monos-4.7 Eos-5.2*
Baso-0.4
___ 05:32AM BLOOD Plt ___
___ 05:32AM BLOOD Glucose-140* UreaN-8 Creat-0.8 Na-139
K-3.6 Cl-101 HCO3-26 AnGap-16
___ 05:32AM BLOOD ALT-21 AST-29 AlkPhos-62 TotBili-0.6
___ 05:32AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.1
___ 05:32AM BLOOD HEPATITIS C VIRAL RNA, GENOTYPE-PND
Brief Hospital Course:
___ morbidly obese male with history of HTN and chronic lower
back pain who presented with acute on chronic hypertension and
admitted to MICU for possible thoracic aortic dissection, found
to have GPC bacteremia and epidural abscesses for which he
underwent L2-S1 laminectomy with hospital course complicated by
difficult intubation/extubation and DVT.
# Epidural abscesses s/p L2-S1 laminectomy: Transferred from OSH
given concern for aortic dissection on imaging. Vascular surgery
reviewed films and did not think there was a dissection,
however, recommended admission to ICU for esmolol drip (SBP goal
of 90-130). A repeat CTA was negative for dissection and the
Esmolol drip was discontinued. As a result, thought to be acute
flare of his chronic pain, unrevealing neuro exam, however, pt
did refuse DRE and a full neuro exam on ICU admission. After
admission, blood cxs returned + for GPCs (eventually speciated
into staph aureus). Given bacteremia, there was concern for
epidural abcess/osteomyelitis. MRI of L/T/C spine without
contrast did not show evidence of diskitis/osteomyelitis or
epidural abscess - however recommended MRI w/contrast. Patient
refused x2 to undergo MRI w/ contrast until pain better
controlled. Patient was transferred to medical floor on ___
after esmolol drip was discontinued in ICU. On ___ due to
continued severe back pain, patient was given narcotics, became
obtunded, requiring non-rebreather. Was transferred back to ICU
on ___ for continued pain management and possible intubation
to undergo MRI w/ contrast and TEE to r/o endocarditis. In the
ICU the patient was intubated and underment an MRI that was
notable for epidural collection in the L2-L4 region and
underwent laminectomy ___ with orthopaedics with drainagle
of purlant materail that was a MSSA collection. He will require
6 weeks of nafcillin with day 1 of treatment the drainage on
___. Stop Date: ___ (min 6 weeks)
- Patient should have staples removed on ___ by physician at
___.
# DVT: Patient states that he had DVT a few months ago treated
at ___ with coumadin. Patient has had prolonged
sedentary course given morbid obesity and complicated hospital
course. He reports he became noncompliant with coumadin when his
uncle passed away. Imaging indicates dvt of left popliteal- and
it is unsure if this is old or new. Patient was started on
heparin drip ___ for treatment of DVT and transitioned to
coumadin 4mg daily. Goal INR ___.
- INR on discharge was 2.9 ___ yesterday)
- daily INR should be collected and medications should be
titrated up/down as indicated to reach goal INR
# Hypertension, controlled on multiple antihypertensives: 24
hour blood pressures within normal limits. At home, patient was
on 100mg atenolol daily, 40mg lasix po BID, lisinopril 40mg
daily, nefidipine Cr90mg daily. Patient has had CTA done during
hospital stay and radiologist has confirmed that there is no
evidence of renal artery stenosis. Patient is currently on
atenolol 100mg po daily, clonidine patch ___, lasix
40mg IV daily, lisinopril 40mg qdaily, nefidipine cr 90mg
qdaily. Systolics were elevated to 200s in the MICU but have
been <180 on the wards. Hydralazine po was added upon transfer
to the wards but discontinued on ___. Dry weight is 186.8
(upon admit) and patient is currently at 173kg. Pain needs to be
controlled to decrease risk of elevated blood pressures.
- continue home dose of 40mg lasix po BID, obtain ___ lytes and
replete as indicated
- oupatient workup for refractory hypertension
- daily weights
# Fever, resolved: T of 101.8 in the ED. Patient afebrile 72
hours prior to discharge. Likely secondary to epidural abscesses
s/p laminectomy. Patient continued to intermittently spike
fevers during his hospitalization. Initial exam was remarkable
for back pain raising possibility of epidural abcess/OM; no
other infectious symptoms. Infectious work-up done in ED
returned with blood cxs + GPC (eventually speciated to staph
aureus). Started on Vancomycin. ID was consulted who recommended
a MRI w/ contrast of spine, TEE and a knee xray (which was
negative - given h/o TKR). Portal of entry for bacteremia was
thought to be IVDU versus skin (given findings of dry skin in
___. TTE done on ___ - did not show any significant
vegetations or significant valvular regurgitation, however exam
was limited due to patient's large body habitus. CXR on ___
did not show any focal consolidation. MRI of L/T/C spine
without contrast did not show evidence of diskitis/osteomyelitis
or epidural abscess - however recommended MRI w/contrast.
Patient refused x2 to undergo procedure until pain better
controlled. TEE showed: No evidence of endocarditis. Normal
left ventricular systolic function. MRI w/ contrast showed
epidural abscess seen which extends from L2-L4 level anterior to
the thecal sac. He underwent laminectomy ___ with
orthopaedics with drainage of purlant materail that was a MSSA
collection. He was transitioned to nafcillin and will require 6
weeks of nafcillin with day 1 of treatment, the drainage on
___. See possible PNA below.
# Klebsiella in the sputum: No evidence of ventilator associated
pneumonia on CXR ___. Patient was started on empiric tx cipro
500BID for 7 day course (started on ___ in MICU but cipro was
discontinued on ___ in order to monitor fever curve. Patient
does not have clinical signs of pneumonia such as new cough but
he did have baseline shortness of breath.
- continue to monitor fever curve and order chest CT for better
eval of lungs if patient fevers again
# Hepatitis C, newly diagnosed: Patient has history of IVDU and
his diagnosis was explained to him prior to discharge but he
showed little insight. Hep B vaccine was administered. Patient
had normal LFTs. Per primary care doctor, right upper quadrant
ultrasound was performed earlier this year and found to be
negative for fibrosis. RUQ u/s was not performed during this
hospital visit given recent normal imaging per PCP. AFP is 1.4.
- Hepatitis C viral load is pending
- Hepatitis C genotyping is pending
- RUQ u/s to assess for liver fibrosis
- Referral to ___ clinic should be done if patient has
elevated Hepatitis C viral burden - see below for contact
information
# Hx of opiate use: Pt denies recent drug use, although has IVDU
(last use ___ ago). Pt reported that he was on methadone,
prescribed by Habit ___ clinic at ___ that
follows pts with opiate abuse - He was started on Methadone 3
months ago at a non chronic back pain dose - 85mg PO QD. Given
bacteremia, there was a concern for current IVDU. It was
confirmed with a friend that the patient last used IV drugs on
the morning of admission. He was difficult to extubate in the
setting of the IVDU as his mental status declined and he was
placed on methadone with improvement in his mental status.
# Pain management s/p laminectomy on methadone. Patient states
he has not used drugs in years. Records indicate that patient
was on 85mg methadone daily administered by ___ clinic.
Must monitor breathing closely since patient has had severe
difficulty with breathing when overdosed on narcotic medications
for pain.
- continued methadone 80mg daily in the hospital
- consider referral to pain clinic outpatient
- continue high dose lidocaine patch to be applied to back and
bengay cream
- continue tramadol and oxycodone PRN- transition to long acting
pain medication based on the amount of use of short-acting
oxycodone
# Hypertension, controlled on multiple antihypertensives: 24
hour blood pressures within normal limits. At home, patient was
on 100mg atenolol daily, 40mg lasix po BID, lisinopril 40mg
daily, nefidipine Cr90mg daily. Patient has had CTA done during
hospital stay and radiologist has confirmed that there is no
evidence of renal artery stenosis. Patient is currently on
atenolol 100mg po daily, clonidine patch ___, lasix
40mg IV daily, lisinopril 40mg qdaily, nefidipine cr 90mg
qdaily. Systolics were elevated to 200s in the MICU but have
been <180 here. Hydralazine po was added upon transfer to the
wards but discontinued on ___. Dry weight is 186.8 (upon
admit) and patient is currently at 173kg. Pain needs to be
controlled to decrease risk of elevated blood pressures.
- continue home dose of 40mg lasix po BID
- daily weights
- outpatient workup for refractory hypertension
# Abdominal pain: patient had persistent abdominal pain during
admission with no evidence of rebound, guarding, or other
concerning symptoms. Likely secondary to gas and symptoms had
improved by discharge
- Patient was discharged on simethicone and maalox
# Shortness of breath: DDX includes Pickwickian syndrome, PE,
OSA. Symptoms improved with head of bed elevated so pickwickian
syndrome is likely contributing given morbid obesity. PE is also
probable given findings of DVT and hx of prior DVT
- patient should remain therapeutic on coumadin INR ___
# Diarrhea, resolved: most likely secondary to antibiotics.
Patient reports symptoms immediately afterwards. C diff
negative.
Transitional Issues:
# Epidural abscesses s/p L2-S1 laminectomy
- Patient should have staples removed on ___ by physician at
___.
- He should call ___t ___-
Patient should call to make an appointment with Dr. ___
___. Patient should call to make an appointment
within the next week for a post-op checkup.
# DVT LLE: Please monitor INR daily for goal ___. Patient was
discharged on coumadin 4g daily. He was started on coumadin
recently on ___. Titrate coumadin up or down as indicated.
# Hip imaging: Bone marrow edema along the right medial
acetabulum extending into the right inferior pubic ramus with
surrounding soft tissue edema. The ddx includes an intraosseous
hemangioma, atypical Paget's disease, or possibly atypical
osteomyelitis. The presence of thickened trabeculae is more
suggestive of a chronic process and an intraosseous hemangioma
is therefore considered most likely. Infection superimposed on
an intraosseous hemangioma rremains a consideration. Clinical
correlation to assess for any localized symptoms and follow-up
imaging of this area to confirm stability is recommended.
(shorter term if sympomatic, otherwise mri or ct in ___ months).
# Hepatitis C: Patient was diagnosed with hepatitis C during
admit. We explained the diagnosis but he does not seem to have
much insight. Please discuss this with him further.
- Hepatitis C viral load and genotype are pending
- He should be referred to ___ clinic at ___ if patient
has a viral load
Contact ___
# Eosinophilia: please repeat cbc and differential tomorrow
- continue to trend daily X 1 week, and if eosinophils continue
to increase, please contact infectious disease clinic at
___ for further work-up. This eosinophilia may be
secondary to nafcillin and patient may need to be reevaluated
for change in antibiotics
# MSSA Bacteremia:
Agent & Dose: Nafcillin 2g q4
Start Date: ___
Stop Date: ___ (min 6 weeks)
- Patient will be followed up outpatient at the infectious
disease clinic- he will be contacted with an appointment
- He should get weekly CBC, chem10 panel, esr, crp. These
results should be faxed to the Infectious Disease clinic at fax
# ___ (phone #: ___
# Hypertension: multiple antihypertensive medications should be
reevaluated on discharge for optimal management of blood
pressures.
# Volume status: Please monitor volume status daily and aim for
goal dry weight of no more than 186.6 (weight at discharge).
Administer more lasix as needed.
- please obtain ___ lytes as needed when diuresing vigorously.
# Pain management: consider referral to pain clinic outpatient
-continue tramadol and oxycodone PRN- transition to long acting
pain medication based on the amount of use of short-acting
oxycodone
- continue methadone 80mg daily and refer to ___ clinic
Habit OPCO, Inc.
___
Phone ___
Fax ___
# OSA:
- maintain patient on autoset CPAP: settings min 4cm H20, max
2cm/H20
# Consider decreasing dose of protonix from 40mg daily to 20mg
daily for GERD
# Disposition: Patient was discharged to:
___ Rehab
# Communication:
Patient's healthcare proxy is ___, uncle
Phone number: ___
___
Patient has a ___ ___
# Code: Full Code (confirmed)
Addendum: ___ Rehab was
called and notified of the new infectious disease and spine
clinic appointments. Discharge summary was faxed both to the
rehab and patient's primary care physician
___
Location: ___
Address: ___
Phone: ___
Fax: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clotrimazole Cream 1 Appl TP BID
2. Atenolol 100 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Ibuprofen 800 mg PO Q6H:PRN Pain
5. Omeprazole 20 mg PO DAILY
6. NIFEdipine CR 90 mg PO DAILY
7. Furosemide 40 mg PO BID
Discharge Medications:
1. Atenolol 100 mg PO DAILY
2. Clotrimazole Cream 1 Appl TP BID
3. Furosemide 40 mg PO BID
4. Lisinopril 40 mg PO DAILY
5. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID
6. Bengay Cream 1 Appl TP QHS posterior back
7. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QSUN
8. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
9. Lidocaine 5% Patch 1 PTCH TD DAILY to posterior back
10. Nafcillin 2 g IV Q4H
11. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
12. Pantoprazole 40 mg PO Q24H
13. Simethicone 40-80 mg PO QID gas
14. Warfarin 4 mg PO DAILY16
15. Methadone 80 mg PO DAILY
16. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
17. Lactic Acid 12% Lotion 1 Appl TP BID
18. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB/Wheeze
19. NIFEdipine CR 90 mg PO QHS
Hold for SPB < 100
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: MSSA bacteremia with epidural abscesses
Secondary diagnosis: DVT LLE, eosinophilia, Hepatitis C
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 to take care of you here at ___. You were
initially transferred here for concern that you had an aortic
dissection. We found that you did not have this on repeat
imaging. We found that you had a bacteria in the blood which we
treated with antibiotics. You will continue these antibiotics
and be seen again by infectious disease clinic. You were found
to have fluid collections in your spine due to bacteria in the
blood- the spine surgeons did surgery to remove these pockets of
fluid. You will have the staples removed at the ___ this week.
We also found that you had another clot in your left leg. You
have had a history of this in the past. We started you on a
blood thinner that you should continue to take. Other testing
showed that you have a virus called Hepatitis C which can affect
the liver. We are waiting on more testing to determine what next
steps we can take. Your primary care doctor ___ discuss this
more with you. You should continue to work with physical therapy
and build up your strength. We were very impressed with the
amount of progress you made while you were here. It was a
pleasure to take care of you and we wish you all the best and a
speedy recovery.
Followup Instructions:
___
|
19891253-DS-17 | 19,891,253 | 26,307,811 | DS | 17 | 2199-10-17 00:00:00 | 2199-10-17 18:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Dilaudid / Hayfever / Tramadol / Nsaids /
Gadolinium-Containing Agents
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mrs ___ is a pleasant ___ woman with history of
breast CA, neurogenic bladder, graves disease, multiple
sclerosis, recently tx'd with IV steroids for flare last week
(last dose 3 d PTA), now presenting with N/V/D x3d. MS flare
___ weakness improved with steroids. Her ___ initially
started with nausea, then progressed to non-bilious, non-bloody
emesis, diarrhea and band-like, predominately RUQ/LUQ
crescendo/decrecendo band-like abd pain the following day. Does
not radiate to the back. She has had difficulty taking PO and
has had approx 5 loose, non-bloody almost gelatinous BMs in the
last 48 hrs, last one this AM. Denies BRBPR or melanotic
stools. She has had subjective fevers but has not taken her
temp recently. Denies sick contacts. Denies EtOH use, hx
gallstones. She has chronic urinary incontinence and straight
caths. In the past she has noted frequency with UTIs; on this
occassion she denies frequency, endorses mild suprapubic
tenderness.
.
In the ED, initial vitals 98.2 78 ___ 100%. Labs notable
for UA with + leuks/blood/nitrites/WBC/bacteria, nl WBC,
elevated ALT/AST/Lipase. Blood and urine cxs sent. The pt
underwent a CTA which showed recontructed, markedely distended
bladder, known nephrogenic metasplasia, limited evaluation due
to streak artifact from hardare, no acute intraabdominal
process. She received Zofran x2, Reglan, GI Cocktail, Fluids
and Cipro for UTI. Given lack of improvement she was admitted
for further management. Vitals prior to transfer: 97.8 69
106/55 16 100%
.
Currently, pt states her symptoms have improved. Abd pain is
minimal.
.
ROS: 10 point review of systems negative except as noted in HPI.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
--MS, secondary progressive
--Breast cancer, s/p bilat mastectomies and reconstruction
--Graves disease
--Osteoporosis
--Cervical spondylosis
--Nephrogenic metaplasia of bladder
--Neurogenic bladder
--Bladder augmentation
--Scoliosis, surgically corrected
Social History:
___
Family History:
Heart disease, kidney disease, neurological disease, skin
disease, and blood disorder. Father: blood disorder and cardiac
bypass. Mother: renal tumor
Physical Exam:
VS - 98.4 106/56 62 18 100% RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, ___, EOMI, sclerae anicteric, MM dry
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, diffusely TTP, worse in upper quadrants, no
masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII intact, ___ strenth with hip
flexion bilaterally, otherwise ___
PSYCH: pleasant, appropriate
BACK: midline surgical scar
.
Discharge Physical exam
Afebrile, 99/51 HR 65, RR 18 100% RA
Pain ___, in luq.
General: still seems anxious, on the verge of tears. Eating
breakfast, with plate of eggs and toast in front of her.
HEENT: OP moist.
remainder of exam deferred.
Pertinent Results:
___ 03:40PM BLOOD WBC-5.6 RBC-3.69* Hgb-13.4 Hct-40.1
MCV-109* MCH-36.2* MCHC-33.3 RDW-16.5* Plt ___
___ 03:40PM BLOOD Neuts-67.1 ___ Monos-5.3 Eos-1.7
Baso-0.5
___ 03:40PM BLOOD Glucose-102* UreaN-18 Creat-0.6 Na-140
K-3.8 Cl-102 HCO3-28 AnGap-14
___ 03:40PM BLOOD Glucose-102* UreaN-18 Creat-0.6 Na-140
K-3.8 Cl-102 HCO3-28 AnGap-14
___ 03:40PM BLOOD ALT-125* AST-97* AlkPhos-59 TotBili-0.8
___ 03:40PM BLOOD Lipase-182*
___ 03:40PM BLOOD Calcium-9.1 Phos-3.9 Mg-2.1
___ 03:55PM BLOOD Lactate-0.8
Hepatitis serologies negative.
CT ___:
1. Markedly distended bladder. Patient is status post bladder
augmentation. In this patient with history of nephrogenic
metaplasia, continued f/u recommendations per Urology.
2. Limited evaluation of intra-abdominal organs due to
extensive streak
artifact generated by metallic hardware. Within this
limitation, no evidence of acute intra-abdominal process.
3. Focal hepatic hypodensities, too small to characterize,
likely cysts or hamartomas.
RUQ US ___:
1. Cholelithiasis without sonographic evidence of
cholecystitis. No biliary dilation.
2. Otherwise, unremarkable abdominal ultrasound.
EGD ___
Normal esophagus and stomach.
.
MRCP ___:
Relevant data:
1. Pancreas appears within normal limits without ductal
abnormalities or complications from prior or acute pancreatitis.
2. Mild hepatic steatosis.
3. Cholelithiasis.
Micro:
Urine culture ___ pan sensitive E coli
Blood cultures ___ negative
Brief Hospital Course:
This is a ___ woman with a history of MS admitted for
N/V/D/abd pain and elevated lipase concerning for pancreatitis,
most likely due to azathioprine use.
# N/V/ABDOMINAL PAIN: This was initially attributed to
pancreatitis, possibly in setting of azathioprine. However, CT
was difficult to interpret and ultrasound without evidence of
obstruction, and she had no history of alcohol use in excess.
Azathioprine was stopped and patient was made NPO and given IVF,
anti-emetics and analgesics. She did not improve rapidly
however. She was seen by GI and underwent endoscopy and MRCP.
These also did not show evidence of an anatomic cause of her
abdominal pain. Ultimately it was thought that there is likely
a functional component, and she was started on hyocsyamine and
buspar as anti-spasmodic agents. She did improve with these
medications to some extent, but continued to have ___ pain at
discharge. She was discharged on a one month supply of both
dicylclomine
(insurance would not cover the hyoscyamine). She was also
discharged with zofran and a higher dose of ativan, as these
were helping with both nausea and anxiety.
Of note, she opted to defer any further testing of the cause of
her pain pending evaluation by her outpatient providers.
At the time of discharge, she was tolerating more food, and
drink and overall seemed improved.
# RELAPSING REMITTING MS: Patient s/p recent flare. Her
azathioprine was stopped due to concern that this medication was
contributing to pancreatitis, and then due to the fact that it
was not affecting her progression of disease. Ms. ___
refused to take Ampyra due to side effects. Patient will
follow-up with neurology as an outpatient.
# ELEVATED LFTS: Chronic and stable. Likely from
azathioprine. Hepatitis serologies were negative.
# UTI: Patient was treated with cipro for 7 days for a
complicated E coli UTI.
Chronic issues
# CHRONIC BACK PAIN: Patient was given ativan and tylenol PRN.
# ANXIETY: Lorazepam was continued. Anxiety did appear to
increase throughout her hospitalization. She was seen by social
work.
# GRAVES DISEASE: Methimazole and levothyroxine were continued
- although she frequently refused.
# DRY EYES: Restasis was held as non-formulary and patient not
using regularly
# OSTEOPOROSIS: Calcium and vitamin D were continued
Transitional issues
- she may require further work up of abdominal symptoms. She
will see her primary doctor next week to discuss with him.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Azathioprine 50 mg PO QAM
2. Azathioprine 100 mg PO QPM
3. cycloSPORINE *NF* 0.05 % ___ unknown
4. Ampyra *NF* (dalfampridine) 10 mg Oral daily
5. Diazepam 10 mg PO Q8H:PRN back spasms
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Lorazepam 1 mg PO BID:PRN anxiety
8. Methimazole 10 mg PO DAILY
9. Acetaminophen 325 mg PO BID:PRN pain
10. Calcium Carbonate 600 mg PO BID
11. Vitamin D 1000 UNIT PO BID
12. bifidobacterium infantis *NF* 4 mg Oral daily
13. Ranitidine 150 mg PO BID
Discharge Medications:
1. Acetaminophen 325 mg PO BID:PRN pain
2. Calcium Carbonate 600 mg PO BID
3. Levothyroxine Sodium 75 mcg PO DAILY
Daily except for ___ take half tablet on ___
4. Lorazepam 1 mg PO TID:PRN anxiety or nausea
RX *lorazepam [Ativan] 1 mg 1 mg by mouth three times daily Disp
#*20 Tablet Refills:*0
5. Methimazole 10 mg PO DAILY
6. Ranitidine 150 mg PO BID
7. Vitamin D 1000 UNIT PO BID
8. BusPIRone 10 mg PO TID
RX *buspirone 10 mg 1 tablet(s) by mouth three times daily Disp
#*90 Tablet Refills:*0
9. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*15 Tablet Refills:*0
10. Ampyra *NF* (dalfampridine) 10 mg Oral daily
You should discuss this with Dr. ___ you would like to stop
taking it.
11. bifidobacterium infantis *NF* 4 mg Oral daily
12. cycloSPORINE *NF* 0.05 % ___ unknown
13. Diazepam 10 mg PO Q8H:PRN back spasms
14. DiCYCLOmine 10 mg PO QID
Monitor for excess sedation
RX *dicyclomine 10 mg 1 capsule(s) by mouth four times daily
Disp #*120 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Abdominal pain
2. UTI
3. Secondary progressive multiple sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you on this admission. You
came to the hospital because you were having abdominal pain.
Your presentation and labs was possibly consistent with
pancreatitis, but your imaging did not show any evidence of
pancreatitis. We performed endoscopy and MRCP, all of which did
not reveal the cause of the pain. The GI doctors and ___ think
this is probably a functional, not anatomic pain, and should get
better over time with antispasm agents. You were also found to
have a UTI.
We started you on Bentyl (dicyclomine) and buspirone to take for
a one month period. You can discuss further treatment with Dr.
___ Dr. ___ you have symptoms beyond the month.
Of note, your insurance would not cover the hyoscyamine that you
were treated with here in the hospital.
Followup Instructions:
___
|
19891253-DS-18 | 19,891,253 | 25,786,771 | DS | 18 | 2199-11-29 00:00:00 | 2199-11-29 15:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Codeine / Dilaudid / Hayfever / Tramadol / Nsaids /
Gadolinium-Containing Agents
Attending: ___.
Chief Complaint:
right hip pain
Major Surgical or Invasive Procedure:
Right hip hemiarthroplasty
History of Present Illness:
___ h/o MS who was crossing ___. today in wheelchair over
tracks when she fell out landing on her R hip. She had immediate
pain and inability to weightbear. She presented to ___ ED
where XR revealed R femoral neck fx. Closed isolated injury.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
--MS, secondary progressive
--Breast cancer, s/p bilat mastectomies and reconstruction
--Graves disease
--Osteoporosis
--Cervical spondylosis
--Nephrogenic metaplasia of bladder
--Neurogenic bladder
--Bladder augmentation
--Scoliosis, surgically corrected
Social History:
___
Family History:
Heart disease, kidney disease, neurological disease, skin
disease, and blood disorder. Father: blood disorder and cardiac
bypass. Mother: renal tumor
Physical Exam:
98.4 70 124/73 18 99% RA
general: uncomfortable, in pain, asking to be left alone
RLE: externally rotated, positioned with knee flexed over pillow
___ +
SILT SPN/DPN/S/S/TN
TP/DP 1+
Pertinent Results:
___ 06:02AM BLOOD WBC-9.2 RBC-2.77* Hgb-9.5* Hct-28.1*
MCV-102* MCH-34.3* MCHC-33.8 RDW-13.8 Plt ___
___ 06:02AM BLOOD ___ PTT-30.1 ___
___ 06:02AM BLOOD Glucose-102* UreaN-6 Creat-0.5 Na-137
K-3.8 Cl-103 HCO3-28 AnGap-10
___ 06:02AM BLOOD Calcium-7.9* Phos-2.5* Mg-2.1
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 femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right hip hemiarthroplasty, which
the patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative Ancef for antibiotics and
Lovenox anticoagulation per routine. The patients 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 was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is WBAT in the right lower extremity,
and will be discharged on Lovenox 40 mg SC for 2 weeks for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Restasis *NF* (cycloSPORINE) 0.05 % ___ BID
2. Ampyra *NF* (dalfampridine) 10 mg Oral q12h
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Diazepam 10 mg PO DAILY:PRN spasms
5. Lorazepam 1 mg PO Q8H:PRN anxiety
6. Calcium Carbonate 1500 mg PO BID
7. Methimazole 10 mg PO QHS
8. Vitamin D 1000 UNIT PO BID
9. Align *NF* (bifidobacterium infantis) 4 mg Oral QD
Discharge Medications:
1. Diazepam 10 mg PO DAILY:PRN spasms
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Lorazepam 1 mg PO Q8H:PRN anxiety
4. Restasis *NF* (cycloSPORINE) 0.05 % ___ daily
5. Calcium Carbonate 1500 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Enoxaparin Sodium 40 mg SC DAILY Duration: 14 Days
RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*14
Syringe Refills:*0
8. Methimazole 10 mg PO QHS
9. Senna 1 TAB PO BID
10. Multivitamins 1 TAB PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Ampyra *NF* (dalfampridine) 10 mg Oral q12h
13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
14. Acetaminophen 650 mg PO Q6H:PRN pain
15. Align *NF* (bifidobacterium infantis) 4 mg Oral QD
Discharge Disposition:
Extended Care
Facility:
___
___ and ___-Acute ___)
Discharge Diagnosis:
Right displaced femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
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:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated
Physical Therapy:
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated
Treatments Frequency:
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
Followup Instructions:
___
|
19891464-DS-10 | 19,891,464 | 26,947,998 | DS | 10 | 2121-10-06 00:00:00 | 2121-10-06 20:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ repair of incarcerated recurrent left inguinal hernia
History of Present Illness:
___ man who presents with a freely movable 3cm by
3cm painful mass in his left inguinal region. The patient first
noticed this mass approximately 16 hours prior to presentation
and 35 to 45 minutes after having a bowel movement. This bowel
movement was of normal caliber and the patient did not report
any
evidence of bleeding nor did he recall any irregularities in his
diet prior to this event. In the past when this has occured he
was able to reduce the bulge himself, but today was unable to do
so. He reports ___ pain particularly when trying to push it
back
in. He denies other symptoms including epigastric pain nausea,
vomiting, shortness of breath or palpitations. He has not
passed
gas since noticing the mass nor has had another bowel movement
Past Medical History:
PMH: shoulder dislocation, anxiety/depression
PSH: bilateral inguinal hernia repairs (mesh on right and
without mesh on left), rotator cuff repair, vasectomy, finger
operation, cateract surgery.
Social History:
___
Family History:
Family History: CAD, bladder cancer
Physical Exam:
On discharge:
NAD
RRR
CTAB
abd soft, NT, ND
ext warm and well perfused
Pertinent Results:
___ 09:20AM BLOOD WBC-9.9 RBC-5.40 Hgb-16.1 Hct-49.4 MCV-92
MCH-29.8 MCHC-32.6 RDW-13.1 Plt ___
___ 09:20AM BLOOD Neuts-65.2 ___ Monos-5.2 Eos-1.8
Baso-1.0
___ 09:20AM BLOOD Glucose-98 UreaN-13 Creat-1.0 Na-141
K-4.1 Cl-105 HCO___ AnGap-14
___ 09:30AM BLOOD Lactate-1.3
___ CT abd
1. Left inguinal hernia contains a small segment of the sigmoid
colon. There is surrounding fat stranding. The bowel wall
enchancement is maintained. There is no fluid within the hernia
sac.
2. Focal hepatic hypodensity, too small to characterize, likely
a cyst or hematoma.
Brief Hospital Course:
Patient presented with incarcerated left inguinal hernia with CT
scan showing a contained small segement of bowel. He was taken
to the operating room and had repair of the hernia. the surgery
went well and he was admitted to the PACU in stable condition.
He was slowly advanced in diet and at the time of discharge he
was tolerating a regular diet, voiding, and had adequate pain
control.
Medications on Admission:
sertraline 25'
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain for 5 days.
Disp:*40 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
for 6 days.
Disp:*60 Tablet(s)* Refills:*0*
4. sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
incarcerated left ingunal hernia
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 your recurrent inguinal hernia that was causing
you pain. The surgery went well and you were brought to the
floor in good condition.
As discussed with you this morning you can take down the
external dressing tomorrow, ___, but should leave the steri
strips on, as instructed below.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications. You will be given stool softeners to help keep your
bowel movements regular as narcotic pain medication can make you
constipated.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
19891610-DS-22 | 19,891,610 | 27,974,538 | DS | 22 | 2160-04-13 00:00:00 | 2160-04-13 17:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L facial droop, dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is ___ speaking ___ yo M with recent
diagnosis of Large B cell lymphoma of the proximal right humerus
s/p mini CHOP complicated by RUE DVT currently being treated
with
Lovenox. Patient presents to emergency room today after episode
at home today of feeling like he had a L facial droop, dizziness
and unsteady gait. Visiting nurse called EMS and patient was
brought to the ED. Upon arrival patient was noted to be febrile
and infectious workup was started. Upon examination patient
states he is feeling quite well and all of his previous symptoms
have resolved. He denies any recent head trauma or falls. He
denies headache, double vision, blurry vision, numbness,
weakness
or tingling.
Past Medical History:
--Lymphoma that was treated back ___ years ago in ___
involving the neck with chemo and XRT
--Bladder cancer treated in ___ denies a history of prostate
cancer, although that is in his chart. He follows with a private
oncologist in ___ for this every 6 months and was evaluated
on ___ and found to be in remission.
--He has multiple skin cancers, which predominantly seems to be
squamous cell carcinoma. He did, however, have a melanoma in
situ in ___ and then a superficial spreading melanoma, ___
level IV in ___ and an atypical melanocytic lesion ___.
He also had one basal cell carcinoma in his right calf in ___
and all of this is summarized in Dr. ___ note from
___.
--Asthma
--COPD
--Hypertension
--Hyperlipidemia
Social History:
___
Family History:
Heart disease in his mother.
Physical Exam:
Admission ___:
PHYSICAL EXAM: Performed with ___ Interpreter
O: T:99.1 BP: 146/70 HR:64 R 18 O2Sats 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4-3mm, EOMs intact
Neck: Supple.
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.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Left nasolabial flattening. Facial strength and
sensation
intact and symmetric.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Baseline RUE weakness- Right Delt ___, R Tri/Bi ___ R
Grip ___. Otherwise full strength. Unable to assess pronator
drift secondary to baseline RUE weakness.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally
Exam upon discharge ___:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2-3mm, EOMs intact
Neck: Supple.
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.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Mild left nasolabial flattening. Facial strength and
sensation
intact and symmetric.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Baseline RUE weakness- Right Delt ___, R Tri/Bi ___ R
Grip ___. Otherwise full strength.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally
Pertinent Results:
___ CT Head w/o contrast
FINDINGS:
Bilateral acute on chronic subdural hematoma, right greater than
left, which
extension along the frontoparietal convexity bilaterally. These
measure 1.3
cm (02:17) on the right and 0.6 cm (02:16) on the left in
maximal width.
There is 3 mm leftwards shift of normally midline structures.
Mild effacement
of the right sided sulci in comparison to the left is noted. No
intraparenchymal hemorrhage. No subarachnoid hemorrhage. There
is no
evidence of infarction, edema or mass. Prominence of the
ventricles and sulci
are consistent with age-related cortical volume loss.
Periventricular,
subcortical and deep white matter hypodensities are likely
sequelae of chronic
small vessel ischemic disease.
No osseous abnormalities seen. The paranasal sinuses, mastoid
air cells, and
middle ear cavities are clear. Calcification of bilateral
cavernous portions
of internal carotid arteries are noted. Soft tissue density
within bilateral
external auditory canals is most consistent with cerumen.
IMPRESSION:
1. Bilateral acute on chronic subdural hematomas, right greater
than left,
with 3 mm leftwards shift of normally midline structures and
mild effacement
of the sulci, right greater than left.
2. No intraparenchymal hemorrhage.
3. Chronic changes as described above.
___ CT Head w/o contrast
FINDINGS:
Again seen are bilateral acute on chronic subdural hemorrhage,
right greater
than left, not significantly changed from prior study from a
day ago. 3 mm
leftward shift of midline structures is stable. No new
hemorrhage or
infarction are seen. The ventricles and sulci are unchanged in
size and
configuration.
No osseous abnormalities seen. Limited evaluation of the
paranasal sinuses,
mastoid air cells, and middle ear cavities appear clear. The
orbits are
unremarkable.
IMPRESSION:
Stable acute on chronic bilateral subdural hemorrhage. No new
hemorrhage or infarction.
Brief Hospital Course:
___ M with hx of lymphoma, with RUE DVT on LVX who originally
presented with a left facial droop and dizziness found to have
bilateral acute on chronic subdural
hematomas on CT admitted to Neurosurgery for further management
and care. Was admitted to floor and begun on keppra for seizure
prophylaxis. Also underwent fever workup as was febrile upon
admission from which he spontaenously defervesced.
___ Admit from ED. UA and chest xray negative
___: Brady with pauses overnight to ___. In nsr this AM with HR
in ___. Seen by cardiology with no further workup
recommendations to date. Repeat Head Ct stable. Medicine
declined for possible ___ pathway as no acute issues.
___: Exam stable. Ambulated with nursing without difficulty.
At the time of discharge the patient's pain was well controlled
with oral medications, and the patient was voiding
spontaneously. The patient's lovenox has been discontinued until
further follow-up. The patient will follow up with Dr.
___ routine in 4 weeks with a NCHCT. He was also
encouraged to follow up with his PCP and oncologist. A
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. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. ammonium lactate 12 % topical apply to dry skin BID PRN dry
skin
4. Atorvastatin 10 mg PO QPM
5. ClonazePAM 0.5 mg PO DAILY
6. Voltaren (diclofenac sodium) 1 % topical use as directed
daily
7. Doxazosin 4 mg PO DAILY
8. Avodart (dutasteride) 0.5 mg oral DAILY
9. Enoxaparin Sodium 60 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
10. Lisinopril 10 mg PO DAILY
11. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
12. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
13. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*50 Tablet Refills:*0
3. Allopurinol ___ mg PO DAILY
4. ammonium lactate 12 % topical apply to dry skin BID PRN dry
skin
5. Atorvastatin 10 mg PO QPM
6. Avodart (dutasteride) 0.5 mg oral DAILY
7. ClonazePAM 0.5 mg PO DAILY
8. Doxazosin 4 mg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
11. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
12. Voltaren (diclofenac sodium) 1 % topical use as directed
daily
13. LeVETiracetam 500 mg PO BID Duration: 40 Days
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*80 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral subdural hematomas
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Diagnosis: Subdural hematoma (Bleeding inside your skull)
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 (LOVENOX,
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 have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
Followup Instructions:
___
|
19891610-DS-24 | 19,891,610 | 24,903,155 | DS | 24 | 2161-03-21 00:00:00 | 2161-03-22 03:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left Arm Swelling
Major Surgical or Invasive Procedure:
None this hospitalization.
History of Present Illness:
This is an ___ year old gentleman with a significant past medical
history of atrial fibrillation on rivaroxaban, TEE/DCCV followed
by AF with heart block and junctional escape s/p dual chamber
PPM ___, and hypertension who presents with left arm
swelling.
He states as per the translator that he noticed his arm swelling
1 week after the implant and thought that is would improve. He
reports that this has been progressing over the last few months.
He said he saw his doctor approximately 1 month ago and they
made a plan to watch to see if it resolved. He presents to the
ED, because it has not improved. However, it has gotten worse
with redness. He states he does not have CP, SOB, palpitations,
fever, or chills.
In the ED, initial vital signs were: 4 98.6 120 96/65 16 97% RA.
Exam was notable for LUE with massive pitting edema and erythema
from biceps/triceps down. Cut on dorsum of left hand without
obvious drainage, purulence, worse erythema in the area.
Difficulty elevating and abducting, but no shoulder pain.
difficulty fully flexing and extending elbow, but again
painless. Full strength. Labs were notable for: normal CBC and
Chem 10 with slightly elevated sodium. CTV and LUE were normal.
Cardiology evaluated the patient and thought that DVT or
obstruction were possible, however they were ruled out by the
CTV. They thought the patient seemed to have evidence of severe
cellulitis of the left arm. The patient was admitted to medicine
after receiving IV vancomycin for mngt of cellulitis.
Upon arrival to the floor, patient's vital signs were 97.7
123/85 110 18 99RA. The patient was not in acute distress. He
had no complaints. A nurse was available to help translate. The
patient's only wish was to go home as soon as possible. We
explained the need to have IV abx and to stay the night in the
hospital.
Past Medical History:
- DLBCL of the right proximal humerus complicated by pathologic
fracture s/p R-mini-CHOP and consolidative ISRT to the RUE in
___VT s/p completion of Lovenox
- Atrial Flutter s/p TEE/DCCV on ___ on rivaroxiban
- Lymphoma that was treated back ___ years ago in ___
involving the neck with chemo and XRT
- Symptomatic Bradycardia s/p ___ Adapta Dual Chamber PPM
on ___
- Systolic Congestive Heart Failure (LVEF ___ in ___
- Hypertension
- Hyperlipidemia
- BPH
- COPD/Asthma
- Chronic Kidney Disease
- Right Shoulder Supraspinatous Tear
- Squamous Cell Carcinoma
- Bladder Cancer s/p surgery in ___
- Melanoma
- Osteoarthritis
- Subdural Hematoma
- Cataract
Social History:
___
Family History:
Mother with heart disease and MI. Father with hip fracture.
Brother with lung cancer.
Physical Exam:
========================
Admission Physical Exam:
========================
VITALS: 98.6 120 96/65 16 97% RA.
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT: ormocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, 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-tender, non-distended,
no organomegaly.
EXTREMITIES: Consistent with ED evaluation: LUE with massive
pitting edema and erythema from biceps/triceps down. Cut on
dorsum of left hand without obvious drainage, purulence, worse
erythema in the area. Difficulty elevating and abducting, but no
shoulder pain. difficulty fully flexing and extending elbow, but
again painless. Full strength.
RIGHT UPPER EXTREMITY: there is a single legion on the forearm
with surround erythema
LOWER EXTREMITIES: non-blanching maculo-papular rash
bilaterally; ___ pitting edema bilaterally
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
========================
Discharge Physical Exam:
========================
PHYSICAL EXAM:
Vitals: Temp 97.8, BP 108/73, HR 118, RR 18, O2 sat 97% RA.
Weight (kg): 66.6 <- 66.7 <- 65.7 <- 67.1 <- 65.6 <- 66.1 kg
<-65.9 <- 67.3 <- 69.7
I/Os: Not Recorded.
General: Pleasant, elderly, in no apparent distress.
HEENT: Normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
Neck: Supple, no LAD, no thyromegaly, JVP flat.
Cardiac: Tachycardic, regular rhythm, normal S1/S2, no murmurs
rubs or gallops.
Pulmonary: Decreased breath sounds at the bilateral bases.
Abdomen: Soft, non-tender, non-distended, no organomegaly,
normoactive bowel sounds.
Upper Extremities: LUE with 1+ pitting edema and erythema from
biceps/triceps down, improved since admission. Cut on dorsum of
left hand without obvious drainage, purulence, worse erythema in
the area. RUE with is a single legion on the forearm with mild
erythema, improved since admission.
Lower Extremities: Non-blanching maculo-papular rash, 1+ pitting
pedal edema bilaterally improved from admission.
Neurologic: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
===============
Admission Labs:
===============
___ 01:14PM BLOOD WBC-8.5 RBC-4.18* Hgb-12.2* Hct-40.4
MCV-97 MCH-29.2 MCHC-30.2* RDW-16.8* RDWSD-60.0* Plt ___
___ 01:14PM BLOOD Neuts-81.9* Lymphs-9.1* Monos-7.6
Eos-0.5* Baso-0.4 Im ___ AbsNeut-7.00* AbsLymp-0.78*
AbsMono-0.65 AbsEos-0.04 AbsBaso-0.03
___ 06:30AM BLOOD ___ PTT-32.7 ___
___ 01:14PM BLOOD Glucose-95 UreaN-39* Creat-1.2 Na-146*
K-4.1 Cl-108 HCO3-31 AnGap-11
___ 01:14PM BLOOD ___
___ 01:14PM BLOOD Albumin-3.4* Calcium-9.3 Phos-3.2 Mg-1.9
___ 02:21PM BLOOD Lactate-2.6*
==============
Interval Labs:
==============
___ 12:08AM BLOOD CK-MB-5 cTropnT-<0.01
___ 06:40AM BLOOD Glucose-99 UreaN-52* Creat-2.0* Na-136
K-4.9 Cl-97 HCO3-28 AnGap-16
___ 06:15AM BLOOD WBC-9.0 RBC-4.34* Hgb-12.4* Hct-40.2
MCV-93 MCH-28.6 MCHC-30.8* RDW-16.1* RDWSD-54.4* Plt ___
===============
Discharge Labs:
===============
___ 11:51AM BLOOD WBC-9.3 RBC-4.60 Hgb-13.2* Hct-43.3
MCV-94 MCH-28.7 MCHC-30.5* RDW-16.4* RDWSD-54.8* Plt ___
___ 11:51AM BLOOD Glucose-106* UreaN-42* Creat-1.6* Na-140
K-4.8 Cl-100 HCO3-35* AnGap-10
==============
Urine Studies:
==============
___ 05:49AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 05:49AM URINE RBC-20* WBC-6* Bacteri-NONE Yeast-NONE
Epi-0
___ 05:49AM URINE Hours-RANDOM UreaN-1262 Creat-118 Na-71
K-59 Cl-85 TotProt-23 Prot/Cr-0.2
___ 05:49AM URINE Osmolal-840
=============
Microbiology:
=============
___ Blood Culture x 2 - No Growth
___ Blood Culture - No Growth
___ Right Forearm Abscess - MRSA
========
Imaging:
========
CTV Chest ___
1. Patent central veins in the chest, without evidence of
central venous thrombosis.
2. Moderate to large bilateral pleural effusions.
3. Sub cm bilateral thyroid nodules which require no further
evaluation.
4. Anasarca and moderate ascites.
LUE US ___
Impresion: Significant subcutaneous edema without the presence
of DVT.
TTE ___
Impression: Normal left ventricular cavity size with severe
global systolic dysfunction c/w diffuse process (toxin,
metabolic, multivessel CAD, etc.). Moderate mitral
regurgitation. Moderate-severe tricuspid regurgitation. Mild
aortic regurgitation. Pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Brief Hospital Course:
Mr. ___ is an ___ gentleman with a
history of atrial fibrillation/flutter s/p TEE/DCCV
cardioversion c/b heart block/ bradycardia requiring dual
chamber PPM on rivaroxaban, systolic congestive heart failure
(EF ___ in ___, hypertension, and DLBCL s/p R-mini-CHOP
and consolidative ISRT complicated by RUE DVT s/p Lovenox course
who presents with left arm swelling and redness.
# Left UE Swelling/Cellulitis: Given the negative US and CTV,
clot and stenosis are ruled out for the patient. One possibility
would be lymphedema although he has no clear reason to develop
swelling. Per Radiology, no study to evaluate for lymphedema. He
was treated for cellulitis with a 7-day course of antibiotics.
He was given Lasix for diuresis and his swelling improved with
wrapping and elevation.
# Multiple Falls: Patient with several falls while in the
hospital. No head strike. Likely related to deconditioning and
elderly age with medical comorobidities. Orthostatics negative.
___ was consulted who recommended rehab but his family refused
for him to go to rehab. He was discharged home with maximum
services.
# Acute on Chronic Systolic Congestive Heart Failure: Last TTE
with LVEF ___ in ___. On exam he has bilateral lower
extremity pitting edema as well as his right upper extremity. No
edema of the left upper extremity. On imaging he has significant
bilateral pleural effusions. Albumin and urinalysis
unremarkable. Patient is not compliant with urine monitoring so
difficult to track I/Os. Repeat TTE shows LVEF 20% with global
systolic dysfunction, similar to previous study. He was
diuressed but suffered ___ so Lasix was held. Currently satting
well on RA and denies respiratory complaints.
# Acute on Chronic Kidney Disease: Baseline Cr 1.2-1.3 with bump
to 2.0. Likely secondary to diuresis. His creatinine improved
with holding diuresis and his Cr at discharge was 1.6. His
lisinopril was held at time of discharge.
# Atrial Fibrillation/Flutter: Per cards/EP consult, he has
paroxysmal AF, sinus node dysfunction, and episode of AF with
heart bock and junctional escape during his prolonged admission
almost 2 months ago during which he had a dual chamber PPM
implanted. He currently appears to be in afib/aflutter. His
pacemaker was interrogated by EP who noted normal pacer function
with acceptable lead measurements and battery status.
Programming changes switched mode to DDIR 60, upper sensor
rate 110, paced AV delay 150 ms, PVARP 300. His rivaroxban was
held due to ___ but restarted at time of discharge given
improvement in renal function. His metoprolol dose was
uptitrated however his heart rate continue to be in the 100s
(improved from 120-130s on admission).
# Hypertension: Held home lisinopril due to ___ and ___ blood
pressures.
# Hyperlipidema: Continued home atorvastatin.
====================
Transitional Issues:
====================
- Please ensure follow-up with PCP, ___, and Cardiology.
- Lisinopril was held at time of discharge due to ___ and ___
blood pressures. Please check renal function at next visit and
restart as tolerated. Cr at discharge was 1.6 with baseline
1.0-1.2.
- Please continue to monitor left upper extremity swelling.
Would encourage compression for symptomatic improvement.
- Metoprolol dose was uptitrated to 200mg daily with improvement
in heart rate to 100s (from 120-130s on admission). Please
continue to monitor heart rate and adjust medications as needed.
Please ensure follow-up with Eletrophysiology.
- Please note patient had several falls and Physical Therapy
recommended discharge to rehab. After discussion with family,
they did not want him to go to rehab. Patient was discharged
home with maximum services. Please follow-up for falls and avoid
sedating medications.
- Weight on Discharge = 66.6 kg
- Contact: ___ (wife/HCP) ___
- Code Status: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. ClonazePAM 0.5 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Avodart (dutasteride) 0.5 mg oral DAILY
5. Doxazosin 4 mg PO HS
6. Metoprolol Succinate XL 37.5 mg PO DAILY
7. Rivaroxaban 15 mg PO DINNER
8. ammonium lactate ___ % topical BID:PRN dry skin
9. Voltaren (diclofenac sodium) 1 % topical DAILY:PRN pain
10. Acetaminophen 325-650 mg PO Q6H:PRN pain
11. Vitamin D 1000 UNIT PO DAILY
12. Artificial Tears 1 DROP BOTH EYES DAILY
13. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Atorvastatin 10 mg PO QPM
3. Docusate Sodium 100 mg PO BID
4. ammonium lactate ___ % topical BID:PRN dry skin
5. Artificial Tears 1 DROP BOTH EYES DAILY
6. Avodart (dutasteride) 0.5 mg oral DAILY
7. Doxazosin 4 mg PO HS
8. Rivaroxaban 15 mg PO DINNER
9. Vitamin D 1000 UNIT PO DAILY
10. Voltaren (diclofenac sodium) 1 % topical DAILY:PRN pain
11. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate 200 mg Take 1 tablet by mouth daily.
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Left Arm Swelling
- Cellulitis
- Atrial Flutter/Fibrillation
Secondary Diagnosis:
- Hypertension
- Hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital due
to left arm swelling. You had an ultrasound and a CT scan which
found no blood clots to explain your arm swelling. The swelling
may be related to lymphedema.
You were given Lasix to try to remove fluid. Your kidney levels
got slightly worse so the Lasix was stopped. They are recovering
at this time.
Your lisinopril was stopped due to your kidney function. Please
discuss with your primary care doctor about restarting this
medication. Your metoprolol dose was increased to help control
your heart rate.
You can wrap your arm with compression stockings to help remove
if the fluid if it becomes more swollen.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Please follow-up with your appointments as listed below.
All the best,
Your ___ Team
Followup Instructions:
___
|
19891640-DS-13 | 19,891,640 | 26,718,333 | DS | 13 | 2151-12-30 00:00:00 | 2151-12-30 15:55:00 |
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 Tibial plateau fracture
Major Surgical or Invasive Procedure:
___: Ex-fix L tibial plateau
History of Present Illness:
___ F PMH of asthma who tripped and fell down 2 stairs earlier
this afternoon. Noticed immediate pain in L knee, unable to bear
weight, was brought to ___ where she was found to
have a L tibial plateau fracture and then transferred to ___
for further care. Did strike her head in the fall, denies LOC.
Past Medical History:
asthma, seasonal allergies. dental surgeries in past, otherwise
no hx of surgery
Social History:
___
Family History:
Non-contributory
Physical Exam:
General: alert and oriented, well appearing, NAD
Vitals: AF VSS
- External fixation in place
- swollen about proximal tibia, compartments compressible
- mild tenderness to palpation in proximal tibia
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 07:54PM BLOOD WBC-10.5* RBC-3.29* Hgb-11.1* Hct-32.6*
MCV-99* MCH-33.7* MCHC-34.0 RDW-14.0 RDWSD-51.6* Plt ___
___ 07:54PM BLOOD Neuts-63.1 ___ Monos-13.3*
Eos-0.5* Baso-1.2* Im ___ AbsNeut-6.63* AbsLymp-2.21
AbsMono-1.39* AbsEos-0.05 AbsBaso-0.13*
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 tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for external fixation L tibial
plateau, 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 be scheduled for
surgery early next week with Dr. ___.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Enoxaparin Sodium 40 mg SC QHS
Start: Today - ___, First Dose: Next Routine Administration
Time
4. Gabapentin 300 mg PO TID
5. Multivitamins 1 TAB PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every ___ hours Disp
#*40 Tablet Refills:*0
7. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L tibial plateau fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
- You were 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:
- NWB 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 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Pin care to pin sites
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
|
19891640-DS-16 | 19,891,640 | 23,804,716 | DS | 16 | 2152-06-19 00:00:00 | 2152-06-19 15:09:00 |
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 displaced femoral neck fracture
Major Surgical or Invasive Procedure:
L total hip replacement
History of Present Illness:
___ year old female with pmhx significant for left tibial plateau
fracture 6 months ago to ED today with Left subcapital hip
fracture. She states that yesterday around 7:00 pm she was
walking and felt her left knee buckle. She fell to the floor,
landing on her left lateral hip. She said that she felt only
mild pain immediately after the fall and continued to ambulate
on the leg. She awoke at 3:00 AM to use the bathroom and noted
the pain in her left hip was increasing and she was having
difficulty ambulating. She called EMS to go to ___
___ this morning when she felt that she could not ambulate
due to pain. At ___ xr showed left subcapital fracture.
Surgical history significant for left tibial plateau fracture in
___ s/p external fixation with ORIF with Dr. ___
___. Post-op course was complicated by infection and
dehiscence of the wound and went back to OR ___ for I&D.
Cultures grew diphtheroides and viridians. She underwent gastroc
flap and skin grafting for wound closure with Dr. ___
___. She was discharged to home with IV vanc x6 wks and
currently follows with ID, on PO doxycycline for suppression
until hardware is removed.
Patient denies fevers, chills, sweats, numbness, new
paresthesias and pain in other extremities.
Past Medical History:
asthma
seasonal allergies
dental surgeries in past
Social History:
___
Family History:
Non-contributory
Physical Exam:
Gen: NAD
Left lower extremity:
- L hip incisional dressing c/d/i
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a displaced L femoral neck fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for a L total hip replacement, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
with home ___ 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
WBAT in the left lower extremity, and will be discharged on
Lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine. She will continue her 100mg Doxycycline BID
for chronic suppression of her L tibial plateau hardware. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam 0.5-1 mg PO QHS:PRN insomnia
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
4. Doxycycline Hyclate 100 mg PO Q12H
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. LORazepam 0.5-1 mg PO QHS:PRN insomnia
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC Q24H Duration: 14 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC Daily Disp #*14 Syringe
Refills:*0
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Every ___ hours as
needed for pain. Disp #*84 Tablet Refills:*0
7. Tizanidine 4 mg PO TID PRN spasm
RX *tizanidine 2 mg 1 capsule(s) by mouth Every 8 hours as
needed for muscle spasm. Disp #*24 Capsule Refills:*0
8. Vitamin D 800 UNIT PO DAILY
9. Doxycycline Hyclate 100 mg PO Q12H
Discharge Disposition:
Home With Service
Facility:
___
___:
L displaced femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weightbearing as tolerated on Left Hip with anterior hip
precautions.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- CALCIUM: it is best to take in Calcium by adjusting your diet.
You may supplement with 2 Tums twice per day.
- DO NOT take Doxycycline and Calcium at the same time as this
may decrease the effectiveness of the Doxycycline medication.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
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
Physical Therapy:
Right lower extremity: Full weight bearing
Left lower extremity: Weightbearing as tolerated.
Anterior Hip Precautions on the LEFT side.
Treatments Frequency:
Dry sterile dressings changed daily until no longer draining.
Elevate leg as much as possible.
Followup Instructions:
___
|
19891717-DS-18 | 19,891,717 | 29,258,820 | DS | 18 | 2116-05-04 00:00:00 | 2116-05-09 20:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
s/p Bicycle crash vs auto
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M unhelmeted bicyclist struck by car (travelling approx 40
mph), thrown from cycle approx 30 ft. There was significant
damage to car. Pt unconsciious at scene per bystanders. Was
brought to ED by EMS and by arrival had regained consciousness
(GCS 15 per report). In ED pt awake and does not remember
accident, but remembers being placed in ambulance by EMS. Pt.
c/o back pain, left shoulder pain, and pain on inspiration.
Past Medical History:
Scoliosis
Family History:
Noncontributory
Physical Exam:
Upon presentation to ___:
T:97.4 BP: 129/87 HR:75 R:19 O2Sats:100-NRB
Awake and alert
Cooperative with exam
Oriented to person, place, and date
Speech fluent with good comprehension
Naming intact
No dysarthria or paraphasic errors
Pupils equally round and reactive to light bilaterally
Visual fields are full to confrontation
Extraocular movements intact bilaterally, no abnormal nystagmus
Facial strength and sensation intact and symmetric
Hearing intact to voice
Palatal elevation symmetrical
Tongue midline without fasciculations
Bilateral periorbital hematomas left > right
Facial abrasions
C-collar in place
Normal bulk and tone bilaterally
Strength full power ___ throughout x 4 extremities
Sensation intact to light touch
No clonus
Toes downgoing bilaterally
Rapid alternating movements normal bilaterally
Pertinent Results:
___ 08:56PM GLUCOSE-84 LACTATE-2.0 NA+-144 K+-4.1 CL--106
TCO2-24
___ 08:55PM UREA N-14 CREAT-0.9
___ 08:55PM WBC-8.5 RBC-4.46* HGB-13.4* HCT-38.9* MCV-87
MCH-30.0 MCHC-34.4 RDW-12.9
___:55PM PLT COUNT-282
___ 08:55PM ___ PTT-27.7 ___
IMAGING:
___ CXR: No acute intrathoracic process
CT Head/ cspine: Small right frontal subdural hematoma without
mass effect. Non-displaced right occipital condyle fracture.
Left preseptal hematoma. Small locules of air in the right
orbit, but no
obvious fracture seen. Globes are intact. No acute C-spine
fractures. Non-displaced R occipital condyle fracture.
CT chest/ abd/ pelv: Compression fracture of T7 and T8
fractures, with involvement of the spinous process of T7,
paraspinal hematoma at that level. No retropulsion into the
spinal canal. No mediastinal or liver injury. A 3.9 cm right
hepatic lobe hyperenhancing lesion, likely represents a
hemangioma. No intra-abdominal trauma.
Brief Hospital Course:
Mr. ___ was admitted to the Acute Care Surgery team and
transferred to the Trauma ICU for close monitoring which
included hourly neuro checks. Repeat CT head imaging in the next
day showed resolution of the right SDH indicating it was likely
artifact rather than a real lesion. His occipital condyle
fracture was managed non-operatively and he is recommended to be
in a hard cervical collar for at least six weeks. Regarding his
spine fractures he was instructed to wear a TLSO brace when out
of bed and he was fitted for this brace.
His clavicle fracture was evaluated by orthopedics and was
nonoperative - he will wear a sling and non weight bear on the
left arm.
Ophthalmology was consulted regarding the periorbital hematomas
which were also determined to be managed conservatively with
outpatient follow up.
On HD 2 he was AAOx3 and with stable imaging no longer requiring
frequent neuro checks and was transferred to the floor.
Once transferred to the floor he received his brace and was
evaluated by Physical and Occupational therapy and was cleared
for home once family/caregiver training for brace use was
provided.
He did experience intermittent nausea which appeared to be
associated with Dilaudid. Once these were stopped the nausea
resolved and his pain was well controlled on prn Oxycodone
Ultram and Tylenol standing.
At time of discharge he was able to ambulate independently with
his TLSO brace and cervical collar in place.
He was discharged to home with friends and will have follow up
with Orthopedics, Neurosurgery, Ortho Spine a with a new PCP
that was set up for him here at ___.
Medications on Admission:
None
Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every ___
hours as needed for pain.
3. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Bicycle crash
Injuries:
-Right occipital condyle fracture
-Left ___ hematoma
-Left clavicle fracture
-Hemagioma
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 following a bicycle crash. The
crash caused a fracture in your skull bone and in the bones
located in your thoracic (chest) spine. The Spine Specilaist
have recommended that you wear a brace called a TLSO when
sitting up and/or when out of bed. You can apply the brace while
in a sitting postiion on side of the bed.
You must continue to wear your hard cervical collar for
occipital condyle fracture for 6 weeks at which time you will
follow up with the Neurosurgery specialists.
You also fractured your left clavicle and a sling is being used
for comfort. It is important that you do not bear any weight on
your left arm. Wear the sling for comfort.
If narcotic pain medications have been prescribed for you do not
drink alcohol, take illicit drugs, drive and/or operate heavy
machinery while on these medications. Take a laxative and stool
softener to prevent constipation.
Followup Instructions:
___
|
19892176-DS-13 | 19,892,176 | 20,994,625 | DS | 13 | 2139-03-30 00:00:00 | 2139-03-30 22:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Dairy Aid / gluten / doxycycline / Tetracycline /
Vicodin / oxycodone / Latex, Natural Rubber
Attending: ___
Chief Complaint:
Abdominal and back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with a PMH of complex
regional pain syndrome (has been trialed on multiple adjunctive
agents including Ketamine infusion, follows with a chronic pain
specialist), history of chronic pancreatitis (though the
diagnosis is not clear), anxiety and other issues who was
recently admitted at ___ from ___ with abdominal
pain of unclear cause, now re-admitted with the same. During
her last admission, she had abdominal pain that was not really
consistent with pancreatitis, and not felt to be typical for her
CPRS. GERD vs. spasm was the leading hypothesis; her dose of
omeprazole was increased and she was started on hyoscyamine.
Her
symptoms gradually improved with bowel rest, and when she was
able to tolerate oral intake, she was discharged home with a
plan to complete an outpatient MRCP for further evaluation of
her pancreas, as well as follow-up in pancreas clinic. The day
after discharge (___) she called GI clinic complaining of
feeling warm and flushed upon standing and persistent abdominal
pain that had not really improved compared with prior. She
noted that her heart rate increased from the ___ while supine to
the 120s with standing. She was able to tolerate oral intake
during this time. She called again on ___ with severe pain and
was referred to the ED for further evaluation. She tells me she
has never had pain
like this before. She notes that she continued to have pain when
she was discharged but it has become progressively worse. The
pain is described as aching and cramping, in the upper abdomen
mostly on the left side, radiating around to the back. It is
difficult to parse out her description of abdominal pain from
back pain, which she says she has been longstanding. She notes
that the pain is worse when
she lies flat but better with standing. She notes that when she
goes from lying to standing the back of her head feels "hot" and
she feels like she might lose consciousness, but she does not
note dizziness. This has been going on for the past several
weeks. She denies any N&V, diarrhea, BRBPR, or dysuria. Her last
bowel movement was this morning, was softer than normal but not
loose. In the ED, initial VS were 97.6 90 99/68 18 100% RA.
Exam was notable for LUQ tenderness. Labs were notable for
normal WBC (5.5 with normal diff); Hgb 14.8 (though it was in
the ___
range after fluid resuscitation during her last admission), and
normal plts. BUN/Cr ___ (baseline Cr 0.5) and lytes WNL
except for HCO3 20. Alk phos minimally elevated at 123, and
Lipase 885
(up from 81 during last admission), other LFTs WNL. Coags WNL,
UA negative, Lactate 1.1, and triglycerides were pending. CXR
without evidence of pneumonia, and EKG without evidence of
ischemia. She received 1L NS, 1L LR, Hydromorphone 0.5 mg IV,
Gabapentin 300 mg PO and was admitted for further workup. VS
prior to transfer were 98.6 67 131/57 18 99% RA.
On arrival to the floor, the patient reports ongoing abdominal
pain and back pain but otherwise has no complaints.
Past Medical History:
1. Complex regional pain syndrome
2. Questionable history of chronic pancreatitis
3. Anxiety
Social History:
___
Family History:
Father had hemochromatosis (she has been tested and is
negative).
Physical Exam:
VITAL SIGNS:
___ Temp: 98.4 PO BP: 118/69 HR: 68 RR: 18 O2 sat: 94%
O2 delivery: RA
EXAMINATION:
GENERAL: Looks mildly anxious, but otherwise comfortable in bed.
On reevaluation was wincing in pain, but towards the end of the
conversation appeared at recent hospital baseline. Stated that
her pain had increased significantly, but improving since
receiving pain medications.
Seen ambulating in hallway with husband throughout the day.
EYES: Anicteric, pupils equally round and reactive to light.
EOMI.
ENT: MMM, NCAT
CV: RRR, no murmurs
RESP: CTAB, no wheezes or crackles
GI: Soft, non-distended. Mild left upper quadrant tenderness
without rebound or guarding. Normal bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Moves all extremities. No lower extremity edema.
SKIN: No rashes or ulcerations noted
NEURO: Alert. Oriented to person, place, situation. Face
symmetric, speech fluent, moves all limbs
PSYCH: Mildly anxious.
Pertinent Results:
___ 01:10PM BLOOD WBC-4.8 RBC-4.00 Hgb-12.6 Hct-37.4 MCV-94
MCH-31.5 MCHC-33.7 RDW-12.8 RDWSD-44.1 Plt ___
___ 04:20PM BLOOD Glucose-115* UreaN-8 Creat-0.8 Na-140
K-4.2 Cl-103 HCO3-26 AnGap-11
___ 07:20AM BLOOD ___ PTT-29.1 ___
___ 07:20AM BLOOD ALT-25 AST-26 AlkPhos-123* TotBili-0.6
___ 01:10PM BLOOD ALT-15 AST-12 LD(LDH)-126 AlkPhos-68
TotBili-0.5
___ 07:20AM BLOOD Lipase-885* GGT-29
___ 01:10PM BLOOD Calcium-8.2* Phos-2.2* Mg-1.3*
___ 04:20PM BLOOD Calcium-9.9 Phos-3.2 Mg-2.0
___ 10:40AM BLOOD %HbA1c-5.2 eAG-103
___ 07:20AM BLOOD Triglyc-144
___ 09:06AM BLOOD Lactate-1.1
MRCP
Normal appearing pancreas with no evidence of pancreatitis. No
bile duct
dilatation or cholelithiasis.
Gastric emptying study
IMPRESSION: Delayed gastric emptying with 15.8% residual at 4
hours (normal: <10%).
Brief Hospital Course:
___ with a PMH of complex regional pain syndrome, history of
chronic pancreatitis (unclear etiology), anxiety and other
issues, recently discharged from ___ after hospitalization
from ___ with abdominal pain of unclear etiology,
now re-admitted with same pain, and elevated lipase.
Admitted with abdominal and back pain. She underwent laboratory
testing significant for elevated lipase of 885. Labs also showed
transiently elevated alkaline phosphatase, however,
supplementary testing revealed a normal GGT that suggests no
biliary obstruction. Furthermore, MRCP revealed a normal
appearing pancreas without evidence of pancreatitis and no bile
duct dilatation or cholelithiasis. Lipase can be elevated in a
multitude of conditions including gastric motility disorder such
as gastroparesis. A gastric emptying study was obtained as
recommended by gastroenterology that revealed delayed gastric
emptying with 15.8% residual at 4 hours (normal: <10%). This may
be reversible if secondary to medication (opiates, for example).
Symptoms are somewhat consistent with this diagnosis, however,
there is also a neuromuscular quality. We recommended a trial of
dietary modification (smaller more frequent meals as explained
by nutrition consultation) and trial of reglan with goal to
taper to lowest possible dose (or discontinue entirely). Patient
was instructed to follow with her PCP (within 1 week),
gastroenterologist (as scheduled), and pain specialist as soon
as possible. The pain specialist should review chronic illness
and recent illness as well as medications. If your symptoms
continue despite these interventions further investigation into
another cause may be appropriate. 5 doses of 2.5 mg morphine
solution was prescribed to help patient manage severe
breakthrough pain episodes (often occurring at night).
Patient should also review warm/flushed feeling and postural
tachycardia with pain specialist as we feel this may be an
autonomic dysfunction component of CRPS or medication side
effect (vs withdrawal).
Patient advised to follow with PCP on incidental finding on CXR,
reported as "New subcentimeter radiodensities project over the
right lung apex and superior and inferior to the distal left
clavicle on AP view, which may be external to the patient.".
There was concern these abornmalities were external to the
patient, but nothing was identified when examined (unclear
temporal relationship to study, however). Patient should likely
have repeat imaging in a few weeks.
Hospital course, assessment, and discharge plans discussed with
patient and husband who expressed understanding and agreed with
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO AT 5 ___
2. ClonazePAM 0.75 mg PO QHS
3. Gabapentin 300 mg PO Q2H
4. DULoxetine 20 mg PO DAILY
5. Hyoscyamine 0.375 mg PO QID
6. Morphine Sulfate (Oral Solution) 2 mg/mL 2.5 mg PO Q6H:PRN
moderate to severe pain
7. TraZODone 50 mg PO QHS:PRN insomnia
8. Omeprazole 40 mg PO BID
9. Docusate Sodium 100 mg PO BID
10. Tizanidine 4 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*21 Tablet Refills:*0
2. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet by mouth four times a day
Disp #*30 Tablet Refills:*0
3. Naproxen 250 mg PO Q12H:PRN Pain - Mild
RX *naproxen 250 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*10 Tablet Refills:*0
4. ClonazePAM 0.5 mg PO AT 5 ___
5. ClonazePAM 0.75 mg PO QHS
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 300 mg PO Q2H
8. Morphine Sulfate (Oral Solution) 2 mg/mL 2.5 mg PO Q6H:PRN
moderate to severe pain
RX *morphine 10 mg/5 mL 2.5 MG by mouth at bedtime Disp #*5
Milliliter Refills:*0
9. Omeprazole 40 mg PO BID
10. Tizanidine 4 mg PO BID
11. TraZODone 50 mg PO QHS:PRN insomnia
12. HELD- DULoxetine 20 mg PO DAILY This medication was held.
Do not restart DULoxetine until follow up with PCP
___:
Home
Discharge Diagnosis:
Delayed gastric emptying
Abdominal and back pain
Volume depletion with postural tachycardia (possible autonomic
dysfuction)
Moderate Malnutrition in context of acute illness
Incidental CXR finding of radiodensity
Complex regional pain syndrome
Anxiety
Insomnia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted with abdominal and back pain. ___ underwent
laboratory testing significant for elevated lipase of 885. Labs
also showed transiently elevated alkaline phosphatase, however,
supplementary testing revealed a normal GGT that suggests no
biliary obstruction. Furthermore, MRCP revealed a normal
appearing pancreas without evidence of pancreatitis and no bile
duct dilatation or cholelithiasis (gallstone disease). As we
discussed, lipase can be elevated in a multitude of conditions
including gastric motility disorder such as gastroparesis. A
gastric emptying study revealed delayed gastric emptying with
15.8% residual at 4 hours (normal:
<10%). As we reported, this can be spontaneous and chronic or
may be reversible if due to an outside trigger like medication
(opiates for example). Your symptoms are somewhat consistent
with this diagnosis. We recommend trial of dietary modification
(smaller more frequent meals as explained by nutritionist) and
trial of reglan with goal to taper to lowest possible dose (or
discontinue entirely). ___ should follow with your PCP (within 1
week), gastroenterologist (within ___ weeks), and pain
specialist as soon as possible. Your pain specialist should
review medications and possible side effect profile. If your
symptoms continue despite these interventions further
investigation into another cause may be appropriate.
It was a pleasure taking care of ___ and we wish ___ the best,
Your ___ hospitalist team
Followup Instructions:
___
|
19892539-DS-16 | 19,892,539 | 25,088,002 | DS | 16 | 2179-04-15 00:00:00 | 2179-04-15 17:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Procardia / Verapamil / Neurontin
Attending: ___.
Chief Complaint:
Right hip pain, following a fall
Major Surgical or Invasive Procedure:
Right long trochanteric fixation nail
Upper endoscopy x2
Multiple blood transfusions
IVC filter placement
History of Present Illness:
Ms. ___ is a ___ y/o woman who presents with right hip pain
after a fall from standing. She was unable to get up
thereafter. She was bending over to take off her husband's socks
and lost her balance. Denies headstrike or loss of consciousness
at the time. On presentation to the ED, she was noted to have
hip xrays demonstrating a hip fracture, and was initially
admitted to the orthopedics service. She subsequently required
transfer to the medical ICU and later the hospital medicine
service, for ongoing medical issues that arose during her
admission.
Past Medical History:
Severe aortic stenosis
Hypertension
Hyperlipidemia
Hypothyroidism
TIA
Asthma
Gout
Polymyalgia rheumatica
Discoid lupus
h/o CHB s/p PPM ___
h/o pulmonary embolus ___ s/p coumadin
h/o Left DVT
s/p Right total knee replacement ___
s/p Left total hip replacement ___
s/p R Mastoidectomy
Social History:
___
Family History:
sister-TIAs
brother with CAD died at age ___
nephews with CAD at age <___
MS and lupus also in the family
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION to the orthopedics service:
NAD, AOx3, VSS
BLE skin clean and intact
RLE shortened and externally rotated. No deformity, erythema,
edema, induration or ecchymosis.
Thighs and legs are soft
R hip pain with any motion
Saph Sural DPN SPN MPN LPN SITLT
Flexion/extension intact toes, ankle and knee bilaterally
w/inability to range R hip
1+ ___ and DP pulses
Contralateral extremity examined with good range of motion,
SILT, motor intact and no pain or edema
Pertinent findings on discharge:
The patient was alert and oriented x 3, appropriate fluent
speech.
She had no evidence of rales on bilateral lung exam. Cardiac
murmur consistent with aortic stenosis remained present. JVP did
not appear elevated.
The patient's wound was healing well.
Pertinent Results:
Initial labs:
___ 10:58PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 10:58PM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:00PM GLUCOSE-120* UREA N-43* CREAT-1.6* SODIUM-140
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-26 ANION GAP-17
___ 10:00PM WBC-8.6 RBC-3.57* HGB-11.4* HCT-33.3* MCV-93
MCH-32.0 MCHC-34.4 RDW-15.0
___ 10:00PM NEUTS-78.6* LYMPHS-11.8* MONOS-6.4 EOS-1.9
BASOS-1.3
___ 10:00PM ___ PTT-27.5 ___
CBC:
___ 04:50AM BLOOD WBC-7.8 RBC-2.65* Hgb-8.3* Hct-23.9*
MCV-90 MCH-31.3 MCHC-34.7 RDW-17.9* Plt Ct-91*
___ 08:45AM BLOOD Hct-21.7*
___ 04:30AM BLOOD WBC-10.9 RBC-2.89* Hgb-8.9* Hct-25.6*
MCV-89 MCH-30.8 MCHC-34.6 RDW-15.4 Plt ___
___ 02:08AM BLOOD WBC-11.2* RBC-3.11* Hgb-9.4* Hct-27.8*
MCV-90 MCH-30.1 MCHC-33.6 RDW-15.3 Plt ___
___ 02:49AM BLOOD WBC-9.5 RBC-2.68* Hgb-8.2* Hct-24.4*
MCV-91 MCH-30.6 MCHC-33.6 RDW-16.2* Plt ___
___ 05:36AM BLOOD WBC-11.0 RBC-3.07* Hgb-9.4* Hct-27.7*
MCV-90 MCH-30.6 MCHC-34.0 RDW-15.8* Plt ___
___ 06:00AM BLOOD WBC-10.1 RBC-3.24* Hgb-10.0* Hct-29.5*
MCV-91 MCH-30.9 MCHC-34.0 RDW-15.7* Plt ___
___ 08:50AM BLOOD WBC-11.5* RBC-3.38* Hgb-10.2* Hct-30.8*
MCV-91 MCH-30.3 MCHC-33.2 RDW-16.0* Plt ___
___ 05:50AM BLOOD Hct-30.0*
Chemistry:
___ 05:36AM BOOD Glucose-89 UreaN-45* Creat-1.1 Na-144
K-3.7 Cl-116* HCO3-21* AnGap-11
___ 12:35PM BLOOD UreaN-35* Creat-1.2* Na-147* K-3.5
Cl-116* HCO3-19* AnGap-16
___ 08:50AM BLOOD UreaN-30* Creat-1.2* Na-144 K-3.2*
Cl-114* HCO3-23 AnGap-10
___ 05:50AM BLOOD UreaN-25* Creat-1.1 Na-144 K-3.4 Cl-114*
HCO3-23 AnGap-10
Radiology:
Hip films:
IMPRESSION: Complete comminuted fracture through the right
greater
trochanter.
Endoscopy:
Impression: Esophagitis
No blood or lesions noted in stomach.
Duodenal ulcer (injection, endoclip)
Otherwise normal EGD to second part of the duodenum
Recommendations: Source of melena appears to be duodenal bulb
ulcer with adherent clot. Injection and endoclip placed.
Aggressive manipulation of clot not performed as stated above.
Recommend continued ICU close monitoring, NPO, PPI gtt, hold
anticoagulation. If recurrent significant bleed with likely
require ___ intervention.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with known critical aortic
stenosis, CKD, CAD s/p CABG, and hypothyroidism who was
initially admitted to the Orthopaedic Surgery Trauma service
after a fall in which she sustained a right intertrochanteric
hip fracture while helping her husband get dressed. Her hospital
course was significant for ___ cardiac arrest and
hypotension and later a GI bleeding episode requiring ICU stay.
During the orthopedic initial course: The patient was taken to
the Operating Room on ___ ___ to undergo open
reduction and internal fixation of the right hip with a
Trochanteric Fixation Nail. Her intraoperative course was
complicated by an episode of hypotension during the anesthesia
induction period. Please see Operative Report for full details.
Post-operatively, the patient was taken to the recovery room
before being transferred to the floor.
On POD#1, she was transfused 2 units of packed red blood cells
for acute blood loss anemia. She was also noted to be confused
that day, and the Geriatrics service was consulted for acute
mental status changes. A CT scan of the head was recommended to
evaluate for an acute bleed; this study was found to be negative
for an acute intracranial process, but did show age-related
involution and chronic small vessel ischemic disease.
The patient's mental status improved over the next few days.
She continued to work with Physical Therapy and made steady
progress. She was transfused 2 units of pRBCs on ___, again
for acute blood loss anemia, as well as 1 unit of FFP.
On the morning of POD#5, the patient was noted to become acutely
hypotensive to ___ in the setting of appearing pale and
complaining of lightheadedness, dizziness, and palpitations.
Her hematocrit had decreased from 29.1 the day before to 24.3;
upon being rechecked 3 hours later, the hematocrit had decreased
to 21.7. The patient was ordered for STAT packed red blood cell
transfusion, and in the interim she received crystalloid for
volume resuscitation. A Trigger was called, and STAT EKG, CXR,
and cardiac enzymes were ordered. The Medicine and Cardiology
services were contacted and presented urgently to see the
patient. The ICU was also contacted given concern for acute
blood loss anemia. Her right (operative) thigh remained soft
and did not appear to be full or acutely swollen.
The patient was transferred to the T/SICU, shortly after which
time she produced a large amount of melena of approximately 1
liter. The GI service was consulted urgently, and EGD was
performed that was significant for severe erosive gastritis and
a duodenal ulcer. Please see report for full details. She was
then transferred to the MICU for further evaluation and
management of her GI bleed.
MICU & Floor Course:
# GIB: Upon admission to the MICU she underwent EGD, which
showed erosive esophagitis and multiple duodenal ulcers, which
were not intervened upon. Her Lovenox was discontinued and she
was placed on Heparin SQ and pneumoboots for DVT ppx. She was
transfused a total of 2 units pRBCs over the course of 48 hours.
Her HCT remained stable and she was called out to the floor. She
initially did well on the floor, but subsequently had several
large melanotic BMs and a significant HCT drop 25-->22. She was
then readmittted to the MICU, where she received another 4 units
pRBCs with HCT ___. Repeat EGD showed slowly bleeding
duodenal ulcer and she had epi injection and hemostatic clips
placed x2 to the site of bleeding. She remained hemodynamically
stable on PPI gtt. On ___ she had IVC filter placed because she
could not be anticoagulated and is at very high risk for DVT.
Her HCTs were trended and she was called back out to the floor.
She had no further melanotic stools and her hematocrits were
stable on the floor. She remained off of DVT prophylaxis due to
her severe GI bleeding during this admission.
# s/p Cardiac Arrest: Shortly after induction in the OR pt
becmae hypotensive requiring compressions and EPI with immediate
RSC. Her arrest was likely related to anestehsia induced
hypotension given prompt resolution with CPR/EPI. She remained
hemodynamically stable after these events, including throughout
her hospital medicine team course.
# Right hip fracture: The patient is weight-bearing as tolerated
per the orthopedics service. She will follow up with them in
clinic for further evaluation and for removal of her incisional
staples. She required planned ___ rehabilitation on
discharge for ongoing therapy, but per report of the ___ team,
she was making the desired progress in her ambulation and ADLs
during her inpatient course.
# Resolved encephalopathy/confusion: These resolved symptoms
earlier in her course were attributed to poor perfusion from
active bleed and hypotension. Also with risk of recent delirium,
likely related to surgery and ICU stay. Her mental status
improved throughout her hospital course and she was awake,
alert, oriented, and appropriate on discharge.
# CKD: Pt's Cr is currently at baseline, likely hypertensive
nephropathy. It remained stable throughout her hospital course.
# Thrombocytopenia: Pt has been chronically thrombocytopenic
since ___ per out records. Platelets 140 on admission to the
MICU. Unclear cause, though would monitor for consumptive
process given recent bleed.
# CAD s/p CABG/AVR: Currently euvolemic, denies CP. She was
restarted on her home metoprolol dose prior to discharge, but
the other antihypertensives were held as the patient was not
hypertensive. She was continued on rosuvastatin.
# Hypothyroidism: The patient recevied levothyroxine.
Transitional Issues:
# Hypertension/medication changes: The patient will be gradually
weaned back on to her home antihypertensive regimen as required
based on her blood pressure. These recommendations were outlined
in the discharge paperwork to assist the rehab facility in
determining which agents would be most prudent to add back at
which timing.
# Hypokalemia: The patient has slightly low potassium. She was
encouraged to eat foods high in potassium.
Medications on Admission:
advair, crestor 40, ASA 81, allopurinol ___, HCTZ 25, lisinopril
2.5, synthroid 88, amlodipine 5, gabapentin 100, metoprolol ER
100
Discharge Medications:
1. Carafate 100 mg/mL Suspension Sig: One (1) tablespoon PO
twice a day for 2 weeks.
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
3. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
8 weeks.
10. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
Right hip intertrochanteric fracture
Bleeding duodenal ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at ___. You were
admitted to the hospital for a broken right hip. While in the
hospital, you developed bleeding from an ulcer in your
intestines. You were admitted to the ICU and had blood
transfusions and two endoscopies that found the source of the
bleeding, and it eventually stopped. You blood counts have been
normal for the last few days. You will need to follow up with
the orthopedic surgeons for your broken hip and with the
gastroenterologists for your bleeding ulcer.
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.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Activity:
- Continue to be weight-bearing as tolerated
- You should not lift anything greater than 5 pounds.
- Elevate right leg to decrease pain and swelling.
Other Instructions
- Resume your regular diet. Eat a banana daily to get enough
potassium.
Medication changes:
DO NOT take aspirin or any other blood thinners until you see
the gastroenterologists in clinic
pantoprazole 40 mg PO q12h for 8 weeks
sucralfate one tablespoon oral suspension PO BID for two weeks
acetaminophen 650 mg PO q6h prn pain
Followup Instructions:
___
|
19892763-DS-15 | 19,892,763 | 26,335,877 | DS | 15 | 2162-11-02 00:00:00 | 2162-11-02 13:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
Cardiac Exercise Test
History of Present Illness:
This is a ___ M w/past hx of suicidal attempt, ideation, and
poorly controlled hyperglycemia presenting with hyperglycemia in
the 400-600s. On the morning of presentation (___), the patient
was noted to be hyperglycemic with a blood sugar of
approximately 550 at his rehab ___ for ___ rehab). He was
then transferred to the ___ for further evaluation. At
that time he endorsed chest pain which has been intermittent in
nature for the past ___ years. He states that he believes his
blood sugars are so high because the staff at the ___
___ have not been giving him his medications.
He has a history of depression and in ___ expressed
SI with a plan to jump in front of a train due to a relapse on
alcohol 2 weeks prior. Patient had been sober for 20 months
prior to ___.
When evaluated in ___, Mr. ___ had been medication
non-adherent for the months prior. He previously had been on
mirtazapine, risperidone, and fluoxetine. He also is a diabetic
and was not taking his insulin when he was evaluated in
___.
In the ___, initial vital signs were 98.0 HR 103 BP 137/70 18
100% RA
From the ___, he was placed into observation status for suicidal
ideation. He was evaluated by psych who ultimately said that
there was no indication for inpatient psych hospitalization.
With respect to his chest pain- troponins were negative x2 in
the ___. He was ordered for an exercise stress test for further
evaluation of chest pain, though this could not be obtained
while he was in the ___. Given ongoing hyperglycemia that was
difficult to control, he is admitted to medicine for further
management of hyperglycemia and chest pain. He was seen by
___ prior to transfer to the medicine floor.
On arrival to the floor, he endorses frustration with respect to
difficulty controlling his blood sugars. He states that he has
had left sided chest pain for the past ___ years. It is sharp,
non-radiating, ___ in severity, and happens intermittently
without provocation and not on exertion. He denies any
exacerbating/alleviating factors. The pain occurs up to 2 times
per day, lasts ___ minutes, and resolves on its own.
He also endorses blurry vision with hyperglycemia. He denies
polyuria, polydipsia, nausea, vomiting, abdominal pain. He
denies SI at this time. States that he had transient episode of
SI while in the ___, though recognizes reasons that would prevent
him from acting on this.
REVIEW OF SYSTEMS: As per HPI
Past Medical History:
- DMII (past ___ years)
- Diabetic neuropathy
- Hypertension
- Bilateral rotator cuff injury
- Sciatica
- H/O TB s/p INH
- Hepatitic C (not on treatment)
Social History:
___
Family History:
Two brothers with EtOH abuse.
Physical Exam:
On Admission:
Vitals: 98.9 173/96 73 97%RA FSG 400
General: Friendly gentlemen, appearing calm, but quick to anger
in regards to discussion about insulin regimen; NAD, NCAT
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes/rales/rhonchi
CV: RRR, normal S1/S2, no MRG
Abdomen: Soft, NTND, normoactive bowel sounds
GU: No Foley
Ext: Warm, well-perfused, no cyanosis/clubbing/edema, 2+ pulses
Neuro: AAOx3, CN II-XII grossly intact, gait normal
On Discharge:
Vitals: 97.9 129/84 84 100%RA
General: Comfortable appearing, awake eating breakfast
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes/rales/rhonchi
CV: RRR, normal S1/S2, no MRG
Abdomen: Soft, NTND, normoactive bowel sounds
GU: No Foley
Ext: Warm, well-perfused, no cyanosis/clubbing/edema, 2+ pulses
Neuro: AAOx3, CN II-XII grossly intact, gait normal
Pertinent Results:
On Admission:
___ 09:00AM BLOOD WBC-4.2 RBC-4.47* Hgb-13.6* Hct-40.8
MCV-91 MCH-30.4 MCHC-33.3 RDW-15.0 RDWSD-50.0* Plt ___
___ 09:00AM BLOOD Glucose-469* UreaN-14 Creat-0.8 Na-128*
K-6.1* Cl-92* HCO3-23 AnGap-19
___ 07:04AM BLOOD Calcium-9.8 Phos-4.9* Mg-1.8
Pertinent Interval:
___ 03:10PM BLOOD cTropnT-<0.01
___ 09:00AM BLOOD cTropnT-<0.01
___ 09:15AM BLOOD %HbA1c-11.0* eAG-269*
___ 09:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
___ 06:48AM BLOOD Triglyc-141 HDL-59 CHOL/HD-3.2
LDLcalc-100
On Discharge:
___ 07:25AM BLOOD WBC-4.0 RBC-4.39* Hgb-13.0* Hct-40.6
MCV-93 MCH-29.6 MCHC-32.0 RDW-15.4 RDWSD-51.9* Plt ___
___ 07:25AM BLOOD Glucose-317* UreaN-25* Creat-0.9 Na-132*
K-5.1 Cl-95* HCO3-24 AnGap-18
Imaging:
___ CXR
FINDINGS:
Cardiomediastinal silhouette is normal. There is no pleural
effusion or
pneumothorax. There is no focal lung consolidation.
IMPRESSION:
No radiographic explanation for chest pain.
___ Stress Test
INTERPRETATION: This ___ year old IDDM man with a history of HTN
and
smoking was referred to the lab for evaluation of atypical chest
discomfort. The patient exercised for 10 minutes of a Gervino
protocol
and stopped for fatigue. The estimated peak MET capcity was 5.2
which
represents a poor functional capacity. No arm, neck, back or
chest
discomfort was reported by the patient throughout the study.
There were
no significant ST segment changes during exercise or in
recovery. The
rhythm was sinus with 1 apb. Appropriate hemodyanmic response to
exercise and recovery.
IMPRESSION: No anginal type symptoms or significant ST segment
changes.
Brief Hospital Course:
Mr. ___ is a ___ with a history of past suicide attempt,
EtOH abuse, multiple arrests and incarcerations, depression,
PTSD, and DM2 who presented from ETOH detox with hyperglycemia.
#Hyperglycemia: Mr. ___ was on ___ and metformin 1000
BID at home with poorly controlled blood sugars. He managed
himself with a rescue sliding scale of his own design, though
frequently had blood sugars in the 400s despite this. While at
rehab he reportedly did not have access to his usual regimen and
when his blood sugars were noted to be in the 400s he was sent
to the ___ was consulted in the ___ and assisted with
management throughout his hospitalization. His insulin regimen
was initially rearranged to lantus + insulin sliding scale.
However, given his social circumstances and inability to check
his blood sugars ___ times daily he was instead switched to
70/30, which he will take twice daily. He will check his blood
sugars in the afternoon and prior to bedtime when possible and
will provide himself with an additional 10 units of Humalog for
rescue for blood sugars 200 and above. He was seen by a diabetes
educator and counseled on diet and insulin administration. He
will need to be scheduled for follow up with the ___ Diabetes
___ upon discharge from ___. Please provide
teaching on insulin administration prior to discharge. Consider
discharging with Kwikpens for ease of administration.
His final insulin regimen is as follows:
Humalin 70/30 50 units with breakfast and 35 units with dinner
Humalog 10 units rescue for blood sugars >200 in the afternoon
and prior to bedtime
Metformin 1000 mg BID
#ETOH use: Mr. ___ has a long history of alcohol use and
was admitted from ___ where he has just completed
detox. He is now discharged to ___ for ongoing
care.
#Depression: Patient endorsed SI while in the ___. This was
initially attributed to substance induced mood disorder and he
was initially sectioned. He was re-evaluated by psychiatry while
in the ___. His SI had subsequently resolved with improved blood
sugars and he was able to express an appropriate safety plan.
While he did have a prior h/o suicide attempt and active ETOH
use, psych advised that specialized care in an outpatient
setting of his choosing is the least constrictive and best way
to maintain the patient's autonomy given his moderate risk.
There were no psychiatric contraindications to discharge. He was
continued on home citalopram.
Chronic:
#Sciatica: Mr. ___ has a history of sciatica. He is
prescribed Percocet as an outpatient by ___ (confirmed) and
was continued on this while in-patient. He is discharged with a
limited supply and should get refills from his PCP if indicated.
#Diabetic neuropathy: Previously on gabapentin, which was
restarted in-house with improvement in pain control.
# Chest pain: Mr. ___ has a ___ year history of intermittent
chest pain. Troponins negative x2 and EKG without ischemic
changes. Exercise stress test revealed estimated peak MET
capcity was 5.2, but no angina symptoms or ST changes. No
recurrence throughout his hospital stay.
#Hypertension: Continued lisinopril and HCTZ
#Tobacco use: Nicotine patch while in house and discharged with
a limited supply
Transitional Issues
--------------
- Patient will need to be scheduled with ___ follow up on
discharge from ___. This should be scheduled within
4 days of discharge with Dr. ___ continuity of care
- Ongoing management of blood sugars
- Patient is Hepatitis C positive and will need referral to the
liver clinic from his PCP as long as he remains sober
- Consider discharging with Kwikpens for ease of insulin
administration if his insurance covers these
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Lisinopril 40 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Amitriptyline 25 mg PO QHS
6. Citalopram 40 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Citalopram 40 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Gabapentin 400 mg PO TID
RX *gabapentin 400 mg 1 capsule(s) by mouth three times daily
Disp #*90 Capsule Refills:*0
7. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour Wear 1 patch daily Disp #*30 Patch
Refills:*0
8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
Please see your primary care physician for refills of this
medication
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every 6 hours Disp #*30 Tablet Refills:*0
9. 70/30 50 Units Breakfast
70/30 35 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hyperglycemia
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 medicine for management of your blood
sugar, which had reached 600 on your arrival to the Emergency
Department. While in the observation unit, your fingerstick
blood sugar ranged from 400-600. We worked with a team from the
___ to adjust you insulin and monitor your
blood sugars. At this time, your blood sugars are better
controlled. We will discharge you on the following regimen:
Insulin 70/30 50 units with breakfast and 35 units with dinner
If your blood sugar is 200 or greater during the day or prior to
bedtime then you will take an additional 10 units of Humalog.
Please see the attached sheet for the details of your insulin
regimen
Additionally, when you first arrived, you complained of left
sided chest pain which had been ongoing for the the past ___
years. EKG and your blood lab tests did not show evidence of any
acute heart condition, and you were monitored on the medicine
floor, until the pain resolved. You received a stress test which
was reassuring.
Please monitor your blood sugar closely and adhere to the
regimen you are discharged on to avoid future events of
hyperglycemia. It will be very important for you to follow up
with your primary care physician and with the diabetes clinic.
Thank you for choosing ___.
Followup Instructions:
___
|
19892880-DS-7 | 19,892,880 | 28,860,858 | DS | 7 | 2177-01-12 00:00:00 | 2177-01-12 14:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
___ - I&D of L proximal tibia
History of Present Illness:
HPI: ___ w/ hx of L ACL repair c/b hardware exposure &
extraarticular absces, most recently s/p L knee I&D on ___
___ returns to ___ with concerns of increased wound
drainage. Patient discharged to self-care on Keflex after the
procedure with instructions to follow-up in 2 weeks.
Patient missed follow-up and presents to the ___ with increased
drainage from incision. Patient states that knee ROM is fine. He
denies fevers and chills.
Past Medical History:
- L ACL repair ___ at ___ c/b extraarticular infection
requiring
reoperation 6 months following
- LLE cellulitis & abscess
Social History:
___
Family History:
denies
Physical Exam:
Vitals: T = 97.6, HR = 78, BP = 124/70, RR = 18, O2Sat = 97% RA
LLE: Wound dehiscence over left proxim-medial tibia with
purulent drainage. Nylon sutures in place. 2+ DP pulse SILT
S/S/SP/DP/Tib. (+) motor ___. Knee ROM ___
degrees without pain
Pertinent Results:
___ 01:41AM ___ PTT-32.0 ___
___ 01:30AM GLUCOSE-99 UREA N-12 CREAT-1.0 SODIUM-139
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13
___ 01:30AM estGFR-Using this
___ 01:30AM CRP-9.3*
___ 01:30AM WBC-6.7 RBC-4.72 HGB-13.4* HCT-41.2 MCV-87
MCH-28.4 MCHC-32.5 RDW-13.4
___ 01:30AM NEUTS-52.0 ___ MONOS-7.9 EOS-3.7
BASOS-1.7
___ 01:30AM PLT COUNT-243
___ 01:30AM SED RATE-7
___ 05:15AM BLOOD Vanco-5.1*
___ 05:16PM BLOOD Vanco-7.1*
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service on
___ with L leg abscess. Patient was taken to the operating
room and underwent ___. Patient tolerated the procedure
without difficulty and was transferred to the PACU, then the
floor in stable condition. Please see operative report for full
details.
Musculoskeletal: prior to operation, patient was WBAT LLE.
After procedure, patient's weight-bearing status was
transitioned to WBAT LLE. Throughout the hospitalization,
patient worked with physical therapy.
Neuro: post-operatively, patient's pain was controlled by IV
dilaudid 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.
Postoperatively, the patient was placed on empiric vancomycin.
Infectious disease was consulted when the cultures began to grow
gram + cocci, who recommended 6 weeks of daptomycin.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #4, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
MVI
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Daptomycin 770 mg IV Q24H
RX *daptomycin [Cubicin] 500 mg 770 mg IV q24h Disp #*42 Vial
Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe SC qPM Disp #*11 Syringe
Refills:*0
5. Multivitamins 1 CAP PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
7. Senna 8.6 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Chronic proximal fibular infection
Discharge Condition:
At the time of discharge, Mr. ___ was ambulating, tolerating
PO's and pain was controlled without nausea.
Discharge Instructions:
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:
- WBAT LLE
Followup Instructions:
___
|
19892936-DS-11 | 19,892,936 | 21,679,045 | DS | 11 | 2128-11-12 00:00:00 | 2128-11-13 15:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tetracycline
Attending: ___.
Chief Complaint:
abdominal pain, fever
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
___ yo male with Type 2 DM, HTN, alcohol abuse in past, and
chronic abdominal pain with recent MRCP showing
choledocholithiasis presents from PCP's office with fever and
abdominal pain. Notes feeling unwell last ___ after work,
developed fever at home, called in sick. Abdominal pain,
generalized in nature, sharp, ___, progressed over weekend,
with recurrent fever. Fever improved with aspirin. Pain did
not improve, worse with movement and eating. Visited PCP ___
___, and given history and known choledocholithiasis,
patient was directed to ___ ED.
In ED, VS: 97.3 57 124/72 16 100% RA
received Unasyn, pain control, RUQ ultrasound performed,
admitted for further eval and management
Upon arrival to the floor, noted ___ abdominal pain, no
appetite, no fevers.
12 ROS as noted above. Recently had excessive alcohol intake in
one setting last month, but otherwise has not been drinking
alcohol over the past month. No nausea or vomiting recently.
Denies dyspnea, chest pain, myalgias. Reports good glycemic
control at home. All other ROS negative.
Past Medical History:
gastroparesis
hypertension
Type 2 diabetes
GERD
depression
CAD
alcohol abuse in past
Surgical history:
Cholecystectomy in ___
Social History:
___
Family History:
no history of GI malignancy
Physical Exam:
VS: 98.1 127/84 HR 61 RR 18 98% RA
General: pleasant, uncomfortable appearing
HEENT: icteric sclerae, clear oropharynx
Neck: no lymphadenopathy
CV: RRR, normal S1, S2, no murmurs
Pulm: lungs clear bilaterally
Abdomen: slightly distended, moderate tenderness throughout with
some mild rebound
Ext: 2+ radial and DP pulses, no clubbing or edema
Skin: no rash
Neuro: CNs ___ intact, strength and sensation grossly intact
Physical Examination on discharge:
VS: 98.4 BP: 162/81 HR: 58 R: 18 O2 96% RA
GEN: Alert, oriented to name, place and situation. Comfortable
in NAD. Fully dressed.
HEENT: NCAT, sclerae non-icteric, o/p clear, MMM.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended. No rebound or guarding.
+BS
EXTR: No lower leg edema, no clubbing or cyanosis
Neuro: non-focal
PSYCH: Appropriate and calm, mood better today
Pertinent Results:
URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-10
BILIRUBIN-MOD UROBILNGN-NEG PH-5.5 LEUK-NEG
URINE COLOR-Yellow APPEAR-Clear SP ___
URINE RBC-<1 WBC-4 BACTERIA-NONE YEAST-NONE EPI-0
GLUCOSE-328* LACTATE-1.4 NA+-134 K+-3.7 CL--93* TCO2-22
GLUCOSE-351* UREA N-18 CREAT-1.2 SODIUM-133 POTASSIUM-3.8
CHLORIDE-92* TOTAL CO2-20* ANION GAP-25*
ALT(SGPT)-248* AST(SGOT)-299* ALK PHOS-679* TOT BILI-9.2*
LIPASE-3460*
ALBUMIN-3.8
WBC-8.3 RBC-4.00* HGB-14.7 HCT-40.0 MCV-100* MCH-36.7*
MCHC-36.7* RDW-13.7
NEUTS-84.2* LYMPHS-9.6* MONOS-5.7 EOS-0.3 BASOS-0.2
PLT COUNT-207
___ PTT-32.3 ___
___ MRCP:
IMPRESSION:
1. Two stones in the distal common bile duct, causing mild
intrahepatic biliary ductal dilatation and peribiliary
inflammation.
2. Diffuse moderate hepatic steatosis.
3. Left colonic diverticula.
___ RUQ ultrasound:
IMPRESSION: Extrahepatic and intrahepatic biliary duct
dilatation without choledocholithiasis. Consider correlation
with MRCP/ERCP.
ERCP: ___
Normal major papilla
Cannulation of the biliary duct was successful and deep with a
sphincterotome
There was a filling defect consistent with a stone in the distal
CBD
A sphincterotomy was performed
Sphincteroplasty was performed with an 8mm balloon
Muliple stone fragments were extracted successfully using a
balloon sweep.
Even after several balloon sweeps, a small fillig defect
remained in the distalmost portion of the CBD. hence a 5cm by
___ double pig tail biliary stent was placed successfully.
Otherwise normal ercp to third part of the duodenum
Discharge labs:
___ 07:00AM BLOOD WBC-5.9 RBC-3.20* Hgb-10.8* Hct-31.6*
MCV-99* MCH-33.7* MCHC-34.2 RDW-13.5 Plt ___
___ 07:00AM BLOOD Glucose-183* UreaN-3* Creat-0.8 Na-141
K-3.4 Cl-104 HCO3-22 AnGap-18
___ 07:00AM BLOOD ALT-57* AST-40 AlkPhos-294* TotBili-1.2
___ 07:00AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.7
___ 08:17AM BLOOD VitB___-___*
Brief Hospital Course:
This is a ___ y/o man with history of prior cholecystectomy,
diabetes complicated by gastroparesis who presented with fever,
chills, and abdominal pain and was found to have chlangitis and
pancreatitis.
# Cholangitis/pancreatitis
Presented with pain and fever concerning for cholangitis. On
admission, his bilirubin was 9.2, Lipase was 3460. He was
started on IV Unasyn. He underwent ERCP which showed a filling
defect in the CBD. Multiple stones were extracted and a stent
was placed. The patient was afebrile following the procedure but
continued to have abdominal pain, likely due to persisent
pancreatitis. He was treated with IV fluids, bowel rest and pain
control. His LFTs trended T. Bili was 1.2 on day of discharge,
his transaminases remained slightly elevated ALT: 57 AST: 40.
As his pain improved, his diet was advanced and he was able to
tolerate a regular diet without abdominal pain prior to
discharge. Blood cultures remained negative. He was discharged
on Po Augmentin to complete a 7 day course.
- will need repeat ERCP in ___ weeks for stent removal and
re-evaulation
#Anemia, Macrocytic
The patient was noted to have macrocytic anemia. There were no
signs of active bleeding. B12 was checked and was 1376, ruling
out B12 deficiency. Macrocytosis may be due to alcohol use.
-- consider further outpatient work up
#History of alcohol abuse:
No signs of withdrawal while hospitalized
Chronic issues:
# GERD
Patient was continued on PPI
# HTN
Continued on atenolol. Lisinopril was initally held but resumed
on discharge.
# Type 2 DM, with complication (gastroparesis)
The patient was maintained on an insulin sliding scale during
his hospitalization. Reglan was resumed once the patient was
eating. Metformin was resumed on discharge.
# Depression
Continued Prozac
# ADHD
Stimulant was held while in house
# Hyperlipidemia/CAD
ASA was held 5 days after ERCP and was resumed on discharge, BB
and Statin were continued.
Transitional issues:
-- needs repeat ERCP in ___ weeks for stent removal and
reevaluation
-- consider further work up of macrocytic anemia
-- continue to encourage abstinence from alcohol given history
of abuse
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amphetamine-dextroamphetamine *NF* 60 mg Oral daily
2. Atenolol 25 mg PO DAILY
hold for SBP < 100, HR < 60
3. Atorvastatin 80 mg PO DAILY
4. Lorazepam 1 mg PO Q6H:PRN anxiety
hold for sedation, RR < 10
5. Colestid *NF* (colestipol) 1 gram Oral hs
6. Cyclobenzaprine 10 mg PO TID:PRN pain
7. DiCYCLOmine 10 mg PO TID
8. Fluoxetine 60 mg PO DAILY
9. Lisinopril 2.5 mg PO DAILY
hold for SBP < 100
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Metoclopramide 5 mg PO QIDACHS
12. Pantoprazole 40 mg PO Q12H
13. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Fluoxetine 40 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
5. Lorazepam 1 mg PO Q6H:PRN anxiety
6. Metoclopramide 5 mg PO QIDACHS
7. Pantoprazole 40 mg PO Q12H
8. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*3 Tablet Refills:*0
9. amphetamine-dextroamphetamine *NF* 60 mg ORAL DAILY
10. Aspirin 81 mg PO DAILY
11. Colestid *NF* (colestipol) 1 gram Oral hs
12. Cyclobenzaprine 10 mg PO TID:PRN pain
13. DiCYCLOmine 10 mg PO TID
14. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Choledocolithasis
Acute pancreatitis
Possible cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with a gallstones in your
bile duct and inflammation of your pancreas. You had a procedure
called an ERCP and the stones were removed and a stent was
placed in your bile duct. You will need the stent removed in ___
weeks.
You were also treated for pancreatitis with bowel rest and
intravenous fluids. You improved and will be discharged home.
You will need to take one additional day of antibiotics.
You will need to follow up with your primary care physician and
with the gastroenterologists for repeat ERCP in ___ weeks.
You should abstain from drinking alcohol as it can cause
pancreatitis. If you need help with stopping, please talk to
your primary care physician or call AA at ___ for
information about meetings.
Followup Instructions:
___
|
19892976-DS-17 | 19,892,976 | 22,830,523 | DS | 17 | 2134-06-17 00:00:00 | 2134-06-17 17:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending: ___
Chief Complaint:
Back Pain, Unable To Ambulate
Major Surgical or Invasive Procedure:
Lumbar epidural steroid injection ___
History of Present Illness:
Ms. ___ is a ___ female with history of L5
disc herniation, endometrial hyperplasia s/p D&C, migraines,
obesity, presenting with acute on chronic back pain.
Her right lower back pain worsened over the past day to the
point where she has been unable to ambulate secondary to the
pain. She has history of L5 disc herniation and is s/p LESI. She
was scheduled to have LESI for ___. She has attempted heat
therapy, stretching, cyclobenzaprine, and Gralize (gabapentin
brand name). She denies any trauma but does travel frequently
for work carrying her own luggage. She reports constipation,
potential urinary incontinence, and saddle numbness. She denies
fevers or chills.
In the ED:
Initial vital signs were: 97.2 89 136/81 16 100% RA
Exam notable for: ___ strength in lower extremities. Decreased
sensation on RLE and in the R inner groin. Delayed rectal tone.
Tenderness to plapation over R sacro-iliac joint.
Labs were notable for: Hgb 11.1, CHEM-7 WNL, Coags WNL
Studies performed include:
___ MR ___ contrast:
1. Stable degenerative changes of the lumbar spine most
significant at L4-5 where there is a right central disc
extrusion demonstrating inferior migration and causing mass
effect on the traversing right L5 nerve root. Moderate spinal
stenosis and indentation of the thecal sac at L4-5 level is also
unchanged.
2. Unchanged annular fissures at L2-L3, L3-L4 and L4-L5.
Patient was given: IV Ketorolac 15 mg x2, IV morphine sulfate 2
mg x2, IV morphine sulfate 4 mg x1, Acetaminophen 1000 mg PO x2,
Lidocaine 5% TD patch, diazepam 10 mg PO x2, oxycodone 5 mg PO
x1,
Consults: Neurology, Spine
Vitals on transfer: 97.9 111/69 18 99% RA
Upon arrival to the floor, the patient reports her lower back
pain is located superiorly to the buttocks and radiates down her
right lateral leg to her toes. Her pain is worse with movement
and her right leg feels weak secondary to the pain. She is
rubbing her right lower abdomen which provides some pain relief
by "putting traction" on her abdominal wall and putting less
tension on her back. She denies any urinary incontinence since
presentation and has not had a BM in 36 hours. At baseline, she
has a daily BM but her BMs have been inconsistent as she has
been travelling over the past few weeks. She took an extra 300
mg of Gralise on ___ night with no improvement in pain.
Prior to one week ago, her back pain was at baseline. Her
baseline pain is ___ and worse in the evening and when she
wears heels.
She denies fevers, chills, N/V, headache, worsening back pain
when supine, dysuria, palpitations, chest pain, SOB, dyspnea, or
acute trauma/falls. She endorses infrequent night sweats but
attributes this to ___. Her last menses was in
___ and ___ prior to that. Her last mammogram was
___ and unremarkable.
Past Medical History:
CHRONIC RHINITIS
MIGRAINES
MORBID OBESITY
NECK PAIN
H/O ECTOPIC PREGNANCY
H/O ENDOMETRIAL HYPERPLASIA
H/O MIGRAINE HEADACHES
H/O SINUSITIS
H/O INFERTILITY
HYSTEROSCOPY, D&C FOR ENDOMETRIAL POLYP ___
CESAREAN SECTION ___ for twin gestation
D&C FOR HYPERPLASIA ___
LAPAROSOCPY FOR LEFT ECTOPIC PREGNANCY
Social History:
___
Family History:
Mother MELANOMA and other skin cancers, FIBROMYALGIA
Father SKIN CANCER, COLON POLYP
MGM DIABETES MELLITUS, ___ DISEASE
MGF PANCREATIC CANCER
MGM BREAST CANCER, HEART ATTACK, ALZHEIMERS
Physical Exam:
ADMISSION EXAM
==========================
VITALS: T 97.8 143/84 82 18 99% RA
GENERAL: alert and interactive, lying in bed in NAD but appears
uncomfortable when transferring
HEENT: NC/AT, PERRLA, EOMI, sclera anicteric, MMM, good
dentition
NECK: supple, no JVD
CARDIAC: RRR, normal S1/S2, no murmurs, rubs, or gallops, 2+
radial and DP pulses
LUNGS: CTAB, no adventitious breath sounds, unlabored
respirations
BACK: no point tenderness, no CVA tenderness
ABDOMEN: soft, non-distended, +BS, non-tender to palpation, no
rebound or guarding
EXTREMITIES: No clubbing or lower extremity edema, warm,
well-perfused
SKIN: warm, no rash
NEUROLOGIC: A/Ox3, CN II-XII intact, ___ LLE strength and ___
RLE strength due to pain, no sensory deficits, ___ ankle
dorsiflexion and plantar flexion bilaterally
DISCHARGE EXAM
==============================
VITALS: 24 HR Data (last updated ___ @ 2336)
Temp: 98.1 (Tm 98.4), BP: 109/73 (109-127/73-83), HR: 90
(78-90), RR: 18, O2 sat: 97% (97-98), O2 delivery: RA
GENERAL: alert and interactive, lying on her side in bed.
Uncomfortable appearing but no acute distress.
HEENT: NC/AT, PERRLA, EOMI, sclera anicteric, MMM, good
dentition
NECK: supple, no JVD
CARDIAC: RRR, normal S1/S2, no murmurs, rubs, or gallops, 2+
radial and DP pulses
LUNGS: CTAB, no wheezes rhonchi rales, no increased work of
breathing
ABDOMEN: soft, non-distended, +BS, non-tender to palpation, no
rebound or guarding
EXTREMITIES: No clubbing or lower extremity edema, warm,
well-perfused
SKIN: warm, no rash
NEUROLOGIC: A/Ox3, CN II-XII intact, ___ LLE strength and ___
RLE
strength at hip flexors due to pain, no sensory deficits to
light
touch, ___ ankle dorsiflexion and plantar flexion bilaterally.
Able to flex both knee and hip to <90 degrees while laying
sideways in bed.
Pertinent Results:
================
ADMISSION LABS
================
___ 08:14PM BLOOD WBC-8.0 RBC-4.16 Hgb-11.1* Hct-35.1
MCV-84 MCH-26.7 MCHC-31.6* RDW-15.7* RDWSD-48.4* Plt ___
___ 08:14PM BLOOD Glucose-82 UreaN-12 Creat-0.6 Na-140
K-4.0 Cl-103 HCO3-24 AnGap-13
========
IMAGING
========
___ R XR ANKLE
Unremarkable right ankle radiographs
___ MRI SPINE
1. Stable degenerative changes of the lumbar spine most
significant at L4-5 where there is a right central disc
extrusion demonstrating inferior migration and causing mass
effect on the traversing right L5 nerve root. Moderate spinal
stenosis and indentation of the thecal sac at L4-5 level is also
unchanged.
2. Unchanged annular fissures at L2-L3, L3-L4 and L4-L5.
================
DISCHARGE LABS
================
___ 08:30AM BLOOD WBC-4.9 RBC-4.19 Hgb-11.3 Hct-35.8 MCV-85
MCH-27.0 MCHC-31.6* RDW-15.9* RDWSD-49.8* Plt ___
___ 08:30AM BLOOD Glucose-87 UreaN-21* Creat-0.6 Na-142
K-4.5 Cl-106 HCO3-24 AnGap-12
Brief Hospital Course:
Ms. ___ is a ___ female with history of L5
disc herniation, endometrial hyperplasia s/p D&C, migraines,
presenting with acute on chronic back pain.
#Acute on chronic back pain:
#Spinal stenosis:
#L5 radiculopathy: Chronic back pain has been present since
___, presented with acute worsening of back pain. MRI
___ showed stable L4-5 disc extrusion causing mass effect
on L5 root as well as spinal stenosis. Pain is more severe and
limiting mobility. Neurosurgery evaluated in ED and recommended
no acute surgical intervention. She received lumbar epidural
steroid injection with CPS on ___. Her home pain medications
were titrated to the following regimen:
- Cyclobenzaprine ___ mg TID PRN
- Gralise (gabapentin) 1500 mg qHS
- Ibuprofen 400 mg TID PRN
- Acetaminophen 650 mg QID PRN
- Lidocaine patch PRN
- Oxycodone ___ mg q6h PRN
- Diclofenac gel PRN
# Constipation: likely multifactorial from pain medication and
significant pain with straining. Discharged on aggressive bowel
regimen and discussed with patient importance of adhering to
bowel regimen
# Chronic rhinitis: continued home loratadine, pseudoephedrine
===================
TRANSITIONAL ISSUES
===================
[] Pain regimen as above. Discussed with patient and will
provide short narcotic script during acute flare. Reviewed risk
of gastritis, renal dysfunction with prolonged NSAID use.
Recommended limiting use of diclofenac gel to small body surface
area
[] Patient scheduled to follow up with outpatient pain provider
[] Patient evaluated by ___ and recommended for rehab, although
patient declined. Discharged with home ___, script for walker
#CODE: Full code (confirmed)
#CONTACT: ___ (husband), Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
2. Loratadine 10 mg PO DAILY
3. Pseudoephedrine 240 mg PO DAILY:PRN Congestion
4. Cyclobenzaprine ___ mg PO TID:PRN Back spasms
5. Gralise (gabapentin) 900 oral QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily PRN Disp #*30
Tablet Refills:*0
3. diclofenac sodium 1 % topical BID:PRN
RX *diclofenac sodium 1 % apply small amount to affected area
BID prn Refills:*0
4. Lactulose 15 mL PO DAILY constipation
RX *lactulose 10 gram/15 mL (15 mL) 15 ml by mouth daily prn
Disp #*1 Bottle Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD QPM Lower back
RX *lidocaine 5 % ___ patches daily prn Disp #*60 Patch
Refills:*0
6. Lidocaine 5% Patch 1 PTCH TD QPM right hip
7. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 10 mg 0.5 - 1 tablet(s) by mouth q6h prn Disp #*28
Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
prn Disp #*30 Packet Refills:*0
9. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
10. Gralise (gabapentin) 1500 mg oral QHS
RX *gabapentin [Gralise] 300 mg 5 tablet(s) by mouth at bedtime
Disp #*75 Tablet Refills:*0
11. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *ibuprofen 400 mg 1 tablet(s) by mouth q8h prn Disp #*90
Tablet Refills:*0
12. Cyclobenzaprine ___ mg PO TID:PRN Back spasms
RX *cyclobenzaprine 5 mg ___ tablet(s) by mouth TID PRN Disp
#*60 Tablet Refills:*0
13. Loratadine 10 mg PO DAILY
14. Pseudoephedrine 240 mg PO DAILY:PRN Congestion
15.Walker
Walker
ICD 10 M51.2 Lumbar disc displacement
LOS: 13 months
Prognosis: good
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
L4-5 disc herniation
Acute on chronic back pain
Chronic rhinitis
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 were admitted for severe back pain
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had an MRI of your spine that continued to show L4-5 disc
extrusion, which is likely causing your pain
- You had a steroid injection into your back to help with your
pain
- You had an x-ray of your ankle which was normal
- Your pain medications were adjusted
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- It is very important that you take your bowel medications:
1. Senna - take twice a day. Can hold if loose stools
2. Polyethylene glycol (miralax) - take daily. Can hold if loose
stools
3 Bisacodyl 10 mg as needed
4. Lactulose 15 mL daily as needed. You can take this up to 3
times a day if worsening constipation.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19893075-DS-11 | 19,893,075 | 27,110,682 | DS | 11 | 2132-11-03 00:00:00 | 2132-11-10 11:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
Percocet / Keflex / oxycodone
Attending: ___.
Chief Complaint:
Left ureteral stone
Major Surgical or Invasive Procedure:
Cystoscopy and left ureteral stent placement
History of Present Illness:
___ year old female transferred from ___ with a 8 x 6 mm
stone in the LEFT proximal ureter. Now with extreme pain,
impaired renal function, UA c/w infection, and febrile to ___.
Past Medical History:
None
Social History:
___
Family History:
Noncontributory
Physical Exam:
NAD
Equal chest rise b/l
Abd soft NTND
Min CVA TTP on left side
Ext WWP
Pertinent Results:
___ 05:55AM BLOOD WBC-18.6* RBC-3.09* Hgb-10.3* Hct-29.9*
MCV-97 MCH-33.3* MCHC-34.4 RDW-12.4 RDWSD-43.4 Plt ___
___ 08:38AM BLOOD WBC-18.1*# RBC-3.35* Hgb-11.1* Hct-32.0*
MCV-96 MCH-33.1* MCHC-34.7 RDW-11.9 RDWSD-42.1 Plt ___
___ 06:30AM BLOOD WBC-7.9# RBC-3.31* Hgb-10.9* Hct-31.4*
MCV-95 MCH-32.9* MCHC-34.7 RDW-12.0 RDWSD-42.1 Plt Ct-81*
___ 06:11AM BLOOD WBC-5.0 RBC-3.35* Hgb-11.0* Hct-32.4*
MCV-97 MCH-32.8* MCHC-34.0 RDW-12.3 RDWSD-43.1 Plt Ct-72*
___ 02:50PM BLOOD WBC-4.5 RBC-3.76* Hgb-12.5 Hct-36.1
MCV-96 MCH-33.2* MCHC-34.6 RDW-12.1 RDWSD-42.5 Plt Ct-73*
___ 02:50PM BLOOD Neuts-76* Bands-4 Lymphs-12* Monos-3*
Eos-0 Baso-0 Atyps-1* Metas-2* Myelos-2* AbsNeut-3.60
AbsLymp-0.59* AbsMono-0.14* AbsEos-0.00* AbsBaso-0.00*
___ 05:55AM BLOOD Glucose-115* UreaN-9 Creat-0.8 Na-132*
K-3.5 Cl-96 HCO3-25 AnGap-15
___ 08:38AM BLOOD Glucose-118* UreaN-13 Creat-0.9 Na-131*
K-3.1* Cl-94* HCO3-25 AnGap-15
___ 06:10AM BLOOD Glucose-98 UreaN-15 Creat-1.1 Na-132*
K-3.1* Cl-99 HCO3-23 AnGap-13
___ 06:11AM BLOOD Glucose-149* UreaN-33* Creat-1.7* Na-134
K-3.1* Cl-99 HCO3-23 AnGap-15
___ 02:50PM BLOOD Glucose-96 UreaN-49* Creat-2.5* Na-135
K-3.4 Cl-100 HCO3-21* AnGap-17
___ 05:55AM BLOOD Phos-3.2 Mg-1.4*
___ 08:38AM BLOOD Phos-3.1 Mg-1.4*
___ 06:11AM BLOOD Phos-2.1* Mg-1.6
___ 02:50PM BLOOD Calcium-7.6* Phos-3.5 Mg-1.7
___ 02:56PM BLOOD Lactate-1.8
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ URINE URINE CULTURE-FINAL {ENTEROCOCCUS SP.,
ESCHERICHIA COLI, ESCHERICHIA COLI} EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
Time Taken Not Noted Log-In Date/Time: ___ 5:44 pm
URINE TAKEN FROM ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IDENTIFICATION AND SUSCEPTIBILITY TESTING REQUESTED PER ___
___
___ (___) ___.
ENTEROCOCCUS SP.. <10,000 organisms/ml.
ESCHERICHIA COLI. <10,000 organisms/ml.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. <10,000 organisms/ml. SECOND
MORPHOLOGY.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ESCHERICHIA COLI
| | ESCHERICHIA
COLI
| | |
AMPICILLIN------------ <=2 S <=2 S 8 S
AMPICILLIN/SULBACTAM-- <=2 S 4 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- <=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM------------- <=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
VANCOMYCIN------------ 1
Brief Hospital Course:
Ms. ___ was admitted to the urology service from the
emergency department with left ureteral nephrolithiasis
management and underwent cystoscopy with left ureteral stent
placement. She received gentamicin and clindamycin in the OR.
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 with gentamicin and
ampicillin. On POD1, the patient spiked a fever to 102 in the
afternoon, and antibiotic coverage was switched to vanc/zosyn at
the recommendation of the antibiotic stewardship service. The
following day, infectious disease was curbsided and she was
switched to ciprofloxacin. She did have one additional episode
of fever to 102.5 on cipro, and a followup ultrasound was
obtained; this showed stent in good position with no abscesses.
Her initial UCx grew mixed flora with <10k of each enterococcus
and GNRs. Though she remained afebrile throughout the evening
of ___, her WBC on ___ was 18, and as such ID recommended
switching from cipro to unasyn. At discharge, patients pain was
controlled with oral pain medications, tolerating regular diet,
ambulating without assistance, and voiding without difficulty.
Ms. ___ was explicitly advised to follow up as directed as
the indwelling ureteral stent must be removed and or exchanged.
She will return for definitive stone management and will
complete a full course of Augmentin as directed.
Medications on Admission:
NONE
Discharge Medications:
1. TraMADol 50 mg PO Q4H:PRN Pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*28 Tablet Refills:*0
2. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*28 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*28 Capsule Refills:*0
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 14 Days
complete this course even if you feel better
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg ONE
TAB by mouth Q12HRS Disp #*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left proximal ureteral stone, bacteremia w/ fever, urinary tract
infection
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 still be 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. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication 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.
-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, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
Followup Instructions:
___
|
19893114-DS-11 | 19,893,114 | 23,619,610 | DS | 11 | 2183-11-03 00:00:00 | 2183-11-04 15:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
pyelonephritis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ with history of renal transplant in ___, HTN, HLD
presenting with R flank pain, polyuria, dysuria. The patient
had a recent admission ___ for UTI/Pyelonephritis. At
that time she had symptoms of dysuria, tactile temps and mid to
R sided abdominal discomfort wrapping around to the back. She
was initially treated with broad spectrum abx, but later
narrowed to cipro for e. coli UTI. She was discharged home.
She was doing well and finished a course of antibiotics on
___. On ___, she noticed some mild dysuria and
frequency. on ___, she developed recurrent epigastric pain
that radiates around to the right flank. Also with some
tenderness over her transplanted kidney. She reports some
nausea and vomiting x2. No diarrhea, chest pain, SOB, cough,
URI symptoms, joint/muscle pain, rash. She reports subjective
fevers and chills with sweats overnight and given her worsening
symptoms, she presented to the ED for further evaluation.
In the ED, initial vitals were: 100.4 78 142/70 20 100%. Spiked
to 103. ___ significant for WBC: 15.1 (N:90.9 L:5.4 M:3.4
E:0.1 Bas:0.1), Lactate 0.9, U/A with WBC 159 although with epi:
15. nitrite negative. Given zofran 4mg IVx1, morphine 5mg IV
x2, ceftriaxone 1gm IV, tylenol 1gm x1. U/S without
abnormalities. She was also given 1L NS and plan for admission
for further management. Vitals prior to transfer: 103 80 126/63
16 100%.
ROS: per HPI, denies headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, diarrhea, constipation, BRBPR, melena,
hematochezia
Past Medical History:
HTN
Renal Failure
Hypercholesterolemia
PSH: kidney transplant ___ (Cadaveric renal transplant, right
iliacfossa and ___ ureteral stent)
Social History:
___
Family History:
DM (brother, mother, father), HTN (brother, mother, father)
positive for HLD, no CAD or cancer.
Physical Exam:
ADMISSION EXAM:
VS: 100.2, BP: 107/63, HR: 77, RR: 16, O2 sat: 99% RA
General: Ill appearing woman, diaphoretic, hair matted down
HEENT: sclera anicteric,
Neck: No JVP
CV: II/VI systolic murmur heard throughout the precordium
Lungs: CTAB bilaterally
BACK: no CVA tenderness
Abdomen: tenderness in the epigastrium, RUQ, and RLQ without
gaurding or rebound tenderness
GU: no foley in place
Ext: no edema, 2+ pulses, bilaterally throughout
Neuro: ___ intact, sensation equal throughout, strenght
___ in all extremities
Skin: no rashes or lesions
,
DISCHARGE EXAM:
VS: Afebrile 98.5 Tm 98.1 Tc 97/63 59 18 99/RA
I/O: 700/800(ON) 1680/1100 BM x 2(24)
General: well appearing Hispanic female, ambulating in room
HEENT: sclera anicteric, PERRL
Neck: No JVP
CV: II/VI systolic murmur heard throughout the precordium
Lungs: CTAB bilaterally
Abdomen: nontender and without guarding or rebound tenderness
GU: no foley
Ext: no edema, 2+ pulses
Neuro: moving all extremities, gait intact
Skin: no rashes or lesions
Pertinent Results:
ADMISSION ___
___ 11:05AM BLOOD ___
___ Plt ___
___ 11:05AM BLOOD ___
___
___ 06:10AM BLOOD ___ ___
___ 11:05AM BLOOD ___
___
___ 11:05AM BLOOD ___
___ 06:10AM BLOOD ___
___ 06:10AM BLOOD ___
___ 11:22AM BLOOD ___
DISCHARGE ___
___ 06:15AM BLOOD ___
___ Plt ___
___ 11:05AM BLOOD ___
___
___ 06:15AM BLOOD ___ ___
___ 06:15AM BLOOD ___
___
___ 06:15AM BLOOD ___
___ 06:15AM BLOOD ___
OTHER ___
___ 04:50PM URINE ___ Sp ___
___ 04:50PM URINE ___
___
___ 04:50PM URINE RBC->182* WBC->182* ___
___
___ 11:00AM URINE ___
___ PENDING AT DISCHARGE
Blood cultures from ___ and ___ NGTD
MICROBIOLOGY
___ 11:00 am URINE CLEAN CATCH.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefepime sensitivity testing performed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
RADIOLOGY
___ Chest xray
No acute cardiopulmonary process.
___ renal transplant u/s
Transplanted kidney is seen in the right lower quadrant
measuring
13.8 cm. Corticomedullary architecture is normal. There is no
hydronephrosis. No stones are identified. The kidney
demonstrates normal vascularity on color flow; however, Doppler
examination is not performed. No perinephric fluid collection
is identified. Partially distended bladder is grossly
unremarkable.
CT abd/pelvis with contrast ___
The lung bases are clear. The visualized heart and pericardium
are
unremarkable. The liver enhances homogeneously. There is
minimal
intrahepatic biliary duct dilatation which may be seen in
patients status post cholecystectomy as is the case in this
patient. The portal vein is patent. The pancreas, spleen, and
adrenal glands are within normal limits. The native kidneys are
atrophic, compatible with known history of chronic kidney
disease. The transplant kidney is seen in the anterior right
hemipelvis. There are multiple areas of decreased contrast
uptake, with loss of corticomedullary differentiation as in
image 2:54. Also in interpolar region of the kidney there is a
large triangular region of hypoenhancement extending to the
cortex which is also compatible with pyelonephritis. A 6 mm
cyst is noted in the posterior aspect of the interpolar region
(2:65), too small to characterize but likely benign. There is
no evidence of hydronephrosis or nephrolithiasis. The small and
large bowel are unremarkable, without wall thickening or
dilatation to suggest obstruction. The appendix is seen and is
not inflamed. There is no retroperitoneal or mesenteric
lymphadenopathy by CT size criteria. The aorta is ___
and the main ___ vessels are grossly patent. There
is no ascites, abdominal free air or abdominal wall hernia.
PELVIC CT: For description of the transplanted kidney, please
refer to
abdomen section of this report. The urinary bladder is
unremarkable. The uterus and adnexa are within normal limits.
A dropped surgical clip is noted the ___ (2:69). The
sigmoid and rectum are within normal limits. There is no pelvic
wall or inguinal lymphadenopathy. The origin of the arterial
supply of the transplanted kidney in the right common iliac
artery is grossly patent. No pelvic free fluid is identified.
OSSEOUS STRUCTURES: There are no lytic or blastic lesions
concerning for
malignancy.
Chest xray ___
The left PICC line extends to the lower portion of the SVC. No
acute cardiopulmonary disease.
Brief Hospital Course:
ASSESSMENT AND PLAN: This is a ___ yo woman with ESRD of unclear
etiology s/p renal transplant in ___ with no history of renal
stones, retention or UTI now with recurrent UTI symptoms 1 day
after completing a course of abx concerning for nidus of
infection.
# pyelonephritis: Patient with recurrent pyelonephritis
presenting with symptoms including dysuria, graft pain, fever
and malaise. She had recently completed a 14 day course of oral
ciprofloxacin after 4 days of IV cefepime in house, but her
symptoms recurred 1 day after stopping the medication suggesting
a nidus for infection vs failure of po antibiotics. ID was
consulted who recommended treatment with full course of IV
antibiotics with presumed failure of PO. Microbiology revealed
new cephalosporin resistant ESBL organism (ecoli) and she was
started on meropenem 500mg IV q6 with resolution of all
complaints. CT abd/pelvis with contrast and renal u/s confirmed
pyelonephritis. Plan for ___ weeks of IV abx via PICC line with
plan for outpatient ID transplant clinic f/u and likely
reimaging of graft after completion of abx course. Blood
cultures no growth to date at time of DC summary. Counseled on
___ voiding to minimize recurrent UTI.
.
# ESRD s/p transplant: Doing well on her current
immunosuppresant regiment. Her creatinine is stable. No
concern for rejection at this time. Slight uptrend in tacrolimus
levels attributed to pt receiving ___ formula in house. Pt
has been on Dr. ___ as outpatient and was switched
back to generic on ___.
She was continued at time of discharge on tacrolimus 6mg q12,
cellcept 500mg PO BID
and bactrim SS daily. Plan for tacrolimus level checked ___
___ faxed to renal ___.
.
# Hypercholesterolemia She was continued on home dose
Pravastatin 20 mg PO DAILY.
# HTN: She was continued on home dose Amlodipine 5 mg PO DAILY
and Metoprolol Tartrate 50 mg PO BID.
TRANSITIONAL ISSUES
- Needs ___ checked: tacrolimus level on ___ plan to fax
results to ___, pt was provided with prescription
for lab draw
- plan for outpatient follow up with transplant ___ clinic, renal
transplant clinic and PCP
- ___ pending at time of discharge include blood cultures
(NGTD)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mycophenolate Mofetil 500 mg PO BID
2. Pravastatin 20 mg PO DAILY
3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
4. Amlodipine 5 mg PO DAILY
5. Metoprolol Tartrate 50 mg PO BID
6. Tacrolimus 6 mg PO Q12H **Dr. ___ only**
Discharge Medications:
1. Outpatient Lab Work
Please check weekly ___: chemistry 7 panel, CBC w/ diff, AST,
ALT, total bilirubin. Fax results to ___ transplant ___ clinic
at ___. ATTN: Dr. ___ or ___
code: 590.1, V42.0
2. ertapenem *NF* 1 gram Intravenous daily Duration: 4 Weeks
RX *ertapenem [Invanz] 1 gram 1 gram IV daily Disp #*30 Gram
Refills:*0
3. Amlodipine 5 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Mycophenolate Mofetil 500 mg PO BID
6. Pravastatin 20 mg PO DAILY
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Tacrolimus 6 mg PO Q12H
Dispense Dr. ___ (generic) ONLY
9. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
RX *sodium chloride 0.9 % 0.9 % 10 ml IV flush daily Disp #*60
Syringe Refills:*1
10. Outpatient Lab Work
Please check transplant ___ in 3 days on ___: tacrolimus
level, chemistry 7 panel. Fax results to ___ transplant clinic
at ___. ATTN: Dr. ___ code: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pyelonephritis
ESRD s/p renal transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at ___. You were admitted
with a kidney infection (pyelonephritis) and the bacteria was
resistant to oral antibiotics. An IV was placed in your arm that
can be used at home for 1 month. The Infectious Disease doctors
___ to see you in clinic in ___ weeks and will determine
how long the antibiotics will need to be continued.
Please follow the medication recommendations listed below.
Followup Instructions:
___
|
19893114-DS-13 | 19,893,114 | 26,301,121 | DS | 13 | 2188-06-11 00:00:00 | 2188-06-11 18:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Dysuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman, with PMH ESRD ___ chronic
glomerulosclerosis s/p DDRT in ___ on chronic
immunosuppression,
HTN/HLD, pre-diabetes, presenting with 2 days of dysuria,
urinary
frequency, and 1 day of generalized body aches and chills. Has
history of complicated UTIs in the past, most recently
pansensitive E Coli ___. She denied pain in kidney graft site,
nausea, vomiting, diarrhea, cough, shortness of breath. She has
a
sore throat and mild headache. She received her flu shot this
year. Compliant with her antirejection medications. No skin
rashes.
In the ED initial vitals: 100.0 92 124/79 18 100% RA
- Exam notable for:
Gen: Appears somewhat uncomfortable but in no acute distress
HEENT: NC/AT. EOMI.
Neck: No swelling.
Cor: RRR. No m/r/g.
Pulm: CTAB, Nonlabored respirations.
Abd: Soft, NT, ND. Typically no pain over her renal transplant
graft site on the right
Ext: No edema, cyanosis, or clubbing.
Skin: No rash.
Neuro: AAOx3. Gross sensorimotor intact.
Psych: Normal mentation.
Heme: No petechial
- Imaging notable for:
Renal Transplant U/S:
1. Apparent interval increase in peak systolic velocity of the
main renal artery near the anastomosis, measuring up to 277
cm/S.
2. Normal intrarenal resistive indices similar to prior.
CXR PA/Lat: No acute cardiopulmonary process.
- Labs notable for:
WBC 12.5 w 85.8% neutrophils
Cr 0.8, HCO3 21
UA: Lg Leuk, Pos Nitr, 32 WBC, 2 RBC, Few Bact, 1 Epi
UCG: Negative
___
FluAPCR: Negative
FluBPCR: Negative
Blood and urine cx: pending
- ED Course notable for:
0630: rigors, shaking chills, fever to 102.7. broadened to vanc
+
cefepime
- Patient was given:
___ 00:00 1L IVF NS
___ 00:04 PO Acetaminophen 1000 mg
___ 01:31 IV Ciprofloxacin 400 mg
___ 06:49 IV CefePIME 2 g
___ 06:49 PO Acetaminophen 1000 mg
___ 06:49 1 L IVF NS
___ 09:10 PO Mycophenolate Mofetil 500 mg
___ 09:10 PO Tacrolimus 4 mg
___ 09:10 IV Vancomycin 1000 mg
___ 09:57 IV Ciprofloxacin 400 mg
- Vitals prior to transfer: 99.6 74 127/74 16 98% RA
Past Medical History:
HTN
Renal Failure
Hypercholesterolemia
PSH: kidney transplant ___ (Cadaveric renal transplant, right
iliacfossa and double-J ureteral stent)
Social History:
___
Family History:
DM (brother, mother, father), HTN (brother, mother, father)
positive for HLD, no CAD or cancer. No CKD/ESRD.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 24 HR Data (last updated ___ @ 1513)
Temp: 101.6 (Tm 101.6), BP: 121/75, HR: 76, RR: 18, O2 sat: 99%,
O2 delivery: Ra, Wt: 149.8 lb/67.95 kg
General: Well developed, well nourished, alert and cooperative,
uncomfortable, but appears to be in no acute distress.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, and
reactive to light and accommodation constricting from 3.5mm to
3.0 mm bilaterally. EOMI in all cardinal directions of gaze
without nystagmus. Vision is grossly intact, hearing grossly
intact. Nares patent with no nasal discharge. Oral cavity and
pharynx are without inflammation, swelling, exudate, or
lesions.
Teeth and gingiva in good general condition.
Neck: Neck supple, non-tender without lymphadenopathy, masses or
thyromegaly.
Cardiac: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is
regular.
Pulmonary: Clear to auscultation without rales, rhonchi,
wheezing
or diminished breath sounds.
Abdomen: Normoactive bowel sounds. Soft, nondistended,
nontender. No guarding or rebound. No masses.
Back: No CVA tenderness
Musculoskeletal: ROM intact in spine and extremities. No joint
erythema or tenderness.
Neuro: Alert and oriented x3. No gross focal deficits.
Skin: Skin type III. No lesions or eruptions.
DISCHARGE PHYSICAL EXAM:
VS:24 HR Data (last updated ___ @ 335)
Temp: 98.1 (Tm 99.1), BP: 132/75 (109-132/69-79), HR: 58
(57-66), RR: 18 (___), O2 sat: 99% (98-99), O2 delivery: Ra,
Wt: 146.9 lb/66.63 kg
General: Well developed, well nourished, alert and cooperative,
uncomfortable, but appears to be in no acute distress.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, and
reactive to light and accommodation constricting from 3.5mm to
3.0 mm bilaterally. EOMI in all cardinal directions of gaze
without nystagmus. Vision is grossly intact, hearing grossly
intact. Nares patent with no nasal discharge. Oral cavity and
pharynx are without inflammation, swelling, exudate, or
lesions.
Teeth and gingiva in good general condition.
Neck: Neck supple, non-tender without lymphadenopathy, masses or
thyromegaly.
Cardiac: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is
regular.
Pulmonary: Clear to auscultation without rales, rhonchi,
wheezing
or diminished breath sounds.
Abdomen: Normoactive bowel sounds. Soft, nondistended,
nontender. No guarding or rebound. No masses.
Musculoskeletal: ROM intact in spine and extremities. No joint
erythema or tenderness.
Neuro: Alert and oriented x3. No gross focal deficits.
Skin: Skin type III. No lesions or eruptions.
Pertinent Results:
ADMISSION LABS:
================
___ 08:40PM BLOOD WBC-12.5* RBC-3.91 Hgb-12.0 Hct-36.7
MCV-94 MCH-30.7 MCHC-32.7 RDW-12.6 RDWSD-43.4 Plt ___
___ 08:40PM BLOOD Neuts-85.8* Lymphs-7.1* Monos-6.3
Eos-0.2* Baso-0.2 Im ___ AbsNeut-10.70* AbsLymp-0.88*
AbsMono-0.78 AbsEos-0.03* AbsBaso-0.03
___ 08:40PM BLOOD Glucose-108* UreaN-24* Creat-0.8 Na-136
K-4.3 Cl-101 HCO3-21* AnGap-14
___ 08:40PM BLOOD ALT-12 AST-18 LD(LDH)-194 AlkPhos-117*
TotBili-0.3
___ 08:40PM BLOOD Albumin-4.3 Calcium-9.4 Phos-3.5 Mg-1.6
___ 01:50AM BLOOD Lactate-1.2
DISCHARGE LABS:
================
___ 05:06AM BLOOD WBC-7.4 RBC-3.30* Hgb-10.1* Hct-31.2*
MCV-95 MCH-30.6 MCHC-32.4 RDW-12.6 RDWSD-43.5 Plt ___
___ 05:06AM BLOOD ___ PTT-25.8 ___
___ 05:06AM BLOOD Glucose-123* UreaN-15 Creat-0.6 Na-139
K-4.0 Cl-101 HCO3-25 AnGap-13
___ 05:06AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.1
___ 05:06AM BLOOD tacroFK-8.2
MICROBIOLOGY:
==============
___ 10:39 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL OF TWO COLONIAL
MORPHOLOGIES.
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---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ Blood culture x2: No growth to date
IMAGING:
===========
___ Renal Transplant U/S:
1. Apparent interval increase in peak systolic velocity of the
main renal artery near the anastomosis, measuring up to 277
cm/S.
2. Normal intrarenal resistive indices similar to prior.
___ CXR PA/Lat: No acute cardiopulmonary process.
Brief Hospital Course:
___ year old female with history of DDRT in ___ for chronic
glomerulosclerosis, pre-diabetes, HTN/HLD presenting with
dysuria, fever and positive UA concerning for pyelonephritis.
ACUTE ISSUES:
==============
# Complicated UTI / Pyelonephritis:
Patient with dysuria, urinary frequency, fever and positive UA
concerning for pyelonephritis. She has a history of resistant
organisms but most recent culture grew pan-sensitive E Coli. She
did well on her last hospitalization with Ceftriaxone
transitioned to Ciprofloxacin for a 2 week course in ___. She was started on Ceftriaxone and transitioned to
Ciprofloxacin again for E coli, which was sensitive with the
exception of ampicillin. Two week course for pyelonephritis (___). Final blood cultures were pending on discharge.
Fever was controlled with Tylenol. Outpatient provider had
concerns for urinary retention given her frequent UTIs.
Post-void residual was 23cc and transplant U/S had no
hydronephrosis so likelihood of significant retention seemed
lower. Patient was referred to urology at request of outpatient
provider.
# Coagulopathy: INR was elevated to 1.4 on admission, likely
nutrition related, improving on discharge to ___ s/p 2 days of
PO vitamin K.
CHRONIC ISSUES:
================
# ESRD with history of DDRT ___:
# Chronic immunosuppression:
Ultrasound on admission showed interval increase in peak
systolic velocity of the main renal artery near the anastomosis,
measuring up to 277 cm/S but normal intrarenal indices.
Creatinine was at baseline. No recent changes in
immunosuppressive agents. Tacrolimus 4 mg BID and Mycophenolate
Mofetil 500 mg BID were continued.
# HTN: Held losartan 50 mg and metoprolol tartrate 50 mg BID for
relative hypotension, restarted losartan on discharge, held
metoprolol for relative bradycardia HR ___.
# HLD: Continued pravastatin 40 mg daily
TRANSITIONAL ISSUES:
======================
[ ] Discharge with Ciprofloxacin to finish 2 week course (___)
[ ] Please monitor HR and BP at followup appointment and titrate
antihypertensives
[ ] Metoprolol was held due to HR ___, please monitor before
restarting
[ ] Urology followup given frequent UTIs and concern for urinary
retention
[ ] Would recheck INR to ensure normalization after Vitamin K
supplementation
[ ] Consider outpatient nutrition consult
# CODE: Full confirmed
# CONTACT: ___ (husband/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. Mycophenolate Mofetil 500 mg PO BID
4. Pravastatin 40 mg PO QPM
5. Tacrolimus 4 mg PO Q12H
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 14 Days
last day ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth morning and
night Disp #*22 Tablet Refills:*0
2. Phytonadione 5 mg PO DAILY Duration: 3 Days
RX *phytonadione (vitamin K1) [Mephyton] 5 mg 1 tablet(s) by
mouth daily Disp #*1 Tablet Refills:*0
3. Tacrolimus 4 mg PO Q12H
4. Losartan Potassium 50 mg PO DAILY
5. Mycophenolate Mofetil 500 mg PO BID
6. Pravastatin 40 mg PO QPM
7. HELD- Metoprolol Tartrate 50 mg PO BID This medication was
held. Do not restart Metoprolol Tartrate until seeing your
primary care doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
s/p renal transplant on chronic immunosuppression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital because you were having fevers, muscle
aches, and problems with urinating.
You started treatment for a urinary tract infection with IV
medicine called ceftriaxone. Your urine grew a bacteria called E
Coli and you switched to a pill called ciprofloxacin.
When you go home, please finish all of the antibiotics even if
you feel better.
Please get labs drawn next week at the ___. You do
not need an appointment. Please take your evening dose of
Tacrolimus at 8 pm the night before. Come before 8 a.m. to get
blood drawn. Do not take your Tacrolimus in the morning before
you get blood drawn.
Please see below for your followup appointments.
You should see a urology specialist because of your issues with
urinating.
It was a pleasure caring for you and we wish you the ___,
Your ___ Team
Followup Instructions:
___
|
19893114-DS-14 | 19,893,114 | 24,569,129 | DS | 14 | 2190-04-24 00:00:00 | 2190-04-24 22:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
___ Surgical or Invasive Procedure:
None
attach
Pertinent Results:
Admission labs:
___ 07:00PM BLOOD WBC-7.9 RBC-3.87* Hgb-11.9 Hct-37.5
MCV-97 MCH-30.7 MCHC-31.7* RDW-12.7 RDWSD-45.7 Plt ___
___ 07:00PM BLOOD Neuts-67.4 ___ Monos-7.0 Eos-2.3
Baso-0.6 Im ___ AbsNeut-5.34 AbsLymp-1.77 AbsMono-0.55
AbsEos-0.18 AbsBaso-0.05
___ 07:00PM BLOOD Glucose-87 UreaN-22* Creat-0.7 Na-135
K-4.4 Cl-100 HCO3-21* AnGap-14
___ 08:52PM BLOOD Lactate-1.0
Discharge labs:
___ 06:46AM BLOOD WBC-6.4 RBC-3.40* Hgb-10.5* Hct-32.9*
MCV-97 MCH-30.9 MCHC-31.9* RDW-12.8 RDWSD-45.1 Plt ___
___ 06:46AM BLOOD Glucose-112* UreaN-16 Creat-0.7 Na-142
K-4.6 Cl-108 HCO3-21* AnGap-13
___ 06:46AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.6
Imaging studies:
___ Renal transplant ultrasound
FINDINGS:
The right iliac fossa transplant renal morphology is normal.
Specifically,
the cortex is of normal thickness and echogenicity, pyramids are
normal, there
is no urothelial thickening, and renal sinus fat is normal.
There is no
hydronephrosis and no perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.64 to
0.7, within the
normal range. The main renal artery shows a normal waveform,
with prompt
systolic upstroke and continuous antegrade diastolic flow, with
peak systolic
velocity of 66.0 cm/s. Vascularity is symmetric throughout
transplant. The
transplant renal vein is patent and shows normal waveform.
IMPRESSION:
Normal right iliac fossa renal transplant ultrasound.
Brief Hospital Course:
Ms. ___ is a ___ yo woman with past medical history of FSGS
likely ___ underlying glomerulonephritis or pre-eclampsia s/p
DDLT in ___ and history of recurrent UTI who presents with
dysuria and found to have UTI.
TRANSITIONAL ISSUES:
====================
[] Follow-up urine culture and urinary symptoms. Antibiotics
transitioned to PO cipro for total of 5-day antibiotic for
cystitis (last day ___.
ACUTE ISSUES:
=============
#UTI (cystitis)
History of recurrent UTI, likely ___ vesiculoureteral reflux
from angle of implantation of transplanted ureter. Last UTI was
in ___, urine culture at that time grew E. coli (resistant
only to ampicillin). Patient was on ___actrim ppx that
was previously discontinued per last ID note. This admission,
patient presented with dysuria and received ceftriaxone in the
ED, with resolution in dysuria. Patient has been afebrile,
hemodynamically stable, exam without evidence of pyelonephritis
on exam. Renal ultrasound without acute findings. Antibiotics
transitioned to PO cipro for total of 5-day antibiotic for
cystitis (last day ___. Urine culture is pending at time
of discharge and will be followed up as outpatient.
#Focal segmental glomerulosclerosis s/p DDLT (___)
Creatinine at baseline at presentation. Home immunosuppression
MMF 500 BID and Tacrolimus 4mg BID were continued.
CHRONIC ISSUES:
===============
#HTN
Continued home Losartan 50mg daily
#Vitamin D Deficiency
Continued home Vitamin D
#HLD
Continued home statin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
2. Mycophenolate Mofetil 500 mg PO BID
3. Pravastatin 40 mg PO QPM
4. Tacrolimus 4 mg PO Q12H
5. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H Duration: 4 Days
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth twice a day
Disp #*8 Tablet Refills:*0
2. Losartan Potassium 50 mg PO DAILY
3. Mycophenolate Mofetil 500 mg PO BID
4. Pravastatin 40 mg PO QPM
5. Tacrolimus 4 mg PO Q12H
6. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
UTI (cystitis)
Focal segmental glomerulosclerosis s/p DDLT (___)
Secondary diagnosis
Hypertension
Hyperlipidemia
Vitamin D deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had burning sensation with urination.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You labs and imaging studies were reassuring. You received
antibiotics with improvement in your symptom.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take the antibiotic cipro (last day ___
- Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the ___!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19893304-DS-14 | 19,893,304 | 23,100,625 | DS | 14 | 2201-03-20 00:00:00 | 2201-03-22 19:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrochlorothiazide / morphine
Attending: ___
Chief Complaint:
Chest pain, lower extremity swelling, malaise
Major Surgical or Invasive Procedure:
Right heart catheterization ___ (WITHOUT pericardiocentesis)
History of Present Illness:
This is a ___ year old woman with H/O HIV and hypertension
presenting with dyspnea on exertion, fatigue and lower extremity
swelling.
In the first week of ___, she started to have fevers up to
101-103 degrees, with myalgias, arthralgias, and lower extremity
edema and edema. She experienced an episode of palpitations with
heart rates to the 120's on ___, at which point she went to
___ on ___, where a CTA chest was negative for
pulmonary embolus or other pathology to explain her symptoms; no
pericardial effusion was seen. She was told her echocardiogram
was "OK" but no records were available for review. Her hs-C
reactive protein was 136 mg/dL and d-dimer >19,000. ___ were
also negative for DVT. Her lab tests at ___ included:
-Hemoglobin 9.6 grams/dl and Hct of 29.4%.
-WBC 3,300 with 58.5% PMNs, L-30.3.
-Serum iron level was 13 with a total iron binding capacity of
245 and ferritin was 236. B12 219.
She was discharged on ___ on metoprolol succinate 25 mg daily
for tachycardia and naproxen 375 mg twice per day.
She has also had some chest pain which improves with leaning
forward. She describes weakness which makes her feel like her
legs will "give out". She has had no cough, sore throat,
earaches. She has had some redness of the eyes since return from
___, thought to be of an allergic component and started on
Systane eye drops with improvement. She denies rash or joint
swelling. No prior similar episodes.
She called her PCP ___ ___ reporting increased lower
extremity swelling and was sent to ED for further evaluation.
Travel history is significant for recent travel to ___ in
___, so initial concern for malaria. Parasite smear and
malaria antigen on ___ was negative. Most recent HIV viral load
in ___ was undetectable. Leptospira IgM negative. Per her
PCP, ___ for tuberculosis was also negative. She was in
___ from ___ through ___, staying in a
city with exposure only to dogs and cats. She lives in ___
with 2 sisters and no pets. She works per ___ as a nursing
assistant. TSH was recently normal.
In our ED initial vitals were: Pain 0 T 98.4 HR 111 BP 107/56 RR
20 SaO2 100% on RA. Examination was notable for JVP at the jaw
with HOB 45 degrees, mid neck with sitting upright and crackles
to midlung bilaterally with 1+ pedal edema. Labs significant for
Hgb/Hct 7.___.1 and NT-proBNP of 621. Chest X-ray showed
bilateral pleural effusions with enlargement of the cardiac
silhouette with a configuration raising concern for underlying
pericardial effusion. Bedside echocradiogram showed moderate
pericardial effusion without tamponade physiology with normal LV
function, IVC small and collapsible. She was transfused a unit
of PRBC's. Vitals on transfer: pain 0 T 98.8 HR 111 BP 111/61 RR
16 SaO2 97% on RA.
On arrival to the cardiology ward, she looked comfortable at
rest with stable vital signs.
ROS: as in HPI. Cardiac review of systems is notable for absence
of paroxysmal nocturnal dyspnea, orthopnea, syncope or
presyncope. On further review of systems, she denied any prior
history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, cough, hemoptysis,
black stools or red stools. All of the other review of systems
were negative.
Past Medical History:
-HIV on Complera with recent CD4 count in ___ 494, viral
load undetectable and patient compliant with ARV medications
-? H/O idiopathic thrombocytopenic purpura (ITP)
-Hypertension
Social History:
___
Family History:
Positive for hypertension and diabetes mellitus. No family
history of early MI, arrhythmia, cardiomyopathies, sudden
cardiac death, other heart disease, inflammatory or
rheumatologic illnesses.
Physical Exam:
On admission
GENERAL: Young black woman, alert and oriented x 3. Mood, affect
appropriate.
VS: T 98.8 BP 118/78 HR 111 RR 18 SaO2 94% on RA. Pulsus
paradoxus of 5 mm Hg.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Injected conjunctiva
NECK: Supple. JVP 1cm above clavicle sitting at 45 degrees
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs, rubs, gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness.
EXTREMITIES: No clubbing, cyanosis or edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
At discharge
GENERAL: lying in bed, tired appearing
VS: T 98.0 BP 103-109/64-67 HR 99-105 RR 16 SaO2 97-98% on RA
I/O: ___
Wt: 71.6 kg yesterday
HEENT: no scleral icterus, MMM
NECK: Supple with JVP of 9 cm.
CARDIAC: slightly tachycardic, regular, no murmurs, no
pericardial rub, pulsus =2
LUNGS: CTAB, normal respiratory effort
ABDOMEN: Soft, non-tender, not distended. +BS
EXTREMITIES: warm, well perfused, trace edema around ankles.
SKIN: No stasis dermatitis, ulcers
Pertinent Results:
___ 04:25PM BLOOD WBC-6.6 RBC-2.95* Hgb-7.7* Hct-24.1*
MCV-82 MCH-26.1 MCHC-32.0 RDW-13.6 RDWSD-40.9 Plt ___
___ 04:25PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
___ 07:50AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-2+ Target-1+
Schisto-OCCASIONAL Burr-1+
___ 03:55PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-SM
___ 03:55PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-1
___ 04:04PM BLOOD Glucose-93 UreaN-7 Creat-0.4 Na-135 K-4.7
Cl-103 HCO3-26 AnGap-11
___ 04:04PM BLOOD ALT-13 AST-23 LD(LDH)-599* AlkPhos-104
TotBili-0.3 DirBili-<0.2 IndBili-0.3
___ 04:04PM BLOOD Calcium-8.7 Phos-4.3 Mg-1.8
___ 04:04PM BLOOD cTropnT-<0.01
___ 04:04PM BLOOD proBNP-621*
___ 07:50AM BLOOD Hapto-460*
___ 07:50AM BLOOD ___ * Titer >1:1280
___ 09:50AM BLOOD C3-145 C4-29
___ 10:16AM BLOOD dsDNA-NEGATIVE
___ 10:16AM BLOOD SM ANTIBODY <1.0 NEG
___ 10:16AM BLOOD RNP ANTIBODY >8.0 POS
___ 09:50AM BLOOD WBC-5.8 RBC-3.46* Hgb-9.2* Hct-28.8*
MCV-83 MCH-26.6 MCHC-31.9* RDW-14.1 RDWSD-42.4 Plt ___
___ 09:50AM BLOOD Glucose-120* UreaN-12 Creat-0.4 Na-139
K-4.2 Cl-105 HCO3-23 AnGap-15
___ 08:20AM BLOOD ALT-12 AST-21 AlkPhos-88 TotBili-0.4
___ 09:50AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.9
ECG ___ 2:12:02 ___
Sinus tachycardia. Non-specific T wave abnormalities in the
lateral leads. Compared to the previous tracing of ___
findings are similar.
CXR ___
There are small bilateral pleural effusions, larger on the left,
with associated atelectasis. Superiorly, the lungs are clear.
There is enlargement of the cardiac silhouette with a
configuration raising concern for underlying pericardial
effusion. No acute osseous abnormalities.
IMPRESSION:
Bilateral pleural effusions. Enlargement of the cardiac
silhouette with a configuration raising concern for underlying
pericardial effusion.
Echocardiogram ___
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>65%). The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is a moderate sized pericardial effusion (2
cm). No right atrial or right ventricular diastolic collapse is
seen. There are no echocardiographic signs of tamponade.
IMPRESSION: Moderate pericardial effusion, largest seen adjacent
to the left ventricular posterior wall, with no
echocardiographic signs of tamponade. High normal left
ventricular systolic function.
Cardiac catheterization ___
Baseline Hemodynamics
RA 5, RVSP 35, PA 35/___, PCW 9
CI 3.5, CO 6.3, PVR 1.4 ___ or 115 dynes-sec/cm5
There was a preserved x and y descent. The filling pressures
were not elevated and were not equalized. The cardiac output was
elevated.
Preprocedure echocardiography in the catheterization laboratory
shows the effusion to be <1 cm.
Impressions:
1. There was no evidence for hemodynamic compromise from the
pericardial effusion.
2. The effusion is too small to safely tap based on
echocardiographic imaging.
Brief Hospital Course:
This is a ___ year old woman from ___ with well-controlled HIV
on HAART and hypertension presenting with anemia,
weakness/fatigue, recent febrile illness, and pericardial
effusion that was not present 3 weeks earlier.
# Pericardial effusion: No tamponade physiology. Initial pulsus
paradoxus of 5. She has HIV which would put her at risk of TB
illnesses but she is well-controlled with an undetectable HIV
VL. Given fevers and tachycardia with weakness, thyroid disorder
could explain this, however TSH on ___ was normal (1.4).
Patient looks too well for a purulent bacterial pericarditis. No
eosinophilia to suggest a parasitic etiology or other
hypereosinophilic process. ? autoimmune etiology. No family
history or personal history of arthritic or rheumatologic
condition. Clinical presentation suggestive of an inflammatory
or infectious process with recent fever, arthralgias, myalgias,
elevated hs-CRP. Negative infectious ___ to date. Normal
eGFR with trace proteinuria not consistent with uremia or
nephrotic syndrome, but may reflect underlying inflammatory
state. No obvious malignancy. Highly positive ___ raises the
possibility of systemic lupus erythematous. Could be "typical"
viral/idiopathic pericarditis, but she has not improved with
NSAID therapy. The initial plan was for a diagnostic
pericardiocentesis once a CCU or CVICU bed became available to
manage a pericardial drain, but bedside echocardiogram in the
cardiac catheterization laboratory showed decreased size of
pericardial effusion, increasing markedly the risk of a
complication if removal of pericardial fluid attempted. Right
heart catheterization clearly showed no evidence of tamponade
physiology, so pericardiocentesis was not undertaken. She was
empirically started on prednisone and colchicine (for
presumptive pericarditis and possibly lupus) and referred for
outpatient rheumatology evaluation.
# Anemia: Unclear etiology. Recent tests of iron stores and B12
ok (B12 low normal). Hemolysis ruled out given normal TBili and
elevated haptoglobin. Reticulocyte count inappropriately low,
which may be related to the same process causing her pericardial
effusion.
# HIV: has been stable and compliant
-resend HIV Viral load and CD4 count
-Continue Complera (ordered as Truvada and Rilpivirine)
# Hypertension: Continued home medications. Effective
contraception is essental while the patient is on teratogenic
agents including ACE-inhibitors.
Transitional issues:
-recommend ___/ possible rheumatologic disease
-continued on HIV regimen
-Discharged on prednisone for 2 weeks with taper to be designed
by outpatient team
-Discharged on colchicine 0.6 mg BID in addition to NSAIDs
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Complera (emtricitab-rilpivirine-tenofov) 200-25-300 mg oral
DAILY
3. Lisinopril 5 mg PO DAILY
4. MedroxyPROGESTERone Acetate 150 mg IM Q3MO
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Potassium Chloride 20 mEq PO DAILY
Discharge Medications:
1. Lisinopril 5 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Colchicine 0.6 mg PO BID
RX *colchicine 0.6 mg 1 capsule(s) by mouth twice daily Disp
#*60 Capsule Refills:*2
4. Naproxen 500 mg PO Q12H
always take with food
RX *naproxen 500 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
5. PredniSONE 20 mg PO DAILY
RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
6. Complera (emtricitab-rilpivirine-tenofov) 200-25-300 mg oral
DAILY
7. MedroxyPROGESTERone Acetate 150 mg IM Q3MO
Discharge Disposition:
Home
Discharge Diagnosis:
-Pericardial effusion
-Pericarditis
-Anemia
-Human immunodeficiency virus infection
-Hypertension
-Elevated anti-nuclear antibody with titer >1:1280 suggestive of
systemic lupus erythematosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted because you weren't feeling well, had some
chest pain and were found to have fluid around your heart by
ultrasound. We attempted to drain the fluid but found that there
was very little there. We decided to treat you aggressively for
a condition called pericarditis which is an inflammation of the
lining around the heart. We are concerned that this may be
caused by an auto-immune condition called systemic lupus
erythematosus, but confirmation labs are pending. We recommend
that you followup with your PCP and rheumatology.
New medications:
colchicine 0.6mg BID for three months
prednisone 20mg daily for two weeks. Talk to Dr. ___
refilling this medicine or tapering it off slowly after the 2
week period.
Continue the naproxen you have been taking, always take it with
food. You will also follow up with your primary care doctor in
the next week.
Be well,
Your ___ care team
Followup Instructions:
___
|
19893454-DS-13 | 19,893,454 | 24,535,949 | DS | 13 | 2163-05-17 00:00:00 | 2163-05-19 14:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Abd pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per admitting resident: ___ s/p Roux-en-Y gastric bypass in ___
who recently underwent revision Roux-en-Y gastrojejunal
anastomosis in the setting of an UGI bleed in the setting of an
anastomotic ulceration refractory to endoscopic control. She was
last seen in the ED on ___ with a concern for a wound
infection as well as non-bloody diarrhea. There was no evidence
of wound infection at the time and she was discharged to home
with a 14 day course of flagyl for presumed c.diff colitis.
She presents to the ED today with a complaint of sudden onset
LUQ pain after drinking hot chocolate. She denies any nausea or
vomiting. She states that she continues to have non-bloody
diarrhea though she notes that she is now only having ___
episodes a day compared to ___ episodes a day prior. She stopped
taking the flagyl a few days ago because she states that her
diarrhea improved by changing the color of her crystal lite. She
has had no difficulty tolerating meals. She also endorses a mild
cough but has otherwise been well without any fevers.
Past Medical History:
Anxiety
Depression
obesity
s/p Roux-en-Y gastric bypass
Social History:
___
Family History:
unknown
Physical Exam:
VS: T 97.7 HR 70 BP 137/50 RR 18 O2 100% RA
General: NAD, Alert and oriented x 3
Cardiac: RRR, No MRG
Lungs: CTA B, no respiratory distress
Abd: Soft, non-distended, mildly tender to palpation left
lateral aspect of incision, no rebound tenderness/guarding
Wounds: CDI, no erythema or induration
Pertinent Results:
___ 09:30AM BLOOD WBC-5.1 RBC-3.44* Hgb-9.9* Hct-30.9*
MCV-90 MCH-28.9 MCHC-32.2 RDW-13.5 Plt ___
___ 06:54AM BLOOD WBC-7.0 RBC-3.29* Hgb-9.5* Hct-29.6*
MCV-90 MCH-28.8 MCHC-31.9 RDW-13.2 Plt ___
___ 07:13PM BLOOD WBC-7.2 RBC-3.53* Hgb-10.1* Hct-31.6*
MCV-90 MCH-28.7 MCHC-32.0 RDW-13.6 Plt ___ Neuts-60.6
___ Monos-4.2 Eos-3.1 Baso-0.7 Glucose-86 UreaN-12
Creat-0.8 Na-141 K-4.8 Cl-102 HCO3-28 AnGap-16 ALT-9 AST-15
AlkPhos-84 TotBili-0.3 Lipase-61* Albumin-3.7
___ CT ABDOMEN W/CONTRAST:
IMPRESSION:
Substantial superficial subcutaneous fat stranding of the upper
anterior
abdominal wall with mild omental stranding deep to the incision
site at the level of the stomach. No evidence for intestinal
perforation or abdominal wall hernia.
Brief Hospital Course:
Ms. ___ presented to the Emergency Department on ___ after developing sudden onset left upper quadrant pain
without associated fevers, chills, nausea or vomiting. An abd/
pelvic CT scan was obtained and unrevealing a source of pain and
was without presence of an abdominal wall hernia; WBC 7.2. The
patient was given intravenous fluids and hydromorphone and
transferred to the floor for further observation.
On HD2, the patient reported improved abdominal pain with
intravenous hydromorphone; she was transitioned to oral
hydromorphone once tolerating a diet with continued good effect.
She remained stable from both cardiac and pulmonary standpoint.
Her diet was advanced to bariatric stage 4, which was well
tolerated without increase in abdominal or nausea/vomiting;
intake and output was closely monitored. Additionally, the
patient was voiding adequately and ambulating the hallways
independently. She was subsequently discharged to home and will
follow-up with her surgeon as previously scheduled.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LaMOTrigine 150 mg PO DAILY
2. BuPROPion 75 mg PO BID
3. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
5. Misoprostol 200 mcg PO QID
6. Venlafaxine 75 mg PO TID
7. biotin *NF* 5 mg Oral daily
8. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral three times a day
9. Cyanocobalamin 500 mcg PO QMOWEFR
10. Multi-Vitamins W/Iron *NF* (pediatric multivit-iron-min) 1
tablet Oral twice a day
11. Ranitidine (Liquid) 150 mg PO BID
Discharge Medications:
1. BuPROPion 75 mg PO BID
2. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) to
six (6) hours Disp #*25 Tablet Refills:*0
3. LaMOTrigine 200 mg PO DAILY
4. Misoprostol 200 mcg PO Q6H
5. Ranitidine (Liquid) 150 mg PO BID
6. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
7. biotin *NF* 5 mg Oral daily
8. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral three times a day
9. Cyanocobalamin 500 mcg PO QMOWEFR
10. Multi-Vitamins W/Iron *NF* (pediatric multivit-iron-min) 1
tablet Oral twice a day
11. Venlafaxine 75 mg PO TID
12. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
RX *docusate sodium 50 mg/5 mL 10 ml by mouth BID; PRN Disp
#*250 Milliliter Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please note the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
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.
You must avoid all NSAIDS including, but not limited to, Advil,
ibuprofen, Aleve, Naproxen, Motrin.
Followup Instructions:
___
|
19894339-DS-19 | 19,894,339 | 25,032,928 | DS | 19 | 2158-06-05 00:00:00 | 2158-06-05 18:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abd distention, new met cancer
Major Surgical or Invasive Procedure:
Paracentesis x2
History of Present Illness:
___ h/o SLE (per records), Fe deficiency anemia
admitted with abd pain, distention, ascites/liver masses concern
for new malignancy. She reported having abdominal pain, diffuse,
nonradiating, associated with mild nausea but no vomiting or
diarrhea for the past few months. She notes that the pain has
steadily worsened - a/w 12 lbs wt loss over the past 3 months.
She was recently evaluated by her outpatient gastroneurologist
___, who reported that she had multiple positive tumor
markers
including CA 125, CA ___, and ordered an outpatient ultrasound
which showed multiple echogenic lesions over the liver
consistent
with possible metastatic disease. Given her worsening anorexia,
abdominal pain, and nausea, she was referred here for further
workup.
She reports poor PO intake and early satiety. Also notes
several weeks of mild dyspnea on exertion and cough. No chest
pain.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, chest pain,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria. A 10 pt review of sxs was otherwise
negative.
Past Medical History:
___
# chronic Fe def anemia (since ___
- EGD, colonoscopy in ___ (___) and ___ (___) all neg
- SB capsule study ___ neg
- ___ EGD - small ___
- Hematemesis ___ - EGD large hiatal hernia, along with
diffuse severe inflammation with hemorrhage characterized by
adherent blood and erythema in the cardia and gastric fundus,
bleeding suspected from gastric ischemia vs. mechanical injury
of
the large hiatal hernia. On PPI, Fe supplement, Carafate
# Systemic lupus erythematosus
# Transient global amnesia
# Idiopathic peripheral neuropathy
# OA
# Diverticulosis
# Colon adenoma
# Primary open-angle glaucoma, moderate stage
Social History:
___
Family History:
Daughter with colon CA ___ years ago - in remission. Sister
and Mother with pancreatic CA.
Physical Exam:
ADMISSION
Vital Signs: 99.0 121/80 80 20 95% RA
GEN: NAD, well-appearing, comfortable
EYES: PERRL, EOMI, conjunctiva clear, anicteric
ENT: dry mucous membranes, no exudates
NECK: supple
CV: RRR s1s2 nl, no m/r/g
PULM: CTA, no r/r/w
GI: soft, mildly tender diffusely, distended, positive fluid
wave. No significant caput medusae on exam.
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
DISCHARGE
97.9 PO 99 / 62 87 20 94 Ra
GEN: NAD, well-appearing, visibly anxious but comfortable
EYES: PERRL, EOMI, conjunctiva clear, anicteric
ENT: moist mucous membranes, no exudates
NECK: supple
CV: RRR s1s2 nl, no m/r/g
PULM: CTA, no r/r/w
GI: soft, mildly tender diffusely, distended, positive fluid
wave. No significant caput medusae on exam
EXT: warm, no c/c/e
SKIN: no rashes
NEURO: alert, oriented x 3, answers questions appropriately,
follows commands, non focal
PSYCH: appropriate
ACCESS: PIV
FOLEY: absent
Pertinent Results:
ADMISSION
___ 08:44PM BLOOD WBC-10.5* RBC-3.46* Hgb-9.7* Hct-30.6*
MCV-88 MCH-28.0 MCHC-31.7* RDW-14.8 RDWSD-47.9* Plt ___
___ 08:44PM BLOOD Neuts-82.0* Lymphs-5.2* Monos-8.3 Eos-3.3
Baso-0.6 Im ___ AbsNeut-8.61* AbsLymp-0.55* AbsMono-0.87*
AbsEos-0.35 AbsBaso-0.06
___ 08:44PM BLOOD Plt ___
___ 08:44PM BLOOD ___ PTT-29.3 ___
___ 08:44PM BLOOD Glucose-136* UreaN-13 Creat-0.8 Na-135
K-4.6 Cl-95* HCO3-22 AnGap-18
___ 08:44PM BLOOD ALT-18 AST-42* AlkPhos-158* TotBili-0.3
___ 08:44PM BLOOD Albumin-3.4* Calcium-9.2 Phos-4.0 Mg-1.7
___ 08:44PM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
DISCHARGE
___ 06:30AM BLOOD WBC-9.5 RBC-3.39* Hgb-9.4* Hct-30.1*
MCV-89 MCH-27.7 MCHC-31.2* RDW-15.5 RDWSD-50.7* Plt ___
___ 06:30AM BLOOD ___ PTT-30.6 ___
___ 06:30AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-89 UreaN-15 Creat-0.7 Na-140
K-3.9 Cl-103 HCO3-25 AnGap-12
___ 06:15AM BLOOD ALT-18 AST-31 AlkPhos-143* TotBili-0.3
___ 06:15AM BLOOD Albumin-3.0* Calcium-8.3* Phos-3.6 Mg-1.9
Other results:
From OSH (___): Cr 0.77, Hep C neg, Hep B SAg neg, CEA 23.6,
CA125 2900, ___ 314.2, AFP 2.5,
(___):
10.5 > 9.7/30.6 < ___ 136 AGap=18
4.6 22 0.8
ALT: 18 AP: 158 Tbili: 0.3 Alb: 3.4
Ascites: Prot 4.8, Gluc 121, WBC 966 (P18 L20 M4) RBC 1294
Blood culture no growth to date
Urine culture negative
Peritoneal fluid culture negative
CXR ___
Compared to chest radiographs ___. Small left
pleural effusion is unchanged. Left basal atelectasis has
increased. No pneumothorax. Right lung clear. No right
pleural abnormality. Heart size normal.
___ Liver biopsy pending
Brief Hospital Course:
# Malignant neoplasm, unknown primary
Evidence of mod-large malignant ascites (peritoneal
carcinomatosis), liver mets, pancreatic tail mass. Has elevated
___, CEA, CA125. Ddx includes pancreatic (favored by
radiographic findings), ovarian (favored by elevated CA125) and
GI primary tumor.
- liver biopsy ___ anticipate results likely next week
- appreciate Atrius oncology consult - oncologist will schedule
follow up with patient in clinic to review pathology results and
treatment options
- had paracentesis with 1.5 L removed ___
- still seemed distended so had another paracentesis on ___ but
per ___, there was no pocket to safely remove fluid this time
-pain treated with codeine prn with bowel regimen. Will give
patient short supply of tylenol and oxycodone (with bowel
regimen) for home until follow up appointment with Atrius
oncology
#Tachypnea
Intermittently tachypneic during hospitalization, although
patient denied SOB or other respiratory symptoms. Repeated CXR,
which showed unchanged small left pleural effusion but increase
in left basal atelectasis. Right lung clear, no right pleural
abnormality. Other vital signs stable, WBC normal, no signs or
sx
of infection. Encouraged incentive spirometry.
#Anxiety
Significant anxiety about medical workup and being in the
hospital.
- Ativan 1 mg q6h prn while inpatient, and gave short supply per
patient/family request on discharge given ongoing anxiety.
# Fe deficiency anemia
# h/o ___ ulcer
- cont PPI
# Peripheral neuropathy
- cont Neurontin
# Glaucoma
- cont ophth drops
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Gabapentin 300 mg PO TID
3. Omeprazole 40 mg PO DAILY
4. Spironolactone 25 mg PO DAILY
5. CarafATE (sucralfate) 100 mg/mL oral QID:PRN
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
7. TraZODone 25 mg PO QHS:PRN insomnia
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hours as
needed Disp #*30 Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily as
needed Disp #*30 Capsule Refills:*1
3. LORazepam 1 mg PO Q8H:PRN anxiety
RX *lorazepam 1 mg 1 tab by mouth every 8 hours as needed Disp
#*10 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed
Disp #*10 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
as needed Disp #*30 Each Refills:*1
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily as
needed Disp #*30 Tablet Refills:*1
7. CarafATE (sucralfate) 100 mg/mL oral QID:PRN
8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
9. Ferrous Sulfate 325 mg PO BID
10. Gabapentin 300 mg PO TID
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Omeprazole 40 mg PO DAILY
13. TraZODone 25 mg PO QHS:PRN insomnia
14. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until you discuss with your PCP
15. HELD- Spironolactone 25 mg PO DAILY This medication was
held. Do not restart Spironolactone until you discuss with your
PCP
___:
Home
Discharge Diagnosis:
Liver tumors
Malignancy ascites
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for a biopsy to evaluate newly
diagnosed liver tumors and ascites (fluid in the abdominal
space). The biopsy results are pending. We also removed some of
the ascites fluid to try to make you more comfortable. The
___ oncologist, Dr. ___ you and will schedule follow up
for you as well. If you don't hear from her by next week, please
call her office.
It was a pleasure taking care of you.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19894425-DS-14 | 19,894,425 | 26,275,322 | DS | 14 | 2200-01-27 00:00:00 | 2200-01-27 15:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
AMS, frequent falls, R sided weakness
Major Surgical or Invasive Procedure:
Left craniotomy for ___ evacuation
History of Present Illness:
Patient is a ___ year old female with PMhx significant for HTN
who has recently been noted to have increasing R sided weakness
and increasing confusion per family which began today. She had
otherwise been an active woman in her normal state of health
prior to these events. She was seen and evalauted and imaging
reveleaed a large left sided SDH with 4mm of MLS. Neurosurgery
was consulted for further assistnace with her care. Of note,
exam was performed with assistance of her family who provided
translation.
Past Medical History:
HTN
Social History:
___
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAM on Admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL. EOMs intact without nystagmus
Neck: Supple.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent in ___ with good comprehension and
repetition.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
3mm bilaterally. Visual fields are grossly full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: R facial.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: RUE and RLE ___ except R AT ___, LUE and LLE full. R
pronator. Normal bulk and tone bilaterally. No abnormal
movements, tremors.
Sensation: Intact to light touch
PHYSICAL EXAM at Time of Discharge:
alert and oriented x3
PERRL
slight R nasolabial flattening
Tongue midline
no pronator drift
MAE ___ strength
incision c/d/i closed with sutures
Pertinent Results:
CT HEAD W/O CONTRAST ___:
IMPRESSION:
1. Acute small left frontoparietal subdural hematoma measuring
0.5 cm in
maximal width.
2. Large left frontoparietal subdural hematoma with evidence of
subacute on chronic hemorrhage and 4 mm rightwards shift of
midline structures.
3. No fracture.
GLENO-HUMERAL SHOULDER ___:
IMPRESSION:
No evidence of fracture or dislocation.
CT HEAD W/O CONTRAST ___:
IMPRESSION:
1. Postsurgical changes related to patient's interval left
frontal craniotomy and subdural hematoma evacuation, now with
approximately 22 mm fluid collection with small amount of blood
and pneumocephalus.
2. Mass effect has mildly improved with interval decrease of
rightward midline shift compared to prior exam.
3. Stable right frontal mixed density subdural hematoma.
4. No new hemorrhage.
CT HEAD W/O CONTRAST ___:
IMPRESSION:
1. Slightly decreased size of left frontotemporal subdural
hematoma with
similar degree of hyperdense components as on the prior CT, and
no evidence of new hemorrhage.
2. Slight decrease in rightward shift of midline structures.
Brief Hospital Course:
The patient was admitted to the ICU on the evening of ___. She
received 1 pack of platelets in the Emergency Department, and
her home dose of aspirin 81mg was held. The patient was made
NPO, started on IVF, and had labs drawn, including type and
screen, for pre-operative work-up. She was taken to the OR on
___ for left craniotomy for left subdural evacuation by Dr.
___. The patient tolerated the procedure well, and the
patient was transferred to the PACU for recovery. Post-operative
head CT showed expected post-operative changes. The patient was
later transferred to the ICU. On ___, the patient remained
stable in the ICU. She had complaints of headache and nausea,
but these were managed appropriately with medication. She was
transferred to the floor in stable condition. Overnight on ___,
the patient had increased confusion and was not moving her right
upper extremity as briskly. A repeat head CT was done, which was
stable. U/A was also sent, which did not show evidence of UTI.
By the morning, her confusion had improved and she was AAOx3.
Her physical exam remained stable. The surgical dressing was
taken down, and her incision, which was closed with sutures, was
noted to be clean, dry, and intact. Physical therapy and
occupational therapy were consulted. Physical therapy
recommended that the patient be discharged to a rehab facility.
On ___, the patient's exam remained stable, and she was
awaiting rehab screening. She was discharged to rehab in good
condition with instructions for follow up.
Medications on Admission:
lisinopril 5mg daily, Vitamin D2 50,000 units 1 cap q2weeks, asa
81, MVI daily, calcium carbonate/vitamine D3 chewable daily,
artifical tears 1 gtt ___
daily, PRo Air 2 puffs q4h prn
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
3. Artificial Tears 1 DROP BOTH EYES DAILY
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC TID
6. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*8 Tablet Refills:*0
7. Lisinopril 5 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN headache
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6H PRN pain Disp
#*45 Tablet Refills:*0
10. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth Q6H PRN
pain Disp #*45 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left subdural 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:
Surgery:
You underwent a surgery called a craniotomy to have blood
removed from your brain.
Please keep your sutures along your incision dry until they
are removed.
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 are allowed to restart your home aspirin dose of 81 mg on
___.
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 have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
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.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
19894443-DS-25 | 19,894,443 | 20,566,241 | DS | 25 | 2203-12-06 00:00:00 | 2203-12-06 16:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Toradol / Codeine / Morphine
Attending: ___.
Chief Complaint:
Low back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH significant for sickle cell disease and possibly
cleared HCV (VL undetectable at ___ ___ who presents with back
pain x 1 day. The pain is described as sharp, stabbing,
non-radiating, and similar to his usual pain crisis. Pain was
not relieved with oxycodone. He denies any fever, chills,
nausea, vomiting, chest pain, shortness of breath, lower
extremity weakness or paresthesias.
In the ED initial vitals were: T98.4 P69 BP116/63 RR18 94%. Labs
were notable for WBC 9.0, Hct 23.3, Tbili 5.3 (direct 4.6), and
LDH 612. Patient was given ceftriaxone and azithromycin for
possible PNA, as well as dilaudid and zofran. Vitals prior to
transfer were: T98.4 P59 BP118/55 RR16 98%NC.
On the floor, patient reports pain is improved but not resolved.
His pain crisis usually start in his lower back then spread
throughout his body. He cannot identify any triggers. He had
pneumonia 1 month ago and has residual cough. He typically
drinks 1.5 gallons of water daily, although he was told he
should drink ___ gallons.
Patient has ___ year history of RUQ abdominal pain, which
started after cholecystectomy. The pain is more severe today. It
is not worse with eating. He denies diarrhea, constipation,
vomiting, change in stools.
Past Medical History:
#Hemoglobin SS disease: Patient has ~3 pain crisis per year
-Followed at ___ by ___ NP
-H/o acute chest syndrome with history of multiple blood
transfusions in the past
-H/o priapism
-Admitted ___ at ___ with back pain, vasooclussive crisis
#HCV ___ transfusions: HCV Ab + ___, viral load negative at ___
___ (unclear if treated or cleared)
#Polysubstance abuse: history of cocaine use, MJ use, and
prescribed narcotics
#Hx PNA: Admitted ___ ___ for PNA, no acute chest, no PE
#S/p cholecystectomy
Social History:
___
Family History:
Brother: ___
Dad: ___, HbSS
Mom: ___, sickle trait (Hgb AS)
Sister: ___
Physical ___:
ADMISSION PHYSICAL EXAM
Vitals: T98.2 BP122/78 P68 RR18 94RA
GENERAL: Lethargic but arousable. Appears comfortable, no acute
distress.
HEENT: Pupils equal and reactive to light. Oropharynx clear.
NECK: Supple, no JVD.
CARDIAC: RRR, S1/S2. No S3, S4. ___ systolic murmur loudest at
ULSB.
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles.
ABDOMEN: +BS, soft, nondistended. TTP in RUQ with voluntary
guarding but no rebound.
MSK: Spinous processes nontender to palaption. Hips with full
ROM and no pain.
EXTREMITIES: Warm and well perfused. Pulses 2+. No pitting
edema.
NEURO: CN II-XII intact. Sensation intact. Motor strength ___.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
Vitals- T 97.4, BP 104-129/52-70, P 53-79, RR ___, O2 94 RA
General: Alert, oriented, no acute distress
HEENT: Mild scleral and sublingual icterus, mucus membranes
moist, oropharynx clear
Neck: supple, no LAD
Lungs: Breathing with ease, clear to auscultation bilaterally,
no wheezes, rales, ronchi
Cor: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: mild tenderness to palpation RUQ, non-distended, no
rebound tenderness or guarding
GU: no foley
Ext: warm, 2+ dorsalis pedis pulses, no clubbing, cyanosis or
edema
Neuro: alert, attentive, speaking in full sentences, normal
tandem gait. PERRL, EOMI, face symmetric, stands from bed
without assist. No gait ataxia.
Pertinent Results:
ADMISSION LABS
--------------
___ 11:09PM BLOOD WBC-9.0# RBC-2.16*# Hgb-8.0* Hct-23.3*
MCV-108* MCH-37.1*# MCHC-34.4 RDW-19.5* Plt ___
___ 11:09PM BLOOD Neuts-30* Bands-1 Lymphs-58* Monos-10
Eos-1 Baso-0 ___ Myelos-0
___ 11:09PM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-3+
Macrocy-2+ Microcy-1+ Polychr-2+ Ovalocy-2+ Target-3+ Sickle-2+
Schisto-1+ Envelop-1+
___ 11:09PM BLOOD ___ PTT-29.2 ___
___ 11:09PM BLOOD Glucose-91 UreaN-9 Creat-0.8 Na-141 K-4.2
Cl-103 HCO3-28 AnGap-14
DISCHARGE LABS
--------------
___ 01:58AM BLOOD Hgb-7.7* Hct-23.1*
___ 10:30AM BLOOD Glucose-83 UreaN-9 Creat-1.0 Na-137 K-4.4
Cl-101 HCO3-28 AnGap-12
___ 10:30AM BLOOD ALT-21 AST-56* AlkPhos-88 TotBili-6.4*
PERTINENT LABS
--------------
___ 11:09PM BLOOD Ret Man-12.8*
___ 11:09PM BLOOD Hapto-<5*
___ 11:09PM BLOOD Lipase-47
___ 11:09PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MICRO
-----
___ BLOOD CX: PENDING AT DISCHARGE
IMAGING
-------
___ CXR:
FINDINGS: Comparison is made to prior radiographs from ___. Heart size is within normal limits. There is minimal
atelectasis at the left lung base. There is no focal
consolidation, pleural effusions or signs for acute pulmonary
edema. No pneumothoraces are identified.
Brief Hospital Course:
Mr. ___ is a ___ year old man with HgbSS disease, recurrent
vasoocclusive crises, history of priapism, chronic hep C (viral
load undetectable at ___ in ___ and polysubstance abuse who
presented to ___ with acute onset low back pain consistent
with vasoocclusive crisis.
Active diagnoses:
#Vasoocclusive crises: He was admitted for a 1 day history of
severe lower back pain in the setting of a Hemoglobin SS disease
(sickle cell disease). Smear was suggestive of active sickling
and hemolysis making the cause of his pain likely an acute pain
crisis. Pain was limited to the R paraspinal area of the lumbar
spine and there was no evidence of midline lumbar spine
involvement (no tenderness to palpation). There was no evidence
of priapism (he has a prior Hx of priapism). Treatment
consisted of pain control and IVFs with ___ normal saline. Pain
was adequately controlled per the patient and by HD#2 and the
pain had returned to his baseline. He was actually treated with
less than his home regimen of oxycodone. He also received 1 u
pRBCs on HD #1 which likely contributed to his improvement. His
hemoglobin at discharge was 7.5. This is within his historical
range for hemoglobin at discharge from ___ in the
past few months. He should have a follow up CBC on ___ in
___ clinic. Home folate and hydroxyurea were continued.
#Hypoxemia: In the late morning on hospital day #1 he was found
to have O2 sats to the mid-80s on room air. His saturation
quickly improved to >95% on 2L of O2. On further auscultation he
appeared to have decreased breath sounds and dullness to
percussion at the R lung base. However, a CXR was done and no
major consolidation was noted. The etiology of his hypoxemia
remains unclear, though it was most likely related to
hypoventilation as he was very somnolent on hospital day #1.
Acute chest crisis (ACS) was unlikely given his normal CXR and
lack of chest pain or shortness of breath. On the day of
discharge he was 94% on room air and his lungs were clear on
examination.
#Hemoglobin SS disease/Macrocytic Anemia: On initial
presentation to the ED (___) his Hct was 23.3. The following
morning (___), his Hct was noted to have dropped to 20.8,
though after significant IV fluid. His anemia was likely due to
a hemolysis from sickle cell disease, as confirmed by labs and
peripheral smear. His bilirubin was elevated (6.4. total),
haptoglobin level decreased (<5), LDH elevated (612) and
reticulocyte was increased (12.8), as expected with a hemolytic
anemia. He was transfused with 1 unit of pRBCs. On repeat Hct he
was 23.1. He should have outpatient CBC done on ___ in
___ clinic.
#Somnolence: Upon admission to the floor (HD #1) he was noted to
have significant somnolence, often appearing to doze off during
history taking and physical exam. This was thought to be due to
overmedicating with pain medications and so his oxycodone and
hydromorphone doses were reduced. It was also thought that he
may have ingested other substances prior to admission, including
long acting oxycodone, which he has at home. He has a history of
substance abuse and was noted to have ingested cocaine this
weekend. Tox screening from the ED was negative though it did
not test for opiates and is unreliable for certain
benzodiazepines. He did not produce a urine sample for testing
for methadone and other CNS depressants. Given his return to
normal mental status on HD#2 it is highly likely that his period
of AMS was due to overmedication. He was counseled to avoid
excessive narcotic use and combinations with other drugs. He was
prescribed a bowel regimen given his chronic opiate use.
Chronic Diagnoses:
#Chronic Hepatitis C: Possibly resolved. Hep C antibody positive
___. Viral load negative at ___ in ___, though
it is unclear if he was treated or cleared the infection
himself. This is related to blood transfusions for Sickle Cell
Disease, per patient and chart review. He denies prior IV drug
use. Could consider repeating viral load or clarifying treatment
with patient to ensure no longer has active disease that would
require treatment.
#Polysubstance abuse: He reported that he had used cocaine a day
or two prior to admission - this is an issue that his outpatient
hematologist has spoken with him about before and which will
need further outpatient workup as it is likely an exacerbating
factor for his underlying sickle cell disease. He was counseled
to avoid excessive narcotic use and combinations with other
drugs. He was prescribed a bowel regimen given his chronic
opiate use.
Transitional Issues:
-repeat CBC in 2 weeks to evaluate Hgb/Hct
-consider down-titration of opiates given somnolence when
admitted on less than home doses of oxycodone
-set up outpatient PCP, currently ___ NP
managing his care, though he stated he was getting a new PCP
-___ repeating HCV viral load or clarifying treatment with
patient to ensure no longer has active disease that would
require treatment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Hydroxyurea 1500 mg PO DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
4. OxyCODONE SR (OxyconTIN) 40 mg PO Q12H
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Hydroxyurea 1500 mg PO DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*30 Capsule Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
take less if you have diarrhea
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice daily
Disp #*30 Capsule Refills:*0
6. OxyCODONE SR (OxyconTIN) 40 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
#Hemoglobin SS disease
#Vasoocclusive pain crisis
SECONDARY DIAGNOSES:
#Anemia, macrocytic
#Intravascular hemolysis
#Opiate dependence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___, you were admitted because of suspected pain crisis
from sickle cell disease causing low back pain. You stated that
your low back is typically where you have pain attacks. Your
labs showed that you had evidence of cells breaking down in your
blood stream, which supports this diagnosis. You were treated
with IV fluids, pain medications, and were given 1 unit of
blood.
When you go home you should take your home medications as
prescribed. You should take Tylenol (max 3 grams per day) for
ongoing pain. We made a follow up appointment with ___
at ___. As has been discussed before, cocaine use puts
you at significant risk for health problems, including sickle
cell crises.
Additionally, you have a history of exposure to hepatitis C. If
you have not been treated, you should discuss treatment with
your hematologist or new primary care doctor because new
treatments are available.
Your ___ team!
Followup Instructions:
___
|
19894538-DS-7 | 19,894,538 | 25,496,571 | DS | 7 | 2131-06-21 00:00:00 | 2131-06-21 16:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
UNknown antibiotic / levofloxacin
Attending: ___.
Chief Complaint:
right femoral neck fracture
Major Surgical or Invasive Procedure:
s/p right hip hemiarthroplasty
History of Present Illness:
___ female ___ depression presents with the above fracture
s/p mechanical fall. Fell down a few stairs while leaving the
___. Denies HS/LOC. Unable to ambulate afterwards.
Denies paresthesias. Denies antecedent hip pain. Likes to do
yoga, cross country ski.
Past Medical History:
Depression
Social History:
___
Family History:
Noncontributory
Physical Exam:
Right lower exam
-dressing c/d/I
-fires ___
-silt s/s/sp/dp/t nerve distributions
-foot WWP
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for a right hip hemiarthroplasty, 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
WBAT RLE with no hip precautions, and will be discharged on
lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 75 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL ___t bedtime Disp #*28
Syringe Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
don't drink or drive while taking
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*20
Tablet Refills:*0
6. Senna 8.6 mg PO BID
7. Sertraline 75 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated right lower extremity, no hip
precautions
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Physical Therapy:
wbat RLE, no hip precautions
Treatment Frequency:
staples/sutures to be removed at 2 week postop appointment in
clinic
Followup Instructions:
___
|
19895232-DS-17 | 19,895,232 | 24,250,280 | DS | 17 | 2169-11-09 00:00:00 | 2169-11-09 20:10:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cortisone / hydrochlorothiazide / Lasix / lactose
/ spironolactone / metoprolol / lisinopril / clonidine
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
___ 12:45AM BLOOD WBC-13.2* RBC-3.52* Hgb-10.1* Hct-30.9*
MCV-88 MCH-28.7 MCHC-32.7 RDW-16.6* RDWSD-52.9* Plt ___
___ 12:45AM BLOOD Neuts-75.1* Lymphs-14.8* Monos-7.9
Eos-1.5 Baso-0.2 Im ___ AbsNeut-9.91* AbsLymp-1.95
AbsMono-1.04* AbsEos-0.20 AbsBaso-0.02
___ 12:45AM BLOOD Plt ___
___ 06:30AM BLOOD ___ PTT-25.3 ___
___ 12:45AM BLOOD Glucose-110* UreaN-43* Creat-1.4* Na-136
K-3.8 Cl-97 HCO3-27 AnGap-12
___ 12:45AM BLOOD ALT-46* AST-37 CK(CPK)-65 AlkPhos-53
TotBili-0.2
___ 12:45AM BLOOD CK-MB-3 proBNP-___*
___ 12:45AM BLOOD Albumin-3.7 Calcium-8.8 Phos-3.3 Mg-2.3
___ 12:45AM BLOOD cTropnT-0.02*
___ 01:37PM BLOOD K-4.4
MICRO:
NONE
IMAGING:
___BD & PELVIS WITH CO
1. Wall thickening of the pylorus and proximal duodenum which
could reflect inflammation from ulcer disease or infection. No
focal fluid collection or perforation.
2. A 8.0 x 5.2 x 6.5 cm right pelvic cystic lesion likely rising
from the
right ovary is new since ___. OBGYN consult and further
evaluation with
nonurgent pelvic MRI are recommended.
3. Interval improvement of chronic right lower lobe
consolidation since the ___ examination, with mild bronchiectasis.
___ Imaging CHEST (PA & LAT)
1. Stable cardiomegaly with mild pulmonary vascular congestion.
2. Right lung base opacification which may represent
atelectasis. However
superimposed pneumonia cannot be excluded.
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-7.1 RBC-3.33* Hgb-9.7* Hct-29.7*
MCV-89 MCH-29.1 MCHC-32.7 RDW-16.5* RDWSD-53.6* Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD ___ PTT-25.3 ___
___ 06:30AM BLOOD Glucose-97 UreaN-30* Creat-1.5* Na-137
K-3.3* Cl-99 HCO3-26 AnGap-12
___ 06:30AM BLOOD ALT-36 AST-27 LD(LDH)-219 AlkPhos-50
TotBili-0.4
___ 06:30AM BLOOD Albumin-3.6 Calcium-8.4 Phos-4.1 Mg-2.1
Brief Hospital Course:
Ms. ___ is an ___ yo F with history of CAD s/p stent, HFpEF,
PAD who presents with chest pain with likely GI etiology.
ACUTE ISSUES:
=============
#Chest pain:
Patient presented with chest pain relieved by nitro with
significant cardiac history. However, she had no chest pain this
admission, troponins not elevated, and EKG was unchanged from
prior (same
rate). LINQ without any events. While consolidation on CXR and
CT, she has had these prior and is being monitored yearly with
CT chest scans with thoracic surgery. Therefore, given that no
fevers, shortness of breath, and only transient chest pain,
antibiotics were held. ___ negative of her right lower
extremity. CT Abdomen with wall thickening of the pylorus and
proximal duodenum which is the likely source of her pain with
inflammation possibly from recent steroids. In speaking with
Sister ___, she states that Sister ___ has had two
deaths in her family recently and has been stressed so also
likely a component of anxiety as well. She was placed on a PPI
PO BID for two weeks.
#chronic HFpEF
Patient with chronic lower extremity edema, notably with R>L. No
evidence crackles, elevated JVP, or volume on CXR/CT. However,
pro-BNP is elevated compared to prior. Bedside ultrasound
without b lines or effusions so continued home bumex.
#leukocytosis:
Given that consolidation was chronic, did not treat as above. No
fevers, dysuria, or other infectious symptoms.
CHRONIC ISSUES:
===============
#CKD
Baseline Cr 1.2-1.4. Currently at baseline.
#PAD s/p RLE stent and bypass ___
-Continued ASA
#Hypertension
-Continued Amlodipine/Imdur
#Hypothyroidism
-Continued Levothyroxine
#Depression
-continued paroxetine
#Myelodysplastic syndrome
#Anemia
Baseline ___.
-Continued home Ferrous gluconate
#Glaucoma
-continued home eye drops
#Insomnia
-continued home alprazolam
#CAD s/p stent ___
-Continued ASA, statin
TRANSITIONAL ISSUES:
====================
[ ] continue PPI BID for two weeks until ___, then
transition back to daily.
[ ] ensure proper follow up for anxiety
[ ] follow up H pylori testing
[ ] discharge weight: 113.5 pounds
[ ] discharge creatine: 1.5
[ ] discharge diuretic: bumex 3mg PO BID
[ ] please monitor weight and volume and assess bumex dose as
needed
[ ] check creatinine and potassium in 1 week as an outpatient to
ensure stable
[ ] CT Chest as an outpatient in ___ for follow up of
consolidation
[ ] A 8.0 x 5.2 x 6.5 cm right pelvic cystic lesion likely
rising from the right ovary. OBGYN consult and further
evaluation with nonurgent pelvic MRI with contrast are
recommended.
[ ] many medication lists per patient with many recent
hospitalizations, please reconcile as an outpatient to ensure on
correct regimen
[ ] continue to assess vertigo and posterior circulation as had
concern for narrowed vertebral vessels on prior admissions
#CODE: Full
#CONTACT: Sister ___ ___
#DISPO: Medicine pending ___ monitoring
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN pain or temp > ___
2. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
3. amLODIPine 5 mg PO DAILY
4. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Bumetanide 3 mg PO BID
8. Docusate Sodium 100 mg PO DAILY:PRN Constipation - Second
Line
9. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
10. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
11. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___)
12. Pantoprazole 40 mg PO Q24H
13. Pramipexole 0.25 mg PO TID
14. Ascorbic Acid ___ mg PO DAILY
15. Ferrous GLUCONATE 324 mg PO DAILY
16. Lidocaine 5% Patch 1 PTCH TD QAM Coxyx
17. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
18. Multivitamins W/minerals 1 TAB PO DAILY
19. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
20. PARoxetine 10 mg PO DAILY
21. HydrALAZINE 10 mg PO Q8H
22. Clindamycin 600 mg PO BEFORE DENTAL PROCEDURES
23. Potassium Chloride 40 mEq PO DAILY
24. Baclofen 10 mg PO Q12H:PRN Muscle Spasms
25. Polyethylene Glycol 17 g PO Q12H:PRN Constipation - Third
Line
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
2. Acetaminophen 650 mg PO Q8H:PRN pain or temp > ___
3. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
4. amLODIPine 5 mg PO DAILY
5. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
6. Ascorbic Acid ___ mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Baclofen 10 mg PO Q12H:PRN Muscle Spasms
10. Bumetanide 3 mg PO BID
11. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
12. Clindamycin 600 mg PO BEFORE DENTAL PROCEDURES
13. Docusate Sodium 100 mg PO DAILY:PRN Constipation - Second
Line
14. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
15. Ferrous GLUCONATE 324 mg PO DAILY
16. HydrALAZINE 10 mg PO Q8H
17. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
18. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___)
19. Lidocaine 5% Patch 1 PTCH TD QAM Coxyx
20. Multivitamins W/minerals 1 TAB PO DAILY
21. PARoxetine 10 mg PO DAILY
22. Polyethylene Glycol 17 g PO Q12H:PRN Constipation - Third
Line
23. Potassium Chloride 40 mEq PO DAILY
24. Pramipexole 0.25 mg PO TID
25. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Duodenitis
Secondary Diagnoses:
HFpEF
CKD
PAD s/p RLE stent and bypass ___
Hypertension
Hypothyroidism
Depression
Myelodysplastic syndrome
Anemia
Glaucoma
Insomnia
CAD s/p stent ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
WHY WAS I ADMITTED?
You were admitted because you were having chest pain.
WHAT WAS DONE WHILE I WAS HERE?
We monitored your heart on telemetry and through lab work. We
performed a CT scan that showed you had inflammation in your
stomach and intestine. We gave you a medication to treat this
inflammation.
WHAT SHOULD I DO NOW?
You should take your medications as instructed.
You should go to your doctors ___ as below.
Please weigh yourself daily and call your doctor if your weight
increases or decreases by more than 3 pounds in a day or 5
pounds in a week.
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
19895419-DS-4 | 19,895,419 | 20,204,854 | DS | 4 | 2127-03-09 00:00:00 | 2127-03-09 15:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Prozac / Trifluoperazine / Haldol / ACE Inhibitors
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS
==============
___ 12:12PM BLOOD WBC-8.4 RBC-5.51 Hgb-15.2 Hct-47.4 MCV-86
MCH-27.6 MCHC-32.1 RDW-12.9 RDWSD-40.1 Plt ___
___ 12:12PM BLOOD Neuts-53.0 ___ Monos-7.9 Eos-2.4
Baso-0.6 Im ___ AbsNeut-4.45 AbsLymp-3.01 AbsMono-0.66
AbsEos-0.20 AbsBaso-0.05
___ 12:12PM BLOOD Plt ___
___ 09:55PM BLOOD D-Dimer-253
___ 12:12PM BLOOD Glucose-431* UreaN-14 Creat-1.3* Na-132*
K-4.2 Cl-89* HCO3-27 AnGap-16
___ 12:12PM BLOOD CK(CPK)-399*
___ 12:12PM BLOOD CK-MB-5 proBNP-9
___ 12:12PM BLOOD cTropnT-0.03*
___ 04:31AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.9 Cholest-111
INTERVAL LABS
=============
___ 12:12PM BLOOD CK-MB-5 proBNP-9
___ 12:12PM BLOOD cTropnT-0.03*
___ 03:23PM BLOOD cTropnT-0.03*
___ 10:23AM BLOOD cTropnT-0.02*
___ 04:31AM BLOOD VitB12-457
___ 05:11AM BLOOD %HbA1c-10.6* eAG-258*
___ 04:31AM BLOOD Triglyc-225* HDL-29* CHOL/HD-3.8
LDLcalc-37
___ 04:31AM BLOOD TSH-2.3
___ 04:31AM BLOOD Trep Ab-NEG
___ 12:12PM BLOOD CK(CPK)-399*
___ 12:30PM BLOOD SED RATE-2
___ 04:31AM BLOOD CRP-4.0
___ 04:31AM BLOOD ALDOLASE-7
DISCHARGE LABS
==============
___ 07:55AM BLOOD WBC-7.9 RBC-5.21 Hgb-14.5 Hct-45.5 MCV-87
MCH-27.8 MCHC-31.9* RDW-13.2 RDWSD-41.6 Plt ___
___ 07:14AM BLOOD Glucose-293* UreaN-13 Creat-1.0 Na-136
K-4.9 Cl-102 HCO3-23 AnGap-11
___ 07:14AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.0
IMAGING
=======
XR CHEST ___:
Low lung volumes with probable bibasilar atelectasis.
XR C-spine ___:
Postsurgical and degenerative changes as described above.
Degree of central stenosis, if any, is difficult to assess.
Limited visualization of neural foramina, which are potentially
narrowed. No evidence of acute abnormality.
TTE ___:
The left atrial volume index is normal. The right atrium is
mildly enlarged. The right atrial pressure could not be
estimated. There is mild symmetric left ventricular hypertrophy
with a normal cavity size.
There is normal regional and global left ventricular systolic
function. Quantitative biplane left ventricular ejection
fraction is 60 % (normal 54-73%). 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. Tissue Doppler
suggests a normal left ventricular filling pressure (PCWP less
than 12mmHg).
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 a
normal ascending
aorta diameter for gender. The aortic valve leaflets (?#) 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 trivial 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: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/ global biventricular systolic
function. Unable to quantify pulmonary artery systolic pressure.
No valvular pathology or pathologic flow identified.
CTA HEAD AND NECK ___
1. Head CT: No acute intracranial pathology.
2. Head CTA: Moderate nonocclusive atherosclerotic
calcifications at the
bilateral carotid siphons. Patent circle of ___ without
evidence of
stenosis,occlusion,or aneurysm.
3. Neck CTA: Patent bilateral cervical carotid and vertebral
arteries without
evidence of stenosis, occlusion, or dissection.
MR CERVICAL AND LUMBAR SPINE ___
MR ___ spine
IMPRESSION:
Images degraded by motion artifact. Within these confines:
1. Multilevel degenerative changes of the lumbar spine, most
prominent at
L3-L4 where there is severe spinal canal stenosis.
2. There is severe bilateral neural foraminal narrowing from
L3-L4 through
L5-S1.
MR ___ SPINE
IMPRESSION:
Please note that only sagittal images of the cervical spine were
obtained, and
these images are significantly degraded by motion artifact,
rendering this
exam essentially nondiagnostic. Consider repeat MRI of the
cervical spine,
possibly with sedation if clinically indicated.
MICRO
=====
___ 01:28AM URINE Color-Straw Appear-CLEAR Sp ___
___ 01:28AM URINE Blood-NEG Nitrite-NEG Protein-20*
Glucose->1000* Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-8.0
Leuks-NEG
___ 01:28AM URINE RBC-4* WBC-2 Bacteri-NONE Yeast-NONE
Epi-1
___ 01:28AM URINE Mucous-RARE*
___ 1:28 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
TRANSITIONAL ISSUES:
=================================
[] MRI L-spine demonstrated severe L3-L4 disc herniation and
spinal stenosis. He did not have weakness or other signs of
neurologic deficits, and so may benefit from outpatient
neurology to help determine time-frame for intervention, if
indicated
[] Home furosemide held given normal biventricular systolic
function on TTE and intravascular euvolemia clinically
suggesting against heart failure; peripheral edema treated with
TEDs stockings
[] Consider restarting home HCTZ held initially due to ___
[] Repeat TTE in ___ years to evaluate mildly thickened AV
leaflets
[] Consider repeating MRI C-spine as outpatient given motion
degraded study here
[] Obtain EMG/NCS of bilateral lower extremity to evaluate poor
proprioception
[] Consider optometry referral for decreased vision in R eye
OTHER ISSUES:
- Discharge Hemoglobin: 14.5
- Discharge Cr: 1.0
- Discharge weight: 131.86 kg (290.7lb)
BRIEF HOSPITAL COURSE
=================================
___ male with a history of diabetes, COPD, congestive
heart failure, chronic lower extremity pain, ? CAD, and
schizophrenia presenting with chief complaint of general body
pain, admitted for NSTEMI. He was ruled out for NSTEMI with
negative troponins and unchanged EKG. His chronic pain and
weakness were worked up for reversible factors and was negative
for metabolic factors, however on MRI was seen to have L3-L4
spinal stenosis. He does not have any acute symptoms of focal
weakness, incontinence of parathesias requiring acute
intervention and will be discharged to rehab for conditioning.
ACUTE ISSUES:
================
#Chest pain
#H/o CAD, unknown interventions
#CHF
#Lower extremity edema
Patient initially presented with chest pounding without other
symptoms, atypical for angina, EKG without evidence of ischemia,
and flat troponins. Given his prior history of CAD, MI, CHF, he
was admitted for concern for NSTEMI, but likely was type 2
causing troponin leak. ___, he had brief chest pain radiating
down his arm found to be arm pain radiating from his neck.
Though low concern for ischemia, repeated EKG and troponins,
which were unchanged. TTE showed normal EF, no wall motion
abnormalities. Lipid panel with elevated triglycerides (though
questionable statin adherence). Home aspirin, atenolol,
atorvastatin were continued. Given two doses of furosemide
___ for symptomatic treatment of his leg edema, however,
his home furosemide will be held on discharge given TTE results
without indication of congestive heart failure and his current
euvolemia. Overall, we think his ongoing arm pain is likely due
to cervical stenosis as further commented below.
#General body pain
#Upper extremity pain
#Lower extremity pain
#Difficulty ambulating
Patient reported chronic pain since spine surgery ___ years ago
and recent falls causing worsened pain. This seems to be chronic
problem due to his known cervical stenosis likely with a
component of deconditioning. His metabolic workup was normal
(CRP, TSH, B12), x-ray of C spine did not show any acute changes
but could not comment specifically on nerve impingement due to
post-surgical changes. Labs for workup of PMR, myopathy (ESR,
RPR, aldolase) were negative. Neurology was consulted for his
weakness and recommended repeat imaging. MRI C-spine and L-spine
were repeated on day of discharge however, likely a motion
degraded study but showed significant disc bulge at L3-L4
causing mod-severe spinal stenosis with bilateral neuroforaminal
narrowing, and cervical MRI was non-diagnostic due to motion.
Given clinical exam without focal weakness, saddle anesthesia or
bowel/urine incontinence, there was no acute indication for any
intervention this admission and will to follow up with neurology
as an outpatient for further management. Neurology raised
concerns that bilateral ___ pain may be due to DVT given risk
factor of nonambulatory status. Wells Score for DVT is 1 which
gives him a moderate risk. D-Dimer on admission was negative
which effectively rules out DVT risk. His home pain medications
were continued, and oxycodone prn was given for severe pain as
he has been prescribed it previously as an outpatient. Physical
therapy was consulted and recommended discharge to rehab.
#Vertigo, resolved
#Blurry vision
New complaints of dizziness and blurry vision on ___. HINTS
exam negative. Neurology was consulted. Vertigo is likely
peripheral given intermittent symptoms as well however, patient
with multiple CVA risk factors so possibility of central cause
is still there. CTA head and neck without any for any
vertebrobasilar insufficiency or other CVA signs. He was started
on meclizine 12.5mg BID with good effect.
#T2DM
#Hyperglycemia
A1c 10.6%. ___ was consulted to assist with insulin titration
and diabetes education. Home oral agents including glipizide,
metformin were held and liraglutide was held as nonformulary. He
will restart home GlipiZIDE 5 mg PO DAILY, MetFORMIN
(Glucophage) 1000 mg PO BID, liraglutide 0.6 mg/0.1 mL (18 mg/3
mL) subcutaneous QAM on discharge. His insulin was up-titrated
to glargine 67U QHS, Humalog 10U QAC.
___, resolved
Cr elevated to 1.3 on admission from unknown baseline. It
improved to 1.0 on repeat labs and was trended and remained
stable. We think he may have been dry due to diuretics on
admission.
CHRONIC ISSUES:
===============
#Schizophrenia
Per psychiatry consult in ED, there was no concern for acute
decompensation at that time. Continued home aripiprazole.
#COPD
Continued home Loratadine, Fluticasone-Salmeterol Diskus
(100/50)
#Chronic constipation
Continued home bowel regimen and as needed enemas while
inpatient.
#GERD
Continued home Omeprazole.
=====================
#CODE: Full (confirmed)
#CONTACT: ___ ___
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.
>30 minutes spent on paitent care and coordination on day of
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ARIPiprazole 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 100 mg PO DAILY
4. Loratadine 10 mg PO DAILY
5. Cyclobenzaprine 5 mg PO TID pain
6. Docusate Sodium 100 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. GlipiZIDE 5 mg PO BID
9. Furosemide 80 mg PO BID
10. Atorvastatin 40 mg PO QPM
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Naproxen 500 mg PO Q12H:PRN Pain - Mild
13. Omeprazole 20 mg PO DAILY
14. Senna 8.6 mg PO BID:PRN Constipation - First Line
15. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
16. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
17. semaglutide 0.25 mg or 0.5 mg(2 mg/1.5 mL) subcutaneous
1X/WEEK
18. Glargine 48 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
19. Hydrochlorothiazide 25 mg PO DAILY
20. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
21. Fluticasone Propionate NASAL 2 SPRY NU BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Calcium Carbonate 500 mg PO QID:PRN gas pain
3. Meclizine 12.5 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 5 tablet(s) by mouth every six (6) hours Disp
#*90 Capsule Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
7. Glargine 67 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
9. ARIPiprazole 10 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Atenolol 100 mg PO DAILY
12. Atorvastatin 40 mg PO QPM
13. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
14. Cyclobenzaprine 5 mg PO TID pain
15. Docusate Sodium 100 mg PO DAILY
16. Fluticasone Propionate NASAL 2 SPRY NU BID
17. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
18. Gabapentin 800 mg PO TID
19. GlipiZIDE 5 mg PO BID
20. Loratadine 10 mg PO DAILY
21. MetFORMIN (Glucophage) 1000 mg PO BID
22. Naproxen 500 mg PO Q12H:PRN Pain - Mild
23. Omeprazole 20 mg PO DAILY
24. semaglutide 0.25 mg or 0.5 mg(2 mg/1.5 mL) subcutaneous
1X/WEEK
25. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
NSTEMI
SECONDARY DIAGNOSES:
Generalized myalgia and arthralgia
Difficulty walking
Vertigo
CAD
Chronic diastolic heart failure
Type 2 diabetes mellitus
Acute kidney injury
Hyponatremia
Schizophrenia
COPD
GERD
Chronic constipation
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 for your worsening pain,
especially your chest pain, and difficulty walking
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
You had labs and an EKG to confirm you were not having a heart
attack.
You had blood tested to look for possible causes of your
weakness that did not show you had any inflammatory or
infectious causes.
You had imaging of your neck and lower back to look for causes
of your pain and weakness.
You experienced dizziness that was not due to a blockage of the
blood vessels in your brain thankfully, and got better with a
new medication
The diabetes doctors saw ___ to help get your sugars under
better control.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
-Please continue to take all your medications and follow up with
your doctors at your ___ appointments.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19895778-DS-6 | 19,895,778 | 25,751,002 | DS | 6 | 2116-09-23 00:00:00 | 2116-09-23 18:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
atypical chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ with DM, HTN, asthma hyperlipidemia p/w left sided
chest pain since ___. The patient reports constant CP
___. The pain is left sided, pleuritic in nature located
left sternal border and under left breast, associated with SOB,
no diaphoresis. The pain is not positional. She denies any
recent URI sx or new strenous activity She endorses nausea and
vomitting ___ since ___ as well. Has not been able to
tolerate POs as home, states she vomits after meals, and has
nausea when not eating. She denies any abdominal pain, diarrhea
or constipation. She endorses subjective fevers and chills at
home.
Also endorses urinary symptoms x 1 week including dysuria,
frequency and urgency with left sided flank pain. No hematuria
Reports this feels similar to previous UTIs in the past. Pt and
son report, that she has had similar symptoms like this in the
past with CP and urinary sx during an admission at
___ in ___ and found to have a UTI. She denies
any sick contacts or recent travel.
In the ED, initial vitals 97.3 81 ___. Pt notes
that she has not taken her lisinopril in 1 weeks since she ran
out. Labs notable for WBC 14.3 (N 80%), AP 131, trops negative
x2, glucose 182, D-Dimer: 1017, lactate 1.7. UA with 3 epis, 8
WBC, negative leuks, positive nitrates, glucose 100, ketones 10,
protein 100. EKG showed sinus, NA/NI, no ST changes from prior.
CXR showed no acute cardiopulmonary process. CTA chest showed no
evidence of PE on prelim read, but did note 2.1 cm intermediate
density left paraspinal lesion at the level of T7, of uncertain
clinical significance. Per ED the patient EEE ___ at
___ where she was able to achieve 7 mets -> MIBI showed no flow
limiting lesion. In the ED she received nitroglycerin,
morphine, ASA 325mg, zofran, GI cocktail (without improvement),
macrobid ___, and levofloxacin 750mg IV. Shortly after
receiving the antibiotics, patient reported that she felt better
and previous complaints resolved. Has been taking in POs in the
ED. Vitals prior to transfer: 98.3, 78, 188/91, 15, 99%RA.
Currently, the patient continues to endorse CP and SOB although
appears comfortable. Currently w/o nausesa or emesis while on
the floor.
ROS: per HPI, denies night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, abdominal pain,
nausea, diarrhea, constipation, BRBPR, melena, hematochezia,
hematuria
Past Medical History:
insulin dependent diabetes
HTN
hypercholesterolemia
Asthma
Social History:
___
Family History:
Mom, deceased, htn
Dad- deceased, htn
Brother- " heart disease", and DM
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - T 98.1 BP 198/72 P 60 RR 16 O2 sat 100% on RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2, CP
reproducible with palpation on left sternal border and under
left breast
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding,left CVAT
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, gait
deferred
DISCHARGE PHYSICAL EXAM
T: 98.1 BP 135/62 ( ___ H 77 RR 18 98 RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly,
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced,irregular rhythm, no CP on palpation
of chest wall
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding,left > Right CVAT
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3,
Pertinent Results:
ADMISSION LABS
___ 01:40AM BLOOD WBC-14.3* RBC-4.53 Hgb-12.4 Hct-38.3
MCV-85 MCH-27.4 MCHC-32.3 RDW-14.3 Plt ___
___ 01:40AM BLOOD Neuts-80* Bands-0 ___ Monos-2 Eos-0
Baso-0 ___ Myelos-0
___ 01:40AM BLOOD Glucose-182* UreaN-13 Creat-0.8 Na-137
K-4.5 Cl-97 HCO3-27 AnGap-18
___ 01:40AM BLOOD ALT-23 AST-36 AlkPhos-131* TotBili-0.6
___ 01:40AM BLOOD Lipase-27
___ 01:40AM BLOOD cTropnT-<0.01
___ 07:50AM BLOOD cTropnT-<0.01
___ 01:40AM BLOOD Albumin-4.7 Calcium-9.5 Phos-4.6* Mg-1.8
___ 01:40AM BLOOD D-Dimer-1017*
DISCHARGE LABS
___ 07:15AM BLOOD WBC-10.0 RBC-4.31 Hgb-11.5* Hct-36.5
MCV-85 MCH-26.8* MCHC-31.6 RDW-14.3 Plt ___
___ 07:15AM BLOOD Glucose-216* UreaN-17 Creat-0.8 Na-136
K-4.0 Cl-98 HCO3-28 AnGap-14
___ 07:15AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.9
___ 03:20AM URINE Blood-NEG Nitrite-POS Protein-100
Glucose-100 Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 03:20AM URINE RBC-3* WBC-8* Bacteri-FEW Yeast-NONE
Epi-3
___ 08:57PM URINE Blood-TR Nitrite-POS Protein-30
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 08:57PM URINE RBC-1 WBC-6* Bacteri-FEW Yeast-NONE
Epi-<1
Imaging
___
CTA
Impression
1. No evidence of pulmonary embolism.
2. 2.1 cm intermediate density left paraspinal lesion at the
level of T7, of uncertain clinical significance. MRI could be
obtained for further evaluation.
CXR
Impression:
No acute cardiopulmonary process.
See report of concurrent Chest CT for important findings not
visible on
conventional CXR
Brief Hospital Course:
ASSESSMENT & PLAN: ___ year old ___ Speaking F hx of htn,
IDDM, HPL, p/w 2 day hx of pleuritic CP and 1 week hx of urinary
sx
#Chest Pain-The patient was admitted with ___ pleuritic chest
pain. She was ruled out for ACS with negative troponins and EKG
showed no ischemic changes. She had an elevated D-dimer, but was
ruled out for PE with a negative CTA. Her CXR was normal making
underlying pneunmonia or pneumothorax unlikely. The patient's
chest pain was reproducible on exam and was likely
musculoskeletal. Her pain was controlled with toradol, and her
chest pain completely resolved on HD 2.
# Pyelonephritis- The patient presented with a one day history
of urinary urgency, frequency and dysuria, left flank pain,
leukocytosis of 14,and UA with positive nitrites, no leuks, 3
RBC, and 8 WBC. Her symptoms were felt to be most consistent
with pylenonephritis. She received Levofloxacin and Macrobid in
the ED and was transitoned to ciprofloxacin while on the floor.
Her symptoms got better on HD 2, and she was discharged home on
ciprofloxacin 500mg BID to complete a 14 day course. She was
also sent home on Tylenol 1gm TID for control of her left flank
pain.
# HTN- The patient's Blood pressures were elevated at 160s-200s
systolic in the context of not taking her home dose of
lisinopril for the week prior to admission. On the floor she was
restarted on her home dose of lisinopril 20mg daily, and
required an additional 25mg PO hydralazine. On HD 2 the
patient's blood pressure were better controlled with Systolic
blood pressures in the 130s. She was discharged and given a
script for her home dose of 20mg lisinopril daily.
Chronic Stable Issues
# Hyperlipidemia- the patient was continued on her home dose of
Atorvastatin
# Insulin Dependent Diabtes. The patinet is followed at the
___ and was on metformin, lantus, and humalog sliding scale.
Her metformin was held on admission and she was maintained on
lantus and humalog sliding scale. Her home regimen of metformin,
lantus, humalog sliding scale were restarted at discharge.
# Asthma- stable. She continued her home dose of pulmicort
90mcg, 2 puffs BID
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO DAILY
2. Pulmicort Flexhaler *NF* (budesonide) 90 mcg/actuation
Inhalation BID
2 puffs
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Lisinopril 20 mg PO DAILY
hold for SBP < 100
5. Lantus Solostar *NF* (insulin glargine) 100 unit/mL (3 mL)
Subcutaneous qAM
35 units qAM
6. Aspirin 81 mg PO DAILY
7. HumaLOG *NF* (insulin lispro) 100 unit/mL Subcutaneous TID
10 units TID per insulin sliding scale
8. Vitamin D 400 UNIT PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Pulmicort Flexhaler *NF* (budesonide) 90 mcg/actuation
Inhalation BID
2 puffs
4. Vitamin D 400 UNIT PO BID
5. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 8 hours
Disp #*60 Tablet Refills:*0
6. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice daily Disp
#*26 Tablet Refills:*0
7. HumaLOG *NF* (insulin lispro) 100 unit/mL SUBCUTANEOUS TID
10 units TID per insulin sliding scale
8. Lantus Solostar *NF* (insulin glargine) 100 unit/mL (3 mL)
Subcutaneous qAM
35 units qAM
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Pyelonephritis
Secondary Diagnosis: Diabetes, Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at ___
___. You were admitted for pain on your left flank,
back and chest as well as burning and frequency of urination.
Your blood tests and the electrocardiogram of your heart were
ressuring that your heart was not the cause of your pain. Your
urine and blood work did indicate that you have a urinary tract
infection, possibly also affecting your left kidney. You were
placed on ciprofloxacin (an antibiotic) to treat this infection
and your symptoms improved. You will need to continue to take
this medication for 13 more days. Please also make sure you stay
well hydrated by drinking lots of water.
Please also restart your blood pressure medication (Lisinopril
20mg daily) to ensure your blood pressure is well controlled. We
have given you a new prescription for this.
Followup Instructions:
___
|
19895786-DS-17 | 19,895,786 | 26,601,468 | DS | 17 | 2163-06-11 00:00:00 | 2163-06-11 15:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right hand weakness and difficulty speaking
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year-old man with a past medical history of
atrial
fibrillation (no on anticoagulation for bleeding complications),
recent cath for ST changes found to have non-occulsive CAD, CKD,
etoh cirrhosis who had an episode this morning of dififculty
understanding and answering questions and right arm clumsiness.
The patient has a poor recollection of the morning's events. He
remembers feeling sick - which he thinks was nauseous, and then
being somewhat confused and some difficulty with speech. Most
of
the history is provided by his home health aide who was present
for the interview. She noted this morning that he didn't seem
himself. She noted when he was given a glass of ginger ale he
was unable to hold it in his right hand and didn't seem to have
much control over the hand. She also noted that he was trying
to
use his iphone with his right hand and was having a lot of
difficulty texting with his right hand. She thought the other
hand was shaky but she didn't test it. She also stated his
language appeared to be off. She felt that he didn't always
seem
to understand her questions. Sometimes his answers seemed slow
or incorrect. She didn't note any slurring, and didn't think he
had any problem with fluency. They decided to call EMS.
He reportedly had a similar symptom to this about 1.5 weeks ago.
The ___ was told that he did have a significant problem with his
language at the time, which she thought was difficulty finding
words. She thinks there may have been some right hand
involvement but she is not sure. He saw a local neurologist who
recommended an MRI which he had done yesterday. It is not known
currently what the results of that scan are.
He has a poor memory of the event and does not remember the hand
clumsiness. He has had a ___ and ___ since his discharge form
rehab in ___. He states his a.fib was diagnosed las
___
and he was started on Pradaxa. During an admission for possible
STEMI he had multiple bleeding complications including a
spontaneous thigh hematoma with a large hct drop. He was taken
of Pradaxa at that time.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. He is unclear if he had
difficulties producing speech or not as detailed above.No bowel
or bladder incontinence or retention. Denies difficulty with
gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. he has had some mild nausea the last few days but
no vomiting, diarrhea, constipation or abdominal pain. No
recent
change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
- atrial fibrillation diagnosed in ___
- recent cath for STEMI but found to have non-occlusive coronary
disease
- Atrial fibrillation
- Alcoholic cirrhosis s/p portal shunt in ___
- CKD - baseline Cr of 1.5-2.3
- Gout/high uric acid
- prior etoh abuse, sober for ___ years
Social History:
___
Family History:
Brother had TIAs is ___, mother and father both lived
to old age.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:98 P:86 R: 16 BP:146/88 SaO2: 100
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, mouth somewhat dry
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity,
limited horizontal range of motion
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: ___, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally,scaly skin throughout, venous
stasis changes on legs.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was slightly dysarthric but
he feels it is at baseline. Able to follow both midline and
appendicular commands. Pt. was able to register 3 objects and
recall ___ at 5 minutes. The pt. had good knowledge of current
events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, slightly increased tone in legs, No
pronator
drift bilaterally - but cannot fully pronate right arm due to
old
injury
No adventitious movements, such as tremor, noted. He does have
some asterixis. Some wasting of hand intrinsics
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: Decreased to temp at feet, normal to pin. Only ___
seconds of vibration at both big toes. Normal proprioception
throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally.
-Coordination: Mild tremor throughout but not end intention on
FNF, normal HKS.
-Gait: Deferred
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
___ 12:55PM BLOOD WBC-6.0 RBC-4.60# Hgb-14.8# Hct-44.5#
MCV-97 MCH-32.3* MCHC-33.3 RDW-16.6* Plt ___
___ 12:55PM BLOOD Neuts-52.9 ___ Monos-5.8 Eos-8.1*
Baso-1.1
___ 12:55PM BLOOD ___ PTT-31.7 ___
___ 12:55PM BLOOD UreaN-54*
___ 12:55PM BLOOD Creat-2.1*
___ 12:55PM BLOOD cTropnT-0.07*
___ 09:45PM BLOOD CK-MB-6 cTropnT-0.06*
___ 05:00AM BLOOD CK-MB-5 cTropnT-0.07*
DISCHARGE LABS:
IMAGING:
CT HEAD ___: IMPRESSION: No acute intracranial abnormality.
CXR ___: IMPRESSION: No evidence of acute disease.
MRI MRA ___ definite evidence of acute infarct. Severe
changes of small
vessel disease and brain atrophy.
The neck MRA demonstrates normal flow in the carotid and
vertebral arteries.
No stenosis or occlusion seen.
The head MRA demonstrates normal flow signal in the arteries of
anterior and
posterior circulation. Bilateral fetal posterior cerebral
arteries with
consequent small basilar arteries identified. The left vertebral
artery
appears to be ending in posterior inferior cerebellar artery.
IMPRESSION: No significant abnormalities on MRA of the head.
EEG: No epileptic discharge or seizure activity. Some change
consistent with age related encephalopathy.
___ 05:20AM BLOOD WBC-6.1 RBC-4.08* Hgb-13.0* Hct-40.6
MCV-99* MCH-31.9 MCHC-32.1 RDW-16.6* Plt ___
___ 05:00AM BLOOD WBC-6.2 RBC-3.86* Hgb-12.5* Hct-37.9*
MCV-98 MCH-32.3* MCHC-32.9 RDW-16.7* Plt ___
___ 05:20AM BLOOD ___ PTT-30.2 ___
___ 05:20AM BLOOD Plt ___
___ 05:20AM BLOOD Glucose-98 UreaN-47* Creat-1.6* Na-134
K-4.1 Cl-105 HCO3-24 AnGap-9
___ 05:00AM BLOOD Glucose-105* UreaN-51* Creat-1.8* Na-140
K-4.1 Cl-109* HCO3-23 AnGap-12
___ 05:20AM BLOOD ALT-22 AST-41* LD(LDH)-227 CK(CPK)-61
AlkPhos-95 TotBili-1.1
___ 05:20AM BLOOD CK-MB-4 cTropnT-0.06*
___ 05:00AM BLOOD CK-MB-5 cTropnT-0.07*
___ 09:45PM BLOOD CK-MB-6 cTropnT-0.06*
___ 05:20AM BLOOD Albumin-2.5* Calcium-8.7 Phos-3.9 Mg-2.0
___ 05:00AM BLOOD %HbA1c-5.3 eAG-105
___ 05:00AM BLOOD Triglyc-35 HDL-54 CHOL/HD-3.5 LDLcalc-127
___ 12:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
___ is an ___ yo man with PMHx of afib (not on
anticoagulation for bleeding complications), recent cardiac cath
for ST changes found to have non-occlusive CAD, CKD and EtOH
cirrhosis who presented for difficulty producing and
comprehending speech and R arm clumsiness. His sx resolved
within 20 mins, making TIA the most likely diagnosis upon
admission. After collecting more collateral information and
imagining, we felt that this event was more likely due to aging
and sequelae of microvascular disease rather than a
thromboembolic event.
# NEURO: he was started on a heparin gtt on arrival given the
likely embolic nature of the TIA to the L MCA territory. We
decreased his ASA from 325mg to 81mg while on the heparin gtt.
However, the heparin gtt was then stopped because his PTT became
supratherapeutic on ___. He remained on aspirin 81 and stopped
the heparin. After collecting more collateral from pt family
members and home nursing, our suspicion for embolic stroke was
greatly decreased. However, we restarted him on low dose of
coumadin with asa bridge. We restarted coumadin given his afib
and underlying risk factors for thromboembolic event after
discussion with his PCP and consultation with hematology.
# CARDS: while here we initially cut his home dose lasix in
half, but continued his home dose metoprolol. We decreased his
ASA dose above, but on discharge he went home on asa 81,
coumadin 2, and normal dose lasix. He had an echo while here,
which showed IMPRESSION: Mild focal LV systolic dysfunction.
Mild mitral regurgitation, likely due to leaflet tethering. Mild
aortic regurgitation. Biatrial enlargement.
# ENDO: His HgA1C was 5.3, LDL was 127 so we continued his home
dose simvastatin. He was put on an insulin sliding scale while
here to maintain euglycemia.
# CODE/CONTACT: Full code; confirmed with patient.
TRANSITIONAL CARE ISSUES:
Anticoagulation discharge on coumadin 2mg po qd with close
follow up with Primary care physician and bridge on asa 81.
Patient to resume normal home ___ services.
Medications on Admission:
- Metoprolol 50mg BID
- ASA 325 qd
- Lasix 40mg qd
- Allopurinol ___ qd
- Simvastatin 10mg qd
- Colace
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
2. furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
INR of ___. .
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
___:
Age related microvascular 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 seen in the hospital for R arm clumsiness and
difficulty with speech. We think that you had a TIA
(mini-stroke). Given your atrial fibrilation, we think it would
be best to start you on coumadin. We will discharge you with a
perscription for coumadin (a blood thinner). This medication
requires close follow up which will be arranged through your
primary care physician, ___.
Note to provider: ___ continue with coumadin until it reaches
a theraputic INR (___). Once this level has achieved steady
state, we recommend stopping aspirin.
We made the following changes to your medications:
We decreased your aspirin to 81mg, started coumadin 2mg per day
which can be adjusted by your PCP.
Please continue to take your other medications as previously
prescribed.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
___
|
19895786-DS-18 | 19,895,786 | 29,062,800 | DS | 18 | 2163-10-02 00:00:00 | 2163-10-02 14:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Pradaxa / OxyContin
Attending: ___
Chief Complaint:
Initially admitted to Orthopedics for Septic Arthritis
transferred to medicine for management on confusion, dysarthria,
acute on chronic renal failure and supra-therapeutic INR
Major Surgical or Invasive Procedure:
___ Irrigation and debridement, liner exchange of left knee
___ endoscopic retrograde cholangiopancreatography
History of Present Illness:
Mr. ___ is an ___ year old male with a history of valvular
atrial fibrillation (on coumadin), EtOH Cirrhosis complicated by
portal hypertension, TIAs and s/p TKA in LLE who was initially
admitted to the orthopedics service for management of septic
arthritis. Patient had a podiatric procedure 3 days prior to
admission for an ingrown toenail and was given Amoxicillin
prophylaxis. He presented to the ED on ___ with a hot,
erythematous, painful right knee, joint aspiration in the ED
revealed septic arthritis, initially started on Vancomycin but
discontinued in hopes for better culture data in the OR. On
___, he underwent left knee incision and drainage and liner
exchange. Culture grew STAPHYLOCOCCUS LUGDUNENSIS, ID consulted
and patient was started on Nafcillin with plan to add Rifampin
for additional coverage. Overnight ___ the patient's
daughter noted patient to be more confused and with garbled
speech during a phone conversation. Medicine was consulted this
morning for evaluation. His neurological exam was in tact per
medicine consult service note and they had low suspicion for
stoke given therapeutic INR on Coumadin and without focal
neurologic deficits. Vital Signs on evaluation at 11am: T 97.6,
119/73, hr 88, rr 16, saturation 100% RA
On transfer to medicine service patient found to be confused at
times, answering questions inappropriately and with slurred
speech. Patient lethargic but alert, oriented to person, place
and time though questions had to be asked a few times since he
answered inappropriately. He is unable to give a good history
and cannot recall many of his medical problems. He denies
headache, confusion, weakness, loss of sensation, changes in
vision, lightheadedness or dizziness.
ROS: (+) per HPI
Denies: fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- TIA ___
- Atrial Fibrillation (valvular) on Coumadin
- C.Cath for STEMI found to have non-occlusive CAD
- Alcoholic cirrhosis s/p portal shunt in ___ (TIPS?)
- CKD - baseline Cr of 1.5-2.3
- Gout/high uric acid
- prior etoh abuse, sober for ___ years
- ___ ___
Social History:
___
Family History:
- Non-contributory to acute presentation
- Brother had TIAs is ___, mother and father both lived
to old age.
Physical Exam:
Medicine Transfer Exam:
VS - 98.5 98.2 98/62 88 16 98%RA
General: Pleasant but confused occasaionally, elderly male
seated in bed in NAD. He answers questions inappropriately at
times and exhibits slurred speech.
HEENT: NCAT, EOMI, sclerae anicteric, neck supple, moist mucous
membranes, OP WNL
CV: RRR, S1S2 clear and of good quality, ___ holosystolic murmur
heard best at the LUSB
PULM: Lungs clear to auscultation bilaterally, moving air well
and symmetrically
ABDOMEN: NABS, soft, non-tender, non-distended, no
hepatosplenomegaly
MSK: Left knee dressings in place, did not take down dressing.
EXTREMETIES: warm and well perfused, 1+ LLEE, palpable distal
pulses. Flexion and extension of L foot intact, diminished motor
function of right foot. Toes edematous. +Asterixis
LYMPH: no cervical lymphadenopathy
SKIN: no rashes, no jaundice
NEURO: Lethargic but alert, confused at times answering
questions inappropriately. Oriented to person, place and time
with repeated questioning, CN ___ grossly intact. Motor
strength intact in UE bilaterally. Motor and sensory function
intact in major joints of LLE. ___ strength with flexion of L
foot and ___ with extension of L foot, sensation intact. Limited
LLE exam given recent surgery to left knee. Asterixis
On discharge, he was afebrile with BP 140/80, HR ___, O2 sats
99% RA. He was alert and oriented x3, no asterixis. Lungs
clear to auscultation.
Pertinent Results:
Admission to medicine labs:
___ 05:40AM BLOOD WBC-6.2 RBC-2.77* Hgb-9.1* Hct-28.8*
MCV-104*# MCH-32.9* MCHC-31.6 RDW-16.4* Plt ___
___ 05:40AM BLOOD Glucose-125* UreaN-47* Creat-2.2* Na-133
K-4.7 Cl-106 HCO3-20* AnGap-12
___ 05:40AM BLOOD ___ PTT-49.1* ___
___ 01:21PM BLOOD ALT-21 AST-32 LD(LDH)-283* AlkPhos-130
TotBili-2.6*
INR trend:
___ 09:35AM BLOOD ___
___ 05:40AM BLOOD ___ PTT-49.1* ___
___ 01:21PM BLOOD ___ PTT-51.4* ___
___ 05:42AM BLOOD ___
ARF trend:
___ 05:40AM BLOOD Glucose-125* UreaN-47* Creat-2.2* Na-133
K-4.7 Cl-106 HCO3-20* AnGap-12
___ 05:42AM BLOOD Glucose-113* UreaN-53* Creat-2.7* Na-134
K-4.6 Cl-104 HCO3-21* AnGap-14
___ 04:57AM BLOOD Glucose-116* UreaN-52* Creat-2.5* Na-137
K-3.9 Cl-108 HCO3-18* AnGap-15
___ 04:52AM BLOOD Glucose-120* UreaN-64* Creat-2.2* Na-140
K-4.0 Cl-110* HCO3-19* AnGap-15
___ 06:40AM BLOOD Glucose-119* UreaN-58* Creat-1.9* Na-141
K-3.6 Cl-111* HCO3-20* AnGap-14
___ 05:16AM BLOOD Glucose-109* UreaN-33* Creat-1.5* Na-138
K-4.1 Cl-110* HCO3-21* AnGap-11
LFTs:
___ 06:00PM BLOOD ALT-32 AST-41* AlkPhos-109 TotBili-1.5
___ 01:21PM BLOOD ALT-21 AST-32 LD(LDH)-283* AlkPhos-130
TotBili-2.6*
___ 05:42AM BLOOD ALT-19 AST-31 LD(LDH)-244 AlkPhos-125
TotBili-3.6* DirBili-3.0* IndBili-0.6
___ 06:40AM BLOOD ALT-24 AST-52* AlkPhos-122 TotBili-6.2*
DirBili-1.7* IndBili-4.5
___ 05:40AM BLOOD ALT-24 AST-55* LD(___)-571* AlkPhos-104
TotBili-7.6* DirBili-2.5* IndBili-5.1
___ 05:40AM BLOOD ALT-21 AST-50* LD(LDH)-577* AlkPhos-94
TotBili-5.3* DirBili-2.0* IndBili-3.3
___ 05:03AM BLOOD ALT-21 AST-38 LD(LDH)-476* AlkPhos-93
TotBili-3.6*
___ 09:01AM BLOOD ALT-22 AST-36 LD(___)-469* AlkPhos-119
TotBili-3.2*
Discharge Labs:
Microbiology:
TISSUE (Final ___:
STAPHYLOCOCCUS ___. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS ___
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
Reports:
- CT Head ___ without acute evicence of bleed.
- RUQ US with dopplers ___
1. Cirrhotic liver with apparent portal vein thrombosis and
markedly
increased arterial blood supply. No focal liver masses are seen.
2. Several liver cysts, possibly peribiliary cysts as well as
some mild
intrahepatic bile duct dilatation is noted.
3. Doppler shows portal vein thrombosis and patent hepatic veins
and IVC.
4. Soft tissue mass in the region of the pancreatic tail,
slightly increased compared to CT of ___.
EGD report ___:
The biliary tree, cystic duct, and gallbladder were opacified.
The CBD measured 8 mm. The cystic duct and CBD overlapped making
delineation difficult. There appeared to be several filling
defects in the cystic duct and a large 18 mm stone in the
gallbladder. There were no definitive filling defects in the
CBD. The intra-hepatic bile ducts demonstrated diffuse pruning
likely secondary to patients known cirrhosis. A limited
sphincterotomy was performed in the 12 o'clock position using a
sphincterotome over an existing guidewire. Balloon sweep x3 was
performed with extraction of a small amount of debris.
Brief Hospital Course:
Primary Reason for Hospitalization:
___ year old male with a history of valvular atrial fibrillation
on coumadin, EtOH Cirrhosis complicated by portal hypertension,
TIAs and s/p TKA of LLE, initially admitted to the orthopedics
service for management of septic arthritis then transferred to
medicine service for management of confusion, dysarthria, ARF
and supratherapeutic INR.
# Hepatic Encephalopathy: On transfer pt had worsening confusion
with hallucinations. History of TIAs and A.fib was concerning
for additional TIA but he was therapeutic on coumadin and head
CT showed no acute change. Given his concurrent rise in
bilirubin and new asterixis on exam, his AMS was felt most c/w
hepatic encephalopathy, likely exacerbated by narcotic pain
medications and infection. RUQ U/S showed no portal vein
thrombus or ascites. Narcotic medications were discontinued and
he was started on aggressive lactulose. His encephalopathy
gradually resolved and on discharge he was AAOX3 and had no
asterixis.
# Cirrhosis: C/b by encephalopathy during hospitalization. Pt
has h/o EtOH cirrhosis s/p portocaval shunting in 1970s. No
known h/o SBP or prior h/o hepatic encephalopathy, was not on
lactulose as an outpatient. Acute decompensation felt most
likely ___ infection, recent surgery and narcotic pain
medication with TIPS predisposes patient to developing HE. RUQ
US completed as above. Hepatology was consulted for further
management, and there was initial concern that biliary
obstruction could be contributing to his acute decompensation
since ERCP from ___ showed CBD stone that was never removed.
However he had no abdominal pain to suggest acute cholangitis.
His liver function and encephalopathy gradually improved
withlactulose, treatment of infection, and discontinuation of
narcotic medications.
# Acute on chronic renal failure: Pt developed acute on chronic
renal failure with creat gradually increasing to 2.8 from
baseline 1.8-2.0. Initially concerning for HRS in setting of
worsening LFTs, however FeUrea suggested intrinsic renal
failure. He also developed a peripheral eosinophilia, which was
felt most c/w acute interstitial nephritis. IV nafcillin was
switched to IV vancomycin, and his creat gradually improved
without steroids. On discharge his creat had improved to 1.5.
# L Knee Septic Arthritis: Stable s/p washout on ___, wound
cultures grew STAPHYLOCOCCUS LUGDUNENSIS, thought likely
bacteremic seeding s/p podiatric procedure. Was initially on IV
nafcillin, switched to IV vancomycin due to concern for AIN as
above. He should complete a 6 week course of antibiotics (will
be completed on ___. He is scheduled to f/u in the
Infectious Disease ___ clinic. Weekly labs including CBC
w/diff, BUN/Creat, ESR, CRP, and Vanco Trough should be drawn
with results faxed to Infectious disease R.Ns. at ___. All questions regarding outpatient antibiotics should
be directed to the infectious disease R.Ns. at ___ or
to on call MD in when clinic is closed. He should also follow
up in ___ clinic for surgical wound check one week after
d/c.
# L Knee Hemarthrosis: Pt's Hct gradually downtrended and he
required RBC transfusion (5 units total). He was noted to have
worsening L knee effusion and ecchymoses, felt most likely to be
source of bleed. He was guaiac negative. His knee was wrapped
with ACE bandage and ice was applied TID. His Hct stabilized
and L knee effusion improved.
# Atrial Fibrillation: Chronic, stable on Coumadin, rate
controlled with home Metoprolol. CHADS2 score of 5 extremely
high risk for stroke, particularly given recent TIA in ___.
He was switched from coumadin to IV heparin sliding scale due to
need for procedures including knee washout and ERCP. He was
restarted on coumadin on ___, INR on discharge was 1.9 so
heparin drip discontinued. He will need continued monitoring of
his INR with goal ___. If he is subtherapeutic, he should be
bridged with IV heparin.
# Urinary retention: The patient developed urinary retention
with 1000cc of retained urine and had a foley placed. The
patient underwent voiding trial, but failed with 600cc of urine
in the bladder so the foley was replaced on ___. Subsequent
voiding trial should be attempted ___. If repeat voiding
trial fails the patient may need to be referred to urology.
# CAD: Recent cath with non-occlusive CAD to 40-50% stenosis.
Continued Aspirin 81 mg PO/NG DAILY, Metoprolol Tartrate 25 mg
PO/NG BID, Simvastatin 20 mg PO/NG QHS.
# HTN: Chronic, stable on home Metoprolol Tartrate 25 mg PO/NG
BID. Would benefit from ACE inhibitor therapy given his chronic
systolic CHF, but this was deferred during hospitalization due
to acute renal failure.
# CHF: Chronic, Systolic CHF with LVEF 35-40%, ischemic related,
well compensated currently ___ Class I based on history prior
to surgery. Continued Metoprolol as above. Patient would benefit
from an ACE-I and should be started after resolution of ARF.
TRANSITIONAL ISSUES:
- Medication changes: started IV vancomycin (will need 6 week
course, to be completed on ___, started tylenol and tramadol
for knee pain, reduced allopurinol to 100mg daily
- Has f/u scheduled in ___ clinic for wound check and
staple removal
- He should have weekly labs (CBC w/diff, BUN/Creat, ESR, CRP,
and Vanco Trough) drawn and results faxed to Infectious disease
R.Ns. at ___.
- Next vancomycin trough should be drawn on ___
- All questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ___ or to
on call MD in when clinic is closed.
- His coumadin was restarted on ___ with heparin bridge,
heparin bridge discontinued on d/c (INR 1.9). INR should be
monitored daily for a few days after d/c to ensure INR is stable
in therapeutic range.
- He should have semi-annual RUQ US and AFP to monitor for HCC
(has liver clinic f/u scheduled)
- Would recommend starting ACE-I as an outpatient due to h/o
systolic CHF
- He maintained full code status
Medications on Admission:
- Furosemide 40 mg PO DAILY
- simvastatin 20 mg Daily
- Metoprolol tartrate 25 mg PO BID
- Allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
- aspirin 81 mg Tablet, PO DAILY (Daily).
- warfarin 2 mg Tablet Daily: Goal INR of ___
Discharge Medications:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. tramadol 50 mg Tablet Sig: ___ Tablet PO Q6H (every 6
hours) as needed for pain.
8. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15) mL
PO three times a day: Titrate to ___ bowel movements daily, hold
if pt having >4 bowel movements daily.
9. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
10. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain: Not to exceed 2g daily.
11. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q48H (every 48 hours): Received on ___, next dose starts ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
primary: Left knee infection, hepatic encephalopathy, acute
renal failure.
secondary: atrial fibrilation, liver cirrhosis, congestive heart
failure, hypertension
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:
Mr. ___,
It was a pleasure treating you during this hospitalization. You
were admitted to ___ because of
an infection in your left knee. You were admitted to the
Orthopedic service where you had an operation to drain the
infected fluid and you were started on IV antibiotics. You
became confused and were found to have hepatic encephalopathy
which was treated with lactulose with improvement in mental
status. Your developed liver failure, kidney failure during your
course but over time, these two problems resolved. You also
received a procedure called an ERCP, which opened the ducts
draining bile from your liver. The procedure was successful and
should help protect against stones getting stuck in your bile
duct.
The following changes to your medications were made:
- START Vancomycin IV to continue for 6 weeks. You will complete
your course of Vancomycin on ___.
- START tylenol and tramadol as needed for pain
- START lactulose to prevent confusion
- REDUCE Allopurinol to 100mg daily (renally dosed)
No other changes were made, please continue taking the rest of
your medications as previously prescribed.
Other Instructions:
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- You should have labs checked and faxed to the infectious
disease department R.Ns. at ___
- All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ___ or to on call
MD in when clinic is closed
Wound Care:
- Keep Incision clean and dry.
- Keep pin sites clean and dry.
- You can get the wound wet or take a shower but no baths or
swimming for at least 4 weeks.
- 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 weight-bearing as tolerated on your left leg
- Elevate left leg to reduce swelling and pain.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Take all medications as instructed.
- Continue antibiotics for the next 6 weeks.
- 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.
It has been a pleasure taking care of you at ___ and we wish
you a speedy recovery.
Followup Instructions:
___
|
19895786-DS-19 | 19,895,786 | 29,798,422 | DS | 19 | 2163-10-22 00:00:00 | 2163-10-23 07:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Pradaxa / OxyContin
Attending: ___.
Chief Complaint:
hip fracture s/p fall
Major Surgical or Invasive Procedure:
left hip hemiarthroplasty
History of Present Illness:
Mr. ___ is a ___ with a history of atrial fibrillation
on coumadin, EtOH Cirrhosis complicated by portal hypertension,
TIAs and s/p TKA of LLE, septic arthritis s/p washout ___,
discharged to rehab on ___, presents back to the hospital s/p
fall with new left hip fracture.
.
Per patient, he received sleeping pill last night for insomnia
(rehab facility confirmed trazadone 25mg), felt groggy this
morning, got up to go to the bureau, slipped and fell landing on
his side. He experienced severe pain in his groin and was
unable to get up from the floor. Rehab staff found him on the
floor. He was responsive, and there was no evidence of seizure,
no notable weakness, and no urinary or fecal incontinence.
Patient denies hitting his head, and there was no evidence of
trauma. He denies chest pain, palpitations, dizziness,
lightheadedness. Patient was taken to the hospital.
.
Of note, patient was noted to syncopize while working with
physical therapy the day prior to presentation. He was noted to
be conversant while eating lunch. Immediately thereafter, he
was walking with ___ and just feel over and became unresponsive.
A Code Blue was called, but prior to resuscitation, staff hit
him hard on the chest, and patient "woke up," asking why he was
being hit. Per ___ staff, patient endorsed a prior
episode similar to this at home several months ago, but patient
was unable to confirm this today.
.
Patient is at rehab recovering from left knee washout, culture
grew staph lugdunensis, and he was on vancomycin, as nafcillin
was implicated in AIN. He is followed in OPAT and his abx
should finish ___. Last dose of vancomycin was on ___, when
he received 750mg q2d. AT rehab, nurses noted that he was
recovering well, regaining range of motion in his knee and
regaining strength, able to walk around the floor.
.
In the ED, initial vitals were 97.5 ___ 22 98%. EKG
showed a. fib at 99, NA, TWI laterally. Lab work revealed INR
6.4, Cr 1.7 (baseline), Hct 35 (higher than baseline at recent
discharge). Head CT was negative for bleed. Patient was given
morphine 5mg x2 for pain. Hip films showed nondisplaced
impaction fracture of the left femoral neck. Patient was seen
by ortho team, who recommended surgical fixation after medical
stabilization. Patient was transferred to the medical floor.
Vitals prior to transfer were: 96.8 ax HR: 99-107 a. fib. RR: 11
O2: 100 BP: 165/98 Pain: ___.
.
On the floor, VS: 97.2 149/97 112 20 98(RA). Patient was
very somnolent, but was arousable and can answer questions,
although responses were slow and patient endorses significant
gaps in his memory. Daughter states that this is his usual
state when he receives pain medication. He denies pain or
discomfort.
Past Medical History:
- ___ I&D and linear exchange L knee
- ___ ERCP
- TIA ___
- Atrial Fibrillation on Coumadin
- C. Cath for STEMI found to have non-occlusive CAD
- Alcoholic cirrhosis s/p portal shunt in ___ (TIPS?)
- CKD - baseline Cr of 1.5-2.3
- Gout
- prior etoh abuse, sober for ___ years
- TKR ___
Social History:
___
Family History:
- Non-contributory to acute presentation
- Brother had TIAs is ___, mother and father both lived
to old age.
Physical Exam:
Physical Exam On Admission:
Vitals: Tc 97.2 BP 149/97 HR 112 RR 20 O2sat 98(RA)
General: Somnolent but arousable and appropriately answers
questions, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: Irregular, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: normoactive bowel sounds, soft, non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding
GU: foley for urinary obstruction
Ext: warm, faintly palpable pulses, evidence of venous stasis
changes b/l shins, left knee surgical site is c/d/i with mild
erythema, skin tear at the left wrist in ulnar dorsal aspect,
skin tear right elbow
Neuro: somnolent, intermittently follows commands, able to move
all extremities, difficult if he's ___ strength b/l upper
extremities or if he's not trying hard enough, no asterixis
Physical Exam on Discharge:
VS: 98 122/72 96 20 99% RA
Gen: No acute distress
HEENT: Anicteric sclerae. moist mucous membranes.
Resp: Faint bibasilar crackles
CV: Tachycardic and irregular. Normal s1, s2. No M/G/R.
Abd: +BS. Soft. NT/ND.
Ext: Left hip with clean dressing in place. No edema.
Neuro: A+O X3
Pertinent Results:
Labs on Admission:
___ 06:50AM BLOOD WBC-9.6# RBC-3.18*# Hgb-10.5*# Hct-35.3*#
MCV-111* MCH-33.1* MCHC-29.9* RDW-21.7* Plt ___
___ 06:50AM BLOOD Neuts-79.4* Lymphs-13.0* Monos-3.3
Eos-3.7 Baso-0.6
___ 06:50AM BLOOD ___ PTT-54.6* ___
___ 06:50AM BLOOD Glucose-129* UreaN-33* Creat-1.7* Na-137
K-4.6 Cl-105 HCO3-22 AnGap-15
___ 06:50AM BLOOD ALT-26 AST-49* CK(CPK)-88 AlkPhos-166*
TotBili-1.7*
___ 04:43AM BLOOD Albumin-PND Calcium-9.4 Phos-3.9 Mg-2.0
___ 04:43AM BLOOD Vanco-22.2*
Cardiac Enzymes:
___ 06:50AM BLOOD CK-MB-8
___ 06:50AM BLOOD cTropnT-0.10*
___ 09:45PM BLOOD CK-MB-5 cTropnT-0.10*
___ 04:43AM BLOOD cTropnT-0.12*
INR trend:
___ 06:50AM BLOOD ___ PTT-54.6* ___
___ 09:45PM BLOOD ___ PTT-49.8* ___
___ 04:43AM BLOOD ___ PTT-42.9* ___
___ 10:53AM BLOOD ___ PTT-42.7* ___
Imaging:
TTE ___:
The left atrial volume is severely increased. The right atrium
is moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild to moderate
regional left ventricular systolic dysfunction with basal to mid
inferior and inferolateral hypokinesis. Doppler parameters are
indeterminate for left ventricular diastolic function. 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 are mildly thickened (?#). There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild focal LV systolic dysfunction. Mild mitral
regurgitation, likely due to leaflet tethering. Mild aortic
regurgitation. Biatrial enlargement.
Cardiac Cath ___:
1) Selective angiography of this right-dominant system
demonstrated
non-obstructive coronary artery disease. The LMCA was normal.
The LAD had minor lumen irregularities in the mid and distal
portions of the vessel; the proximal diagonal branch had 40-50%
stenosis. The LCx had minor irregularities. The RCA had ___
stenosis at the distal posterolateral segment artery.
2) Limited resting hemodynamics revealed moderate-to-severe
systemic
arterial hypertension, with a central aortic pressure of 161/97
mmHg.
pMIBI ___ (___): No evidence of infarct or ischemia;
normal wall motion; calculated EF 53%; TID 0.97.
CT Head ___:
IMPRESSION:
No acute intracranial process. Age-related involutional changes.
Hip Unilateral 2 views ___:
IMPRESSION: Nondisplaced impaction fracture of the left femoral
neck
Chest Xray ___:
IMPRESSION:
1. No acute cardiopulmonary process.
2. Stable mild cardiomegaly.
3. Mild vascular engorgement.
3. Left PICC terminating in the low SVC.
Femur ___:
1. Grossly unchanged appearance of left femoral neck fracture
with mild
foreshortening, but no displacement in the interim.
2. Changes of a prior left total knee arthroplasty with
orthopedic hardware in place and intact.
3. Calcified atherosclerotic vascular disease of the superficial
femoral
artery.
HIP ___:
The patient is status post left hemiarthroplasty in overall
anatomic alignment on this single AP view. No periarticular
fracture is detected. Subcutaneous emphysema and staples are
consistent with recent surgery.
CXR ___:
In comparison with the study of ___, there is increased
opacification at both bases with obscuration of the
hemidiaphragms, consistent with layering pleural effusions, more
prominent on the right. Compressive atelectasis is seen at both
bases. Cardiac silhouette is at the upper limits of normal in
size or slightly enlarged. There may be mild pulmonary vascular
congestion.
Little change in the appearance of the PICC line.
DISCHARGE LABS:
___ 04:46AM BLOOD WBC-6.7 RBC-2.75* Hgb-9.0* Hct-29.8*
MCV-108* MCH-32.7* MCHC-30.2* RDW-19.3* Plt ___
___ 04:46AM BLOOD ___ PTT-39.8* ___
___ 04:46AM BLOOD Glucose-116* UreaN-39* Creat-1.4* Na-137
K-5.1 Cl-108 HCO3-22 AnGap-12
___ 04:46AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ with a history of atrial fibrillation on
coumadin, EtOH cirrhosis complicated by portal hypertension,
TIAs and s/p TKA of LLE, septic arthritis s/p washout ___,
discharged to rehab on ___, presents back to the hospital s/p
fall with new left hip fracture, s/p arthoplasty of left femoral
neck, course complicated by hypotnesion, UTI, atrial
fibrillation, and supertherapuetic INR.
Active Issues:
# Surgical Repair of Left femoral neck fracture: S/p mechanical
fall. He underwent hemiarthroplasty of the affected hip with
1300cc of blood loss and rec'd a unit of blood and platelets in
the OR. He was relatively hypotensive in the PACU requiring
moderate pressor support while on propofol which was weaned
following extubation. He was monitored overnight in the MICU
without any significant events and called back out to the floor.
The orthopedic service continued to follow the wound. A wound
vac was placed by the team on ___. It did not drain any fluid
and wound vac was removed on ___. Per ortho, staples should be
removed on post - op day 14, 7 days from discharge. An
appointment should be made for him to follow - up in the ___
clinic in 2 weeks (phone number in discharge -planning).
# Hypotension: Once patient was transferred back to the floor,
he had several episodes of transient asymptomatic hypotension to
SBPs 60 - 70s. The first episode was on ___. At this point,
his Hct was stable and there was no evidence of acute bleed.
Patient was orthostatic with ambulation. Both the orthostasis
and the hypotension resolved with 1 L bolus NS. At this point
in time, both his metoprolol and tamsulosin were held.
Metoprolol was restarted on ___ once BPs had stabilized and
uptitrated for control of atrial fibrillation while tamsulosin
continued to be held. On the AM of ___, patient again had a
hypotensive episode to SBPs in the ___, asymptomatic which
resolved with 1 L NS bolus. At this point, he had a low grade
temp to 100.4 and was mildly confused. Urinalysis returned
positive and patient was started on IV ceftriaxone for presumed
UTI, urine cultures pending at time of discharge. He had no
further hypotensive episodes. Still unclear if etiology
dehydration versus infection, likely combination of both.
# Urinary Tract infection: As described above, patient had a
hypotensive episode on AM of ___ associated with confusion and
low grade fever. Urinalysis showed + leuk esterase, 14 WBCs, few
bacteria, thus, he was started on 1 g IV ceftriaxone q24 for
treatment of complicated UTI. He currently has an indwelling
foley catheter to treat urinary retention (see below). His
urine cultures were pending at the time of discharge.
# Confusion: Beginning on the AM of ___, patient began to have
short intermittent periods of confusion, but would be quickly
reoriented. Thought to be secondary to urinary tract infection.
On day of discharge, patient was still have brief periods of
confusion, but much less frequent, and again, was able to be
reoriented.
# Urinary Retention and BPH: Patient with long history of BPH
and urinary retention treated with tamsulosin. Tamsulosin was
held following hypotensive episode on ___ and had not yet been
retstarted. Patient failed voiding trial on ___ and foley
placed while off tamsulosin. No that his blood pressures have
normalized, plan should be to restart tamsulosin, discontinue
foley, and give patient another voiding trial, especially given
UTI as above.
# Atrial Fibrillation: Patient has chronic atrial fibrillation,
rate controlled on metoprolol succinate 50 once a day.
Metoprolol was discontinued when patient became hypotensive as
above. Once patient's blood pressures stabilized, his heart
rates returned to ___ 120s-130s. Metorpolol tartrate was started
on ___ and uptitrated to the current dose of 37.5 mg TID. His
rates have now stabilized at ___ metoprolol can be
uptitrated as needed at ___. Anticoagulation as below.
# Elevated INR. Patient's INR was 6.4 on admission. He was
given vitamin K IV 2mg x 2 for reversal. His INR trended down
pre-op. Received one dose of warfarin following repair, INR rose
to 5.1, and was given vitamin K for reversal to prevent post-op
hemorrhage. INR trended down to 2.1 on ___, thus coumadin was
restarted at 1 mg once a day, which he was continued on through
discharge. INR 2.7 on day of discharge.
# Syncope/Fall: Patient states that fall morning prior to
admission was purely mechanical and he remembered the entire
episode. On the contrary, at rehab, patient was noted to
syncopized, be unresponsive, and then arousable after
stimulation. He had just eaten, so unlikely was hypoglycemic,
has not had problems with hypoxia. Staff noted pulse of 83,
irregular, so not in RVR or bradycardic. As patient had just
eaten and gotten up, could have vasovagaled. Likely also an
element of orthostatic hypotension per above. Patient had no
further syncopal episodes while in house. Please place patient
on fall precuations at rehab as he poses a significant fall
risk.
# L Knee Septic Arthritis: S/p washout on ___, wound cultures
grew STAPHYLOCOCCUS ___, thought likely bacteremic
seeding s/p podiatric procedure. Was initially on IV nafcillin,
switched to IV vancomycin due to concern for AIN as above. He
is scheduled for a 6 week course of vancomycin to finish ___.
He followed in the Infectious Disease ___ clinic. He remained
on vancomycin at a dose of 750mg q48h; trough of 18 on ___ so
remained on same dose.
# OPAT Labs while on Vancomycin:
Patient needs Weekly:
CBC w/diff
BUN/Ct
ESR CRP and
Vanco Trough
All laboratory results should be faxed to Infectious disease
R.Ns. at ___
All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ___ or to on call
MD in when clinic is closed.
Patient's antibiotic course to complete ___. He needs to be
scheduled in the ___ clinic for follow - up. Please call ___ to schedule patient to see ___ or ___
___.
Inactive issues:
# Alcoholic Cirrhosis: Complicated by portal vein thrombosis and
encephalopathy during last hospitalization after undergoing TKA,
was started on rifaximin and lactulose, continued at rehab, and
patient remains on these medications. Patient is s/p portocaval
shunting in ___. Patient's MELD score on admission was 34.
Was continued on lactulose and rifampin.
# CAD: ___ cath showed non-occlusive CAD to 40-50% stenosis,
but ___ TTE showed EF 30%, so likely have intervening event
during that month. Patient is not currently in decompensated
heart failure. At rehab recently, he was diuresed for pleural
effusions, but CXR from today shows no evidence of pulm edema,
effusions, and patient is satting 97(RA). Patient was continued
on Aspirin 81 mg PO/NG DAILY, Metoprolol as above, rosuvastatn
40 qhs.
# HTN: Metoprolol as above.
# CKD: Baseline Cr of 1.5-2.3, currently 1.4. All medications
were renally dosed.
# Gout: Stable, currently asymptomatic. Patient was continued
on allopurinol.
Transitional issues:
- Wound vac in place, needs orthopedics follow - up
- Foley catheter removal and voiding trial as above
- Continue treatment of UTI
- OPAT Labs faxed to ___ clinic and OPAT appointments as above
Medications on Admission:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. -
recent held
2. metoprolol succcinate 50 mg daily
3. sodium bicarbonate 325mg bid
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. pravastatin 40mg qPM
7. zofran 4mg q8h
8. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15) mL
PO three times a day: Titrate to ___ bowel movements daily, hold
if pt having >4 bowel movements daily.
9. warfarin 3 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
10. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain: Not to exceed 2g daily.
11. vancomycin 750mg q48h
12. mirtazapine 15mg qhs
13. tamsulosin 0.4mg qhs
14. omeprazole 40mg daily
15. rifaximin 400mg tid
16. allopurinol ___
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Vancomycin 750 mg IV Q48H
3. sodium bicarbonate 325 mg Tablet Sig: One (1) Tablet PO twice
a day.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
8. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): titrate to 3 BMs daily.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
15. tramadol 50 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day)
as needed for pain.
16. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
17. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
18. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
left proximal femur fracture s/p left hip hemiarthroplasty
Secondary Diagnosis:
Septic left knee
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted after a fall at your
rehabilitation center and found to have a left hip fracture. You
went for a left hip repair and did well. You were continued on
antibiotics to help manage your knee infection. We also started
you on antibiotics for a urinary tract infection. We continued
your medications for atrial fibrillation and your coumadin.
The following changes were made to your medications:
STOP metoprolol succinate
START metoprolol tartrate
DECREASE Coumadin to 1 mg daily
START IV ceftriaxone for treatment of UTI
STOP Tamsulosin
START Ultram as needed for pain
Please see below for your follow up appointments.
Followup Instructions:
___
|
19896361-DS-20 | 19,896,361 | 24,105,587 | DS | 20 | 2150-02-23 00:00:00 | 2150-03-07 11:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Gadolinium-Containing Contrast Media / Avapro / Crestor /
Lipitor / lisinopril / Zocor / Iodinated Contrast Media - IV Dye
/ ACE Inhibitors / ___ Receptor Antagonist /
colchicine
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
EGD ___
Colonoscopy ___
History of Present Illness:
___ y/o F with PMH HFpEF (EF 40%), CKD stage III, PVD, DM, sent
in by PCP for blood transfusion with hgb 6.7. Hgb ___. Stool at PCP ___ was guaiac negative. Hasn't noticed blood
in stool or urine. Labs at PCP showing significant iron
deficiency, was on iron supplementation ___ year ago but stopped
due to constipation. No abdominal pain or history of PUD.
She also notes increased dyspnea on exertion over the last ___
days and reports a 10b weight gain above her dry weight
(143-148) in the past week. She was seen by her PCP who had her
increase her torsemide from 40mg daily to 60mg daily. She notes
that has helped her breathing and she has lost a few pounds by
doing so. Still feels legs swollen and belly bloated. Sleeps on
1 pillow, unchanged. Denies PND. Of note had URI 1 week ago and
notes increased weight began following cold.
In the ED, initial vitals: 99 58 165/54 18 100RA
- Labs notable for: Hgb 6.2, Cr 1.9(recent Cr 2 in ___, but
___ 8 months ago), BNP 306___
- Imaging notable for: Cardiomegaly without superimposed acute
cardiopulmonary process.
- Patient given: ___ lasix
- Vitals prior to transfer: BP 136/50
On arrival to the floor, pt reports no SOB, CP, abdominal pain,
nausea vomiting, no bloody in stool. reports she has voided X3
already.
Past Medical History:
1. Type 2 DM
2. Non-ischemic cardiomyopathy with EF of 25% in ___, 25% in
___, 35-40% in ___.
3. CAD with 100% RCA chronic total occlusion with good
collaterals on cath ___ and ___
3. HTN- renal angio ___ demonstrated 40% narrowing in the
proximal left renal artery which was non-obstructive
4. Hyperlipidemia
5. Claudication since ___ s/p right distal SFA and mid SFA
stenting ___
6. Hysterectomy/Oophorectomy
7. Sciatica s/p cortisone injections ___ with significant
improvement
8. Varicose veins right ___
Social History:
___
Family History:
There is considerable peripheral vascular disease in her family.
Her mother had an enlarged heart and had 11 children.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4 146/63 75 18 100RA
Weight: 70.6 kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple,
JVP not elevated, no LAD
Lungs: crackles at the bases bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mild distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, 2+ edema to midshin
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
DISCHARGE PHYSICAL EXAM
VS: 98.7 130-160/59-67 ___ 18 95-98/RA
Weight: 69.2 kg
General: well-appearing obese woman lying comfortably flat in
bed
HEENT: MMM, sclera anicteric
Neck: JVP ~11cm
CV: RRR, normal S1/S2, ___ holosystolic murmur heard best at
LUSB
Lungs: Non-labored, CTAB. Able to lie flat in bed comfortably.
Abdomen: Obese, soft, NDNT, normal BS.
Ext: Warm, edema improved.
Neuro: Normal mental status. CN grossly intact. Normal gait and
coordination.
Pertinent Results:
-----------------
TTE ___
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. There is mild global left ventricular hypokinesis (LVEF
= 40%). Right ventricular chamber size is normal with borderline
normal free wall function. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild global left ventricular systolic dysfunction.
Borderline right ventricular systolic function. Mild mitral
regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary hypertension.
ADMISSION LABS
=====================
___ 09:00PM BLOOD WBC-9.8 RBC-3.02* Hgb-6.2* Hct-21.8*
MCV-72* MCH-20.5* MCHC-28.4* RDW-17.9* RDWSD-46.1 Plt ___
___ 09:00PM BLOOD Neuts-73.6* Lymphs-14.9* Monos-9.5
Eos-1.3 Baso-0.2 NRBC-0.2* Im ___ AbsNeut-7.17*
AbsLymp-1.45 AbsMono-0.93* AbsEos-0.13 AbsBaso-0.02
___ 09:00PM BLOOD Glucose-110* UreaN-49* Creat-1.9* Na-141
K-4.4 Cl-102 HCO3-23 AnGap-20
Cardiac Markers:
___ 09:00PM BLOOD CK-MB-<1 cTropnT-<0.01 ___
___ 05:55AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 12:55PM BLOOD ___
Anemia Studies:
___ 09:00PM BLOOD Ret Aut-2.7* Abs Ret-0.08
___ 09:00PM BLOOD Iron-19*
___ 09:00PM BLOOD calTIBC-446 Ferritn-17 TRF-343
___ 05:55AM BLOOD calTIBC-412 Ferritn-18 TRF-317
___ 05:25AM BLOOD tTG-IgA-5
DISCHARGE LABS
====================
___ 05:25AM BLOOD WBC-8.9 RBC-3.82* Hgb-8.5* Hct-29.1*
MCV-76* MCH-22.3* MCHC-29.2* RDW-19.5* RDWSD-53.0* Plt ___
___ 12:55PM BLOOD ___ PTT-30.8 ___
___ 05:25AM BLOOD Glucose-101* UreaN-32* Creat-1.7* Na-142
K-4.1 Cl-104 HCO3-22 AnGap-20
___ 05:25AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.6
MICRO
===================
None
PATHOLOGY
===================
PATHOLOGIC DIAGNOSIS:
1. Antrum polyps biopsies:
A. One fragment with adenocarcinoma, at least intramucosal. No
submucosal tissue present for
evaluation. Additional levels examined. Slides reviewed with Dr.
___.
B. One fragment of hyperplastic polyp.
2. Ascending colon polypectomy: Colonic mucosa with a lymphoid
aggregate.
3. Transverse colon polypectomy: Adenoma.
4. Sigmoid polypectomy: Colonic mucosa, no adenoma seen.
IMAGING & STUDIES
===================
EKG ___:
Normal sinus rhythm. Ventricular quadrigeminy. Ventricular
hypertrophy.
Non-specific ST-T wave changes. Compared to the previous tracing
of ___
the patient is no longer in bigeminy but quadrigeminy.
CXR ___:
Cardiomegaly without superimposed acute cardiopulmonary process.
TTE ___:
Conclusions: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. There is mild global left ventricular
hypokinesis (LVEF = 40%). Right ventricular chamber size is
normal with borderline normal free wall function. The diameters
of aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Mild global left ventricular systolic dysfunction.
Borderline right ventricular systolic function. Mild mitral
regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary hypertension.
EGD ___
Impression:Several benign appearing polyps that were oozing
were noted in the stomach body, cardia, and antrum, ranging in
size from 5mm-20mm. These polyps are a possible, though not
definitive source of patient's anemia. (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations:Follow-up biopsy results.
Proceed to colonoscopy.
Colonoscopy ___
Impression:Diverticulosis of the ascending colon
Polyp in the ascending colon (polypectomy)
Polyps in the transverse colon (polypectomy)
Polyp in the sigmoid colon (polypectomy)
Otherwise normal colonoscopy to cecum and terminal ileum
Recommendations:Follow-up polypectomy results.
No findings in the colon to explain patient's anemia. If anemia
persists, could consider capsule endoscopy as an outpatient to
evaluate the ___ bowel.
PAST IMAGING & STUDIES (from Atrius records)
===============================
Echo (___)
1. Sinus rhythm with frequent PVC's.
2. Mildly dilated LV.
3. There is mild concentric left ventricular
hypertrophy.
4. Overall left ventricular systolic function is
mild-moderately reduced, with an estimated LVEF of 40%.
Frequent ectopy makes determination of EF difficult.
portions of basal-mid anteroseptum, inferoseptum,
inferior walls appear moderately hypokinetic more than
other segments, which in some images appear nearly
normal.
5. Tissue and transmitral Doppler demonstrate
pseudonormal filling (moderate grade II diastolic
dysfunction).
6. The left atrial volume is moderately increased.
7. There is mild-to-moderate tricuspid regurgitation
present.
8. Estimated PA systolic pressure, calculated from peak
TR velocity, is mildly increased at 42 mmHg above RA
pressure.
9. Compared with the findings of the prior report of
___, there has been moderate improvement in LV
systolic function. PASP is mildly lower. Diastolic
function was not completely evaluated on prior study.
Cardiac Cath ___:
RCA: total chronic occlusion, distal RCA well filled by
left-to-right collaterals
LM: 30% diffuse calcified lesion
LAD: minor luminal irregularities
LCx: 30% mid lesion
No intervention.
Cardiac Cath ___:
FINAL DIAGNOSIS:
1. 1-vessel CAD.
2. Well-compensated right- and left-heart hemodynamics.
3. Successful PTA/stent of the right SFA.
4. ASA indefinitely. Plavix 77mg QD for 6 months.
5. Post-procedure hydration for prevention of contrast
nephropathy, but monitor closer for evidence of CHF.
Adenosine Stress ___:
A ___ area of moderate stress-induced myocardial ischemia in
the distribution of the LCx or OM branch with adenosine stress.
Severely abnormal global LV systolic function. There is evidence
of mild ischemic stunning (suggested by more pronounced wall
motion abnormalities involving apical-lateral/inferolateral
segments) which may be indicative of severe lesion in that
territory. Compared to ___ study: reversible anterior defects
are no longer seen; inferolateral/apical-lateral reversible
defects are more prominent on current study.
Brief Hospital Course:
___ with HFrEF, 1vCAD, CKD3, admitted for acute on chronic iron
deficiency anemia and HFrEF exacerbation. ECG/trops were
negative for ischemia. Dyspnea and fatigue improved rapidly with
pRBC transfusions and IV Lasix, and Hb stabilized. She underwent
EGD and colonoscopy which found no clear source for bleeding
except benign-appearing gastric polyps. TTE found mild global LV
dysfunction (EF 40%), borderline RV function, moderate TR,
moderate pHTN. She was euvolemic at discharge on prior torsemide
and increased afterload/neurohormonal regimen (see below).
===================
ACTIVE ISSUES
===================
# ACUTE ON CHRONIC IRON DEFICIENCY ANEMIA
Patient has chronic iron deficiency and was previously on oral
supplements but discontinued these last year. She presented to
her PCP with dyspnea and fatigue and was found to have Hb of 6.7
(gradual decline from 10.9 in ___ 8.0 in ___. She was
transfused 2 units pRBCs with appropriate increase in her Hb and
her symptoms improved. Repeat iron studies were consistent with
iron deficiency. EGD and colonoscopy were done and found no
definitive source for bleeding except for some benign-appearing
gastric polyps. Patient will benefit from continuing iron
supplementation and potential further workup as outpatient.
# ACUTE ON CHRONIC SYSTOLIC HEART FAILURE
Patient presented with dyspnea on exertion, weight gain, edema,
and markedly elevated BNP (30,679) consistent with HF
exacerbation. TTE after diuresis found mild global LV
dysfunction (EF 40%), borderline RV function, moderate TR,
moderate pHTN. Possible precipitants for this exacerbation
include anemia (high output HF?) or undiagnosed OSA. ECG and
troponins were negative for ischemia, and telemetry was negative
for arrhythmia. Symptoms improved rapidly with pRBC transfusions
and IV Lasix boluses, and patient was transitioned back to her
home torsemide dose. Home carvedilol was continued,
spironolactone was started, and hydralazine/imdur were increased
(see below). ___ were not started due to allergy.
# HYPERTENSION
Patient had elevated SBPs this admission to 150s-160s from
baseline 120s-140s. Home carvedilol was continued, and
hydralazine/imdur were increased.
# 1-VESSEL CAD
___ cath found RCA chronic total occlusion with collaterals.
Stress MIBI in ___ found moderate infero-lateral/apical-lateral
reversible defects. No evidence was found for active ischemia
this admission on history, ECG, trops, or TTE. Home aspirin,
statin, and carvedilol were continued, and anti-hypertensives
were increased (see below).
# ACUTE ON CHRONIC RENAL FAILURE ___ on CKD STAGE III)
Cr 1.9 on admission from baseline of 1.3-1.4 in ___, but 2.0 in
___. ___ likely due to HF exacerbation; improved with
diuresis to 1.6-1.7. Possible contribution from recent
colchicine and subsequent GI upset and dehydration in ___.
Possible etiologies for CKD include HTN, DM2.
===================
CHRONIC ISSUES
===================
# TYPE 2 DIABETES MELLITUS
A1c 7.3 ___. Home metformin was held and Humalog ISS
administered during hospitalization.
===================
TRANSITIONAL ISSUES
===================
IRON DEFICIENCY ANEMIA:
-Discharge Hgb/Hct: 8.5/29.1, would recheck at next PCP appt
-___ testing pending at discharge, please f/u in OMR.
-Consider capsule endoscopy if celiac negative and anemia
worsening.
-Would repeat iron studies after PO supplementation and consider
IV iron infusions given severe iron deficit, poor tolerance of
PO iron, HFrEF, and CAD.
HFrEF:
-TTE on day of discharge with mild global LV hypokinesis (EF
40%), borderline RV function, mild MR, moderate TR, moderate
pHTN.
-Discharge weight: 69.8 kg
-Discharge diuretic: torsemide 60mg daily
-Discharge afterload/neurohormonal regimen:
--carvedilol 37.5mg BID continued
--___ held in past due to cough
--spironolactone 12.5mg daily started
--hydralazine increased from 25mg BID to TID; would titrate up
if tolerated
--isorbide mononitrate increased from 30mg daily to 60mg daily;
would titrate up if tolerated
-CAD regimen not changed: ASA 81mg, pravastatin 80mg (allergic
to other statins), carvedilol 37.5mg BID
-Consider referral for outpatient sleep study to evaluate for
OSA as cause for HF exacerbation, HTN (high risk given obesity,
snoring, daytime fatigue).
# CODE STATUS: Full
# CONTACT: Name of health care proxy: ___
___: daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 37.5 mg PO BID
2. MetFORMIN XR (Glucophage XR) 750 mg PO DAILY
3. HydrALAZINE 25 mg PO BID
4. Pravastatin 80 mg PO QPM
5. Torsemide 60 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
Take with iron at least 30 minutes before eating food
RX *ascorbic acid (vitamin C) 250 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 250 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*1
3. Ferrous Sulfate (Liquid) 300 mg PO DAILY
RX *ferrous sulfate 220 mg (44 mg iron)/5 mL (5 mL) 10 mL by
mouth daily Disp #*473 Milliliter Milliliter Refills:*1
4. Polyethylene Glycol 17 g PO DAILY constipation
RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth daily
Refills:*1
5. Senna 17.2 mg PO BID constipation
RX *sennosides 8.6 mg ___ tablets by mouth twice a day Disp
#*120 Tablet Refills:*0
6. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
7. HydrALAZINE 25 mg PO TID
RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. Aspirin 81 mg PO DAILY
10. Carvedilol 37.5 mg PO BID
11. MetFORMIN XR (Glucophage XR) 750 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Pravastatin 80 mg PO QPM
14. Torsemide 60 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Acute blood loss anemia
Acute on chronic non-ischemic systolic heart failure
SECONDARY DIAGNOSES:
Chronic iron deficiency anemia
Acute on chronic renal failure
Coronary artery disease
Hypertension
Diabetes mellitus, type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why you were admitted:
- Shortness of breath and anemia
What we did while you were here:
- We gave you blood transfusions
- You had an EGD and colonoscopy to find a source of bleeding
- We gave you medications to remove excess fluid and help your
heart pump better
Instructions for when you leave the hospital:
- Take your iron supplements every day with ascorbic acid
(Vitamin C) at least 30 minutes before food.
- Continue taking all of your other medications as prescribed
- Follow up with primary care doctor and cardiologist (see below
for details).
- Weigh yourself every morning. Call you doctor if you weight
goes up more than 3 pounds.
We wish you a speedy recovery!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19896442-DS-18 | 19,896,442 | 24,416,022 | DS | 18 | 2156-05-24 00:00:00 | 2156-05-24 21:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
pollen / midazolam
Attending: ___.
Chief Complaint:
RUQ Pain
Major Surgical or Invasive Procedure:
___ Laparoscopic Cholecystectomy
History of Present Illness:
___ with cholangitis ___ choledocholithiasis s/p ERCP
w/sphincterotomy ___. Pt stablized and discharged. Scheduled
for lap ccy with Dr. ___ ___. On day of discharge, TB
elevated to 6.0 but pt wanted to leave still. Outpt labs show
downtrending LFTs.
Pt was in USH until 10 ___ the night prior to admission when
after eating pasta and chicken, he had abdominal pain and NBNB
emesis. No f/c. He presented to the ED with continued abdominal
pain mainly on right side and emesis.
Past Medical History:
PMH: Anxiety, Depression, Seasonal allergies, cholelithiasis
PSH: Sinus surgery x 2 (chronic sinusitis), Removal L palm cyst,
Thyroid surgery for goiter (date/details ___, sphincterotomy
Social History:
___
Family History:
Mother: deceased ___ ___ lymphoma; Father: deceased ___
"old age"
Physical Exam:
Admission Physical Exam:
96.9 81 168/86 16 100%
NAD, A+OX3
RRR
CTAB
Soft, TTP RUQ without clear sign of murphys, no epigastric pain,
no rebound
No c/c/e
Discharge Physical Exam:
Vitals Tmax 98.2, Tcurrent 98.0, HR 86, BP 130/70, RR 18, 98% RA
Gen: AAO, NAD
___: RRR, S1S2, no M/R/G
Pulm: CTABL, no wheezes, rhonchi or rales
Incisions: C/D/I, no drainage, no erythema
Abd: +BS, nontender, nondistended
Ext: No edema, palpable pulses
Pertinent Results:
___ 03:44AM ___ PTT-30.9 ___
___ 01:34AM ___ COMMENTS-GREEN TOP
___ 01:34AM LACTATE-2.0
___ 01:15AM GLUCOSE-119* UREA N-13 CREAT-0.9 SODIUM-138
POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14
___ 01:15AM estGFR-Using this
___ 01:15AM ALT(SGPT)-38 AST(SGOT)-31 ALK PHOS-86 TOT
BILI-0.9
___ 01:15AM LIPASE-34
___ 01:15AM ALBUMIN-4.3
___ 01:15AM WBC-9.5 RBC-4.26* HGB-13.5* HCT-40.2 MCV-94
MCH-31.7 MCHC-33.7 RDW-14.0
___ 01:15AM NEUTS-71.7* ___ MONOS-4.0 EOS-1.2
BASOS-0.2
___ 01:15AM PLT COUNT-142*
Ultrasound- RUQ
IMPRESSION:
1. Stone in the gallbladder neck; full gallbladder which
contains layering
sludge and is not tensely distended. No sonographic ___
sign, but this
may be limited if the patient has received pain medication.
2. No intra or extrahepatic biliary ductal dilation.
Brief Hospital Course:
___ is a ___ year old male with history of
choledocholithiasis causing cholangitis s/p ERCP and
sphincterotomy ___. He was admitted to ___ on ___ with
recent history of right upper quadrant pain likely ___
cholelithiasis, possible cholecystitis. He was admitted to the
___ surgery service, and made NPO and started on IV
fluids.
He was taken to the OR on ___ for a laparoscopic
cholecystectomy. For full operative details, please see the
operative report dated ___. He tolerated the procedure
well, and was extubated following the procedure. He was taken
to the PACU for a brief stay, and remained hemodynamically
stable while there. He was then transferred to the surgical
floor where he remained afebrile and hemodynamically stable.
His vital signs and pain control were routinely monitored. He
was advanced to regular diet, which he tolerated without any
nausea or vomiting. His pain was well controlled with po pain
medications. The patient voided without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirrometry, 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. Citalopram 10 mg PO DAILY
2. ClonazePAM 2.5 mg PO QHS
Discharge Medications:
1. Citalopram 10 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*100 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4 hours Disp #*40
Tablet Refills:*0
4. ClonazePAM 2.5 mg PO QHS
5. Acetaminophen ___ mg PO Q8H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
1. Symptomatic cholelithiasis.
2. Symptomatic choledocholithiasis.
3. Acute cholecystitis with hydrops.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*You have steri-strips, they will fall off on their own. Please
remove any remaining strips ___ days after surgery.
Mr. ___ was admitted to the general surgery service at
___ on ___ after a
laparoscopic cholecystectomy. He recovered well from the
procedure and was discharged home on ___. On discharge, he
was tolerating a regular diet, passing flatus and had his pain
controlled on oral pain medications. He will follow up in the
general surgery clinic in ___ weeks.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
___
|
19897276-DS-14 | 19,897,276 | 28,994,803 | DS | 14 | 2176-04-12 00:00:00 | 2176-04-12 18:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L subdural hematoma
Major Surgical or Invasive Procedure:
___: Left ___ evacuation
History of Present Illness:
___ 4 weeks postpartum, vaginal delivery on ___ with
epidural c/b postpartum hemorrhage with Bakri balloon placement
and 2 units PRBC's and blood patch for spinal headaches on
POD#3.
2 weeks postpartum, she was diagnosed with preeclampsia with
SBP's to the 170's, was started on labetalol with improvement.
She did not undergo any evaluation for bleeding disorder that
she
is aware of.
She presented to OSH with 2 weeks intermittent headache
with nausea, 2 episodes vomiting in the past few days. Headache
is worse when flat, does wake her from sleep. She does have
nausea/vomiting but denies vision changes/diplopia,
weakness/paresthesias or dizziness. She feels her balance is
off.
CTA/MRI @ OSH shows 12mm subacute L SDH with 6mm MLS. She was
also treated for UTI at OSH ED.
She was transferred to ___ for further evaluation.
Past Medical History:
NSVD ___ c/b postpartum hemorrhage- currently breastfeeding.
Preeclampsia
Social History:
___
Family History:
Her family history includes Hypertension in her father
and mother; ___ in her son. ___ family history of
bleeding disorders.
Physical Exam:
ON ADMISSION:
==================
Gen: WD/WN, comfortable, NAD.
HEENT: Atraumatic Pupils: PERRL EOMs Full
Neck: Supple.
Lungs: No resp distress
Extrem: Warm and well-perfused.
Date and Time of evaluation: ___ 19:15
___ Coma Scale:
[ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
15 Total
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension. No dysarthria
or
paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,5mm to
4mm bilaterally.
II, 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.
============
ON DISCHARGE:
============
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: Right 3-2mm Left 3-2mm
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
IPQuadHamATEHLGast
[x]Sensation intact to light touch
Wound: Left crani site
[x]Incision OTA with staples, single drain site suture
[x]Left SD drain to EVD setup intact with serosang
drainage
Pertinent Results:
Please refer to OMR for pertinent lab and imaging results.
Brief Hospital Course:
Patient presented to the ED on ___ from outside hospital with
L SDH. She was admitted to ___ on the neurosurgery service.
#Left subdural hematoma with brain compression
Pain and nausea was controlled on medications per OB and
pharmacy recommendations as the patient continued to breastfeed
while in the hospital. The patient went to the OR on ___ s/p
burr hold for subdural hematoma evacuation. A subdural drain was
placed intraoperatively and removed on POD#2. NCHCT on ___ was
stable. She was discharged home in stable condition on POD#2.
#Preeclampsia
Her blood pressure was closely monitored and she continued her
home labetalol on admission. BP remained within normal
parameters.
#Heme
Hematology was consulted to ensure there is no underlying
bleeding disorder that caused the post-partum hemorrhage and
SDH. It was felt the SDH was caused by CSF leak requiring blood
patch after epidural and hyptertension from preeclampsia.
Hematology labs were not concerning for underlying bleeding
disorder.
Medications on Admission:
labetalol (NORMODYNE) 200 mg tablet, Take 2 tablets (400 mg
total) by mouth every 12 (twelve) hours.
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
capsule(s) by mouth Q8H PRN Disp #*42 Capsule Refills:*0
2. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild
3. Docusate Sodium 100 mg PO BID
4. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8H PRN Disp #*30
Tablet Refills:*0
5. Labetalol 400 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Subacute subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Surgery
You underwent a surgery called a craniotomy to have blood
removed from your brain.
Please keep your sutures and staples along your incision dry
until they are removed.
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 may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
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.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
19897314-DS-15 | 19,897,314 | 27,325,591 | DS | 15 | 2203-02-01 00:00:00 | 2203-02-03 11:20:00 |
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, Left Shoulder Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with PMHx of hypothyroidism,
who presents with left shoulder pain after a syncopal event.
The patient was in her usual health until the morning of ___,
when she arose from bed. She felt slightly dizzy on standing,
which she says has happened many times before, although she
cannot recall exactly how long this LH on standing has been
occurring. The patient states that she was walking to her
closet,
and felt dizzy; the next thing she remembers is waking up on the
floor with severe left shoulder pain, as well as mild left knee
pain and a headache. She does not recall the events between
feeling dizzy and waking up on the floor. Her husband was with
her, and states that the interval between these events was about
2 seconds. She believes she may have lost consciousness, but is
unsure. She did hit her head, and is not on any blood thinning
medications. There were no rhythmic jerking movements of the
extremities, and there was no urinary incontinence. She noted
immediate left shoulder pain without numbness, tingling, or
weakness in the left upper extremity.
Of note, the patient has never syncopized before. She is
relatively healthy and only has a history of hypothyroidism.
There is a family history of cardiac death in the patient's
sister, who died in her ___ postpartum under unclear
circumstances in ___. The family was told it was "due to
heart
problem," but they are uncertain what this problem is. No other
history of sudden death.
In the ED:
Initial vital signs were notable for:
T97.8, HR72, BP131/72, RR16, 100% RA, Pain ___
Exam notable for:
Normal cardiac exam, no murmurs. Tenderness to palpation along
the distal third of the clavicle on the left. There is no
tenderness to palpation along the length of the humerus
including
the head. The humeral head is possibly dislocated anteriorly.
Labs were notable for:
141 | 102 | 14
----------------< 83 Ca 9.5, Mag 2.0, Phos 3.3
4.3 | 27 | 0.7
13.7
6.3 >------< 176
41.7
UA: unremarkable
Studies performed include:
CLAVICLE LEFT X-RAY:
No acute fracture seen.
GLENO-HUMERAL SHOULDER X-RAY:
No acute fracture or dislocation of the left shoulder.
TTE
No structural cardiac cause of syncope identified. Normal
biventricular cavity sizes, regional/global systolic function.
No
valvular pathology or pathologic flow identified. Normal
estimated pulmonary artery systolic pressure. Normal left
ventricular diastolic function.
EKG: Sinus rhythm 61. Normal PR. QRS duration prolonged at 123.
Normal QTC. No ischemic ST segment deviations or T wave
inversions to suggest ischemia. Slurred upstroke of QRS c/f
delta wave in II, V4-V5.
Repeat EKG: Sinus rhythm 55. Normal PR interval. Normal QTc
interval. PVC is present. There is no concerning ST
segment deviation to suggest ischemia. Slurred upstroke of the
QRS complex is again noted in II, V4-V5.
Patient was given:
- 1L NS
- Ibuprofen 600mg PO
- Acetaminophen 1000mg PO
Consults: Cardiology
Vitals on transfer:
T98.5, HR 55, BP 94/61, RR 18, 96% RA
Upon arrival to the floor, patient reportedly feeling very well.
Denied any CP, SOB, palpitations, N/V, weakness, numbness,
sensory deficits, balance issues, dizziness/LH, anxiety/panic
attack sxs. L shoulder pain had significantly improved since
arrival in the ED.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
Hypothyroidism
Social History:
___
Family History:
Mother (living) - HTN, Chronic Lymphocytic Leukemia, Spinal
Stenosis
Father (deceased, ___ - Hypothyroidism
Sister (deceased) - sudden death, patient told it was from a
cardiac etiology (unclear), 4 months postpartum
MGM (deceased, MI, age late ___ - "leaky valve"
Physical Exam:
VS: ___ 0004 O2 delivery:
24 HR Data (last updated ___ @ 004)
Temp: 98.1 (Tm 98.1), BP: 107/67 (98-113/62-75), HR: 55
(54-63), RR: 18, O2 sat: 99% (98-100), O2 delivery: A, Wt: 141.1
lb/64 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: Tenderness to palpation along the distal third of
the clavicle on the left, and at anterior shoulder. No
tenderness
to palpation along the length of the humerus. No L knee pain, no
evidence of effusion, and normal ROM. Pulses DP/Radial 2+
bilaterally.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. Normal finger-to-nose pointing. ___
strength throughout, although somewhat difficult to assess in
LUE
due to pain. Limited ability to abduct L arm ___ pain. No focal
neurologic defiicts. Normal sensation. AOx3.
Pertinent Results:
___ 10:00AM GLUCOSE-83 UREA N-14 CREAT-0.7 SODIUM-141
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-27 ANION GAP-12
___ 10:00AM WBC-6.3 RBC-4.49 HGB-13.7 HCT-41.7 MCV-93
MCH-30.5 MCHC-32.9 RDW-12.5 RDWSD-43.1
Left Clavicle XR, Left Shoulder XR
IMPRESSION:
No acute fracture or dislocation of the left shoulder. No
clavicle fracture.
TTE
Conclusion:
The left atrial volume index is mildly increased. There is no
evidence for an atrial septal defect by 2D/
color Doppler. There is normal left ventricular wall thickness
with a normal cavity size. There is normal
regional and global left ventricular systolic function. There is
no resting left ventricular outflow tract
gradient. Tissue Doppler suggests a normal left ventricular
filling pressure (PCWP less than 12mmHg).
There is normal diastolic function. Normal right ventricular
cavity size with normal free wall motion.
The aortic sinus diameter is normal for gender with normal
ascending aorta diameter for gender. The
aortic arch diameter is normal. There is no evidence for an
aortic arch coarctation. The aortic valve
leaflets (3) appear structurally normal. There is no aortic
valve stenosis. There is no aortic regurgitation.
The mitral valve leaflets appear structurally normal with no
mitral valve prolapse. There is trivial mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is physiologic tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial
effusion.
IMPRESSION: No structural cardiac cause of syncope identified.
Normal biventricular cavity sizes,
regional/global systolic function. No valvular pathology or
pathologic flow identified. Normal estimated
pulmonary artery systolic pressure. Normal left ventricular
diastolic function.
Brief Hospital Course:
Patient presented to the ED on ___ with a syncopal episode that
occurred after getting out of bed, walking to her closet, and
feeling dizzy. She remembers waking up on the
floor with severe left shoulder pain, as well as mild left knee
pain and a headache. She does not recall the events between
feeling dizzy and waking up on the floor. Her husband was with
her, and states that the interval between these events was about
2 seconds. She hit her head and shoulder during her fall.
In the ED, studies performed include CBC, BMP, UA, X-Ray of left
clavicle and gleno-humeral shoulder, TTE, and 2 EKG's. Labs were
notable for normal CBC (Hb 14.4), unremarkable chemistry, and
negative UA. TTE was unremarkable. X-rays showed no fracture or
dislocation of the left shoulder.
EKG was notable for sinus rhythm, normal axis, normal intervals,
no hypertrophy, no signs of ischemia, and slurred upstroke of
QRS c/f delta wave in II and lateral leads.
Patient received 1L NS, Ibuprofen 600mg PO, and Acetaminophen
1000mg PO in the ED.
On the floor, patient denied any CP, SOB, palpitations, N/V,
weakness, numbness, sensory deficits, balance issues,
dizziness/LH, anxiety/panic attack sxs. L shoulder pain had
significantly improved since arrival in the ED. She reports no
headache in the morning.
Patient was on continuous telemetry monitoring with no
arrhythmias seen. Cardiology reviewed data, and agreed with the
team that the history most closely aligned with orthostatic
hypotension with dizziness preceding the event which occurred
shortly after rising from bed. Cardiology did not advise event
monitoring. The patient was discharged with close PCP
___. She was advised to liberalize fluid intake and rise
from seated position slowly, especially early in morning.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vivelle-Dot (estradiol) 0.0375 mg/24 hr transdermal twice
weekly
2. Levothyroxine Sodium 37.5 mcg PO DAILY
3. proGESTerone micronized 100 mg by mouth DAILY
4. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 37.5 mcg PO DAILY
2. proGESTerone micronized 100 mg by mouth DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Vivelle-Dot (estradiol) 0.0375 mg/24 hr transdermal twice
weekly
Discharge Disposition:
Home
Discharge Diagnosis:
Orthostatic Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you had a syncopal
episode.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given pain medication for your shoulder and head
pain.
- The electrical activity of your heart was monitored.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please follow up on your appointment with your PCP ___.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19897675-DS-9 | 19,897,675 | 20,344,270 | DS | 9 | 2193-04-10 00:00:00 | 2193-04-10 10:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Codeine / Wool Alcohols / bandaids
Attending: ___.
Chief Complaint:
Rash and joint pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/DM, psoriaisis presents with fever, leukocytosis and
pustular dermatitis of palms. Pt reports that sx began 6 days
ago with back/hip pain and rash on hands. Rash has gotten
progressively worse, is painful, has associated edema of hands.
She has never had a similar rash. Reports psoriasis and excema
of feet. No recent travel, no new sexual partners.
In ___ pt given nebs, morphine, vanc and cetriaxone.
On arrival to the floor pt reports pain in hands, wrists, hip
pain is improved.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
DM
OSA
IBS
Trigger fingers
Trigeminal neuralgia
Social History:
___
Family History:
+DM, no other autoimmune diseases
Physical Exam:
Tm 101 Tc99.4 118/62 90 16 95%ra
PAIN: 6
General: nad
HEENT: +small pustule of L posterior pharnyx
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: ___ hands with multiple pustules/vesicles in various stages
concentrated on palms, but also on fingers and posterior aspect
of hands. +Edema L>R of hands
Neuro: alert, follows commands
Pertinent Results:
___ 10:19PM GLUCOSE-167* UREA N-14 CREAT-0.7 SODIUM-134
POTASSIUM-3.6 CHLORIDE-96 TOTAL CO2-29 ANION GAP-13
___ 10:19PM CALCIUM-9.3 PHOSPHATE-2.9 MAGNESIUM-1.9
___ 10:19PM CRP-GREATER THAN 300
___ 10:19PM WBC-13.8* RBC-3.97* HGB-12.9 HCT-37.4 MCV-94
MCH-32.5* MCHC-34.6 RDW-12.5
___ 10:19PM NEUTS-77.8* LYMPHS-13.8* MONOS-7.0 EOS-1.0
BASOS-0.4
___ 10:19PM PLT COUNT-356
___ 10:19PM SED RATE-118*
___ 10:21PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:21PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 10:21PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-1
Brief Hospital Course:
This ___ year old female with a questionable history of psoriasis
(no psoriatic lesions were noted) presenting with polyarthritis
and palm and sole rash that was characterized as eruptive and
pustular. Dermatology saw Ms ___ and ___ that the rash
could be consistent with pustular psoriasis even though she had
no risk factors (did not start using steroids previously and has
unclear history of psoriasis). Biopsy was consistent with this
diagnosis. However, biopsy cannot distinguish between this and
keratoderma blenorrhagicum which is associated with HLA B27
seronegative spondyloarthropathies, especially reactive
arthritis. G/C and chylamydia were negative, however she did
describe a preceeding sore throat and sick contacts with fever
and sore throat and her ASO titers returned mildly positive.
Given increasing joint swelling in wrists bilaterally with no
improvement with NSAIDs, we started her on PO prednisone taper.
She will see Rheumatology as an outpatient. Plain films were
obtained of the left hand with no acute changes. She was
discharged on prednisone with significant improvement in
arthritic symptoms and synovitis and stable rash. Syphilis and
parvovirus titers returned negative. A single blood culture of
6 showed gram + organisms in clusters later identified as
coag-negative Staphylococcal species (contaminant).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 200 mg PO TID
2. DiCYCLOmine 40 mg PO QID
3. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
4. Byetta (exenatide) 10 mcg/0.04 mL subcutaneous BID
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. losartan-hydrochlorothiazide 50-12.5 mg oral daily
7. Rosuvastatin Calcium 2.5 mg PO DAILY
8. Carvedilol 12.5 mg PO BID
9. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN headache
10. Niacin SR 1000 mg PO BID
11. exemestane 25 mg oral daily
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN headache
2. Carvedilol 12.5 mg PO BID
3. DiCYCLOmine 40 mg PO QID
4. Gabapentin 200 mg PO TID
5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
6. Niacin SR 1000 mg PO BID
7. Rosuvastatin Calcium 2.5 mg PO DAILY
8. PredniSONE 30 mg PO DAILY
RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
9. Byetta (exenatide) 10 mcg/0.04 mL subcutaneous BID
10. exemestane 25 mg oral daily
11. losartan-hydrochlorothiazide 50-12.5 mg oral daily
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. PredniSONE 20 mg PO DAILY Duration: 3 Days
RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
14. PredniSONE 10 mg PO DAILY Duration: 3 Days
RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
15. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
16. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain
RX *oxycodone-acetaminophen [Endocet] 5 mg-325 mg 1 tablet(s) by
mouth q6 Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Inflammatory arthritis and rash
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted for worsening rash and arthritis. We feel
that the rash and arthritis are probably inflammatory (not
infectious or contagious in origin) and likely are related to an
autoimmune process. For this reason, we started you on
steroids, with significant improvement in your joint swelling.
You will need to be on prednisone 30 mg X 3 days, 20 mg X 3
days, 10 mg X 3 days, 5 mg X 3 days, then can stop. Rheumatology
will contact you regarding a follow up appointment next week.
Followup Instructions:
___
|
19897771-DS-3 | 19,897,771 | 29,112,374 | DS | 3 | 2189-08-15 00:00:00 | 2189-08-15 13:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
Right hip trochanteric fixation nail
History of Present Illness:
___ hx of HTN, colitis, who lives independently presenting after
a mechanical fall from a chair with right hip pain and inability
to bear weight. Patient feels she slipped getting out of her
chair after dinner and fell onto her right side. Denies HS or
LOC. Uses cane at baseline for ambulation. Denies any
paresthesias.
Past Medical History:
PMH:
HTN
Colitis
Anemia
Pseudogout
Osteoporosis
PSH:
Right eye enucleation
Thyroidectomy
Hysterectomy
Appendectomy
Right knee arthroscopy
Family History:
NC
Physical Exam:
Right lower extremity:
Incision clean, dry, intact, no excessive erythema, induration,
drainage
SILT in DP/SP/S/S/T distributions
___
2+ DP pulse
Pertinent Results:
___ 04:50AM BLOOD Hct-26.9*
___ 05:50AM BLOOD Hct-26.1*
___ 08:55PM BLOOD ___ PTT-27.5 ___
___ 06:15AM BLOOD Glucose-130* UreaN-17 Creat-1.1 Na-135
K-4.8 Cl-97 HCO3-30 AnGap-13
___ Femur (AP&Lat): Comminuted angulated right proximal
femur intertrochanteric fracture.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right intertrchanteric hip fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for right trochanteric fixation nail,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics per routine. The
patient preferred Heparin for anticoagulation; therfore she was
given Heparin 5000 units SC BID. The patients 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 was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
right lower extremity, and will be discharged on subcutaneous
heparin for DVT prophylaxis. The patient will follow up in two
weeks per routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course, and all questions were answered prior to discharge.
Medications on Admission:
Levothyroxine 100mcg
Metoprolol tartrate 50mg AM, 25mgPM
Diazide 1 tab QAM
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Calcium Carbonate 500 mg PO TID
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC BID
RX *heparin (porcine) 5,000 unit/mL (1 mL) 5000 units SC twice a
day Disp #*28 Cartridge Refills:*0
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*80 Tablet Refills:*0
8. Vitamin D 800 UNIT PO DAILY
9. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
10. Metoprolol Tartrate 50 mg PO QAM
11. Metoprolol Tartrate 25 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right intertrochanteric hip fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
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 Heparin 5000 units twice 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.
ACTIVITY AND WEIGHT BEARING:
- Right lower extremity: weight bearing as tolerated
Physical Therapy:
Right lower extremity: weight bearing as tolerated
Treatments Frequency:
Wound: Right thigh surgical incision
Frequency: Please inspect wound and change dressing daily with
gauze (dry). It can be left open to air if non-draining.
Followup Instructions:
___
|
19897794-DS-18 | 19,897,794 | 25,666,387 | DS | 18 | 2176-01-26 00:00:00 | 2176-01-29 15:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tramadol / Nsaids / Oxycodone
Attending: ___.
Chief Complaint:
dysuria, increased urinary frequency, recurrent UTI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ ESRD on HD w/ baseline dysuria/chronic uti who is on
trimethoprim suppression therapy for UTI coming in with
continued dysuria, which has been constant x1month, but acutely
worsened overnight with the urge to urinate Q30min. Had
previously been voiding ___ per day, improved with
dialysis. Denies fevers, chills, flank and back pain. Notes
burning around her urethra with urination that became persistent
overnight. Has was referred by PCP to Dr. ___,
for management of "chronic bladder infection." She has had a
positive Klebsiella culture at the beginning of ___, then a
positive enterococcus at the end of ___, sensitive only to
linezolid of the antibiotics tested. She had another positive
urine culture growing Klebsiella and E. coli on ___. Had
negative urine cultures ___, and ___. Both of the
last two negative cultures were actually mixed bacterial flora
consistent with contamination and the last one consistent with
fecal contamination. Her urinalyses over the course of the year
have shown anywhere from negative to moderate amount of blood,
typically, the nitrites are negative, proteins positive, and the
leukocytes are large in amount. In ___ she was treated with
a short course of cipro (3 days) and in ___ she was treated
with a prolonged course of linezolid for VRE UTI. She has
currently been taking trimethoprim suppression therapy (50mg
Qhs) for her recurrent UTI. She most recently had a urine
culture on ___, that was similar to ___, growing Klebsiella and
E. coli both sensitive to Bactrim, Tobramycin and Gentamycin.
Denies diarrhea or loose stools, though occasionally has a loose
stool after dialysis sessions.
.
In the ED, VS 97.2 91 168/53 16 100%, pain ___. UA showed >182
WBC, many bact, large leuks, nitrate neg, mod blood, epi 1. CT
abd showed no stone or clear sign of pyelonephritis. Bedside US
showed no urinary retention. Given 1 dose of DS Bactrim. Patient
was sent directly to dialysis. VS on transfer were 98.3, 62,
149/56, 16, 94%RA. Patient completed a session of dialysis
without issues and was trasnferred to the floor for further
management.
.
On the floor, patient is comfortable without any complaints. VS
T 97.1, BP 117/50, HR 60, RR 21. Denies current frequent
urination and states the dysuria has improved.
Past Medical History:
RENAL HISTORY:
TTS
# ESRD DUE TO: probably diabetic nephropathy
# ON RENAL REPLACEMENT SINCE: ___
# ACCESS HISTORY AND COMPLICATIONS:
- Rt IJ tunneled catheter
- recent creation of LUE AVF (brachiocephalic) ___, not yet
ready for use
PAST MEDICAL HISTORY:
- Diabetes, insulin-dependent, complicated by nephropathy
- Dyslipidemia
- Hypertension
- CAD s/p CABG ___, recent NSTEMI with cath in ___
- systolic CHF with mild symm LVH, most recent EF ___
- asthma: uses albuterol once per day and Flovent once per day,
but has not used these in months (since starting dialysis, per
daughter)
- sciatica
- arthritis s/p knee replacement
- gout
- GERD
- osteoporosis
- colonic adenomas with last colonoscopy ___ (hyperplastic
only, next colonoscopy ___
- low back pain
- recurrent UTIs (klebsiella, e.coli, VRE)
Social History:
___
Family History:
Her daughter has a history of a horse-shoe kidney and her
grandson has a history of ureteral reflux. + Colon Cancer.
Mother, coronary artery disease. Father, stroke. Brother,
cancer. Sister, cancer.
Physical Exam:
Admission Exam:
Vitals: VS T 97.1, BP 117/50, HR 60, RR 21
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: old well healed midline vertical scar. soft,
non-tender, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. No suprapubic
tenderness, no CVAT.
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis. 1+
edema
Skin: thin, old ecchymoses on arms
Neuro: A&Ox3, strength ___ thoughtout, sensation intact to light
touch and temperature throughout
Access: tunneled right IJ without erythema, left AVF + bruit,
+thrill
.
Discharge exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: old well healed midline vertical scar. soft,
non-tender, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. No suprapubic
tenderness, no CVAT.
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis. 1+
edema
Skin: thin, old ecchymoses on arms
Neuro: A&Ox3, strength ___ thoughtout, sensation intact to light
touch and temperature throughout
Access: tunneled right IJ without erythema, left AVF + bruit, +
thrill, good capillary refill
Pertinent Results:
Admission Labs:
___ 09:35AM BLOOD WBC-10.0 RBC-3.43* Hgb-11.0* Hct-32.1*
MCV-94 MCH-31.9 MCHC-34.1 RDW-15.2 Plt ___
___ 09:35AM BLOOD Neuts-75.4* ___ Monos-3.2 Eos-1.6
Baso-0.7
___ 09:35AM BLOOD Glucose-156* UreaN-67* Creat-4.7* Na-133
K-4.9 Cl-93* HCO3-29 AnGap-16
Admission UA:
___ 07:45AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 07:45AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 07:45AM URINE RBC-31* WBC->182* Bacteri-MANY Yeast-NONE
Epi-1
___ 07:45AM URINE WBC Clm-MOD
Cardiac Enzymes:
___ 03:00PM BLOOD CK-MB-2 cTropnT-0.05*
___ 12:17AM BLOOD CK-MB-2 cTropnT-0.05*
___ 06:40AM BLOOD CK-MB-2 cTropnT-0.05*
.
DISCHARGE LABS:
___ 06:40AM BLOOD WBC-9.7 RBC-3.45* Hgb-10.9* Hct-32.6*
MCV-95 MCH-31.7 MCHC-33.6 RDW-15.9* Plt ___
___ 06:40AM BLOOD Glucose-82 UreaN-43* Creat-3.9*# Na-138
K-5.3* Cl-96 HCO3-30 AnGap-17
___ 06:40AM BLOOD Calcium-9.5 Phos-6.1* Mg-2.8*
Micro:
___ Blood culture: NGTD
___ 7:45 am URINE
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Previous ___ Urine Culture:
___ 2:34 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I =>32 R
CEFAZOLIN------------- =>64 R =>64 R
CEFEPIME-------------- =>64 R =>64 R
CEFTAZIDIME----------- =>64 R =>64 R
CEFTRIAXONE----------- =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 64 I
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S 2 S
Imaging:
___ CT abd: 1. No evidence of nephrolithiasis.
2. 1-cm hyperdense lesion in the interpolar region of the right
kidney likely
represents a small hemorrhagic cyst; could be confirmed on
ultrasound.
3. Extensive abdominal vascular calcifications.
4. Hiatal hernia.
5. Cholelithiasis.
6. Air in the urinary bladder is compatible with recent
catheterization; if
none, correlate with urinalysis to exclude infection. Bladder
relatively
collapsed. Apparent mild wall thickening of the bladder may
relate to
underdistention, but given history of UTIs, correlate with
urinalysis.
Brief Hospital Course:
___ w/ complicated PMH including ESRD on HD (TTHSat) w/
recurrent UTIs on trimethoprim suppression therapy, who
presented with acutely worsened urinary symptoms and a recent
urine culture positive for Klebsiella and E. coli both sensitive
to Bactrim.
.
# Recurrent UTI: Patient has had several UTIs in the past
several months growing klebsiella, VRE, and E.coli and has been
treated with cipro and linezolid in ___ and ___
respectively. Patient has had intermittently negative urine
cultures throughout this time and was being managed with
trimethoprim suppression therapy. Presented with worsening
symptoms and a ___ urine culture positive for Klebsiella and E.
coli both sensitive to Bactrim, Tobramycin and Gentamycin.
Initially treated with bactrim and meropenem. ___ urine culture
grew E.coli, sensitive to Bactrim, so antibiotics were narrowed
- Bactrim DS, given daily (after dialysis sessions).
.
# ESRD on HD: Patient goes to ___ dialysis ___
(___). Renal was consulted in the ED and
patient got HD prior to arrival to floor and got dialysis as in
inpatient according to her outpatient schedule. Nephrocaps
vitamin D and calcitriol were continued. Had an AV fistula
placed in ___, but not ready for use currently. Had some
tingling concerning for steal phenomenon. Transplant surgery was
consulted who said that this likely represented a steal syndrome
and that they would follow up with her after discharge
.
#Nausea vomiting and diaphoresis: Patient reported an episode of
n/v and diaphoresis, which she does report happens after
dialysis occasionally. EKG showed sinuys bradycardia with HR46
but no e/o ischemia. BP stable. Thought to be due to increased
vagal tone. Cardiac enzymes were negative. Patient was given a
250 cc bolus and reassessed. Symptoms resolved but her heart
rate remained in the ___ so her beta blocker dose was decreased.
.
# Anemia: Related to CKD, patient is on Epo shots (gets Aranesp
as an outpatient). Epo continued as an inpatient per renal
consult. Hematocrit remained relatively stable over admission in
the low ___.
.
# DM: Continued on home regimen of NPH and put on HISS.
.
# HL: Continued on home atorvastatin.
.
# CHF, CAD, HTN: Continued on home lisinopril, ASA, plavix,
metoprolol.
.
# chronic back pain: Continued on home hydrocodone-aetaminophen.
.
# GERD: Continued on home ranitidine.
.
# Gout: Continued on home allopurinol.
Transitional Issues:
-Follow up with Dr. ___ up with transplant regarding fistula
Medications on Admission:
1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY. Not on
dialysis days, TTHSat.
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
4. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO BID.
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Two (2) Inhalation Q6H (every 6 hours) as
needed for wheeze. (not taking)
6. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
Q6H as needed for pain.
8. fluticasone 110 mcg Aerosol Sig: Two Puff Inhalation BID
(not taking)
9. B complex-vitamin C-folic acid 1 mg Sig: One (1) Cap PO DAILY
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Vitamin D-3 1,000 unit Sig: One (1) Tablet, PO once a day.
13. Aranesp (polysorbate) Injection
14. allopurinol ___ mg Tablet Sig: One (1) Tablet PO once a day.
15. NPH insulin human recomb Subcutaneous. 26units Qhs and
10units Qam.
16. estradiol 10mcg tab intravaginally weekly
17. phenazopyridine 100mg tab TID for pain
18. ranitidine 150mg daily
19. trimethoprim 50mg BID One half Tablet(s) by mouth twice a
day for 3 days then ___ tablet every night at bedtime. Started
___.
20. Regular Insulin 10 units in AM then in evening, dose
according to sliding scale
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
Q6H (every 6 hours) as needed for back pain.
6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
(___): Not on dialysis days.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO twice a day.
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2*
13. Aranesp (polysorbate) Injection
14. estradiol 10 mcg Tablet Sig: One (1) Vaginal once a week.
15. phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for pain.
16. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO QHD (each hemodialysis) for 2 weeks.
Disp:*12 Tablet(s)* Refills:*0*
17. insulin glargine 100 unit/mL Solution Sig: 10 Units Qam and
26 Units Qpm Subcutaneous twice a day.
18. Humalog insulin
Per sliding scale
19. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO every
other day.
Disp:*15 Capsule(s)* Refills:*2*
20. phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO three
times a day for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Urinary Tract infection
.
Secondary Diagnoses:
ESRD on dialysis
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ you for coming to the ___
___. You were in the hospital because you had a urinary tract
infection that was not being adequately treated as an
outpatient. You were intitally treated with strong antibiotics
to cover a variety of possible bacteria, however your
antibiotics were narrowed to Bactrim, as your urine culture grew
bacteria (E. coli) that was sensitive to this antibiotic. Your
symptoms continued to improve and so you are safe for discharge
with follow up with your urologist/gynecologist, Dr. ___.
.
You also had a slow heart rate so we decreased your metoprolol
dose. Please address this with your primary doctor.
.
Medication Recommendations:
Please Start Bactrim 2 tabs after dialysis for two weeks
Please Decrease Metoprolol to 25 mg twice daily
Please continue taking all other medications as you have been
Followup Instructions:
___
|
19897794-DS-19 | 19,897,794 | 29,765,983 | DS | 19 | 2176-05-10 00:00:00 | 2176-05-13 10:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tramadol / Nsaids / Oxycodone
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of CAD s/p CABG in ___, PCI in ___, and
NSTEMI ___ with inability to stent, systolic CHF (EF ___,
ESRD on dialysis, DM type II, and chronic UTIs, transferred from
OSH after presenting there one day ago with shortness of breath.
The patient reports that she was last dialyzed on ___ (2
days prior to presentation at OSH), but did not achieve her dry
weight at that session. She states the dyspnea came on suddenly
last night, prompting her presenation to the OSH. No recent
cough, fevers, or chest pain. At the OSH ED she was started on
BiPAP, lasix IV (150cc UOP), NTG patch, and then transfered here
for further evaluation.
Of note, the patient has been havin difficulty tolerated HD, has
had ___ wt gain over past 2wks. SOB improved after ___ HD
session. Last HD on ___. Since then has felt fatigued, mild SOB
which worsened around 3AM. +PND. Also notes chronic dysuria and
nausea/diarrhea for past 3d.
In the ED, initial vitals were HR 101, RR 27, BP 140/50,
initially requiring BiPAP for O2 sat 97%. Exam notable for ___
HSM at apex, R>L basilar rales, JVD 7cm, 1+ LLE edema. CXR
showed vascular congestion with bilateral effusions. EKG w old
LBBB, no ischemic changes. Labs notable for elevated Trop 0.07
and WBC 21K (PMN pred.). Cardiology was consulted and initially
felt that she would need to go to the CCU, however while in the
ED she was able to be weaned off BiPAP and maintain sat of 96%
on 3L NC (off BiPAP). She was then admitted to the ___
service.
While waiting for a bed on ___ 3, the patient went for
dialysis. During HD, she had ___ headache which did not improve
with acetaminophen. Also had slight nausea. On arrival to the
floor,
BP in low 100s, (99/46) at the end of dialysis
removed 2L of fluids
renal fellow recommending fiorcet
.
REVIEW OF SYSTEMS
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG in ___ with LIMA to proximal LAD, SVG to distal LAD, SVG
to OM2 AND OM3
- PCI: DES to proximal LAD in ___.
- CHF: Systolic CHF with mild symm LVH, most recent EF ___
(TTE ___
3. OTHER PAST MEDICAL HISTORY: (per OMR)
ANEMIA
ASTHMA
GASTROESOPHAGEAL REFLUX
GOUT
GUTTATE PSORIASIS
HYPERCHOLESTEROLEMIA
HYPERPARATHYROIDISM
HYPERTENSION
INSULIN DEPENDENT DIABETES MELLITUS
MULTINODULAR GOITER
OSTEOARTHRITIS
OSTEOPOROSIS
SCIATICA
SHOULDER PAIN
END STAGE RENAL DISEASE
Social History:
___
Family History:
Her daughter has a history of a horse-shoe kidney and her
grandson has a history of ureteral reflux. + Colon Cancer.
Mother, coronary artery disease. Father, stroke. Brother,
cancer. Sister, cancer
Physical ___:
ADMISSION PHYSICAL EXAMINATION:
VS: T= 97.7, BP=127/40, HR=85, RR=16, O2 sat= 96% 3L
GENERAL: Elderly female in NAD, very tired but comfortable
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of ~10 cm.
CARDIAC: PMI laterally displaced. RRR, normal S1, S2. Soft II/VI
systolic murmur heard throughout precordium, likely from AV
fisula. S3 gallop heard.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bibasilar crackles up
botom ___ of thorax, scattered wheezes, no rhonchi
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: warm and well-perfused, 1+ pitting edema of
bilateral ___
___: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
DISCHARGE PHYSICAL EXAM:
OBJECTIVE:
VS: T= 98.6, BP=100-120s/38-52, HR=60-84, RR=18, O2 sat= 97% 1L
Weight: 85-> 81-> 81.5 kg (before dialysis
I/O: 1600/200 (24h), ___
GENERAL: Elderly female in NAD, very tired but comfortable Lying
nearly flat with no dyspnea
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVP flat
CARDIAC: PMI laterally displaced. RRR, normal S1, S2. Soft II/VI
systolic murmur heard throughout precordium, likely from AV
fisula. No gallop heard today
LUNGS: Resp were unlabored, no accessory muscle use. Bibasilar
crackles, scattered wheezes, no rhonchi
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: warm and well-perfused, 1+ pitting edema of
bilateral ___
___: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
LABS:
On admission:
___ 06:10AM BLOOD WBC-21.8*# RBC-2.62* Hgb-8.4* Hct-27.8*
MCV-106*# MCH-31.9 MCHC-30.0*# RDW-17.1* Plt ___
___ 06:10AM BLOOD Neuts-92.2* Lymphs-4.7* Monos-2.8 Eos-0.1
Baso-0.3
___ 06:10AM BLOOD ___ PTT-25.4 ___
___ 06:10AM BLOOD Glucose-346* UreaN-69* Creat-6.1*# Na-133
K-5.3* Cl-94* HCO3-25 AnGap-19
___ 07:10PM BLOOD CK(CPK)-76
___ 06:10AM BLOOD CK-MB-4
___ 06:10AM BLOOD cTropnT-0.07*
___ 06:10AM BLOOD Calcium-9.4 Phos-4.2# Mg-2.1
___ 06:20AM BLOOD Type-ART PEEP-5 FiO2-60 pO2-246* pCO2-42
pH-7.43 calTCO2-29 Base XS-3
Cardiac enzymes:
___ 06:10AM BLOOD CK-MB-4
___ 06:10AM BLOOD cTropnT-0.07*
___ 07:10PM BLOOD CK-MB-5 cTropnT-0.13*
___ 05:29AM BLOOD CK-MB-3 cTropnT-0.13*
Anemia work up:
___ 05:29AM BLOOD calTIBC-230* VitB12-676 Folate-GREATER TH
___ TRF-177*
On discharge:
___ 05:48AM BLOOD WBC-10.7 RBC-2.27* Hgb-7.5* Hct-25.1*
MCV-110* MCH-32.9* MCHC-29.9* RDW-18.1* Plt ___
___ 05:48AM BLOOD Glucose-93 UreaN-36* Creat-3.6*# Na-138
K-5.0 Cl-100 HCO3-27 AnGap-16
___ 05:48AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0
MICRO:
___ URINE CULTURE (Final ___:
ENTEROCOCCUS FAECALIS. >100,000 ORGANISMS/ML..
FOSFOMYCIN Susceptibility testing requested by ___
___
___. FOSFOMYCIN sensitivity testing performed by
___.
FOSFOMYCIN = SENSITIVE.
LACTOBACILLUS SPECIES. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
___ 10:23 pm STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
This test was cancelled because a FORMED stool specimen
was received, and is NOT acceptable for the C. difficle DNA
amplification testing..
___ Blood cultures negative x2
IMAGING/STUDIES:
___ CXR:
CHEST, AP UPRIGHT: Dialysis catheter has been removed. Changes
of coronary artery bypass grafting, with median sternotomy and
mediastinal clips. Mild cardiomegaly and central vascular
congestion persist. Mild interstitial edema has developed.
IMPRESSION: Mild pulmonary edema.
Brief Hospital Course:
___ with history of CAD s/p CABG in ___, PCI in ___, and
NSTEMI ___ with inability to stent, systolic CHF (EF ___,
ESRD on dialysis, DM type II, and chronic UTIs, presenting with
one day history of shortness of breath, found to have CHF
exacerbation, now transferred to ___ for further management.
ACTIVE ISSUES BY PROBLEM:
# Acute on chronic systolic CHF: EF ___ on last TTE in
___. Subacute decompensation likely related to difficulty
achieving dry weight during dialysis, ~ 5kg above dry weight on
admission (EDW = 80kg). No sign of ischemia, slight troponin
elevation likely ___ renal failure. Required BiPAP initially on
arrival at ___, however she was quickly weaned to 3L NC. She
underwent dialysis 3 days in a row, and symptoms were greatly
improved with volume removal through ultrafiltration. Not
started on lasix while in-patient, but she was given a rx for PO
lasix to have at home and take as directed by her cardiologist
Dr. ___ she is gaining weight and becoming dyspneic
between HD days. She was continued on ASA 325, plavix,
atorvastatin, metoprolol and lisinopril on discharge.
# Urinary tract infection: frequent UTIs and chronic dysuria
with grossly positive UA on admission, urine culture grew
vancomycin-sensitive enterococcus (resistent to tetracycline).
Started on meropenem initially, then linezolid for one day once
the culture grew enterococcus, then switched to fosfomycin on
discharge (fosfomycin sensitive). She will continue this for
another 9 days (3 doses every 3 days) for treatment of
complicated UTI.
INACTIVE ISSUES BY PROBLEM:
# CAD: s/p CABG in ___, PCI in ___. No chest pain but trop
0.07 -> 0.12 on admission, likely small leak from demand ischmia
that is not cleared well secondary to renal failure. Troponin
remained flat. Continued on maximal medical management with ASA
325, plavix, atorvastatin, metoprolol and lisinopril
# ESRD: on HD ___. Underwent dialysis shortly after
arrival in the ED, given fluid overload and respiratory
distress. EDW is 80 kg, but recently had difficulty reaching dry
weight due to low BPs and leg cramps in dialysis. She was
dialyzed 3 days in a row (___) with achievement of
dry weight on discharge. She was given a presciption for PO
lasix to have in case of volume overload at home between
dialysis sessions. She was continued on nephrocaps.
# ANEMIA: thought to be secondary to renal failure, hct/hgb has
drifted down from her recent baseline. No sign of bleeding.
MCV is high at 107, had been normocytic before. Iron studies
showed anemia of chronic disease, B12 and folate were normal.
Would like benefit from further work up as an outpatient.
# Diabetes mellitus type II: continued on outpatient regimen of
NPH and regular sliding scale
# GASTROESOPHAGEAL REFLUX: continued ranitidine
TRANSITIONS OF CARE:
- CHF: dialyzed to dry weight with relief of symptoms. Started
on PO lasix prn for acute exacerbations while in between
dialysis sessions. Instructed the patient to weigh herself
daily and if her weight was increasing and having shortness of
breath, to call Dr. ___ for instructions
regarding taking lasix at home.
- UTI: will continue fosfomycin for 9 more days (3 doses)
- Anemia: high MCV with anemia of chronic disease on iron
studies, normal B12 and folate, would benefit from further work
up/management as an outpatient
- FULL CODE
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Ranitidine 150 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Aspirin 325 mg PO DAILY
4. Nephrocaps 1 CAP PO DAILY
5. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q6H:PRN back
pain
6. Atorvastatin 40 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Lisinopril 5 mg PO 4X/WEEK (___)
Hold for SBP <100. Do not give on dialysis days
9. Docusate Sodium 100 mg PO BID
10. Senna 1 TAB PO BID:PRN constipation
11. Allopurinol ___ mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO BID
13. Aranesp (polysorbate) *NF* (darbepoetin alfa in polysorbat)
Injection unknown
14. Estradiol 0.01 mg PO 1X/WEEK (___)
Vaginal
15. Phenazopyridine 100 mg PO TID:PRN dysuria
16. NPH 10 Units Breakfast
NPH 26 Units Dinner
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Fosfomycin Tromethamine 3 g PO EVERY 3 DAYS Duration: 3 Doses
Dissolve in ___ oz (90-120 mL) water and take immediately
RX *Monurol 3 gram every 3 days Disp #*3 Packet Refills:*0
2. Allopurinol ___ mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q6H:PRN back
pain
8. NPH 10 Units Breakfast
NPH 26 Units Dinner
Insulin SC Sliding Scale using REG Insulin
9. Lisinopril 5 mg PO 4X/WEEK (___)
Hold for SBP <100. Do not give on dialysis days
10. Metoprolol Succinate XL 25 mg PO BID
11. Nephrocaps 1 CAP PO DAILY
12. Ranitidine 150 mg PO DAILY
13. Senna 1 TAB PO BID:PRN constipation
14. Vitamin D 1000 UNIT PO DAILY
15. Aranesp (polysorbate) *NF* (darbepoetin alfa in polysorbat)
0 injection INJECTION Frequency is Unknown
16. Estradiol 0.01 mg PO 1X/WEEK (___)
Vaginal
17. Furosemide 80 mg PO ASDIR
Take as directed by your cardiologist Dr. ___
shortness of breath and weight gain
RX *furosemide 80 mg as directed Disp #*30 Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Acute on chronic congestive heart failure
Urinary tract infection
SECONDARY DIAGNOSES:
Coronary artery disease
Chronic kidney disease stage V
Anemia of chronic disease
Diabetes mellitus type II
Gastroesophageal reflux
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
You were admitted to the hospital because of difficulty
breathing. We found that you had too much fluid in your body
causing congestive heart failure, and you improved after an
extra session od dialysis to help remove fluid.
We also found that you have a urinary tract infection, so we are
starting you on an antibiotic to treat this.
Changes to your medications:
START fosfomycin 3g every 3 days for 3 doses (over 9 days) to
treat your UTI
If you become short of breath at home, you can take lasix 80mg
orally one time. Talk with your visiting nurse prior to taking
this medication.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs in 2 days.
Followup Instructions:
___
|
19897794-DS-20 | 19,897,794 | 29,849,146 | DS | 20 | 2176-07-20 00:00:00 | 2176-07-25 18:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tramadol / Nsaids / Oxycodone
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of CAD s/p CABG in ___, PCI in ___, and
NSTEMI ___ with inability to stent, systolic CHF (EF ___,
ESRD on dialysis (TTS), DM type II, and chronic UTIs with SOB
starting around 9pm this evening. Per d/w pt and daughter she
was feeling well until one day prior to arrival. She woke up her
daughter who called EMS, who noted FSBG > 500 and significant
SOB. Her symptoms were somewhat relieved by nebulizers.
.
No recent illnesses or triggers. Had a slice of pie this evening
but often does. Took her insulin as she usually does. No
preceding fever, cough, dysuria. Had some diarrhea after HD on
___ but often does and this has not continued. Notes that
her ___ were normal (___) until this evening when she had a
___ in the 300s.
.
She also explains that this evening after dinner she had a large
glass of water and some ice chips which was more than her fluid
restriction of 5 cups per day. She is wondering if this is what
set her over in terms of her pulmonary edema.
.
In the ED, initial vitals were 97.8 101 154/76 34 99% on a NRB.
Labs notable for a glucose of 795, AG acidosis of 20, Na 126,
BNP 22700 ___ ___ in ___, WBC 12.8. ECG showed sinus
at 102, old LBBB and CXR showed bilateral pulmonary edema. She
was started on a Nitro gtt and BiPAP, as well as an insulin gtt.
.
At time of transfer VS 95 140/59 97/BipAP ___ FiO2 40% on nitro
1 mcg/kg/min and insulin 8/hr.
.
On arrival to the MICU she was on BiPAP and in NAD. She was
requesting ice chips. No other complaints
Past Medical History:
- CAD w/CABG in ___ with LIMA to proximal LAD, SVG to distal
LAD, SVG to OM2 AND OM3
- PCI: DES to proximal LAD in ___.
- CHF: Systolic CHF with mild symm LVH, most recent EF ___
(TTE ___
- ESRD ___ likely diabetic nephropathy on HD since ___
- Type 2 Diabetes, ___, complicated by nephropathy
- Dyslipidemia
- Hypertension
- asthma
- sciatica
- arthritis s/p knee replacement
- gout
- GERD
- osteoporosis
- colonic adenomas with ___ colonoscopy ___ (hyperplastic
only, next colonoscopy ___
- low back pain
- recurrent UTIs (klebsiella, e.coli, VRE)
Social History:
___
Family History:
Her daughter has a history of a ___ kidney and her
grandson has a history of ureteral reflux. + Colon Cancer.
Mother, coronary artery disease. Father, stroke. Brother,
cancer. Sister, cancer
Physical ___:
ADMISSION PE:
Vitals: T: 99.0 BP: 125/65 P: 78 R: 18 O2: 97/2L on the floors
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple, unable to appreciate elevated JVP, no LAD
CV: Regular rate and rhythm, ? S4, no murmurs, rubs, gallops
Lungs: bibasilar crackles, no wheeze
Abdomen: soft, ___, bowel sounds present,
no organomegaly
GU: foley
Ext: 2+ edema, W/W/P, dital pulses palpable
Neuro: ___ intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, ___ intact
.
DISCHARGE:
Vitals - T98.3 (___), BP 138/53 (113/44 - 166/74), HR 61
(___), RR 20, O2 98%RA (___)
FSBG: 197<201<325
General- Slightly obese woman laying comfortably in bed, Alert
and orientedx3, in no acute distress. initially asleep
HEENT- anicteric sclera, moist mucous membranes, oropharynx
clear
Neck- supple, JVP not elevated, no lymphadenopathy
Lungs- Clear to auscultation bilaterally. No rales, crackles, or
ronchi
CV- regular, normal S1 + S2; no murmurs, rubs, or gallops
Abdomen- soft, ___, normoactive bowel
sounds, no rebound tenderness or guarding. No CVA tenderness.
scar from prior hystorectomy
GU- no foley
Ext- mildly cool with 2+ pulses palpable bilaterally. mild ankle
edema. bruising on lower extremities resolving. no clubbing or
cyanosis. scars from bilateral knee surgeries
Neuro- ___ intact, motor and sensory function grossly
intact.
Pertinent Results:
ADMISSION LABS:
___ 04:19AM BLOOD ___
___ Plt ___
___ 12:31AM BLOOD ___
___ Plt ___
___ 12:31AM BLOOD ___
___
___ 04:19AM BLOOD Plt ___
___ 04:19AM BLOOD ___ ___
___ 12:31AM BLOOD Plt ___
___ 12:31AM BLOOD ___ ___
___ 04:19AM BLOOD ___
___ 04:19AM BLOOD
___ 11:07AM BLOOD ___
___
___ 06:12AM BLOOD ___
___ 04:19AM BLOOD ___
___
___ 12:31AM BLOOD ___
___
___ 04:19AM BLOOD CK(CPK)-41
___ 04:19AM BLOOD ___
___ 12:31AM BLOOD ___
___ 12:31AM BLOOD ___
___ 11:07AM BLOOD ___
___ 04:19AM BLOOD ___
___ 12:47AM BLOOD ___ Base
___ TOP
STUDIES:
( TTE: )
The left atrium is moderately dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis (LVEF = XX %). Right ventricular
chamber size is normal. with borderline normal free wall
function. The ascending aorta is mildly dilated. The aortic
valve leaflets are mildly thickened (?#). There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Severe (4+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension
( TEE - Pre Cardioversion)
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There are simple atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Moderate (2+)
mitral regurgitation is seen. There is no pericardial effusion.
IMPRESSION: No spontaneous echo contrast or thrombus in the
___. moderate mitral regurgitation. Complex atheroma
in the aortic arch and descending aorta.
DISCHARGE LABS:
___ 12:49PM BLOOD ___
___ Plt ___
___ 12:49PM BLOOD ___
___
___ 12:49PM BLOOD ___ ___
___ 12:49PM BLOOD ___
___
___ 12:49PM BLOOD ___
___ 02:58AM BLOOD ___
Brief Hospital Course:
Ms. ___ is an ___ with a history of CAD s/p CABG in ___,
PCI in ___, and NSTEMI ___ with inability to stent, systolic
CHF (EF ___, ESRD on dialysis (TTS), DM type II presenting
with DKA (AG 20), shortness of breath, pulmonary edema, 1 month
of dysuria, and brief fever. Pt required 2 days in ICU without
intubation to remove excess fluid and manage DKA. Also had new
onset Afib managed with DCCV, Warfarin, and Amiodarone.
.
#. DKA: Patient with history of type 2 diabetes diagnosed ___
years ago (insulin dependent) who presented with DKA (AG 20),
possibly triggered by her UTI. Started on insulin drip in ED and
tx to MICU. She was not given IVF as she also had pulm edema due
to ESRD and poor urine ouptut. Her anion gap closed to 12 and
dyspnea/pulm edema resolved with insulin and nitro drip in MICU.
Patient was transfered to Medicine ___ 5 for further management
of unstable blood glucose levels. ___ was involved early and
titrated her insulin regimen daily. Please see the discharge
insulin scale per ___ as she ranged ___ on day of
discharge.
.
# NEW ONSET AFIB- S/P successful DCCV on ___. Pt's EKGs on
___ and ___ were significant for afib; EKG on (___)
demonstrated aflutter. Prior EKGs taken on admission and in
___, ___, and ___ were negative for
afib/aflutter. As patient has CHF, hypertension, age >___, she
has a CHADS score=4 she was started on Warfarin therapy after
bridging with Heparin. She had TTE, TEE that did not show
thrombus and then cardioversion that induced sinus rhythm on
___. She was placed on Amiodarone 400mg BID x 1 mo, then
200mg BID for 2 weeks thereafter. Pt was continued on home dose
of metoprolol 12.5mg BID, warfarin 2mg, and home ASA 325mg. Pt's
cardiologist, Dr. ___ was informed of this procedure and
pt was made aware to contact the office for close follow up.
Pt's INR will be checked at ___ and titrated by ___
anticoag nurses.
.
# PYURIA - With dysuria x 1 month. Pt was started on Linezolid
given UCx grew VRE sensitive to Linezolid. Pt has history of
chronic UTIs, and 1 month pain on urination. Pt has been a
symptomatic for past 4 days, but noted some mild morning of
admission. No CVA or suprapubic tenderness on exam. Pt is
afebrile, normal WBC. BCx negative, no sepsis physiology. Pt
treated with Linezolid PO 600mg/day (Day 1: ___, Day 7: ___.
BCx were negative.
.
## ESRD (HD ___- Patient is on strict
fluid restrictions (no more than 5 cups/day). She has poor urine
output. Nephrology followed patient during admission. Continued
renal med dosing, low na diet, and nephrocaps.
.
## SOB WITH RESPIRATORY DISTRESS - Resolved after MICU
admission. ___ DKA with osmotic fluid overload. Pt originally
presented with severe dyspnea, required BiPAP; found to have
bilateral pulmonary edema likely secondary to fluid shifts d/t
hyperglycemia in setting of ESRD. Pulmonary edema resolved per
CXR ___. Patient remained asymptomatic and ___ on RA on
discharge.
.
## MACROCYTIC ANEMIA - Macrocytic anemia present at baseline.
Baseline HCT high ___ to low ___. Was normocytic until ___. HCT trend 31.5<33.7<34.5, MCV 102<101<102. Consider Epo
therapy as an outpatient due to ESRD. We started empiric B12 and
Folate ___
.
#### TRANSITIONAL
- Pt new diagnosis of Afib, started on Warfarin and Discharged
on Warfarin 2mg/day ___ 5mg, ___ INR 3.1,
___ INR 2.7), INR to be checked on ___ before PCP visit
- ___ d/w pt about frequency of checking INR
- Please determine the need to keep patient on/off Plavix given
she is on ASA and Warfarin ___ Cardiology note on discharge
stated to keep Plavix off, and given ASA and Warfarin we kept
Plavix off at discharge, ___ stent > ___ year ago)
- Consider 12 Lead EKG to see if pt still in sinus at every
outpatient appointment
- Started on Amiodarone 400mg bid until ___, followed by 2
weeks of 200mg bid
- ___ followed patient during her hospital stay and
recommends follow up with her PCP in regards to blood sugar
control, did not feel strongly about ___ clinic follow up
- Consider starting/continuing EPO, given chronic anemia (HCT
low ___ in the setting of ESRD.
Medications on Admission:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Citalopram 10 mg PO DAILY
6. Ranitidine 150 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Lisinopril 5 mg PO 4X/WEEK (___)
10. Vitamin D 1000 UNIT PO DAILY
11. Nephrocaps 1 CAP PO DAILY
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
13. Vagifem *NF* (estradiol) 10 mcg Vaginal qWeek
14. Metoprolol Succinate XL 25 mg PO BID
15. Nitroglycerin SL 0.4 mg SL PRN chest pain
may repeat every 5 minutes x 3 doses
16. Acetaminophen ___ mg PO TID:PRN pain
17. Docusate Sodium 100 mg PO BID
18. NPH insulin human recomb *NF* 100 unit/mL Subcutaneous BID
10 units in AM, 26 units in ___
19. insulin regular human *NF* 100 unit/mL Injection BID
6 units in AM then in evening, dose according to sliding scale
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Outpatient Lab Work
___: ___
LAB: INR
WHEN: ___ or ___ before PCP appointment
FAX TO: ___
Fax: ___
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Lisinopril 5 mg PO 4X/WEEK (___)
8. Nephrocaps 1 CAP PO DAILY
9. Ranitidine 150 mg PO DAILY
10. Senna 1 TAB PO BID:PRN constipation
11. Vitamin D 1000 UNIT PO DAILY
12. Amiodarone 400 mg PO BID
for 30 days ___ day ___ then 200mg PO BID x 2 wks
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*58
Tablet Refills:*0
13. NPH 20 Units Breakfast
NPH 16 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro [Humalog KwikPen] 100 unit/mL Up to 18 Units
per sliding scale four times a day Disp #*3000 Unit Refills:*0
RX *NPH insulin human recomb [Humulin N Pen] 100 unit/mL (3 mL)
20 Units before Breakfast; 16 Units before bedtime; via
subcutaenous injection 20 Units before BKFT; 16 Units before
BED; Disp #*1200 Unit Refills:*0
14. Linezolid ___ mg PO Q12H
GIVE AFTER HEMODIALYSIS on those days
___ dose ___
RX *linezolid [Zyvox] 600 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
16. Citalopram 10 mg PO DAILY
17. Docusate Sodium 100 mg PO BID
18. Nitroglycerin SL 0.4 mg SL PRN chest pain
may repeat every 5 minutes x 3 doses
19. Vagifem *NF* (estradiol) 10 mcg Vaginal qWeek
20. Warfarin 2 mg PO DAILY16
RX *warfarin [Coumadin] 2 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
21. Metoprolol Tartrate 12.5 mg PO BID
Hold for SBP <100, HR <60
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diabetic Ketoacidosis
Acute on chronic systolic heart failure (EF ___
New onset 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 ___,
___ you for choosing ___. You were admitted because you had
difficulty breathing and your blood sugar level was very high.
You also had a urinary tract infection, which may have
precipitated the increase in your blood sugar. An ___ on ___
showed some fluid in your lungs, which has since resolved. While
you were here, you developed a dysfunction in the beating of
your heart called atrial fibrillation. We treated this with a
shock that returned your heart back to a normal rhythm.
You were followed by ___ and they recommended
a new insulin regimen for you: AM: 20 Units NPH; Insulin Sliding
Scale during the day; HS:16 Units NPH. The details are attached.
We also started you on a new medicine called coumadin
(warfarin), which requires you to check a blood lab called INR.
We wrote a prescription for you to have this done on ___
(before seeing your primary care doctor on that same day). Your
INR on ___ after Hemodialysis was 2.7.
We reduced your metoprolol dose due to concerns about your blood
pressure. When you see your PCP for your followup appointment,
please have them recheck your blood pressure and discuss
restarting your home dose of metoprolol at that time.
We set up appointments for you to follow up with your PCP and
cardiologists. Please see details below.
MEDICATIONS:
START Warfarin 2 mg by mouth once daily
START Amiodarone 400 mg by mouth twice per day ___ dose
___, then switch to 200 mg twice per day for two weeks)
START Linezolid ___ mg by mouth twice/day ___ dose ___
STOP Plavix (Clopidogrel)
CHANGED Metoprolol succinate 25 mg twice daily to Metoprolol
tartrate 12.5 mg twice daily.
Followup Instructions:
___
|
19897837-DS-16 | 19,897,837 | 27,376,452 | DS | 16 | 2170-02-15 00:00:00 | 2170-02-15 16:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
unknown
Attending: ___
Chief Complaint:
Rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o M w/ hx of CKD, HTN, HLD who
presents
with a rash.
About two days ago he presented to the ED with 5-days of leg
redness chills and low grade fever (99-100). He also had
endorsed
weakness and poor appetite at that time but no other
accompanying
symptoms. He was diagnosed with cellulitis and discharged on 10
day course of cefpodoxime with plans for close PCP ___.
However, over the following two days his family noted that he
was
looking worse and more lethargic. They also recorded a temp of
38.5C. He was then noted to develop a non-blanching rash across
his forehead. He has no known hx of drug allergy and denied any
itching, difficulty breathing or swelling. He also noted that
over the past 24 hours he had increased urinary frequency but no
dysuria.
In the ED, initial vitals:
100 | 82 | 143/55 | 18 | 97% RA
- Exam notable for:
Warm, dry. Scattered 1 x 1 cm nonblanching papular erythematous
rash at forehead, abdomen, upper extremities. Erythema at left
ankle. Blanching, warm. Full painless range of motion of left
ankle. Palpable DP and ___ pulses. 1+ pitting edema left ankle
extending to distal shin
- Labs notable for:
\13.2/ 131 | 99 | 51
6.3 ---- 159 -------------< 136
/40.1\ 5.5 | 15 | 2.9
Whole blood K+ 4.6
UA non-inflammatory
- Imaging notable for:
CXR:
There are slightly low lung volumes. Heart size is upper limits
of normal. There is some tortuosity of thoracic aorta,
unchanged.
There are patchy bibasilar opacities at the lung bases medially
which may represent early infiltrate or atelectasis. ___
to
resolution is recommended. There are no pneumothoraces or large
pleural effusions. Bilateral humeral heads articulate with the
acromion consistent with rotator cuff rupture.
- Patient was given:
___ 12:42 IV CeFAZolin ___ Started
___ 12:50 IV CeFAZolin 1 g ___ Stopped (___)
___ 14:11 IV Vancomycin ___ Started
___ 15:21 IV Vancomycin 1000 mg ___ Stopped
(1h ___
- Consults:
None
Past Medical History:
CKD
HTN
HLD
Social History:
___
Family History:
Not known
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: ___ 1807 Temp: 97.8 PO BP: 158/74 R Lying HR: 71 RR: 20
O2 sat: 97% O2 delivery: Ra
GENERAL: Pleasant, lying in bed comfortably
HEENT: Dry mucous membrane
CARDIAC: RRR, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: soft, nontender, nondistended,
EXT: Warm, well perfused, 1+ pitting edema to shins
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: Nonblanching patchy rash on forehead and top of head as
well as small papules across chest/abdomen. Erythematous rash
with warmth of anterior left ankle and dorsal aspect of foot; no
purulence or fluctuance.
DISCHARGE PHYSICAL EXAM:
=======================
___ Temp: 97.8 PO BP: 131/74 L Lying HR: 68 RR: 20 O2
sat: 97% O2 delivery: Ra
GENERAL: Pleasant, lying comfortably in bed
HEENT: NCAT, EOMI, PERRLA, oropharynx without erythema or
exudate, otherwise normal, no cervical LAD, coalesced,
non-blanching patchy rash over scalp with minimal scale, not
pruritic or painful
CARDIAC: normal S1/S2 with regular rate/rhythm, no murmurs,
rubs,
or gallops
LUNG: Appears in no respiratory distress, end expiratory wheezes
bilaterally but c/w upper airway sounds
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, no left lower extremity edema, left
ankle erythema has resolved, without purulence, not tender to
palpation
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII grossly intact, motor and
sensory function grossly intact
SKIN: Patchy non-blanching rash on scalp, improved erythematous
diffuse rash on back, non-pruritic, non-painful
Pertinent Results:
ADMISSION LABS:
==============
___ 11:33AM BLOOD WBC-6.3 RBC-4.15* Hgb-13.2* Hct-40.1
MCV-97 MCH-31.8 MCHC-32.9 RDW-14.4 RDWSD-50.9* Plt ___
___ 11:33AM BLOOD Neuts-72.7* Lymphs-16.5* Monos-9.1
Eos-0.0* Baso-0.6 Im ___ AbsNeut-4.55 AbsLymp-1.03*
AbsMono-0.57 AbsEos-0.00* AbsBaso-0.04
___ 11:33AM BLOOD Plt ___
___ 11:33AM BLOOD Glucose-136* UreaN-51* Creat-2.9* Na-131*
K-5.5* Cl-99 HCO3-15* AnGap-17
___ 11:33AM BLOOD ALT-30 AST-72* AlkPhos-97 TotBili-0.3
___ 11:33AM BLOOD Albumin-3.3*
___ 02:16PM BLOOD K-4.6
INTERMEDIATE LABS:
==============
___ 04:21AM BLOOD WBC-7.9 RBC-3.64* Hgb-11.4* Hct-36.0*
MCV-99* MCH-31.3 MCHC-31.7* RDW-14.5 RDWSD-52.6* Plt ___
___ 04:21AM BLOOD Plt ___
___ 04:21AM BLOOD Glucose-93 UreaN-59* Creat-3.4* Na-138
K-5.2 Cl-102 HCO3-22 AnGap-14
___ 04:21AM BLOOD Calcium-8.1* Phos-4.7* Mg-2.5
DISCHARGE LABS:
==============
___ 04:40AM BLOOD WBC-7.9 RBC-3.60* Hgb-11.3* Hct-36.6*
MCV-102* MCH-31.4 MCHC-30.9* RDW-14.6 RDWSD-54.9* Plt ___
___ 04:40AM BLOOD Plt ___
___ 04:40AM BLOOD Glucose-103* UreaN-49* Creat-2.7* Na-140
K-6.4* Cl-107 HCO3-21* AnGap-12
___ 04:40AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.6
___ 09:18AM BLOOD ___ Comment-GREEN TOP
___ 09:18AM BLOOD K-5.9*
___ 5:58 am BLOOD CULTURE
___ 01:46AM BLOOD K-5.5*
MICRO
=====
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:00 am BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
TRANSITIONAL ISSUES
==================
[ ] discharge K 5.5
[ ] will have labs drawn by ___.
SUMMARY
========
Mr. ___ is a ___ y/o M w/ hx of CKD, HTN, HLD who
was admitted for cellulitis after initial treatment with
cefpodoxime appeared to cause a rash and fevers. He was changed
to Bactrim and then IV clindamycin for a 7 day course of
antibiotics with some improvement in his cellulitis. However, he
developed a new acute kidney injury thought to be due to the
Bactrim that improved prior to discharge. He also went into
atrial fibrillation for a brief period of time, which resolved
with fluids, and he was discharged in normal sinus rhythm.
ACUTE ISSUES:
============
# Cellulitis: Patient had been seen in the ED for left ankle
cellulitis and was started on cefpodoxime. However he developed
a rash and fever so was admitted for further management. He was
trialed on Bactrim ___, but his cellulitis worsened, so he
was changed to IV clindamycin through ___. Throughout his
admission, he was afebrile, CBC was without leukocytosis, and
blood cultures were negative. His ankle was erythematous but
never swollen, painful, and never had restricted range of
movement. Ankle XR showed no bony involvement. Triamcinolone
ointment was started per Derm recs to reduce erythema in his
foot and ankle.
#New atrial fibrillation, resolved: Patient became tachycardic
with PVCs briefly on ___ and was found to be in atrial
fibrillation on EKG. He denied chest pain palpitations,
shortness of breath, and denied history of previous afib. He
converted to NSR after receiving a 500cc LR bolus, and it was
felt his afib was due to the stress of the cellulitis. A TTE ___
showed normal EF, mild AR, mild MR. ___ was held
due to his increased risk of bleed, but he was monitored on tele
throughout his admission.
# Milaria: Patient developed a maculopapular rash on his back
and chest and arms that became more confluent during his
admission. It was initially thought to be due to the cefpodoxime
but did not resolve after stopping the cefpodoxime. Derm was
consulted and felt it was a heat rash, or milaria. He was
treated by keeping his back dry and cool. The rash was never
painful or pruritic.
# Seborrheic Dermatitis: Patient developed non-blanching patchy
rash that is not painful or pruritic across scalp. Rash
initially thought to be drug rash due to cefpodoxime. However,
rash still present despite d/c'ing cefpodoxime, and rash did not
worsen. Derm was consulted and believed it is most consistent
with seborrheic dermatitis. He was treated with ketoconazole
shampoo three times a week.
___: Patient experienced increase in creatinine from 2.7
(baseline 2.3-2.5) to max of 3.5 after Bactrim use and
discontinuation. UA showed no leuks, sediment was bland with no
muddy brown casts, urine eos negative, urine protein to
creatinine ratio 0.3. Home Lasix was held. Renal consulted and
not concerned for pre-renal or intrinsic process, more concerned
for post-Bactrim use and diuresis. Renal U/S ruled out
post-obstructive process, showed normal kidney size and normal
flow within renal arteries. The creatinine rose over several
days but improved on its own. At discharge, patient's creatinine
was 2.7.
# Hyperkalemia: Toward end of hospital stay, patient developed
hyperkalemia to 6.4 ___ut with repeat whole blood K as
high as 5.9. There was a value of 8.8 that was thought to be
spurious as resultant level was 4.9. For the K of 8.8 he was
given lasix, calcium gluconate, insulin and dextrose. EKG
without acute changes. Thought to be due to renal function from
Bactrim use vs underlying chronic kidney disease. Patient
mentioned that he follows with nephrology at ___,
and the hyperkalemia has been noted before. He was unconcerned,
but we requested he avoid foods high in potassium and to get
___ labs. Dietary modifications were given to home health
nurse and wife. He was discharged with 40mg of Potassium.
CHRONIC ISSUES:
=============
# HTN: continued home amlodipine and atenolol
# CODE: full
# CONTACT: (daughter) ___
Agree with discharge summary as documented. 35 minutes were
spent in discharge preparation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Senna 8.6 mg PO BID
3. Gemfibrozil 600 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. diclofenac sodium 1 % topical DAILY:PRN
6. Calcitriol 0.25 mcg PO EVERY OTHER DAY
7. Allopurinol ___ mg PO DAILY
8. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Ketoconazole Shampoo 1 Appl TP 3X/WEEK (___)
RX *ketoconazole 2 % apply as directed three times per week
Refills:*0
2. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID
RX *triamcinolone acetonide 0.1 % apply to ankle three times a
day Refills:*0
3. Furosemide 40 mg PO DAILY
4. Allopurinol ___ mg PO DAILY
5. amLODIPine 5 mg PO DAILY
6. Atenolol 25 mg PO DAILY
7. Calcitriol 0.25 mcg PO EVERY OTHER DAY
8. diclofenac sodium 1 % topical DAILY:PRN pain
9. Gemfibrozil 600 mg PO DAILY
10. Senna 8.6 mg PO BID
11.Outpatient Lab Work
please check chemistry by ___
276.7 hyperkalemia
fax to ___.
Address: ___ ROOM ___, ___, ___
Phone: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
================
Cellulitis
SECONDARY DIAGNOSIS
===================
Acute Kidney Injury
Seborrheic Dermatitis
Miliaria
Atrial fibrillation
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for a skin infection around your ankle.
- You developed a kidney injury from one of your antibiotics, so
then we treated your kidney.
What was done for me while I was in the hospital?
- Your skin infection on your ankle was treated with antibiotics
and a steroid cream.
- Your kidneys were monitored, and they healed on their own.
- Your scalp rash was treated with medical shampoo.
What should I do when I leave the hospital?
- Please continue taking your home medications.
- Please continue your steroid cream until your ankle is no
longer red.
- Please follow up with the kidney doctors to make sure your
kidneys continue to do well.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19898116-DS-14 | 19,898,116 | 22,663,876 | DS | 14 | 2127-05-15 00:00:00 | 2127-05-16 13:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
lisinopril / losartan
Attending: ___
Chief Complaint:
acute onset of speech
difficulties and right sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
NEUROLOGY STROKE ADMISSION/CONSULT NOTE
Neurology at bedside after Code Stroke activation within: 5 mins
Time/Date the patient was last known well: 1:30 am
I was present during the CT scanning and reviewed the images
within 20 minutes of their completion.
___ Stroke Scale Score: 9
t-PA administered:
[] Yes - Time given: __
[x] No - Reason t-PA was not given or considered: out of window
Thrombectomy performed:
[] Yes
[x] No - Reason not performed or considered: Hemorrhagic
transformation
NIHSS Performed within 6 hours of presentation at: 11:50
NIHSS Total: 9
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 1
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 1
6a. Motor leg, left: 2
6b. Motor leg, right: 1
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 1
10. Dysarthria: 0
11. Extinction and Neglect: 2
REASON FOR CONSULTATION:
HPI:
Mr. ___ is a ___ year old left-handed man with past
medical history of multiple myocardial infarctions with 3-vessel
CABG in ___, DMII, HTN, and hyperlipidemia whom presents with
word finding, slurred voice, and right sided weakness. Patient
woke up at 5AM this morning and felt that his left side,
particularly the left arm was numb and weak. He said no when
asked if he could dress himself. Patient was able to get to the
kitchen table. Patient called EMS and was taken to ___. Last
known normal at outside hospital was documented as ___ ___,
but this is based on when the patient normally goes to sleep.
Patient claims he was normal and went to bed at 1:30 am. In
documentation from outside hospital, it is noted that he called
his sister yesterday morning and his voice sounded slurred.
Patient's blood pressure at presentation to ___ was 210/126 and
pulse was 82. Patient was given NIHSS of 7 NCHCT with
hypodensity
in left middle cerebral artery distribution with small left
frontal subarachnoid hemorrhage. CTA head and neck with
completely occluded right ICA and occluded left CCA and ICA as
well. Patient was given lisinopril 20 mg daily and metoprolol 50
mg and his blood pressure dropped to as low as 114/84. Patient
was transferred to ___ for further evaluation. In ED upon
arrival, SBP as low as ___. Patient in ___ ED received aspirin
81 mg and 2 liters of fluid bolus and maintenance fluids at 100
ml/hour. Patient also started on phenylephrine drip to MAP >90.
Patient admitted to the NeuroICU for close neurological
monitoring.
ROS:
On neurological review of systems, the patient denies headache,
confusion, loss of vision, blurred vision, diplopia, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. No
bowel or bladder incontinence or retention.
On general review of systems, the patient denies recent fever,
chills, night sweats, or recent weight changes. Denies cough,
shortness of breath, chest pain or tightness, palpitations.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain.
Past Medical History:
Per family:
Multiple heart attacks
CABG (___)
DMII
Hypertension
High cholesterol
GERD
Bilateral hip replacement (family thinks titanium hardware)
Social History:
Patient from ___. Lives alone in a house, worked most
of
his life self employed as a ___. Patient currently on
disability. Patient used to be alcoholic, "drank quite a bit
for
many years". Patient has been sober for about one year. He
participates in AA. Patient denies and current alcohol or
illicit
drug use.
- Modified Rankin Scale:
[] 0: No symptoms
[x] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
Mother died of heart attack at ___
Father died of liver/pancreatic cancer at ___.
Sister - heart problems but no heart attack
Physical Exam:
On Admission:
==============
PHYSICAL EXAMINATION:
Vitals: T: 98.8 HR: 57 BP: 139/70 RR: 15 SaO2: 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self, hospital, month. Unable
to relate history due to expressive aphasia. Spoke in very short
halting phrases. Able to name both high and low frequency
objects. Able to read with halting hesitancy. Able to follow
both midline and appendicular commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 5 to 3mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate could not be visualized.
XI: Unable to shrug L shoulder on command
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift on L.
R arm drifts upwards. No adventitious movements, such as tremor
or asterixis noted.
LUE appears full strength but ___ deltoids possible motor
neglect.
RUE full strength, gives resistance
LLE ___ IP - fluctuating strength. Appeared improved with HOB
down.
RLE ___ IP - could sustain antigravity
-Sensory: Decrease pinprick and light touch to RUE and RLE.
Impaired proprioception on RUE. Extinction to DSS in visual and
tactile stimulation.
-Reflexes:
Plantar response was upgoing on L and mute on R.
-Coordination: No dysmetria on FNF.
-Gait: Unable to assess
=======================================
Discharge exam:
General: pleasant, no acute distress
HEENT:NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
CV: RRR, no M/R/G noted
Lungs: CTA bilaterally
Abdomen: soft, NT/ND
Ext: No ___ edema
Skin: no rashes or lesions noted.
Neuro:
MS- Oriented to self, ___ only. Some word finding, repetition,
command difficulty. Poor calculation (unable to perform 3+4,
3x4). Able to name both high and low frequency objects.
Bilateral
apraxia.
CN- Pupils 3->2mm PERRL, EOMI. VFF. Very mild dysarthria. Tongue
protrudes to midline
- Motor: Normal bulk and tone. RUE slight pronation, no drift.
R
hand clumsy finger tapping.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: Diminished sensation to light touch and noxious RUE.
-Reflexes: Plantar reflex extensor on the right and mute on the
left.
Pertinent Results:
TTE:
The left atrial volume index is normal. There is no evidence of
an atrial septal defect or patent foramen ovale
by 2D/color Doppler or agitated saline at rest and with
maneuvers. The estimated right atrial pressure is ___
mmHg. There is normal left ventricular wall thickness with a
normal cavity size. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the basal
halves of the inferior and inferolateral walls (see
schematic) and preserved/normal contractility of the remaining
segments. No thrombus or mass is seen in the
left ventricle. The visually estimated left ventricular ejection
fraction is 45%. There is no resting left
ventricular outflow tract gradient. Tissue Doppler suggests an
increased left ventricular filling pressure (PCWP
greater than 18mmHg). Normal right ventricular cavity size with
normal free wall motion. The aortic sinus
diameter is normal for gender with mildly dilated ascending
aorta. The aortic arch diameter is normal with a
normal descending aorta diameter. 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 with no
mitral valve prolapse. There is mild [1+] mitral regurgitation.
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: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with mild
regional systolic dysfunction most consistent with single vessel
coronary artery disease (PDA
distribution). Mild mitral regurgitation with normal valve
morphology. Mildly dilated ascending
aorta. No structural cardiac source of embolism (e.g.patent
foramen ovale/atrial septal defect,
intracardiac thrombus, or vegetation) seen.
MRI brain:
1. Multifocal acute to early subacute infarctions, moderately
large in the left MCA territory, small in the anterior right
cingulate gyrus in the right
ACA territory, punctate in the right superior frontal gyrus in
the MCA territory, and multiple punctate small acute to early
subacute infarcts in the
right centrum semiovale.
2. No evidence for blood products. No significant mass effect.
3. Occlusion of bilateral internal carotid arteries is again
seen
with distal supraclinoid reconstitution, better assessed on the
___ CTA.
CTA: OSH records
Brief Hospital Course:
Patient was admitted to the NeuroICU ___ after presenting with
right sided numbness and weakness.
#superficial left parietal and smaller left frontal/insular
infarcts as well as smaller left mesial frontal infarcts.
-Patient's initial neurologic examination was pertinent for
Broca's aphasia, right facial weakness, dysarthria, right
proximal weakness in arm and leg, and right sided sensory loss
throughout face, arm and leg. Patient's examination was noted to
be very dependent on position and deteriorated when he was not
in supine position. Patient, for example, had full strength of
left iliopsoas when laying down, but when moved to ___ 30
degrees had weakness. Patient's CTA head and neck showed
bilateral carotid occlusive disease and it was thought that he
is dependent on his posterior circulation (mainly left PCOM) as
well as contribution from his ophthalmic arteries. He underwent
MRI brain which showed a superficial left parietal and smaller
left frontal/insular infarcts as well as smaller left mesial
frontal infarcts. Etiology likely combination of stump emboli
and hypoperfusion. His BP was maintained SBP 140-200, briefly
requiring phenylephrine. Patient on day two of admission was
resumed on his home DAPT therapy. Prior to transfer from ICU
service, patient was able to sit in bedside chair without change
in neurologic exam. He was started on a diabetic, heart healthy
diet and tolerating without difficulty.
He underwent a TTE which showed an EF of 45% and no cardiac
source of emboli.
His A1c was 5.3 and LDL 89. He was maintained on his home
Atorvastatin 80 mg daily and fenofibrate 145 mg daily were
continued. His home metformin was held and he was maintained on
insulin sliding scale.
Of note, in order to not drop his blood pressure and assist with
perfusion to the brain his home Chlorthalidone 21 mg daily was
held and his home Toprol XL 100mg daily was changed to
Metoprolol Tartrate 25 mg PO/NG BID.
Of note, he was noted to have urinary retention with large
residuals >800. Foley was placed and he was started on started
finasteride daily. Urology was consulted and recommended voiding
trial and possible foley removal in clinic on ___.
He was seen by ___ who recommended rehab.
A ___ of heart monitor will be arranged as outpatient.
He was discharged in stable condition.
=================================
Transitional issues:
-needs to follow up with neurology. Appointment scheduled.
-needs to follow up with urology on ___ for voiding trial and
possible foley
removal. Please call ___ to arrange the appointment
-please do not drop his blood pressure below 140.
-will arrange ___ of heart monitor as outpatient
=================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? () Yes (LDL = 89) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () 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
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. If no, why not? (I.e. patient at baseline
functional status)
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: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Ranitidine 150 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Fenofibrate 145 mg PO DAILY
7. Chlorthalidone 21 mg PO DAILY
8. Vitamin D 500 UNIT PO DAILY
9. Ascorbic Acid ___ mg PO DAILY
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO BID
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Clopidogrel 75 mg PO DAILY
7. Fenofibrate 145 mg PO DAILY
8. Ranitidine 150 mg PO DAILY
9. Vitamin D 500 UNIT 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: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
You were hospitalized due to symptoms of acute onset of speech
difficulties and right sided weakness resulting from an ACUTE
ISCHEMIC STROKE, a condition where a blood vessel providing
oxygen and nutrients to the brain is blocked by a clot. The
brain is the part of your body that controls and directs all the
other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
#Diabetes
#Hypertension
#High cholesterol
We are changing your medications as follows:
-Metoprolol Tartrate 25 mg PO/NG BID
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as well as with urology as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19898586-DS-18 | 19,898,586 | 25,476,976 | DS | 18 | 2160-12-31 00:00:00 | 2161-01-01 12:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
.
History of Present Illness:
___ yo M with past medical history notable for cholecystectomy
and right liver lobe resection, CVA, dissected left carotid who
presented to the emergency room with abdominal pain. He reports
that his pain started on ___ after eating blueberry muffins
and orange juice. The pain was in the epigastrium, persistent
and heavy in quality, no radiation. The pain was ___ in
intensity on ___. He was seen at ___ and per that
note his pain was gone by the time of ED presentation. CT
abdomen was unrevealing and he was discharged home. He felt ok
___ and ___ noted only some chills, no abdominal pain
or fevers. Today, he believes this morning, he developed
recurrence of his pain that was identical in nature but only
___ in intensity. He was seen by his primary care physician
who referred him to the emergency room. He denies any
associated nausea or vomiting or bowel changes. He denies
melena or BRBPR. He does note subjective fevers and chills.
Pain is not affected by eating and he otherwise does not note
specific exacerbating or relieving factors. Currently his pain
is down to ___ and only really present with palpation. He
notes this pain is identical to the pain that he had during
___ and prior to his CCY and liver resection. He had no
pain between his admission in ___ and this admission.
.
Notably, the patient was admitted in ___ with
abdominal pain that was attributed to stress. He had a MRI,
however, that showed thormbosed left anterior branch of the left
portal vein supplying segment II of the liver. For this, he was
started on coumadin. The plan was for six months of
anticoagulation followed by repeat imaging to ensure clot had
dissolved. The patient reports that he had a MRI to follow this,
he believes in ___, and this showed resolution of the clot
so the coumadin was discontinued.
.
ED course:
Triage vitals T 100.5 HR 106 BP 126/80 RR 18 SpO2 94% RA
He had an (apparently asymptomatic) episode of SVT to the 140s
which responded to carotid massage. Unclear if EKG obtained
during this episode. EKG at baseline was unchagned. He was
given 650 mg acetaminophen and 4.5 g Zosyn and reportedly the
ERCP team was consulted.
Vitals prior to tx T 100.4 HR 87 RR 22 SpO2 97% RA, ___ ___
pain
.
ROS:
- General: + fevers, + chills, no sweats, weight loss
- Eyes: No blurry vision, diplopia, loss of vision, photophobia
- ENT: No dry mouth, oral ulcers, tinnitus, sinus pain, sore
throat
- Lungs: + cough for past two weeks productive of clear thick
sputum, shortness of breath, dyspnea on exertiondenies
- Cardiac: no chest pain, pressure, palpitations, orthopnea, PND
- GI: as per hpi
- GU: no dysuria, hematuria, urgency, frequncey
- MSK: no arthralgias or myalgias
- Neuro: no weakness, numbness, seizures, difficulty speaking,
changes in memory.
- Skin: no rash or pruritis
- Psychiatry: + depression or suicidal ideation
Past Medical History:
s/p cholecystectomy - ___
s/p right liver lobe resection - ___ - ___ ?dilated bile
duct
h/o BPH s/p radical prostatectomy ___
h/o CVA - ___ - thalamic stroke ___ ?PFO
h/o PFO - thought to have been cause of CVA, but no signs of PFO
on bubble study in ___
h/o basal cell carcinoma of right cheek s/p excision ___
h/o basal cell carcinoma of left elbow s/p excision ___
h/o dissected left carotid with pseudoaneurysm
Social History:
___
Family History:
He denies family history relevant to current admission.
Physical Exam:
Vital Signs:
T 99.3 BP 138/80 P 80 RR 16 SpO2 96% RA
Physical examination:
- Gen: Well-appearing in NAD.
- HEENT: Conj/sclera/lids normal, PERRL, EOM full, and no
nystagmus. Hearing grossly normal bilaterally. Oropharynx clear
w/out lesions.
- Neck: Supple with no thyromegaly or lymphadenopathy.
- Chest: Normal respirations and breathing comfortably on room
air. Scant crackles at left base. No wheezes or rhonchi.
- CV: Regular rhythm. Normal S1, S2. + Ectopy. III/VI systolic
murmur heard throughout precordium, loudest at apex. 2+
carotids.
- Abdomen: Normal bowel sounds. Soft, tender to palpation over
epigastrium and right upper quadrant, + voluntary guarding, +
focal rebound. Mild distension. Liver/spleen not enlarged.
- Extremities: No ankle edema.
- MSK: Joints with no redness, swelling, warmth, tenderness.
- Skin: No lesions, bruises, rashes.
- Neuro: Good fund of knowledge. Able to discuss current events
and memory is intact. CN ___ intact. Speech and language are
normal. No involuntary movements or muscle atrophy. Normal tone
in all extremities. Motor ___ in upper and lower extremities
bilaterally. Sensation to light touch intact in upper and lower
extremities bilaterally.
- Psych: Appearance, behavior, and affect all normal. No
suicidal or homicidal ideations.
Discharge Exam:
VSS
GEN: Patient lying comfortably in bed nad a+ox3
HEENT: MMM oropharynx clear
NECK: supple no thyromegaly
CV: rrr no m/r/g
RESP: ctab no w/r/r
ABD: soft nt nd bs+
EXTR: no ___ edema good pedal pulses bilaterally
DERM: no rashes, ulcers or petechiae
neuro: cn ___ grossly intact non-focal
PSYCH: normal affect and mood
Pertinent Results:
___:15AM WBC-12.0* RBC-4.82 HGB-13.9* HCT-41.9 MCV-87
MCH-28.8 MCHC-33.1 RDW-13.7
___ 11:15AM NEUTS-86.0* LYMPHS-6.4* MONOS-7.3 EOS-0.2
BASOS-0.2
___ 11:15AM GLUCOSE-178* UREA N-16 CREAT-0.9 SODIUM-137
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-32 ANION GAP-12
___ 11:15AM ALT(SGPT)-30 AST(SGOT)-26 ALK PHOS-97 TOT
BILI-1.0
___ 11:15AM LIPASE-39
___ 11:15AM ALBUMIN-3.8
___ 11:15AM ___ PTT-27.7 ___
.
___ 01:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 01:30PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 01:30PM URINE HYALINE-1*
___ 01:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
.
RUQ U/S (___):
IMPRESSION: Left intrahepatic biliary duct dilatation that is
unchanged compared to CT two days ago. A more focal cystic
dilatation more posteriorly either represents an area of
intrahepatic biliary duct dilatation or previously seen/chronic
thrombosed left portal vein branch. There are a few scattered
hyperechoic foci that may represent pneumobilia. No evidence of
focal hepatic abscess. If clinically indicated, MRI can be done
for better detail.
.
CT ___ (___):
IMPRESSION:
PERSISTENT FOCAL BILIARY DILATATION IN THE LEFT LATERAL
SEGMENTS BUT
WITH RESOLUTION OF ABNORMAL PERFUSION. THIS APPEARANCE MAY
INCLUDE
CHRONIC SEGMENTAL THROMBOSIS OF A DISTAL PORTAL VENOUS
BRANCH IN
SEGMENT III, BUT THE ATROPHIC REGION APPEARS OVERALL TO
REPRESENT
SEQUELAE OF THE PRIOR ABNORMALITY RATHER THAN AN ACUTE
PRESENTATION.
SIMILAR MILDLY PROMINENT RETROPERITONEAL LYMPH NODES,
PROBABLY
REACTIVE AND UNCHANGED.
REGARDING THE HEPATIC ABNORMALITY, IF THE ETIOLOGY IS
UNCLEAR, MRCP
MAY BE OF SOME VALUE IN ASSESSING FURTHER AND IN PARTICULAR
TO
DELINEATE PORTAL VENOUS AND BILIARY ANATOMY.
ERCP:
___:
Procedures: Because of the evidence of mild sphincter
restenosis, a sphincteroplasty 8mm CRE balloon was introduced
for dilation successfully.
One stone and a small amount of sludge was extracted
successfully using a balloon.
Impression: Evidence of a prior sphincterotomy was noted at the
major papilla.
Successful biliary cannulation was achieved with the
sphincterotome.
A single 6 mm stone was seen in the lower common bile duct.
There was evidence of prior right hepatectomy. There was mild
diffuse biliary dilation. No strictures or stones were seen in
the left intrahepatic branches.
The lower bile duct tapered at the ampulla, suggestive of mild
sphincter restenosis.
Because of the evidence of mild sphincter restenosis, a
sphincteroplasty 8mm CRE balloon was introduced for dilation
successfully.
One stone and a small amount of sludge was extracted
successfully using a balloon.
Otherwise normal ERCP to ___ portion of duodenum
Discharge labs
___ 07:35AM BLOOD WBC-6.8 RBC-4.60 Hgb-13.1* Hct-40.7
MCV-88 MCH-28.5 MCHC-32.2 RDW-13.6 Plt ___
___ 07:35AM BLOOD Glucose-88 UreaN-6 Creat-0.6 Na-140 K-3.7
Cl-101 HCO3-32 AnGap-11
___ 07:35AM BLOOD ALT-75* AST-54* AlkPhos-167* TotBili-0.6
Brief Hospital Course:
#. Cholangitis: patient was started on IV abx(unasyn) and IV
hydration and MRCP was performed showing multiple filling
defects consistent with choledocholithiasis. Patient was taken
to ERCP and a sphincterotomy was performed with stone extration.
The patient tolerated the procedure well and LFT abnormalities
improved post procedure. He will continue antibiotics for 14
days as he was found to have bacteremia(see below). Pt was
tolerating po > 24 hours prior to discharge. He will follow up
with his PCP within one week.
.
#Bacteremia: pt blood cultures + gram neg rods, likely ___
cholangitis. He will need to continue antibiotics for 2 weeks
total(augmentin). Final cultures were pending on discharge, but
sensitivites were checked and the organism was pan sensitive.
.
Transition Issues
1. Continue augmentin for 10 more days
2. Holding aspirin and NSAIDs for 5 days post ERCP(restart ___
3. Follow up appointment with PCP to be scheduled by patient
within one week
Medications on Admission:
Aspirin 81 mg daily
Hydrochlorothiazide 25 mg daily
Lantanoprost 0.005% drops at bedtime
Levetiracetam 500 mg twice daily
MVI daily
Simvastatin 40 mg daily
Eye caps (vitamin) 2 caps BID
Omeprazole 20 mg daily
Westcort 0.2% topical treatment to perinium
Carac 0.5% topical cream to scal daily
Zoloft 25 mg daily
Discharge Medications:
1. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
8. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day: restart on ___.
9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: DO NOT restart
taking until ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis(infection from gallstone blocking the bile duct)
gram neg rod bacteremia(bacteria in your blood)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain and found to have
gallstones obstructing your bile ducts and an
infection(cholangitis). An ERCP was performed and the stone was
removed. You will need to continue on antibiotics for 14 days
total because of your infection. Please plan to follow up with
your primary care physician in the next week.
DO NOT take aspirin, naproxen, aleve, ibuprofen, advil or other
NSAIDs for one week(restart ___. If you have pain use
tylenol
New meds:
1. Augmentin 850 mg twice daily: continue taking until you run
out
Followup Instructions:
___
|
19898586-DS-20 | 19,898,586 | 28,045,483 | DS | 20 | 2161-07-16 00:00:00 | 2161-07-16 17:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cardura / horse serum / NSAIDS (Non-Steroidal Anti-Inflammatory
Drug)
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo p/w RUQ and epigastric abd pain. Pain has been present for
several days. Is intermittent, does not notice increase with
food, but has not had an appetite since pain started and has
been taking minimal PO. Had been to ___ ED twice in
the past week due to leg pain which was attributed to a
ileopsoas tear according to the patient. On second visit he also
had the abd pain which brings him in now. He was told at that
time to stop taking IBP. Pt cannot quantify how muc IBP he had
been taking. No other changes in medications no heavy alcohol
use or recent increase in alcohol consumption. Pain associated
with mild nausea, no emesis. No diarrhea, consitpation, BPR. No
sick contacts.
In ED VS stable. Pt given GI cocktail, PPI, morphine with
improvement of pain. However, pt very concerned about pain
returning. Admitted for further work up and arrangement of out
pt pain managment plan.
ROS: ?weight loss, otherwise negative
Past Medical History:
s/p cholecystectomy - ___
s/p right liver lobe resection - ___ - ___ ?dilated bile
duct
BPH s/p radical prostatectomy ___
CVA - ___ - thalamic stroke ___ ?PFO
?PFO - thought to have been cause of CVA, but no signs of PFO on
bubble study in ___
basal cell carcinoma of right cheek s/p excision ___
basal cell carcinoma of left elbow s/p excision ___
dissected left carotid with pseudoaneurysm
pituitary adenoma
glaucoma
seizure disorder
Social History:
___
Family History:
+ gallbladder disease
Physical Exam:
Admission exam:
VS: 98 ___ 20 95%ra
Gen: nad, lying in bed
Heent: membranes dry
Resp: comfortable
CV: rrr ___ systolic murmur
Abd: nabs, soft, mildly tender epigastrium/RUQ, nd, no rebound
Ext: no e/c/c
Neuro: alert, answering questions appropriately
Discharge exam:
AVSS
Gen: no distress, sitting in chair
HEENT: MMM, sclera anicteric
CV: RR, nl rate, +murmur, systolic
Lungs: comfortable, CTAB
Abd: soft, nontender (with focused exam of epigastric and RUQ
area), nondistended, no rebound/guarding, + BS
Ext: wwp, no edema
Skin: no rashes
Neuro: appropriate
Pertinent Results:
___ 07:25PM GLUCOSE-112* UREA N-11 CREAT-0.7 SODIUM-129*
POTASSIUM-3.9 CHLORIDE-88* TOTAL CO2-28 ANION GAP-17
___ 07:25PM ALT(SGPT)-12 AST(SGOT)-20 ALK PHOS-90 TOT
BILI-0.5
___ 07:25PM LIPASE-35
___ 07:25PM cTropnT-<0.01
___ 07:25PM WBC-5.8 RBC-4.66 HGB-13.2* HCT-39.3* MCV-84
MCH-28.3 MCHC-33.5 RDW-13.1
___ 05:15AM BLOOD Glucose-100 UreaN-9 Creat-0.6 Na-132*
K-4.2 Cl-93* HCO3-31 AnGap-12
CXR: The heart size is normal. The aorta is tortuous. The
mediastinal and hilar contours are otherwise unchanged, and no
pulmonary vascular congestion is present. Except for mild
bibasilar atelectasis, the lungs are clear without focal
consolidation. No pleural effusion or pneumothorax is
identified. Diffuse demineralization of the osseous structures
is re- demonstrated. Degenerative changes of both glenohumeral
joints are partially imaged. IMPRESSION: Mild bibasilar
atelectasis. No focal consolidation to indicate pneumonia.
CTAP: IMPRESSION: 1. Chronic thrombus within a branch of the
left anterior portal vein, slightly improved since prior study
from ___. 2. Unchanged post right hepatectomy changes.
No suspicious hepatic lesion. 3. Persistent left-predominant
intrahepatic biliary ductal dilatation. 4. Unchanged ___ile duct without clear obstructing lesion. 5. Unchanged small
hiatal hernia. No bowel obstruction or inflammation. 6. Normal
appendix. 7. Stable para-aortic retroperitoneal lymphadenopathy.
Brief Hospital Course:
___ with RUQ and epigastric abdominal pain likely secondary to
gastritis and found to have hyponatremia likely secondary to
decreased PO intake and hydrochlorothiazide use. His pain
completely resolved with GI cocktail (maalox). He tolerated a
full regular breakfast and lunch without problems. His Na
trended up to 132. He will be discharged with a close follow up
appointment with his PCP.
# Gastritis: The patient was taking ibuprofen which likely lead
to gastritis. His abdominal imaging was reassuring as were LFTs
and lipase. His pain was completely resolved with maalox. He
tolerated a normal diet. He was discharged with an increased
dose of omeprazole (for the next two weeks), ranitidine (home
dose) and as needed mylanta (over the counter). He was warned
not to take NSAIDs again. The information was discussed with the
patient and also his son (HCP). He has close follow up with Dr.
___ further evaluation and management.
# Hyponatremia/Hypochloremia: This was thought to be secondary
to poor PO intake and hydrochlorothiazide use. The
hydrochlorothiazide was held and he was given gentle NS IVF with
improvement of Na. He advised to hold the hydrochlorothiazide
for the next 2 days and maintain good PO intake. His PCPs office
was notified and he will have lab work on ___. As an
inpatient his blood pressure was adequately controlled and he
should tolerate being off this medication for a couple days.
# History of CVA: He stopped taking his aspirin when diagnosed
with muscle tear. This was resumed during the hospitalization
without problems. He should continue to take this medication. He
is not on a statin.
# Thigh pain: Per patient he was discharged with "psoas muscle
tear" at ___. It is unclear how this diagnosis was made;
however, currently he is pain free. He will continue to take
tylenol and oxycodone as needed for pain. He was instructed not
to take NSAIDs.
# Somnolence: Patient with brief episode of somnolence. Related
to poor sleep pattern in hospital and trazadone given overnight.
Improved prior to discharge.
Inactive issues:
# Seizure Disorder: cont keppra.
# HTN: held HCTZ given hyponatremia.
# Pituitary Tumor: cont home cabergoline (once discharged)
# Glaucoma: cont home xalatan
Transitional issues:
# recheck Na
# follow up with PCP for abdominal and leg pain
# CT findings: will fax report to PCP
# blood pressure monitoring - resume HCTZ on ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. cabergoline *NF* 0.5 mg Oral unknown
2. Hydrochlorothiazide 25 mg PO DAILY
3. LeVETiracetam 750 mg PO BID
4. Multivitamins W/minerals 1 TAB PO DAILY Start: In am
5. Omeprazole 20 mg PO DAILY Start: In am
6. Vitamin D 1000 UNIT PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Ranitidine 150 mg PO BID
9. Acetaminophen 500 mg PO Q6H:PRN pain
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
3. LeVETiracetam 750 mg PO BID
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Omeprazole 40 mg PO DAILY
RX *omeprazole 20 mg 2 capsule(s) by mouth daily Disp #*60
Capsule Refills:*0
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
7. Ranitidine 150 mg PO BID
8. Vitamin D 1000 UNIT PO DAILY
9. cabergoline *NF* 0.5 mg Oral qweekly
10. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
abd pain
RX *aluminum-magnesium hydroxide [Mylanta] 500 mg-500 mg/5 mL
___ ml by mouth every 6 hours Disp #*1 Bottle Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
gastritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain. The cause of this pain is
likely related to inflammation of your stomach. This may have
been caused by taking ibuprofen. Please do not take this
medication in the future (or any other NSAIDs ie advil, motrin,
etc). You were treated with maalox, omeprazole and ranitidine
with resolution of your pain. You had no leg pain while you were
here. You tolerated a regular diet.
Of note, your blood sodium level was low. This was likely
related to poor oral intake and the medication called
hydrochlorothiazide. This improved while you were admitted.
The following changes were made to your medications:
1. omeprazole 40mg PO daily for the next 2 weeks. Then resume
20mg omeprazole daily.
2. Maalox, as needed for stomach discomfort. This is over the
counter.
3. HOLD hydrochlorothiazide for next 2 days. You can resume this
medication at that time if you have a good diet. If you are not
eating a good diet please discuss with your primary care
physician.
Followup Instructions:
___
|
19898601-DS-19 | 19,898,601 | 23,343,457 | DS | 19 | 2153-02-13 00:00:00 | 2153-02-13 16:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
food impaction
Major Surgical or Invasive Procedure:
EGD with solid food bezoar removal
History of Present Illness:
___ year old woman with achalasia s/p ___ myotomy in ___
with subsequent GERD, followed in ___ clinic here who presents
with suspected food impaction. Pt ate plantain on ___ which she
felt like was stuck in her esopagus. She tried to induce
vomiting and was able to get some portions out but still had
sensation of impaction. She has been unable to eat even soft
foods since then. She presented to the ED for evaluation of
impaction. GI consulted while pt in ED and she was admitted for
endoscopy tomorrow. She denies any pain or shortness of breath.
No fevers or chills. She does have GERD symptoms which have been
a little worse with this episode, but generally controlled with
her BID omeprazole.
Of note, pt has had stricture dilatation in the past. However,
her last endoscopy on ___ did not reveal any structural
abnormalities. She did have inflamed distal esopagus but
biopsies were unremarkable.
ROS: negative except as above
Past Medical History:
# Achalasia - symptomatic since ___ while in ___, had
___ myotomy in ___, followed by Dr ___ at ___
# Asthma - generally well controlled
# Hemorrhoids
Social History:
___
Family History:
No history of achalasia.
Physical Exam:
Vitals: T 98.1 BP 117/43 HR 53 RR 16 O2 sat 100%RA
Gen: well appearing woman in no distress
HEENT: oropharynx is clear, trachea midline
CV: rrr, no r/m/g
Pulm: clear with no wheeze
Abd: soft, nontender, nondistended, hypoactive bs healed midline
scar
Ext: no edema
Neuro: alert and oriented x3, no gross deficits
Pertinent Results:
___ CXR:
Heart size is normal. The mediastinal and hilar contours are
normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural
effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
No radiopaque foreign bodies are identified.
___ EGD Report:
Findings: Esophagus:
Lumen: A moderate dilation in the middle third and lower third
of the esophagus.
Contents: A large, solid particle of food was impacted in the
lower third of the esophagus. The bezoar was carefully pushed
into the stomach, it was subsequently fragmented with a large
snare and divided into several small pieces.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Impression: Dilation at the middle third and lower third of the
esophagus
Food impaction (solid bezoar) in the lower third of the
esophagus
Recommendations: In hospital care, NPO for 6 hours, then clear
liquids for 24 hours.
Antireflux regimen: Avoid chocolate, fatty foods, caffeine,
onions, garlic, beer, alcohol and soft drinks with gas. Must
chew on small pieces of food and elevate the head of the bed at
least 6 inches and go to bed with an empty stomach.
Brief Hospital Course:
___ year old woman with asthma, achalasia s/p ___ myotomy ___
years ago with recently normal EGD who presents with sensation
of food impaction. She does report frequent sensations of
incomplete food passage from the esopagus which generally
resolve with her inducing vomiting. She was not successful this
time.
Pt underwent EGD where they identified a solid food bezoar
impacted in the distal esophagus. The bezoar was "carefully
pushed into the stomach, it was subsequently fragmented with a
large snare and divided into several small pieces."
Gastroenterology reports that pt likely has gastroparesis, and
has recommended dietary modification to treat. They recommend:
- On day of discharge: do not eat or drink for 6 hours, then
clear liquids for 24 hours.
- eat small frequent meals, rather than 3 large meals. Divide
meals into 6 small meals per day.
- Cut food up small, and chew well.
- Alternate bites of food with drinking liquid.
- Remain upright for at least an ___ hours after meals, and go
to bed on an empty stomach.
- Avoid chocolate, fatty foods, caffeine, onions, garlic, beer,
alcohol and soft drinks with gas.
- Elevate the head of the bed at least 6 inches.
- continue omeprazole as previously prescribed.
# GERD
- continued bid omeprazole
# Asthma - stable
- continued prn albuterol
Contact - Husband, ___ ___
___: discharged to home
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
3. Hydrocortisone (Rectal) 2.5% Cream ___AILY hemorrhoid
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
2. Omeprazole 20 mg PO BID
3. Hydrocortisone (Rectal) 2.5% Cream ___AILY hemorrhoid
Discharge Disposition:
Home
Discharge Diagnosis:
# Food impaction (solid bezoar) in the lower third of the
esophagus
# Dilation at the middle third and lower third of the esophagus
# Probable gastroparesis
Secondary:
# GERD
# Achalasia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were found to have food stuck in your lower esophagus,
likely a result of gastroparesis. Gastroenterology recommends
modifying your diet to prevent this in the future:
- On day of discharge: do not eat or drink for 6 hours, then
clear liquids for 24 hours.
- You are encouraged to eat small frequent meals, rather than 3
large meals. Divide your meals into 6 small meals per day.
- Cut your food up small, and chew well.
- Alternate bites of food with drinking liquid.
- Remain upright for at least an ___ hours after meals, and go
to bed on an empty stomach.
- Avoid chocolate, fatty foods, caffeine, onions, garlic, beer,
alcohol and soft drinks with gas.
- Elevate the head of the bed at least 6 inches.
Followup Instructions:
___
|
19898644-DS-14 | 19,898,644 | 24,332,969 | DS | 14 | 2137-08-04 00:00:00 | 2137-08-11 17:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Magnesium Citrate / iodopropynyl butylcarbamate / propylene
glycol / Iodinated Contrast Media - Oral and IV Dye
Attending: ___.
Chief Complaint:
Abdominal distention
Major Surgical or Invasive Procedure:
___ ___ paracentesis
History of Present Illness:
Ms. ___ is an ___ female with history of
platinum-resistant metastatic ovarian cancer who presents for
abdominal pain and distension.
Patient reports worsening abdominal pain and distension over the
past several weeks. She has become progressively more
uncomfortable. The pain is mostly in her upper abdomen. Also
notes wheezing and mild cough but denies shortness of breath.
She
took three Tylenol last night and two this morning. She notes
nauseas without vomiting this morning. Also notes constipation
and last BM on ___.
On arrival to the ED, initial vitals were 97.6 86 117/77 20 98%
RA. Exam was notable for abdomen distended, firm, diffusely
tender to palpation with positive fluid wave. Labs were notable
for WBC 8.6, H/H 11.8/37.0, Plt 395, Na 139, K 5.0, BUN/Cr
___, trop < 0.01, INR 1.1, and lacate 1.8. CXR showed small
to
moderate right pleural effusion. Bedside abdominal ultrasound
noted significant ascites. Prior to transfer vitals were 98.1 83
118/70 18 99% RA.
On arrival to the floor, patient reports fatigue. She is unable
to rate her pain. She denies fevers/chills, night sweats,
headache, vision changes, dizziness/lightheadedness,
weakness/numbnesss, shortness of breath, hemoptysis, chest pain,
palpitations, vomiting, diarrhea, hematemesis,
hematochezia/melena, dysuria, hematuria, and new rashes.
Past Medical History:
Osteoporosis
mild depression
colon polyp
chronic ankle pain, shoulder pain and back pain
left wrist fracture
OSA - refuses mask
thyroid cyst
melanoma
Social History:
___
Family History:
- Breast cancer and multiple myeloma in sister diagnosed age ___
- ___ cancer in paternal aunt diagnosed in her ___
- Mother had emphysema
- Stomach cancer metastasized to lungs in father
- ___ cancer in brother
- No known family history of uterine, ovarian, cervical or colon
cancer
Physical Exam:
ADMISSION EXAM:
VS: Temp 98.2, BP 145/91, HR 96, RR 18, O2 sat 93% RA.
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Decreased breath sounds at bases bilaterally. Scattered
expiratory wheezes.
ABD: Distended, firm, diffuse mild tenderness to palpation
without rebound, diminished bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
DISCHARGE EXAM:
VS: 98.5 142 / 70 81 22 95 2L
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Decreased breath sounds at bases bilaterally. ___
expiratory
wheeze throughout, worse in upper lung fields
ABD: Distended, firm, diffuse mild tenderness to palpation
without rebound, diminished bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION RESULTS:
___ 02:50PM BLOOD WBC-8.6 RBC-4.00 Hgb-11.8 Hct-37.0 MCV-93
MCH-29.5 MCHC-31.9* RDW-14.0 RDWSD-47.8* Plt ___
___ 02:50PM BLOOD Glucose-98 UreaN-20 Creat-0.8 Na-139
K-5.0 Cl-102 HCO3-22 AnGap-20
___ 02:50PM BLOOD cTropnT-<0.01
___ 07:57AM BLOOD Albumin-3.7 Calcium-8.8 Phos-4.1 Mg-2.1
___ 03:15PM BLOOD Lactate-1.8
ASCITES STUDIES:
___ 09:08AM ASCITES TNC-818* RBC-577* Polys-24* Lymphs-18*
___ Macroph-58* Other-0
___ 09:08AM ASCITES Albumin-3.0
DISCHARGE RESULTS:
___ 07:57AM BLOOD WBC-7.3 RBC-3.67* Hgb-10.9* Hct-33.6*
MCV-92 MCH-29.7 MCHC-32.4 RDW-14.0 RDWSD-47.5* Plt ___
___ 07:57AM BLOOD Glucose-107* UreaN-20 Creat-0.8 Na-141
K-4.3 Cl-105 HCO3-23 AnGap-17
RELEVANT CYTOLOGY:
PERITONEAL FLUID:
POSITIVE FOR MALIGNANT CELLS.
Consistent with metastatic adenocarcinoma. See note.
Note: The tumor is morphologically similar to prior positive
cytology (___-___).
RELEVANT IMAGING:
___ CXR:
FINDINGS:
Persistent small to moderate right pleural effusion is noted.
Linear right midlung opacity may be due to small amount of fluid
within the fissure. There are low lung volumes. There is no
superimposed confluent consolidation. Mild cardiac enlargement
and tortuosity of the thoracic aorta again noted. No acute
osseous abnormalities.
IMPRESSION:
Small to moderate right pleural effusion.
Brief Hospital Course:
Ms. ___ is an ___ woman with history of
platinum-resistant metastatic ovarian cancer who presents for
abdominal pain and distension. She was a febrile/without
leukocytosis. Exam was notable for fluid shift. She underwent
uncomplicated ___ paracentesis with 3L of fluid removed
with slight improvement in her symptoms. ___ did not recommend
pleurX catheter, as she has not needed paracentesis that
frequently. Moreover, when suggested to the patient, she
declined pleurX catheter at this time.
She was also given Rx for albuterol inhaler for wheezing,
although the reported wheezing may be due to compression of
airways secondary to abdomen with large ascites. O2 sats
remained 92-93% on RA.
# Abdominal Pain/Distension
# Malignant Ascites: Patient with increasing abdominal pain and
distension. Bedside ultrasound in ED with ascites. Exam
consistent with worsening ascites. Has required paracentesis for
recurrent malignant ascites, last in ___, however recent
attempts were aborted due to lack of fluid. PleurX was discussed
with the patient, who declined at this time. She underwent
paracentesis with ___, with drainage of ~3L of fluid, with
significant improvement in her symptoms.
# Wheezing: Thought initially due to be due to IV contrast dye
although that was about two weeks ago. Wheezing resolved after
paracentesis. Patient was discharged with albuterol prn should
wheezing return.
# Platinum-Resistant Metastatic Ovarian Cancer: Progression
through multiple lines of therapy. Not currently pursuing future
treatment. Metastatic to peritoneum, liver, and lymph nodes.
Patient was seen by palliative care while inpatient for
discussion about hospice. Plan to have hospice ___
visit/evaluate the patient at home.
# Constipation: Continued home bowel reg
# Depression: Continued home citalopram
TRANSITIONAL ISSUES:
====================
-Patient seen by palliative care inpatient; Hospice ___ will
visit/evaluate patient as an outpatient at home
CODE: DNR/DNI
COMMUNICATION: Patient
EMERGENCY CONTACT HCP: ___ (sister/HCP)
___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Lactulose 15 mL PO DAILY:PRN constipation
3. Senna 8.6 mg PO BID:PRN constipation
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. Bisacodyl 10 mg PO DAILY:PRN constipation
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing/shortness of
breath
RX *albuterol sulfate [Proventil HFA] 90 mcg ___ puffs inh Q4H
PRN Disp #*1 Inhaler Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Citalopram 20 mg PO DAILY
5. Lactulose 15 mL PO DAILY:PRN constipation
6. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Malignant ascites
Metastatic ovarian carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
Why were you here:
-You were admitted for abdominal pain/swelling from fluid
What was done for you:
-3L of the abdominal fluid from your cancer was removed
successfully and you felt slightly better
-Palliative care saw you and the hospice nurses ___ come visit
you at home to talk to you
-We also gave you a prescription for albuterol in case you have
shortness of breath/wheezing at home. This wheezing was most
likely from the fluid in your abdomen putting pressure on your
lungs
What to do next:
-Continue to take your medications
-Follow-up at the appointments listed below
We wish you all the best,
Your ___ team
Followup Instructions:
___
|
19898805-DS-14 | 19,898,805 | 28,419,294 | DS | 14 | 2120-02-28 00:00:00 | 2120-02-28 17:41:00 |
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:
ADMISSION LABS
==============
___ 10:00AM BLOOD WBC-8.0 RBC-4.58 Hgb-14.1 Hct-42.2 MCV-92
MCH-30.8 MCHC-33.4 RDW-12.1 RDWSD-40.7 Plt ___
___ 10:00AM BLOOD Neuts-63.8 ___ Monos-5.5 Eos-0.5*
Baso-0.5 Im ___ AbsNeut-5.11 AbsLymp-2.35 AbsMono-0.44
AbsEos-0.04 AbsBaso-0.04
___ 10:00AM BLOOD Glucose-86 UreaN-12 Creat-0.7 Na-141
K-4.0 Cl-106 HCO3-24 AnGap-11
___ 10:00AM BLOOD HCG-<5
MICRO
=====
___ 01:00PM URINE Color-Straw Appear-Hazy* Sp ___
___ 01:00PM URINE RBC-2 WBC-21* Bacteri-FEW* Yeast-NONE
Epi-6
IMAGING
=======
___ CXR
No comparison. The lung volumes are normal. Normal size of the
cardiac
silhouette. Normal hilar and mediastinal contours. No
pneumonia, no
pulmonary edema. No pleural effusions. No pneumothorax.
___ CT Head
There is no evidence of intracranial hemorrhage. No mass
effect,
hydrocephalus or shift of normally midline structures.
Ventricles, cisterns and sulci appear within normal limits.
Gray-white matter distinction appears preserved in with.
Surrounding soft tissue structures appear normal. There is no
evidence of fracture or bone destruction. Visualized paranasal
sinuses and mastoid air cells appear clear.
___ EKG
Sinus bradycardia.
___ EKG
Normal sinus rhythm
Normal ECG
DISCHARGE LABS
==============
___ 05:50AM BLOOD WBC-7.9 RBC-4.52 Hgb-13.9 Hct-42.5 MCV-94
MCH-30.8 MCHC-32.7 RDW-12.0 RDWSD-41.7 Plt ___
___ 05:50AM BLOOD Glucose-85 UreaN-13 Creat-0.7 Na-142
K-4.2 Cl-106 HCO3-24 AnGap-12
___ 05:50AM BLOOD Calcium-9.5 Phos-4.2 Mg-2.0
Brief Hospital Course:
TRANSITIONAL ISSUES
===================
[ ] Patient to get outpatient TTE in the next week. The order
has been placed in OMR for this to be performed at ___.
[ ] Patient to get outpatient event ___ of Hearts) monitor for
2 weeks. The order has been placed in OMR for this to be
scheduled by ___.
[ ] Patient to follow-up with Dr. ___ at ___
Cardiology in ___ weeks to follow up on the results of the above
studies. Patient to call office at ___ to make the
appointment.
BRIEF HOSPITAL COURSE:
======================
___ previously healthy woman with history of anxiety
presented with 2 witnessed syncopal events that occurred with
prodrome of chest discomfort and dizziness with negative
inpatient workup discharged in stable condition with no further
episodes and with plan for close outpatient follow-up with event
monitor, TTE, and cardiology follow-up.
ACUTE ISSUES
=============
#Syncope
Patient with two syncopal episodes with prodrome of chest
discomfort and dizziness, without precedent exertion, and with
rapid recovery - suggestive of vasovagal etiology. EKG with RSR'
in V1-V3. Arrhythmia is a possibility however this EKG finding
can be a normal variant. Tele has been NSR. Patient also with
anxiety, so could represent a panic attack though progression to
full syncope is drastic. Seizure is less likely given patient
with no post-ictal state or hallmarks of GTC (tongue biting,
urinary/fecal incontinence). Labs have been without
abnormalities. CT Head unremarkable. Orthostatic vitals normal.
Cardiology followed during admission and recommended outpatient
TTE, event monitor, and cardiology follow-up in ___ weeks. These
two studies have been ordered through ___ and will be scheduled
in the next ___ weeks.
CHRONIC ISSUES
==============
#Anxiety
Patient continued on home sertraline.
#CODE: Full
#CONTACT: ___ (mother) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 100 mg PO DAILY
2. ValACYclovir 500 mg PO Q24H
3. Loestrin ___ (21) (norethindrone ac-eth estradiol) 1.5-30
mg-mcg oral daily
Discharge Medications:
1. Loestrin ___ (21) (norethindrone ac-eth estradiol) 1.5-30
mg-mcg oral daily
2. Sertraline 100 mg PO DAILY
3. ValACYclovir 500 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You fainted.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had blood tests which were all normal.
- You had imaging of your chest and head which was normal.
- You were seen by Cardiology and were kept on a heart monitor
which was normal.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
-Please follow the instructions below to make sure you schedule
a heart ultrasound/Echo, get an event heart monitor, and make
Cardiology and PCP appointments as below.
Please take care!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19898813-DS-17 | 19,898,813 | 29,500,226 | DS | 17 | 2154-03-22 00:00:00 | 2154-03-22 13:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left elbow pain
Major Surgical or Invasive Procedure:
Phlebotomy
Left elbow joint aspiration
History of Present Illness:
___ yo male referred to the ED by his PCP due to abnormal
CBC (elevated WBC, hemoglobin, and platelets). Pt saw his PCP
this AM to follow up on a UTI diagnosed and treated with an
antibiotic last week. He completed the course of abx 4 days ago.
His UTI sx began while he was in ___ for three weeks starting
on ___. He developed gross hematuria and dysuria. He did
not
seek medical attention there but upon return to ___ sought
care and was prescribed nitrofurantonin for 5 days from ___. He
went for f/u and saw his new PCP ___. (He does not go to
doctors ___ Prior to the development of the hematuria which
he thought was secondary to him eating bad fruit in ___ he
was
feeling very well.
During the visit, he mentioned L elbow pain and swelling which
started 3 days ago. PCP prescribed ibuprofen (400mg) which he
reports has decreased pain. Last dose was at 11 pm. Swelling and
erythema has worsened. Pt has had pain in his elbow in the past,
but never this bad or with swelling. He also denies trauma,
fever, or chills. He also reports L hand swelling last night
which has improved. About a year ago his L index finger was
swollen and resolved after daughter drained blood with an
acupuncture needle. He was also recently diagnosed with HTN and
prescribed losartan today.
He reports cough when he lays down at night and ? reflux.
Exam in the ED : No acute destress. Callus with circumferential
erythema and mild swelling of L elbow. Tender to palpation.
Decreased ROM and strength due to pain. Intact sensation and
pulses. Minimal L hand swelling, Heberden node on L index
finger.
Full ROM of hand. Decreased strength.
Weight loss, bleeding, nose bleeds,h/o anemia
ROS:
He reports a distant history of epistaxis last ___ years ago. He
has lost ___ lbs. He reports recent increased fatigue. He is in
severe pain in his L elbow it is not worse than it has been, but
the initial improvement he felt after the joint was tapped has
gone away. He does not report fevers or shaking chills. He has
noticed easy bleeding when he brushes his teeth. He had nights
sweats from ___ - ___ but these have resolved. He
reports mild chest pain when he is cooking or moving around
which
resolves after a second. It is not associated with diaphoresis,
nausea, palpitations or shortness of breath. He does not report
blurry vision when he wears his glasses. Per onc h/o dizziness
after showers.
Pertinent positives and negatives as noted in the HPI. All
other
systems were reviewed and are negative.
VS upon presentation:
Yest 20:36 |10 |98.2 |68 |163/77 |16 |96% RA
Tmax = ___
Meds given:
___ 01:08 PO Acetaminophen 1000 mg ___
___ 16:10 PO Colchicine ___
___ 17:02 PO Colchicine .6 mg ___
Heme recs:
Please add on the following labs:
- Heme/onc smear for consultant review
- LDH
- Fibrinogen
- Ca/Mg/Ph/Uric Acid
Past Medical History:
HTN
No other past medical history
Social History:
___
FAMILY HISTORY:
His father died at ___ and his mother died at ___ of natural
causes.
Family History:
His father died at ___ and his mother died at ___ of natural
causes.
Physical Exam:
ADMISSION EXAM:
___ 1856 Temp: 98.5 PO BP: 153/76 HR: 69 RR: 18 O2
sat: 96% O2 delivery: RA
GENERAL: Alert and pleasant. He looks very uncomfortable from
his
elbow.
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: L elbow with increased erythema and pain with active and
passive range of motion. + effusion. ___. Site of tap c/d/I.
Neck supple, moves all extremities, strength grossly full and
symmetric bilaterally in all limbs
? Resolved gouty tophus vs Herbeden's node at R index finger
DIP.
SKIN: L elbow erythema noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
GENERAL: Alert and in no apparent distress
CV: Heart regular, normal perfusion, no JVD appreciated
RESP: Normal respiratory effort with no stridor or labored
breathing.
GI: Abdomen soft, non-distended, non-tender
MSK/Skin: left elbow with improved erythema, minimal swelling,
full ROM,
non-tender
NEURO: Alert, oriented, face symmetric, no focal deficits
PSYCH: normal thought content, normal mood and affect
Pertinent Results:
ELBOW (AP, LAT & OBLIQUE) LEFT Study Date of ___ 12:38 AM
IMPRESSION:
1. No evidence of fracture or dislocation in the left elbow.
2. Moderate degenerative changes in the left elbow. Small left
elbow joint effusion.
3. Spurs about the medial and lateral epicondyle and of the
olecranon.
EXAMINATION: CHEST (PA AND LAT) ___
FINDINGS:
Limited evaluation of the lateral chest radiograph due to low
lung volumes. Heart size is mildly enlarged. The mediastinal
and hilar contours are unremarkable normal. The pulmonary
vasculature is normal. Mild patchy opacities in the lung bases
may reflect atelectasis. No focal consolidation. No pleural
effusion or pneumothorax is seen. There are no acute osseous
abnormalities.
IMPRESSION:
Somewhat limited lateral view due to low lung volumes. Patchy
opacities in lung bases may reflect atelectasis. Infection is
not excluded in the correct clinical setting.
CXR ___ FINDINGS:
Compared to prior radiograph, the lungs are well expanded.
There is unchanged cardiomegaly, and the mediastinal contour is
unchanged. The aorta is tortuous. There is no evidence of
pulmonary edema, pneumothorax or pleural effusion. Improved
right lower lobe opacities with mild residual opacification.
IMPRESSION:
Improved right lower lobe opacities with mild residual
opacification.
___ 09:32AM BLOOD WBC-32.0* RBC-8.61* Hgb-20.8* Hct-69.3*
MCV-81* MCH-24.2* MCHC-30.0* RDW-22.7* RDWSD-59.7* Plt ___
___ 10:15PM BLOOD WBC-33.9* RBC-8.28* Hgb-19.9* Hct-64.9*
MCV-78* MCH-24.0* MCHC-30.7* RDW-22.1* RDWSD-54.8* Plt ___
___ 05:55AM BLOOD WBC-35.5* RBC-7.90* Hgb-18.9* Hct-61.4*
MCV-78* MCH-23.9* MCHC-30.8* RDW-21.8* RDWSD-54.3* Plt ___
___ 10:15PM BLOOD Neuts-87.1* Lymphs-3.6* Monos-4.8*
Eos-1.2 Baso-2.2* NRBC-0.2* Im ___ AbsNeut-29.51*
AbsLymp-1.21 AbsMono-1.63* AbsEos-0.41 AbsBaso-0.75*
___ 12:42AM BLOOD ___ PTT-47.7* ___
___ 05:55AM BLOOD ___ PTT-45.5* ___
___ 07:55AM BLOOD ___
___ 10:15PM BLOOD Glucose-87 UreaN-15 Creat-0.9 Na-135
K-5.2 Cl-97 HCO3-25 AnGap-13
___ 05:55AM BLOOD Glucose-76 UreaN-14 Creat-0.9 Na-141
K-4.5 Cl-99 HCO3-29 AnGap-13
___ 10:15PM BLOOD AlkPhos-134* TotBili-1.1
___ 07:55AM BLOOD ALT-21 AST-71* LD(LDH)-1032* AlkPhos-146*
TotBili-1.5
___ 05:55AM BLOOD ALT-14 AST-19 LD(___)-315* CK(CPK)-43*
AlkPhos-145*
___ 05:55AM BLOOD CK-MB-1 cTropnT-<0.01
___ 10:15PM BLOOD Albumin-3.7 Calcium-8.9 Phos-3.9 Mg-2.0
UricAcd-7.2*
___ 07:55AM BLOOD Calcium-8.8 Phos-4.2 Mg-1.9 UricAcd-7.4*
Iron-70
___ 09:32AM BLOOD Cholest-161
___ 07:55AM BLOOD calTIBC-296 ___ Ferritn-64 TRF-228
___ 09:32AM BLOOD %HbA1c-5.7 eAG-117
___ 09:32AM BLOOD Triglyc-82 HDL-50 CHOL/HD-3.2 LDLcalc-95
___ 09:32AM BLOOD TSH-1.5
___ 09:32AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 10:15PM BLOOD CRP-41.0*
___ 10:15PM BLOOD Lactate-1.7
Brief Hospital Course:
SUMMARY/ASSESSMENT:
___ yo M PMHx HTN who presented with L elbow pain and swelling,
found to have acute gout flare, as well as CBC showing
erythrocytosis, thrombosis and leukocytosis consistent with new
diagnosis of polycythemia ___.
ACUTE/ACTIVE PROBLEMS:
# L ELBOW ERYTHEMA AND PAIN
# ACUTE GOUT FLARE:
The patient was seen by orthopedic surgery in the ED. He
underwent left elbow joint tap which showed only PMNs and no
organisms on gram stain. Joint cultures negative to date.
Joint fluid did reveal negatively birefringement monosodium
urate crystals consistent with gout flare. He was seen by
Rhematology in consultation. He was treated with Colchicine
0.6mg PO daily and Indomethacin 50mg PO TID x 3 doses on ___.
He continues on colchicine at discharge. He is scheduled to
follow-up with Rhematology for consideration of uric acid
lowering therapy in the future.
#LEUKOCYTOSIS/ERYTHROCYTOSIS/THROMBOCYTOSIS
#NIGHT SWEATS
#FATIGUE
#BLEEDING GUMS
#COAGULOPATHY
Lab findings are most consistent with Polycythemia ___. The
Hematology Oncology consult team saw him and recommended
checking serum erythropoietin (EPO) levels. He had normal iron
studies. Hematology said peripheral blood mutation screening for
JAK2 will be sent as an outpatient. Given patients CBC findings
and symptoms consistent with polycythemia, he received
phlebotomy in the ER on ___ and on the floor on ___ & ___
to achieve a hematocrit < 55%. He was started on Aspirin 81mg
PO daily and should continue this indefinitely. He understands
the rationale for taking this medicine. He does not smoke and
understands that he is not supposed to smoke, especially with
PCV. He had no evidence of tumor lysis. He is scheduled to
follow-up with Hematology Oncology for further work-up and
treatments.
#CHEST PAIN: Had an episode of chest pain while in hospital.
___ have been secondary to hyperviscosity syndrome. Cardiac
enzymes and EKG did not show any evidence of ischemia; CXR
showed atelectasis. He had normal Hb A1C and total cholesterol
of 161 with TSH 1.5.
#HTN: continued home losartan
TRANSITIONAL ISSUES:
[] Repeat CBC weekly to follow blood counts
[] Ensure patient scheduled for weekly phlebotomy to achieve Hct
< 55%
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h PRN Disp
#*240 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
3. Colchicine 0.6 mg PO DAILY
RX *colchicine 0.6 mg 1 tablet(s) by mouth once a day Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute gout flare
Polycythemia ___
___ Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with left elbow pain. You were found
to have a gout flare in the elbow. You were treated with a
medication called colchicine. You should continue to take
cholchicine daily to reduce the change of having another gout
flare.
While in the hospital, you were noted to have elevated blood
counts - elevation seen in the white blood cell counts, red
blood cell counts and platelets. This is consistent with a
diagnosis of Polycythemia ___, a blood disorder. You were seen
by the Hematology Oncology Specialists for this problem. You
were started on a daily aspirin to reduce your risk of stroke.
Please continue to take aspirin and colchicine daily. Please
take Tylenol and oxycodone only as needed for pain. Oxycodone
can be sedating. Do not take this medication before driving and
do not take with alcohol. Use sparingly.
Please follow-up with the Rheumatology doctors for further
treatment of your gout. Please follow-up with the Hematology
Oncology doctors for further treatment of your Polycythemia ___
blood disorder. Please follow-up with your Primary Care doctor
for further monitoring.
Followup Instructions:
___
|
19898828-DS-9 | 19,898,828 | 22,869,649 | DS | 9 | 2148-10-22 00:00:00 | 2148-10-22 17:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
salmon oil
Attending: ___
Chief Complaint:
Abdominal pain, nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old male with past medical history significant for
pre-diabetes who presents as a transfer from ___
after multiple episodes of N/V in the past 24 hours with labs
concerning for DKA.
Patient has been experiencing weakness over the last 2 weeks in
addition to an unintentional 20 pound weight loss (175-159) as
well as associated increased thirst, frequent urination, and
blurry vision. On the day prior to admission he began
experiencing abdominal discomfort and nausea/vomiting. This
morning he noticed blood in the emesis (about 1 oz) and it
prompted him to go to ___. At ___
he was noted to have a blood glucose of 360, leukocytosis to 19,
VBG of 7.15/32, and anion gap metabolic acidosis, He also had
a CTAP which was unremarkable. He was started on an insulin
drip, given Zofran, morphine, and 2L NS. His last episode of
emesis was about 9 AM this morning at ___ prior to
receiving his second dose of Zofran.
Patient denies any recent fevers, chills, sick contacts, travel,
URI symptoms, chest pain, palpitations, dyspnea, abdominal pain,
dysuria, rashes.
In the ED, initial VS were: Temp 99 BP 151/95 HR 120 RR 16 100%
RA
Patient was given:
-IV Insulin Drip started at 2 units/hr
-1 liter NS bolus
-D5NS + 40 mEq K @ 250 cc/hr
Labs significant for:
1) WBC 19.8 (88.7% N) Hgb 15.7 Hct 47.1 Plt 271
2) 142 110 9
===========<196 AG: 25
3.7 7 0.9
3) Calcium 8.1 Mag 1.4 Phos 2.5
4) VBG 7.18/26; lactate 1.4
5) Lipase 23; AST 10 ALT 23 Alk phos 103 T bili 0.2
Imaging notable for:
CXR ___: Lungs are fully expanded and clear.
Cardiomediastinal and hilar silhouettes and pleural margins are
normal.
VS prior to transfer: BP 132/71 HR 116 RR 21 100% RA
On arrival to the FICU, patient was tachycardic to the 110s,
afebrile, BP 132/65, RR 16, 94% RA. His abdominal pain and N/V
were improved.
Past Medical History:
-Pre-diabetes
-Seasonal allergies
Social History:
___
Family History:
-Father: DM ___ grandmother DM ___
-Several family members on father's side with vitiligo
-No other known autoimmune conditions
Physical Exam:
ADMISSION EXAM:
=================
VITALS: Reviewed in metavision
GENERAL: Young male, fit, appears stated age, no acute distress
HEENT: Sclera anicteric, oropharynx clear, dry mucous membranes
NECK: supple, JVP not elevated, no LAD, no thyromegaly
LUNGS: CTAB, no wheezes, crackles, 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 and well perfused
NEURO: No focal deficits
DISCHARGE EXAM:
=================
VITALS: Afebrile, HDS
GENERAL: Young male, fit, appears stated age, no acute distress
HEENT: Sclera anicteric, oropharynx clear, dry mucous membranes
NECK: supple, JVP not elevated, no LAD, no thyromegaly
LUNGS: CTAB, no wheezes, crackles, 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 and well perfused
NEURO: No focal deficits
Pertinent Results:
ADMISSION LABS
=================
___ 11:40AM WBC-19.8* RBC-5.26 HGB-15.7 HCT-47.1 MCV-90
MCH-29.8 MCHC-33.3 RDW-13.0 RDWSD-42.4
___ 11:40AM NEUTS-88.7* LYMPHS-6.3* MONOS-3.8* EOS-0.0*
BASOS-0.4 IM ___ AbsNeut-17.58* AbsLymp-1.24 AbsMono-0.76
AbsEos-0.00* AbsBaso-0.07
___ 11:40AM PLT COUNT-271
___ 11:40AM ALBUMIN-4.4 CALCIUM-8.1* PHOSPHATE-2.5*
MAGNESIUM-1.4*
___ 11:40AM LIPASE-23
___ 11:40AM ALT(SGPT)-23 AST(SGOT)-10 ALK PHOS-103 TOT
BILI-0.2
___ 11:40AM GLUCOSE-196* UREA N-9 CREAT-0.9 SODIUM-142
POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-7* ANION GAP-25*
___ 11:46AM LACTATE-1.4
___ 11:46AM ___ PO2-43* PCO2-26* PH-7.18* TOTAL
CO2-10* BASE XS--18
___ 01:30PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-30*
GLUCOSE-1000* KETONE-150* BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 05:07PM %HbA1c-12.1* eAG-301*
Brief Hospital Course:
Mr. ___ is a ___ year-old male with past medical history
significant for pre-diabetes who presents as a transfer after
multiple episodes of nausea and vomiting for one day, concerning
for DKA.
#Mixed anion gap non-anion gap metabolic acidosis
#Abdominal pain/nausea and vomiting
#Ketonuria
#Leukocytosis
Patient has a history of "pre-diabetes" and presented with
metabolic acidosis- anion gap related to DKA and non-anion gap
related to fluid resuscitation. Given his young age, acutely
elevated Hgb A1c to 12.1, and concurrent vitiligo, his
presentation was concerning for late onset diabetes.
Beta-hydroxybutyrate and gad65/c-peptide/ia-2 antibody were
sent. Infectious workup was negative. He was maintained on
insulin drip on presentation and transitioned to subcutaneous
insulin on the morning on ___. He was tolerating a regular
diet without any issues. He will need to be discharged with
insulin. His curent insulin regimen is: Lantus 20U qAM + 6U
Humalog before breakfast/lunch, 8U before dinner + SSI 1:25,
starting at 150, 2U with 1-unit increments, and starting 200 at
bedtime. Transitional issues include ensuring that CM reaches
out to insurance to cover insulin as well as insulin education.
#Hematemesis: Patient has likely ___ tear in the
setting of recurrent emesis. Emesis has since resolved. There
was no evidence of pneumomediastium, free peritoneal air, or
subcutaeneous emphysema on CXR. It could also be related to
ongoing cannabis use with hyperemesis syndrome.
#Tachycardia
Likely related to volume depletion from osmotic diuresis.
Resolved with fluids.
CHRONIC ISSUES:
===============
#Vitiligo
#Seasonal allergies: Loratadine prn
TRANSITIONAL ISSUES:
====================
[]f/u c-peptide, anti-GAD, ia-2 Ab, TSH
[]Per ___, Lantus 18U qAM + 6U Humalog qAC pre
breakfast/lunch, 8U AC pre lunch + SSI 1:25, starting at 150, 2U
with 1-unit increments, and starting 200 at bedtime.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Loratadine 10 mg PO DAILY seasonal allergies
Discharge Medications:
1. BD Ultra-Fine Nano Pen Needle (pen needle, diabetic) 32
gauge x ___ SQ x5
5x daily
RX *pen needle, diabetic [BD Ultra-Fine Nano Pen Needle] 32
gauge X ___ Use to inject insulin up to 5times daily ACHS Disp
#*100 Box Refills:*2
2. Glargine 20 Units Breakfast
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [OneTouch Verio] Check BG 4x/day
Disp #*100 Strip Refills:*2
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) AS DIR 20 Units before BKFT; Disp #*2 Syringe Refills:*2
RX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR
6U baseline w/ breakfast/lunch, 8U baseline w/ dinner, 0U
baseline beore bedtime, w/ sliding scale Disp #*2 Syringe
Refills:*2
RX *lancets [OneTouch Delica Lancets] 30 gauge check BG 4x/day
Disp #*100 Each Refills:*2
RX *lancets [OneTouch Delica Lancets] 33 gauge check BG 4x/day
Disp #*100 Each Refills:*2
3. urine glucose-ketones test 1 each miscellaneous X2 PRN
RX *urine glucose-ketones test check after two high BG twice a
day Disp #*30 Strip Refills:*0
4. Loratadine 10 mg PO DAILY seasonal allergies
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
Type 1 diabetes mellitus
Discharge Condition:
Discharge conditionstable
Mental statusalert and oriented x3
Ambulatory
Discharge Instructions:
You were admitted to the hospital for new onset type 1 diabetes
and diabetic ketoacidosis [a complication of diabetes]. You
were admitted to the ICU for continuous insulin infusion and
close glucose monitoring. Your blood glucose level and your
electrolyte imbalances normalized and your transfer to the
general medicine floors. You are followed by endocrinologist
from ___ ___ the entire time you were
hospitalized.
Please refer to your discharge medication list regarding your
ongoing insulin regimen. You should follow-up with ___
___ after your discharge from the hospital.
Followup Instructions:
___
|
19899101-DS-22 | 19,899,101 | 23,568,631 | DS | 22 | 2126-10-30 00:00:00 | 2126-10-30 09:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right sided cp/SOB
Major Surgical or Invasive Procedure:
___
VATS right upper lobe apical blebectomy and mechanical and
chemical pleurodesis.
History of Present Illness:
Mr. ___ is a ___ with a PMH pertinent for spontaneous L PTX
s/p
VATS blebectomy, mechanical and chemical pleurodesis in
___ now p/w a new spontaneous R PTX. Patient was having sexual
intercourse with his girlfriend last night at midnight when he
had sudden onset of upper R chest pain, ___ in severity,
nonradiating, which he describes as "dull pressure", neither
provoked or palliated by any known stimuli. Subsequently patient
found it difficult to breath upon exertion and had some SOB even
at rest. When symptoms did not abate, he presented to the
emergency department where a CXR was taken that demonstrated a
moderate R apical PTX with his lung deflated to the level of the
fourth intercostal space.
Notably the patient was seen in ___ for a spontaneous
pneumothorax on the L side. This was initially managed
conservatively with placement of a chest tube, resolved, and the
patient was discharged to home shortly after. He returned to
clinic ___ and was found to have a recurrent PTX c/f
tension physiology, and so was admitted from clinic and taken
for
a L VATS blebectomy with mechanical and chemical pleurodesis. He
had one subsequent follow-up appointment after being discharged
for that hospitalization where he was noted to have no residual
PTX. Since that time he has had no episodes of chest pain or
SOB
until this one. On ROS he denies fever, chills, fatigue,
hemoptysis, or palpitatations. He also notes that until 3 days
ago he was not taking his levothyroxine, and while he has now
recently started taking his medication again his dosage and
prescription are out of date.
Past Medical History:
Hypothyroidism
Asthma
Social History:
___
Family History:
non-contributory
Physical Exam:
Temp: 98.1 HR: 76 BP: 126/74 RR: 18 O2 Sat: 99% RA
GENERAL
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY
[x] CTA/P [x] Excursion normal [x] No fremitus
[x] No egophony [x] No spine/CVAT
[ ] Abnormal findings:
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [ ] Abnormal findings:
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl [x] Axillary nl
[x] Inguinal nl [ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ 01:50AM WBC-7.9 RBC-4.63 HGB-13.7 HCT-41.3 MCV-89
MCH-29.6 MCHC-33.2 RDW-12.6 RDWSD-41.1
___ 01:50AM GLUCOSE-101* UREA N-19 CREAT-0.9 SODIUM-136
POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-21* ANION GAP-19
___ CXR :
Small right apical pneumothorax, minimally increased in size
compared to the previous study.
Brief Hospital Course:
___ was evaluated by the Thoracic Surgery service in the
Emergency Room and admitted to the hospital for further
management of his right pneumothorax. He was followed
clinically and with serial chest xrays and given his prior
history of a pneumothorax on the left side, surgery was
recommended.
He was taken to the Operating Room on ___ and underwent a
VATS right upper lobe apical blebectomy and mechanical and
chemical pleurodesis. He tolerated the procedure well and
returned to the PACU in stable condition. He maintained stable
hemodynamics and his pain was controlled with a Dilaudid PCA.
His chest tube was on suction and had no air leak. His chest
xray showed almost full expansion of the right lung.
Following transfer to the Surgical floor he continued to
progress well. His chest tube was removed on ___ after a
successful waterseal trial and his post pull chest xray revealed
a stable right apical space. His port sites were healing well
and his pain medication was changed to Oxycodone which was
effective. He was up and walking independently and his room air
oxygen saturations were 96%. He was discharged to home on
___ and will follow up with Dr. ___ in 2 weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Acetaminophen 1000 mg PO Q8H pain
RX *acetaminophen 325 mg 3 tablet(s) by mouth every eight (8)
hours Disp #*100 Tablet Refills:*3
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
5. Milk of Magnesia 30 mL PO Q12H:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Right spontaneous pneumothorax.
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 a collapsed lung and
required surgery. You've recovered well and are now ready for
discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours in between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other
symptoms that concern you.
Followup Instructions:
___
|
19899194-DS-24 | 19,899,194 | 27,175,397 | DS | 24 | 2156-02-19 00:00:00 | 2156-02-19 16:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors / tamsulosin
Attending: ___.
Chief Complaint:
Fatigue, DOE
Major Surgical or Invasive Procedure:
Cardioversion ___
History of Present Illness:
___ y/o male with hx of CAD s/p CABG, a-fb, CHF, biventricular
ICD on Xarelto presents to the ED with presyncope without
palpitations or chest pain and new onset melena. No abdominal
pain or fever.
Of note, the patient was recently admitted and discharged from
___ for a one week stay d/t orthostasis. Per the discharging
team, the while the patient has had long standing orthostasis,
particularly when walking up stairs, this was noted to be acute
worse more recently. He initially presented to ___ on
___ w c/f DOE and left sided chest sensation of thumping. EP
interrogated device on ___ and found to have chest wall
capture, otherwise functioning normally. Polarity changed from
LV tip-RV to LV ring-RV with improvement of thumping sensation.
___ nuclear stress test showed reversal apical
anterolateral wall ischemia, EF 50%, old IMI and inferoseptal
hypokinesis. Taken to cath lab on ___ and found to have CTO of
RCA. No intervention taken at that time, but to consider
treatment at a later date if continued to have symptoms.
Discharged on ___.
Less than 24 hours later patient had PCP follow up. ___ note,
his PCP note makes mention of significant weight loss of unclear
etiology. CT scan of chest with questionable GGO requiring 3
month follow up. He also had outpatient evaluation for
intermittent hemoptysis, however outpatient eval by ENT and
bronch were negative. Given persistent dizziness, patient
readmitted to cardiac DACU.
In DACU, was noted to have significant DOE when walking short
distances on flat surfaces as well as going up a flight of
stairs. He felt significantly impaired. Review of inpatient
vital sheets reveal 20 SBP drop orthostasis during
hospitalization. Repeat TTE ___ similar to that from ___.
Given fleeting nature of DOE, EP c/s for cardioversion as pAF
thought to be contributing. Underwent DCCV on ___, with
successful cardioversion. Pt also increased amiodarone, stopped
Lasix and received fluid bolus through this hospitalization. Pt
discharged on ___.
On ___ ___ called CNP office to review that patient felt light
headed today with headache that started earlier in the day.
Orthostatics at home 92/58 --> 80/50. Patient had dosed
valsartan 40 night prior. Given 500cc bolus and told to decrease
valsaratan to 20mg.
Follow up with OP cardiology on ___ with improved sx, back to
baseline functional status, although notes that he complained of
persistent dizziness, and BP log with ongoing orthostatis and
low-normal blood pressures. BP 114/57, no orthostatics taken at
that time. Advised to stop valsartan.
On ___, remote transmission noted that the patient had gone
back into pAF. ___ also called to inform that patient's
orthostasis acutely worsening complaining of LH with any
movement. Pt self-reported black stools, and diarrhea with black
stook. Orthowstatics 110/58 -->100/58. Sent to ED for
evaluation.
In the ED, initial vitals were: 97.5 76 106/54 18 98% RA
Exam notable for no abdominal pain, + hemoccult, melenotic
stools
Labs showed H/H 13.0/40.7; INR 1.7. HypoNa 127, BUN/Cr ___
Imaging showed CXR neg for acute process
Received 40 IV PPI
Transfer VS were 98.1 69 105/54 16 98%RA
Decision was made to admit to medicine for further management.
On arrival to the floor, patient confirms the above. Timeline
of last two days:
___ --felt well, baseline. Went shopping with wife. At 6pm
"like bang" felt acute onset fatigue, exhaustion, DOE,
dizziness. At ___ noted stools were black but formed. Went to
sleep
___: noted black diarrhea "all over the toilet." Notified
___. At noon had another black BM, "more watery." Denies overt
BRBPR.
Feels well at rest, but with minimal exertion feels headache,
dizziness and exhaustion exactly the same as prior episodes.
States "I can't live like this." Has not had a repeat BM since
noon. Also notes that this most recent hospitalization is where
he learned he was back to being in atrial fibrillation.
Review of systems:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
ATRIAL FIBRILLATION
CHRONIC KIDNEY DISEASE
CONGESTIVE HEART FAILURE
CORONARY ARTERY DISEASE
DIZZINESS
DYSPNEA ON EXERTION
HEADACHE
HEMATURIA
HYPERLIPIDEMIA
HYPERTENSION
HYPOTESTOSTERONISM
SINUSITIS
SLEEP APNEA
CARPAL TUNNEL SYNDROME
THYROID NODULE
SHOULDER PAIN
PERIODIC LIMB MOVEMENT
IMPLANTED CARDIAC DEFIBRILLATOR
OSTEOARTHRITIS
SKIN CHECK
HEMOPTYSIS
PULMONARY NODULE
H/O DEEP VENOUS THROMBOPHLEBITIS
H/O PITUITARY ADENOMA
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
- Father died of MI at age ___.
- Mother without cardiac history.
- Sister died of lymphoma.
- Another sister died of lymphoma.
- Brother died of lymphoma at age ___.
- Another brother died of stomach cancer at age ___.
- Brother died of bone cancer.
- Another brother throat cancer.
Physical Exam:
ADMISSION EXAM:
Vital Signs: 97.9 PO 123 / 71 71 18 97 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding . rectal exam deferred
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 EXAM:
VS - 97.6PO 108 / 66 70 18 96 RA
General: well appearing, NAD
HEENT: MMM, EOMI
Neck: no JVD, no LAD
CV: rrr, no m/r/g
Lungs: CTAB, breathing comfortably
Abdomen: soft, nontender, nondistended, no HSM appreciated
GU: deferred
Ext: warm and well perfused, pulses, no edema
Neuro: grossly normal
Pertinent Results:
ADMISSION LABS:
___ 01:35PM ___ PTT-27.5 ___
___ 01:35PM PLT COUNT-153
___ 01:35PM NEUTS-43.6 ___ MONOS-15.8* EOS-2.8
BASOS-0.5 IM ___ AbsNeut-1.75 AbsLymp-1.48 AbsMono-0.63
AbsEos-0.11 AbsBaso-0.02
___ 01:35PM WBC-4.0 RBC-4.37* HGB-13.0* HCT-40.4 MCV-92
MCH-29.7 MCHC-32.2 RDW-14.6 RDWSD-49.7*
___ 01:35PM ALBUMIN-3.8 CALCIUM-8.7 PHOSPHATE-4.6*
MAGNESIUM-2.4
___ 01:35PM proBNP-6201*
___ 01:35PM cTropnT-<0.01
___ 01:35PM ALT(SGPT)-26 AST(SGOT)-57* ALK PHOS-67 TOT
BILI-0.3
___ 01:35PM GLUCOSE-95 UREA N-22* CREAT-1.4* SODIUM-127*
POTASSIUM-5.6* CHLORIDE-93* TOTAL CO2-20* ANION GAP-20
___ 01:57PM LACTATE-2.0 K+-4.8
CXR ___
No acute cardiopulmonary process.
DISCHARGE LABS:
___ 08:14AM BLOOD WBC-4.7 RBC-4.23* Hgb-12.4* Hct-38.7*
MCV-92 MCH-29.3 MCHC-32.0 RDW-14.8 RDWSD-49.8* Plt ___
___ 08:14AM BLOOD Plt ___
___ 08:14AM BLOOD Glucose-91 UreaN-24* Creat-1.3* Na-136
K-4.3 Cl-100 HCO3-23 AnGap-17
___ 07:40AM BLOOD proBNP-2481*
Brief Hospital Course:
___ year old man with a history of CAD, AF and systolic HF who
presents with recurrent dyspnea, lightheadedness and headache,
thought to be due to symptomatic atrial fibrillation, now s/p
DVVC.
#Dyspnea/Lightheadedness/orthostasis: Appears symptoms most
likely related to being back in atrial fibrillation. Likely
dependent on atrial kick. H/H stable, sx unlikely to be d/t
anemia. Consulted EP who took patient for cardioversion on
___. Also recommended reloading the patient on amiodarone - 400
BID x 7 days starting ___ followed by 400 daily x 7 days and
then 200 daily ongoing. He will follow up with Dr. ___ in
Cardiology in 1 month. Baseline TFTs and LFTs were collected
inpatient given amiodarone load and will be followed up by Dr.
___ cardiology consult recommendations.
#AF s/p DCCV ___: reverted back to afib on admission. Continue
on Rivaroxaban. EP and amiodarone as above
#FULL CODE
========================
TRANSITIONAL ISSUES
[ ] Amiodarone as follows: 400 BID x 7 days (___) followed
by 400 daily x 7 days (___) and then 200 daily ongoing. He
was provided with a prescription for his amidarone BID through
___ and daily ___
[ ] Needs prescription for amiodarone 200 daily ___ ongoing
[ ] Baseline TFTs and LFTs collected and pending upon discharge.
To be followed up by cardiology
[ ] Pt reported dark stools, however, appeared dark green to
medical providers with stable CBC; please consider repeat CBC in
1 week and further outpatient workup as necessary
[ ] Blood cultures pending at the time of discharge
[ ] Follow up with Dr. ___ in cardiology for consideration of
PVI if recurrent afib.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Levothyroxine Sodium 88 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Rivaroxaban 20 mg PO DINNER
7. Rosuvastatin Calcium 20 mg PO QPM
8. Ferrous Sulfate 325 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN CP
10. testosterone 40.5 mg topical DAILY
11. Vitamin B Complex 1 CAP PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Amiodarone 400 mg PO BID Duration: 11 Doses
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*11
Tablet Refills:*0
RX *amiodarone 400 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
2. Aspirin 81 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN CP
8. Rivaroxaban 20 mg PO DINNER
9. Rosuvastatin Calcium 20 mg PO QPM
10. testosterone 40.5 mg topical DAILY
11. Vitamin B Complex 1 CAP PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Atrial fibrillation
Anemia
Secondary diagnoses:
Chronic Systolic/Diastolic Heart Failure
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___
___.
Why did I have to stay in the hospital?
You had to stay in the hospital because of fatigue and atrial
fibrillation.
What was done for me?
You were seen by the cardiologists (electrophysiology) who
interrogated your pacemaker and also cardioverted you so that
you would not be atrial fibrillation anymore. Your medications
were also adjusted.
What should I do after I leave the hospital?
You should follow up with your cardiologist.
You should follow up with your regular doctor.
You should take your medications as prescribed.
Please weigh yourself every morning, and call your doctor if
weight goes up more than 3 lbs.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19899252-DS-17 | 19,899,252 | 27,406,381 | DS | 17 | 2112-04-15 00:00:00 | 2112-04-15 14:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left knee pain s/p AVR (25 mm ___ bioprosthetic), CABG x2
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo male with pmh of CAD/RCA ___, syncope, chronic
atrial fibrillation, and known aortic stenosis s/p CABG x2 and
tissue AVR on ___ (see OP note for complete details). Was
discharged to rehab on ___,
and recovering well with variable INR levels. Seen in wound
clinic ___ for right leg EVH site seroma (of note, OP note
incorrectly lists LEFT leg as vein harvest leg), which had been
slowly improving with ACE wraps and elevation. He has been
compliant with all medicines and walking 15minutes daily without
problems. Was due to see Dr. ___ postop visit today.
Last night at 10pm, lying in bed, he had acute onset severe
___ left knee pain. He took 50mg Ultram and 50mg trazodone,
and slept. This morning, he had severe left knee pain that
limited his mobility. He took his medications, became
nauseated, and then went to local urgent care clinic. One
episode N/V there, and
was sent to ___ ER for concern of septic arthritis. No fever,
chills, diaphoresis, palpitations, dyspnea, or abdominal pain
complaints.
Hemodynamically stable in ER. Afebrile with normal WBC.
Orthopedic evaluation in progress.
Past Medical History:
PMH: Coronary Artery Disease status post LAD Cypher stenting,
PTCA first diagonal, ___
Hypertension
Hypercholesterolemia
Atrial fibrillation
Aortic Stenosis
Basal Cell Carcinoma
Squamous Cell Carcinoma
Diverticulosis
Type 2 diabetes (diet control)
Colon Polyps
Macular degeneration
PSH:
L1-L4 Laminectomy ___
Right Knee Replacement
Partial Thyroidectomy
Mohs Procedure
Left foot surgery
Bilateral cataracts
Social History:
___
Family History:
Father died of MI at age ___
Physical Exam:
General: Weight changes
Skin: Eczema [] Psoriasis [] Skin Cancer [x] Basal cell
CA/Squamous Cell CA s/p Mohs procedure Denies[]
HEENT: Hearing aide(s) [] Glasses [x] Denies[]
Respiratory: Asthma [] COPD [] Pneumonia [] ___
Sputum
[] Home Oxygen [] Denies []
Cardiac: Chest pain [] SOB [] DOE [] Orthopnea [] PND []
Syncope [] Arrythmia [] Atrial fibrillation: chronic[x]
Persistent[] Denies []
GI: Nausea [x] Vomiting [x] Diarrhea [] Constipation: BM every
___, last yesterday [x]
Heartburn/GERD [] Liver disease [] Denies [x]
GU: Dysuria [] Frequency [] Prostate [] GYN [] Denies [x]
Musculoskeletal: acute right knee pain, Arthritis [x] hands,
feet, back and wrist. painless left knee seroma at EVH
site[x],(preop): Left ankle with chronic edema, Denies []
Peripheral Vascular: Claudication [] Varicose vein
disease/surgery/injections [] Denies [x]
Psych: insomnia since d/c [x] anxiety [] depression [] Denies
[x]
Endocrine: Diabetes [x] thyroid [] denies [x]
Oncology: Denies[x]
Hematology: subtherapeutic INR, on lovenox ___, then
supratherapeutic (3.5 on ___: no coumadin, 3.7 on ___: 1mg
coumadin), managed by ___. ___
ID: Denies [x]
Neuro: TIA [] CVA [] Neuropathy [] Seizures [] Other:
(preop)left leg with pain every am and resolves on its own after
he is out of bed and walking, Denies[]
Pertinent Results:
___ 06:15AM BLOOD WBC-11.9* RBC-3.99* Hgb-13.8* Hct-38.8*
MCV-97 MCH-34.6* MCHC-35.6* RDW-12.2 Plt ___
___ 06:15AM BLOOD ___
___ 06:15AM BLOOD Glucose-200* UreaN-38* Creat-1.2 Na-133
K-4.2 Cl-91* HCO3-32 AnGap-14
___ 06:15AM BLOOD ALT-35 AST-54* AlkPhos-126 Amylase-12
JOINT FLUID ANALYSIS WBC RBC Polys Lymphs Monos
___ 10:35 ___ 92*1 0 8
Source: Knee
REVIEWED BY ___ ___
JOINT FLUID Crystal
___ 10:35 NONE
Source: Knee
Brief Hospital Course:
Mr. ___ was admitted from home for left knee pain-not his
harvest leg. Of note he was being followed by Csurg for a seroma
on his vein harvest leg, on his right knee. On admission he had
an INR of 4.2. He takes coumadin for chronic atrial
fibrillation, which was held throughout his stay while the INR
drifted down to a low of 3.3 at discharge. The left knee was
aspirated by the orthopedic service and the fluid was found to
be negative for bacteria. He was advised to follow-up with the
orthopedic trauma clinic if his pain continues beyond two weeks.
During his stay he also developed pseudo-gout of the left ankle
and was seen by rheumatology. They recommended a prednisone
taper, which he will continue for six days after discharge. He
is a diet controlled diabetic normally, but his glucose levels
had been trending in the 200s to 300s since the initiation of
steroids. Due to the short course of his steroids, Dr. ___
___ the rheumatology service felt it was safer not to discharge
Mr. ___ with glucose-lowering agents. On hospital day five he
was discharged to home with visiting nursing and home physical
therapy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Psyllium 1 PKT PO DAILY
6. Simvastatin 20 mg PO DAILY
___ MD to order daily dose PO DAILY
8. Metoprolol Tartrate 75 mg PO TID
9. Polyethylene Glycol 17 g PO DAILY
10. Ranitidine 150 mg PO BID
11. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
12. Warfarin 2 mg PO DAILY16
13. Furosemide 20 mg PO BID
14. Potassium Chloride 20 mEq PO BID
Discharge Medications:
1. Psyllium 1 PKT PO DAILY
2. Simvastatin 20 mg PO DAILY
3. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol [Ultram] 50 mg one tablet(s) by mouth every six
hours Disp #*40 Tablet Refills:*0
4. Aspirin EC 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Acetaminophen 650 mg PO Q6H:PRN pain, T>38.5C
7. Metoprolol Tartrate 50 mg PO TID
RX *metoprolol tartrate [Lopressor] 50 mg one tablet(s) by mouth
three times daily Disp #*90 Tablet Refills:*2
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
___ MD to order daily dose PO DAILY
10. Warfarin 0.5 mg PO ONCE Duration: 1 Dose
do not take coumadin on ___. The ___ will dose
your coumadin thereafter
RX *warfarin [Coumadin] 1 mg 0.5 (One half) tablet(s) by mouth
once Disp #*30 Tablet Refills:*2
11. PredniSONE 20 mg PO DAILY Duration: 3 Days
Tapered dose - DOWN
RX *prednisone 20 mg one tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
12. PredniSONE 10 mg PO DAILY Duration: 3 Days
start this dose after finishing the prednisone 20mg daily dosing
Tapered dose - DOWN
RX *prednisone 10 mg one tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left knee hemearthritis
left ankle pseudo-gout
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
19899324-DS-20 | 19,899,324 | 26,170,092 | DS | 20 | 2166-10-09 00:00:00 | 2167-01-28 14:51:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Spastic paraplegia
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Ms. ___ is a ___ F recent immigrant from ___ who has a
paraplegia of no known etiology which has progressed over the
last ___ years who now presents with 3 days of abdominal pain
with nausea and vomitting.
While still living in ___ in ___ Ms. ___
reports first experiencing pain her sole of first her right foot
and, months later, extending to her left foot. The pain moved
proximally up her legs; by ___ it has extended to the knees
and by ___ to the hips and waist. The pain did not extend
beyond her wasit. By the end of ___, the pain worsened and she
had difficulty walking. She was not walking in ___. Pain
has been increasing, causing her legs to feel "tighter and
tighter" per Neuro, which causes significant pain when moved as
well as painful "spasms." Pain would sometimes extend to the
lower abdomen. Mrs. ___ began to experience bowel and
bladder incontinence in ___. She currently wears a
diaper. Again per Neuro, in ___ her hips and legs "became
heavy" and she felt as though she was loosing strength.
Simultaniously she also began to feel numbness in her feet which
spread proximally, reaching the waist by ___.
Ms. ___ moved from ___ four weeks ago. She was
occasionally prescribed prednisone to Tx her paraplegia when she
had painful episodes. She reports the prednisone would help with
her rigidity but not with her pain. Ms. ___ paraplegia
was never diagnosed in ___. Pt. reports being in good health
prior to onset of paraplegia with no sickness precipitating or
occuring concurantly with the paraplegia.
Starting three days prior to admission Ms. ___ began
feeling an abdominal pain in her lower abdomen. This was similar
to previous episodes of abdominal pain. She vomitted and felt
nauseas. She denies diarrhea, bloody stool, fevers, chills.
In the ED, initial VS were Temp 97.8, HR 107, BP 146/98, RR 18,
P02 100%.
-Exam notable for a mildly tender abdomen in lower quadrants, no
guarding. Numbness to light touch noted b/l ___, strength ___ b/l
___, ___ UE, ___ rigid b/l. A pelvic exam could not be performed
in the ED due to ___ rigidity. Rectal exam showed brown stool,
hemoccult negative.
-Labs noteable for WBC 10.2 (41.9% lymph), Hgb 11.1, MCV 91,
HCO3 20, lactate 2.2, wnl liver enzymes, HGC <5.
-Imaging: the only acute abdominal process on CT Abd & Pelvis w/
contrast was "a large amount of simple fluid distending the
vagina" and radiology recommended a correlation with direct
pelvic exam.
Mrs. ___ received 2000mL NS IVF and 5mg morphine IV. Neuro
was consulted. A decision was made to admit to medicine for
further management.
On arrival to the floor, patient reports feeling well. She is
with two family members. She sometimes experiences shortness of
breath during prior similar painful episodes, however she denies
SOB.
Past Medical History:
Spastic Paraplegia
Social History:
___
Family History:
Patient reports that father and siblings are all in good health.
Her mother had HTN and diabetes.
Physical Exam:
===============
ADMISSION EXAM:
===============
VS - T 98.2, 150/96, 110, RR 20, O2 100% on RA
GENERAL: NAD, comfortable in bed
HEENT: AT/NC, EOMI, PERRL, MMM
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, tender in lower abdomen - pain did
not increase with palpation, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing. Not moving lower extremities
w/ rigidity resisting movement
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact bilaterally, though possible nystagmus.
Greatly diminished sensation of feet and legs bilaterally.
Upward Babinski sign bilaterally. ___ strength in feet and legs.
Legs rigid and unmovable on exam. Sustained clonus in both
ankles without extinction. +4 reflexes in lower extremities
bilaterally. +3 reflexes in upper extremities bilaterally. ___
strength in upper extremities in all modalities tested. Upper
extremity sensation WNL in B/L UEs.
===============
DISCHARGE EXAM:
===============
PHYSICAL EXAMINATION:
GEN - speaks ___ Creole, pleasant and cooperative
HEENT - NC/AT, MMM, mild injection of L eye
NECK - full ROM, supple
CV - RRR
RESP - normal WOB
ABD - obese, soft
NEUROLOGICAL EXAMINATION
Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and
comprehension. Normal prosody. Able to follow both midline and
appendicular commands.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline.
-Motor: Normal bulk throughout. Significantly increased lower
extremity tone bilaterally with extremities held in stiff
extension. No pronator drift bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 0 0 0 0 0 0 0
R 5 ___ ___ 0 0 0 0 0 0 0
She requires assistance to lift her torso but can remain seated
without assistance.
Rectal tone (done ___- sphincter is open and does not
constrict with insertion of finger and patient cannot constrict
sphincter voluntarily.
-Sensory: Significantly diminished (but still partially intact
sensation) to light touch, temperature, vibration from feet to
T10 dermatome anteriorly (at the level of the umbilicus), T10
dermatome on the back R and T6 dermatome on the back L. Severely
diminished proprioception on the LLE (JPS intact only at hip)
with JPS intact with large amplitude movements at R toe.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 4 3, sustained clonus at ankle
R 2 2 2 4 3, 10 beats clonus at ankle
Plantar response was majestically up bilaterally.
Significant for brisk flexion at hip, knee, ankle at both legs
with some possible simultaneous adduction of the contralateral
leg with any sensory stimulation of the foot. No response to
thigh pinch.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally.
-Gait: Non-ambulatory
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 01:10PM PLT COUNT-293
___ 01:10PM NEUTS-47.2 ___ MONOS-9.0 EOS-1.3
BASOS-0.3 IM ___ AbsNeut-4.83 AbsLymp-4.28* AbsMono-0.92*
AbsEos-0.13 AbsBaso-0.03
___ 01:10PM WBC-10.2* RBC-3.80* HGB-11.1* HCT-34.6 MCV-91
MCH-29.2 MCHC-32.1 RDW-14.5 RDWSD-47.8*
___ 01:10PM HCG-<5
___ 01:10PM calTIBC-293 FERRITIN-117 TRF-225
___ 01:10PM ALBUMIN-4.0 IRON-35
___ 01:10PM LIPASE-31
___ 01:10PM ALT(SGPT)-10 AST(SGOT)-21 ALK PHOS-78 TOT
BILI-0.2
___ 01:10PM estGFR-Using this
___ 01:10PM GLUCOSE-87 UREA N-9 CREAT-0.7 SODIUM-135
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-20* ANION GAP-19
___ 01:28PM LACTATE-2.2*
==================
PERTINENT RESULTS:
==================
___ 01:10PM BLOOD Neuts-47.2 ___ Monos-9.0 Eos-1.3
Baso-0.3 Im ___ AbsNeut-4.83 AbsLymp-4.28* AbsMono-0.92*
AbsEos-0.13 AbsBaso-0.03
___ 06:55AM BLOOD ALT-7 AST-17 LD(LDH)-225 AlkPhos-74
TotBili-0.2
___ 01:10PM BLOOD ALT-10 AST-21 AlkPhos-78 TotBili-0.2
___ 01:10PM BLOOD Lipase-31
___ 07:00AM BLOOD TotProt-7.5 Calcium-9.9 Phos-4.2 Mg-2.0
___ 06:55AM BLOOD VitB12-449 Folate-11.4
___ 01:10PM BLOOD calTIBC-293 Ferritn-117 TRF-225
___ 07:00AM BLOOD Prolact-33* TSH-2.8
___ 06:55AM BLOOD 25VitD-19*
___ 01:10PM BLOOD HCG-<5
___ 06:55AM BLOOD CRP-23.2*
___ 01:28PM BLOOD Lactate-2.2*
___ 6:55 am SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
Imaging:
CT Abdomen/Pelvis (___): IMPRESSION:
1. Large amount of simple fluid distending the vagina.
Correlation with
direct pelvic exam is recommended.
2. No other acute abdominal process.
MRI C/T/L-Spine (___): IMPRESSION:
1. 4.3 x 1.1cm homogeneously enhancing extradural spinal canal
mass extending from C7-T3, causing severe cord compression and
cord edema/contusion at these levels. There is also extension
into and obliteration of the left C7-T1 and T1-T2 neural
foramens. Its appearance, including partial encasement of the
cord, heavily favors lymphoma or leukemia. Meningioma is also on
the differential, although somewhat atypical in this case given
less avid enhancement compared to the surrounding meninges.
Neuroblastoma is unlikely in this age group.
2. Mild degenerative changes in the cervical and lumbar spine,
most prominent at L5-S1 where there is disc bulging/superimposed
central protrusion without critical spinal canal narrowing at
this level.
NOTIFICATION: Preliminary findings were telephoned to Dr. ___
___ by ___ on ___ at 12:59PM, at time of discovery.
CT Chest (___): IMPRESSION:
Minimal bilateral pleural effusion, probably not clinically
significant. No adenopathy or other evidence of intrathoracic
malignancy.
Cervicothoracic extradural spinal mass, better demonstrated on
MR, ___, reported separately.
CT C-Spine (___): IMPRESSION:
1. The previously described enhancing extradural spinal canal
mass extending from C7-T3 is essentially in visible on CT and is
better assessed on recent MR of the spine.
2. No osseous abnormality detected.
3. Degenerative disc disease with disc protrusion flattening the
spinal cord at C3-4.
MRI PItuitary (___): IMPRESSION:
Normal pituitary.
CT T-spine w/ contrast (___): IMPRESSION:
1. Severe spinal canal narrowing with spinal cord compression at
the T1-T2
vertebrae levels due to compression from recently discovered
mass.
2. Mild scalloping of the T1 vertebrae.
3. Normal alignment and no evidence of fractures.
Brief Hospital Course:
Ms. ___ is a ___ F ___ who immigrated
to the ___ approximately 1 month ago, who presents for
evaluation of a ___ year history of progressive spastic
paraplegia, with associated abdominal pain.
ACTIVE ISSUES:
#Paraplegia:
The patient presents with a ___ year history of worsening
bilateral lower extremity weakness, which has since gradually
progressed to spastic paraplegia. The patient remains in a
wheelchair or bedbound, with baseline incontinence of both urine
and stool. The patient had never received any neuraxial imaging
while in ___. Imaging upon admission was remarkable for a 4.3
x 1.1cm homogeneously enhancing extradural spinal canal mass
extending from C7-T3, compressing the spinal cord at those
levels. The differential diagnosis for the mass included
Schwannoma, meningioma, lymphoma, among others. Neurology,
Neurosurgery, and orthopedic spine services were consulted for
further evaluation and attempt to biopsy the lesion.
Hematology/oncology provided recommendations for further
evaluation and instructions regarding biopsy preparation for
pathology. The patient was transferred to the neurology service
for further evaluation. Attempt was made to coordinate a biopsy
of her spinal canal mass with Neurosurgery and Spine surgery in
a combined surgery, but the patient preferred to wait and make a
decision as an outpatient for biopsy and further management.
Baclofen was started prior to discharge for her spasticity.
#Abdominal pain:
The patient presented with a history of chronic abdominal pain,
which was worse when patient's lower extremity spasms worsened.
A CT abdomen/pelvis demonstrated simple fluid collection in the
vagina; hCG was negative. OB/GYN was consulted, and it was felt
that this fluid was not contributing to the patient's abdominal
pain, and that a speculum examination should be performed when
the patient's spasticity improves to the degree that examination
could be conducted. The patient's abdominal pain was attributed
to cervical/thoracic cord compression leading to spasticity of
the abdominal muscles. The patient's abdominal pain improved
throughout her hospital stay.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 (One)
powder(s) by mouth daily prn Refills:*2
2. Baclofen 10 mg PO TID
Take 1 tab three times a day.
RX *baclofen 10 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Spinal cord mass from C7-T3 levels, causing spastic paraplegia,
bowel and bladder incontinence, and loss of sensation
Amenorrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for paralysis of both your
legs, along with incontinence, and difficulty feeling your legs.
We performed imaging tests of your spine which showed a very
large mass that is pushing on your spinal cord, which is causing
your symptoms. The mass is concerning for a cancer, which is why
we recommended taking you to surgery to remove the mass for
biopsy. However you declined surgery at this time. You should
follow up in the Brain Tumor clinic to discuss further options
for care.
For your lower leg spasms, we started you on a medication called
baclofen. You can take 10mg three times a day for the first
week, then go up to 15mg three times a day after that.
For your amenorrhea (lack of menstrual periods), we performed an
MRI of your brain which was normal. To complete the remainder of
your workup, you should call the Obstetric/Gynecology clinic at
___ to arrange an appointment.
It was a pleasure taking care of you.
Sincerely,
Your ___ Team
Chè Madam ___,
___ admèt ___,
ansanm ak enkonvenyans, ak difikilte ___ fèt
tès ___ kolòn vètebral ___ ki ___ anpil ___ ki ap
pouse sou mwal epinyè ___ a, ki ___ sa ki lakòz sentòm ___ yo. ___
___ sou ___ kansè, ki ___ rekòmande ___
___ yo retire ___ refize
___ sa ___ ta dwe swiv ___
Timè ___ sèvo yo diskite sou plis opsyon ___ swen.
___ spasm pi ba janm ___ kòmanse ___ sou ___ yo
rele baklofèn. ___ ka ___ 10mg twa ___ premye semèn
___, Lè sa a, ___ al 15mg twa ___ sa.
___ a ___ de peryòd règ), ___ fè ___ MRI ___ sèvo
___ ki ___ nòmal. ___ w konplete rès ___ workup ___ ta dwe
rele Obstetrik / jinekoloji ___ ___ ___ fè
aranjman ___.
___ swen ___,
___ Ekip ___
Followup Instructions:
___
|
19899743-DS-20 | 19,899,743 | 22,200,044 | DS | 20 | 2123-04-30 00:00:00 | 2123-04-30 13:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
crush injury
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y o M s/p crush injury, was working, crushed by dirt, pushed
against metal pipe, -HS, -LOC
Past Medical History:
none
Social History:
___
Family History:
non-contributory
Physical Exam:
ON ADMISSION
Constitutional: uncomfortable secondary to pain
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
Pelvic: +pelvic tenderness
Extr/Back: right leg abrasion; + tibia tenderness; left hip
pain, strength ___ all extremities
Neuro: Speech fluent,mild lethargy
Psych: Normal mood
___: No petechiae
ON DISCHARGE
Vitals - 98.4 66 111/54 18 95% RA
General - NAD
CV - RRR
Resp - nonlabored breathing, no resp distress
Abd - Soft, nondistended, no ttp
MSK & extremities/skin - abrasions to R lateral arm and R
lateral lower leg, R knee ttp, no leg swelling b/l
Pertinent Results:
CXR ___
1. Exclusion of the left lateral chest wall. Otherwise, no
acute
cardiopulmonary abnormality.
2. Multiple radiopaque densities project over the upper chest,
likely external
to the patient, but clinical correlation is needed.
CT HEAD ___
No acute intracranial abnormalities.
CT C-SPINE ___
1. No acute fracture or malalignment of the cervical spine.
2. Mild degenerative changes with small disc bulge at C4-C5
resulting in mild spinal canal narrowing.
CT TORSO ___
1. No acute intrathoracic or intra-abdominal injury identified.
2. 2 right perifissural lung nodules, likely reflect of
subpleural lymph
nodes.
B/L FEMUR XR ___
No fracture or dislocation.
B/L TIB/FIB XR ___
No acute fracture in either tibia or fibula.
Brief Hospital Course:
___ was admitted for pain control and a CPK on admission
of 327. He was hydrated aggressively with D5W + bicarb to
prevent renal injury. His CPK peaked to 655. A tertiary survey
was performed on ___ revealing no additional injuries.
Throughout his hospitalization he remained afebrile and
hemodynamically stable. On discharge he was ambulating, voiding,
and tolerating a regular diet without difficulty.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg 2 capsule(s) by mouth every six hours
Disp #*30 Capsule Refills:*0
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 capsule(s) by mouth every six hours Disp
#*3 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
crush injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after a crush injury. Your CT scans showed no
injuries, your labs suggested some mild degree of muscle injury
for which you were hydrated aggressively. You have recovered
well and are now ready for discharge.
Followup Instructions:
___
|
19899950-DS-17 | 19,899,950 | 26,110,742 | DS | 17 | 2174-07-23 00:00:00 | 2174-07-23 15:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Dilantin / Bactrim / hydrochlorothiazide / lisinopril
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Intubation (___)
Lumbar puncture
History of Present Illness:
History of Present Illness:
Mr. ___ is a ___ yo male with a history of a benigh
pituitary tumor s/p resection ~ ___ years ago with reoccurance of
growth s/p XRT, in addition to history of DM, HTN, HL, OSA on
CPAP here after new onset seizure witnessed by his wife 4 hours
prior to presenting to ___. The history is obtained from the
wife as the patient does not remember anything pertaining to the
event. The wife reports that the patient was in his usual state
of health and went to bed the night before presenting to the
hospital. Around midnight, she heard her husband make a noise
that sounded like gagging and found her husband looking as
though he was not breathing. His lips were blue. She took off
his CPAP machine as she figured it must have been
disfunctioning. Shortly thereafter he began to exhibit
seizure-like activity that lasted for a minute and is presumed
to be a generalized tonic-clonic seizure based on description.
She reports that the patient has not had seizure previously.
He had no infectious symptoms the day prior. The patient was
taken by EMS to ___, where he was nonverbal and was not
following commands. Per records, he presented with a nasal
trumpet airway and was assisted with bag valve respiration in a
postictal state that was not improving. He reportedly had no
localization of pain or spontaneous eye opening. He did not
arrest but was intubated given altered mental status. He
initially had several laboratory abnormalities including
elevated CK, CK-MB, LFTs, amylase, and lipase. His inital ABG
after intubation showed: pH 6.7, PCO2 54, PO2 239. HCO3 was
6.7. After less than an hour, he was transferred to ___ for
further management. He was not given IV bicarbonate. He was
given 100mg IV keppra (due to an allergy to dilantin, which was
previously used for seizure prophylaxis after his pituitary
tumor resection). He was given ativan, propofol, and
succinylcholine. A CBC and chemistries were pending at the time
of transfer.
On arrival to the ___, his initial vitals in the ED were: 50,
140/106, 93%, but his BP dropped to 60/30's within 10 minutes of
arrival. The patient was started on Norepinephrine IV gtt. A
head CT was performed and negative for intracranial processes.
He was empirically started on ceftriaxone and vancomycin for
possible community-acquired meningitis. He was also started on
acyclovir for possible HSV encephalitis. The patient was also
started on Norepinephrine IV gtt for hypotension, and he had a
femoral central line and OGT placed.
He was transferred to the MICU for further management. Lumbar
puncture was attempted unsucessfully, so interventional
radiology did a flouro-guided LP. The patient did well in the
MICU and was successfully extubated. He was then transferred to
Neurology.
Past Medical History:
1) Pituitary adenoma s/p resection ~ ___ years ago with
reoccurance of growth s/p XRT
2) panhypopituitarism
3) Diabetes Mellitus
4) HTN
5) HL
6) OSA on CPAP
Social History:
___
Family History:
Mother with CVA
Father with dementia
Physical Exam:
ADMIT EXAM:
Vitals: HR: 50, BP 140/106 (but his BP dropped to 60/30's within
10 minutes of arrival), 02 Sat 93%, RR: Vent
General: sedated on vent, not responding to commands. in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley, R femoral triple lumen central line.
Ext: pulses in all extremities
Neurology consult exam on admission:
BP 115/64 HR 76 overbreathing vent w/ A/C ___ sedated
w/midazolam gtt
- Head: NC/AT, no conjunctival pallor or icterus
- Cardiovascular: RRR, no M/R/G
- Respiratory: Nonlabored, clear to auscultaton with transmitted
vent sounds anteriorly
- Abdomen: obese but nondistended, normal bowel sounds, no
tenderness/rigidity/guarding
- Extremities: Warm, no cyanosis/clubbing/edema, palpable
dorsalis pedis pulses.
- Skin: No rashes or lesions
Neurologic Examination:
- Mental Status: intubated. Opens eyes to tapping on shoulder.
Follows simple commands like squeezing hands, opening & closing
eyes.
Cranial Nerves: [II] PERRL 3->2 brisk. [III, IV, VI] EOM intact
horizontally, no nystagmus. [V] Corneals intact [VII] No facial
asymmetry. [IX, X] Cough present
Motor: Normal bulk and tone. No tonic-clonic motions observed,
rare spontaneous motions. Able to withdraw to pain in all
extremities.
Sensory Responds to pain in all extremities and midline
Reflexes
L ___ 2 2
R ___ 2 2
DISCHARGE EXAM:
NAD, comfortable
Alert, oriented, conversing appropriately
Neurological exam nonfocal except for right eye peripheral field
defect (old per patient)
Pertinent Results:
IMAGING:
MRI ___-
FINDINGS:
There is a focal area of altered signal intensity in the left
frontal lobe,
with T1 hypo and T2 hyperintense appearance in the center
surrounded by
hypointense signal and negative susceptibility within, likely
related to old
blood products. There is no abnormal enhancement noted within
except for
minimal rim enhancement.
No foci of abnormal enhancement are noted elsewhere to suggest a
mass lesion.
There are a few small foci of slightly increased DWI signal in
the right
parietal lobe (series 1402, image 20, 22), which are too small
to be
accurately characterized and may represent tiny infarcts.
However, these are
not well seen on the ADC sequence.
A few small scattered FLAIR-hyperintense foci are noted,
non-specific in
appearance. There is increased signal intensity, diffusely to a
mild extent
in the mastoid air cells on both sides. There is moderate
mucosal thickening
with fluid in the ethmoid air cells and sphenoid sinuses. The
portal mucosal
thickening and retention cysts are noted in the maxillary
sinuses on both
sides.
The patient is status post surgery, in the sella.
Areas of increased T1 signal are noted, in the floor of the
sella as well as
in the suprasellar location and anterior to the sella likely
related to the
prior procedure/fat packing.
On the post-contrast images, there is a slightly heterogeneously
enhancing
pituitary gland with enlargement noted. There is possible mild
extension of
the tumor into the cavernous sinus on the right side. However,
study is
somewhat limited due to the orientation of the images.
The infundibulum is not well seen. Part of the optic chiasm is
seen.
IMPRESSION:
1. Focal area of altered signal intensity in the left frontal
lobe with very
minimal peripheral enhancement and extensive foci of negative
susceptibility
within, likely relates to an area of prior blood products. No
abnormal
vessels noted adjacent. Correlate with history for prior
trauma.
2. Two small foci of increased DWI signal in right parietal
lobe-
acute-subacute tiny infarcts- attention on f/u.
2. Pan-paranasal sinus disease involving the ethmoid and
sphenoid sinuses
predominantly and mild in the mastoid air cells on both sides.
3. Post-surgical changes in the sella, along with an enlarged
pituitary
gland, with slight heterogeneous enhancement. This may
represent
residual/recurrent adenoma.
Comparison with prior studies can be helpful to assess interval
change.
Otherwise, consider followup in a few weeks/months to assess
stability/progression. There is possible mild extension of the
tumor into the
cavernous sinus on the right side. However, study is somewhat
limited due to
the orientation of the images.
EEG ___ -
FINDINGS: CONTINUOUS EEG RECORDING: Began at 18:05 on the
evening of ___ and continued until 7 the next morning.
Again, it showed a very low voltage, relatively rapid background
of about ___ Hz, with some anterior
predominance. There was a In the recording from 20:30 until
22:30 the first evening. Otherwise, the background remained the
same through the end of the recording.
SLEEP: No normal waking or sleep patterns were evident.
CARDIAC MONITORING: showed a generally regular rhythm with an
occasional PVC.
SPIKE DETECTION PROGRAMS: Showed muscle and other artifact, but
there were no clearly epileptiform features.
SEIZURE DETECTION PROGRAMS: Showed no electrographic seizures.
PUSH BUTTON ACTIVATIONS: There were none.
IMPRESSION: This telemetry captured no pushbutton activations.
It showed a low voltage faster pattern, uniform in all head
regions, throughout recording. This suggests medication effect.
There were no areas of focal slowing, and there were no
epileptiform features or electrographic seizures.
ECG ___ -
Sinus rhythm. Right bundle-branch block. Slight ST segment and T
wave
abnormalities of unknown significance.
ECHO ___ -
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.9 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.8 cm
Left Ventricle - Fractional Shortening: 0.35 >= 0.29
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Stroke Volume: 87 ml/beat
Left Ventricle - Cardiac Output: 6.98 L/min
Left Ventricle - Cardiac Index: 2.93 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 8 < 15
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 21
Aortic Valve - LVOT diam: 2.3 cm
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A ratio: 1.40
Mitral Valve - E Wave deceleration time: 228 ms 140-250 ms
TR Gradient (+ RA = PASP): 22 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Mild ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. No ASD
or PFO by 2D, color Doppler or saline contrast with maneuvers.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta.
AORTIC VALVE: No AS. Mild (1+) AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular
calcification. Trivial MR. [Due to acoustic shadowing, the
severity of MR may be significantly UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion. There is an anterior space
which most likely represents a fat pad, though a loculated
anterior pericardial effusion cannot be excluded.
GENERAL COMMENTS: Contrast study was performed with 1 iv
injection of 8 ccs of agitated normal saline at rest. Suboptimal
image quality - poor echo windows. Suboptimal image quality -
body habitus. Suboptimal image quality - ventilator.
Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. The ascending aorta is mildly
dilated. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Trivial mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
There is an anterior space which most likely represents a
prominent fat pad.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild aortic regurgitation. No ASD or PFO seen. Limited
study.
HEAD CT ___ -
No acute intracranial hemorrhage, large vascular territory
infarct, shift of midline structures or mass effect is present.
The ventricles and sulci are normal in size and configuration.
The patient is status post a right
craniotomy. High-density lining the left frontal gray matter
likely
represents cortical laminar necrosis. Visible paranasal sinuses
and mastoid air cells show diffuse polypoidal mucosal thickening
in both maxillary sinuses and within the ethmoidal air cells and
frontal sinus . A moderate amount of fluid is noted in the
sphenoid air cells.
CXR ___ -
Slightly rotated positioning. Compared with ___ at 5:35
a.m., the
cardiomediastinal silhouette is stable. There is more
pronounced focal
opacity in the right midzone, in the perihilar area. This may
reflect the
presence of atelectasis, but an early infiltrate is in the
differential.
There is upper zone redistribution, but I doubt overt CHF.
There is minimal
atelectasis at the left base peripherally, with increased
retrocardiac
density, consistent with left lower lobe collapse and/or
consolidation.
Suspect small amount of fluid at the right costophrenic angle,
unchanged.
IMPRESSION:
1) More pronounced focal opacity in the right perihilar region
-- ?
atelectasis or early pneumonic infiltrate. Otherwise, no
significant change.
MICRO/PATH:
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
TOXOPLASMOSIS -
ADMIT LABS:
___ 02:56AM BLOOD WBC-15.4* RBC-3.53* Hgb-11.5* Hct-34.2*
MCV-97 MCH-32.5* MCHC-33.5 RDW-12.7 Plt ___
___ 09:26AM BLOOD ___ PTT-23.8* ___
___ 08:23AM BLOOD Plt ___
___ 08:23AM BLOOD Glucose-182* UreaN-23* Creat-1.5* Na-138
K-3.3 Cl-108 HCO3-22 AnGap-11
___ 08:23AM BLOOD ALT-46* AST-61* LD(LDH)-262*
___ AlkPhos-28* TotBili-0.1
___ 08:23AM BLOOD CK-MB-18* MB Indx-0.9 cTropnT-0.06*
___ 08:23AM BLOOD Albumin-3.9 Calcium-7.2* Phos-3.5 Mg-2.2
___ 08:23AM BLOOD Free T4-0.56*
___ 08:23AM BLOOD TSH-0.34
___ 02:56AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:58AM BLOOD ___ pO2-89 pCO2-43 pH-7.18*
calTCO2-17* Base XS--11 Comment-GREEN TOP
___ 02:58AM BLOOD Glucose-179* Lactate-6.7* Na-136 K-4.5
Cl-106
RELEVENT LABS:
___ 08:23AM BLOOD WBC-11.6* RBC-3.91* Hgb-12.4* Hct-37.2*
MCV-95 MCH-31.7 MCHC-33.3 RDW-13.0 Plt ___
___ 03:51AM BLOOD WBC-7.5 RBC-3.41* Hgb-10.8* Hct-32.7*
MCV-96 MCH-31.7 MCHC-33.1 RDW-13.0 Plt ___
___ 03:51AM BLOOD ___ PTT-25.3 ___
___ 03:51AM BLOOD Plt ___
___ 04:54PM BLOOD Glucose-144* UreaN-22* Creat-1.4* Na-139
K-4.2 Cl-109* HCO3-21* AnGap-13
___ 03:51AM BLOOD Glucose-131* UreaN-20 Creat-1.3* Na-139
K-4.4 Cl-109* HCO3-21* AnGap-13
___ 03:51AM BLOOD ALT-38 AST-67* LD(LDH)-242 CK(CPK)-2874*
AlkPhos-27* TotBili-0.2
___ 03:51AM BLOOD Lipase-20
___ 04:54PM BLOOD cTropnT-0.02*
___ 03:51AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.0
___ 07:00AM BLOOD Type-ART Temp-36.3 Rates-28/ Tidal V-450
PEEP-28 FiO2-100 pO2-169* pCO2-40 pH-7.30* calTCO2-20* Base
XS--5 Intubat-INTUBATED
___ 08:56AM BLOOD Lactate-1.6
Cardiac nuclear pharmacologic stress perfusion:
SUMMARY FROM THE EXERCISE LAB:
For pharmacologic coronary vasodilatation 0.4 mg of regadenoson
(0.08 mg/ml) was
infused intravenously over 20 seconds followed by a saline
flush. He had
atypical symptoms with the infusion with an uninterpretable ECG.
IMAGING METHOD:
Resting perfusion images were obtained with Tc-99m sestamibi.
Tracer was
injected approximately 45 minutes prior to obtaining the resting
images.
Following resting images and 20 seconds following intravenous
regadenoson,
approximately three times the resting dose of Tc-99m sestamibi
was administered
intravenously. Stress images were obtained approximately 30
minutes following
tracer injection.
Imaging protocol: Gated SPECT.
This study was interpreted using the 17-segment myocardial
perfusion model.
INTERPRETATION:
The image quality is adequate but limited due to soft tissue
attenuation.
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 68% with an
EDV of 87 ml.
IMPRESSION:
1. Normal myocardial perfusion.
2. Normal left ventricular cavity size and systolic function.
Brief Hospital Course:
# Neurologic:
The description from the patient's wife, who witnessed the
event, and the elevated creatine kinase seem consistent with
seizure activity. A head CT and a head MRI were both done and
showed no acute intracranial processes. The flouro-guided lumbar
puncture showed 1 WBC and slightly elevated protein. A 24 hour
electroencephalogram showed global slowing consistant with alpha
coma. This was likely post-ictal in etiology. He has been placed
on levetiracetam 750mg BID for seizure prophylaxis. Since
transfer to Neurology, he has been found to be fully oriented on
each exam. He has had no focal neurological defects except R
temporal visual field cut in R eye, described as a chronic
problem per patient.
He will begin to see a Neurologist. In 2 months he should have a
repeat MRI to determine whether or not his sellar mass remains
stable.
# Respiratory:
Initial respiratory difficulty presumably was a result of
altered mental status during post-ictal phase. He initially had
a lactic acidosis and consistent ABG abnormalities, likely as a
result of seizing. He was easily extubated following resolution
of the post-ictal phase. He had no further respiratory distress
during the admission.
# Cardiovascular:
Initial lab abnormalities included elevated cardiac enzymes.
Also EKG showed RBBB and inferolateral ST depression of 1mm in
limb leads and 2mm in lateral precordial leads.
On initial presentation he was hypotensive so he received
pressor support and anti-hypertensive medications were held.
Thereafter he received home medication, amlodipine.
Given the EKG changes and CKMB elevation on admission, it was
decided that during his admission he should have a
pharmacological stress test with nuclear imaging. This was
normal.
Throughout this admission he slept with CPAP to continue his
treatment for OSA. It has been recommended that he see a sleep
specialist in order to reassess his current CPAP machine
settings as he and his wife state that the patient hasn't seen a
sleep specialist in ___ years.
# Endocrine:
He has panhypopituitarism as a result of his trans-sphenoidal
pituitary resection. A stress dose of steroids was given in the
MICU. Throughout his admission he was continued on thyroid
hormone replacement, DDAVP, and prednisone. He should follow up
with an endocrinologist to discuss his regimen, including
whether he needs stress-dose steroids for illness and other
emergency situations.
# Renal:
Renal failure on initial presentation presumably due to
prolonged hypoperfusion due to seizure activity. His creatinine
was trended and decreased during his stay, thus suggesting
prerenal failure as the etiology. Medications were renally dosed
and nephrotoxins were avoided.
# FEN/GI:
He was given omeprazole daily. He had no difficulties eating,
drinking, or taking medications by mouth throughout this
admission.
# Musculoskeletal:
He was seen and evaluated by the physical therapy team. He has
an appropriate level of mobility and will just need follow up
for his L shoulder pain, thought to be a rotator cuff injury. It
is recommended that he have outpatient Orthopedics follow-up as
well as outpatient ___ for his L shoulder injury.
# DISPO:
He will return home with 24-hour assistance from wife; no other
in-home services are deemed necessary at this time.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Prednisone 7.5 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Alendronate Sodium 70 mg PO QFRI
4. Desmopressin Nasal 4 sprays NAS BID
**Refrigerate**
5. Amlodipine 10 mg PO DAILY
hold for SBP<100
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
hold for SBP<100
2. Desmopressin Nasal 4 sprays NAS BID
**Refrigerate**
3. Levothyroxine Sodium 150 mcg PO DAILY
4. PredniSONE 7.5 mg PO DAILY
5. LeVETiracetam 750 mg PO BID
6. Alendronate Sodium 70 mg PO QFRI
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Panhypopituitarism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after having a first generalized seizure. Most
likely, this was caused by post-surgical changes in your brain
from your pituitary surgery. After being stabilized and
intubated at ___, you were transferred to our
ICU. In the ICU, several diagnostic studies were obtained,
including head imaging and a lumbar puncture (spinal tap). Once
you were extubated, you were transferred to the general
neurology floor. You were monitored with continuous EEG, and
there were no concerning findings on this. Because you initially
had some EKG changes, we also performed a nuclear stress study
of your heart, which was normal.
Because you had a seizure, we started you on an antiepileptic
medication called levetiracetam (Keppra), please continue taking
this at 750 mg twice daily.
You should not drive for 6 months after your last seizure. You
should also avoid placing yourself in potentially dangerous
situations such as climbing up ladders, swimming without
supervision etc.
You will need to follow up with a neurologist to manage your
seizure medications. Also, a follow-up brain MRI should be
obtained in ___ months to make sure that the changes seen in
your brain are stable.
You should follow up with an endocrinologist to manage your
panypopituitarism, that is: the absence of the hormones produced
by the pituitary gland. Specifically, you should discuss whether
you should get a home prescription for stress dose steroids in
case of an illness.
You should also follow up with your sleep clinic to assess
whether your home CPAP machine is optimally calibrated, because
uncontrolled sleep apnea can lead to fatigue during the day and
occasionally makes seizures more likely.
You should follow up with occupational therapy and perhaps an
orthopedic surgeon for your rotator cuff injury. We will give
you a script for occupational therapy.
Followup Instructions:
___
|
19900111-DS-4 | 19,900,111 | 25,876,146 | DS | 4 | 2198-07-17 00:00:00 | 2198-07-17 21:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfasalazine / unknown topical substance
Attending: ___
Chief Complaint:
Dysphagia
Major Surgical or Invasive Procedure:
PEG tube placement
Pheresis port removal
History of Present Illness:
Ms. ___ is a ___ yo female with approximately 2 months of
jawpain and progressive dysphagia. She first noted the onset of
her symptoms on ___ and initially had difficulty tolerating
solids. This gradually progressed to inability to tolerate
liquids on ___. She endorses progressive hoarseness since
that time. Her symptoms were also accompanied by bilateral
intermittent earaches, headaches, jaw pain and throat irritation
and she was initially diagnosed with TMJ and GERD.
She was seen by ENT in ___ and was found to have severe
crichopharyngeal dysfunction. She underwent microlaryngoscopy
vocal fold injection for vocal fold hypomobility as well as
esophagoscopy, esophageal dilation and cricopharyngeal Botox
injection on ___.
She was evaluated by neurology with suspicion of motor neuron
disease given findings of tongue deviation, dysphagia, and
dysphonia and was ordered for CT, paraneoplastic panel, and
brain MRI. CT of her neck revealed a 4.6 cm mass adjacent to or
arising from the left lobe of the thyroid.
She underwent FNA with report of squamous cell carcinoma and was
transferred to OMED for further workup and management of newly
diagnosed head and neck cancer.
Review of systems is notable for intermittent bilateral
posterior headache, horseness, and earache. She endorses
hoarseness and wheezing, though denies shortness of breath and
chest pain. She cannot endorse odynophagia as she is unable to
swallow any liquids or solids at this time, and is unable to
swallow her secretions. She denies abdominal pain, dysuria,
fevers, chills, muscle aches, joint pains. She does endorse
constipation.
Past Medical History:
Dysphagia:
She has most recently undergone microlaryngoscopy vocal
fold injection for vocal fold hypomobility as well as
esophagoscopy, esophageal dilation and cricopharyngeal Botox.
Anxiety
Hip fx in ___ s/p 3 fixation
Hypothyroidism
Migraine headaches
Social History:
___
Family History:
Father had ___ Disease and died at ___
Brother died of amyloidosis
Physical Exam:
Admission Exam
Vitals- 98.2 152/73 78 20 99% RA
General- Alert, oriented, no acute distress
HEENT- Right tongue deviation. Sclera anicteric, MMM, oropharynx
clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Pheresis port in place on right chest
Neuro- CNs2-12 intact apart from tongue deviation to the right,
motor function grossly normal,
Discharge Exam
General- Alert, oriented, uncomfortable due to nausea
HEENT- Right tongue deviation. Sclera anicteric, MMM, oropharynx
clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- PEG tube in place, dressing c/d/i. Mild tenderness to
palpation over PEG tube site.
GU- no foley
Ext- Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Pertinent Results:
Admission Labs
___ 10:15AM BLOOD WBC-11.4*# RBC-4.31 Hgb-12.7 Hct-37.9
MCV-88 MCH-29.5 MCHC-33.5 RDW-12.2 Plt ___
___ 10:15AM BLOOD Neuts-81.9* Lymphs-9.0* Monos-4.8 Eos-3.6
Baso-0.6
___ 06:45AM BLOOD ESR-79*
___ 10:15AM BLOOD Glucose-112* UreaN-13 Creat-0.6 Na-137
K-3.7 Cl-98 HCO3-27 AnGap-16
___ 06:45AM BLOOD ALT-22 AST-13 LD(LDH)-169 AlkPhos-86
TotBili-0.4
___ 06:45AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.2
___ 06:45AM BLOOD TSH-0.46
___ 06:45AM BLOOD CRP-22.9*
___ 10:19AM BLOOD Lactate-1.5
Discharge Labs
___ 07:10AM BLOOD WBC-10.6 RBC-4.13* Hgb-12.5 Hct-37.1
MCV-90 MCH-30.2 MCHC-33.6 RDW-12.9 Plt ___
___ 07:10AM BLOOD Plt ___
___ 07:10AM BLOOD Glucose-97 UreaN-10 Creat-0.5 Na-135
K-3.9 Cl-96 HCO3-32 AnGap-11
___ 07:10AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.3
EMG: ___
Clinical Interpretation: Borderline abnormal study. There is
increased
individual jitter in one fiber pair on SFEMG. Although this does
not meet
diagnostic criteria, a post-synaptic disorder of neuromuscular
transmission as in myasthenia ___ is a consideration.
Botulinum toxin injections can increase jitter in muscles
distant from the site of injection. There is no
electrophysiologic evidence for a generalized disorder of motor
neurons as in amyotrophic lateral sclerosis.
CT abdomen ___
IMPRESSION:
1. No clear evidence to suggest malignancy in the abdomen or
pelvis.
2. Distended gall bladder filled with stones. Trace
inflammatory change
immediately posterior to the GB. These findings raise concern
for but are not entirely diagnostic of acute cholecystitis. If
patient has abnormal LFT's or right upper quadrant tenderness,
further evaluation with ultrasound is recommended.
CT Chest ___
IMPRESSION:
1. 3.2-cm (TRV) x 4.1-cm (AP) x 4.7-cm (CC) heterogeneous mass
in the region of the left lobe of the thyroid (3;8), which
laterally displaces the left carotid from the larynx, and may
invade the cricoid cartilage,
cricopharyngeus, upper esophagus, innominate and left subclavian
arteries.
NOTE: This could be secondary to thyroid cancer, however this
mass is highly concerning for a squamous cell carcinoma. A
dedicated neck CT is recommended for further evaluation.
2. Multiple nodules in the right lung measuring up to 5-mm.
Given that the neck mass is highly suspicious for malignancy, a
6-month follow up is
recommended to assess for stability of the nodules.
CT Neck ___
IMPRESSION: 4.6 cm mass adjacent to or arising from the left
lobe of the
thyroid. Further characterization with ultrasound can be
considered, but
ultimately biopsy would be required for definitive diagnosis.
No cervical lymphadenopathy.
Cytology Report ___
CYTOLOGY REPORT - Final
Specimen(s) Submitted: FINE NEEDLE ASPIRATION, THYROID
Diagnosis FNA, Thyroid, Left.
Specimen Adequacy: Adequate.
General Category: Positive for keratinizing squamous cell
carcinoma
Note: Tumor cells are positive for TTF-1, but negative for
thyrogobulin and p16 (pathcy non-specific pattern). Primary
thyroid
squamous cell carcinoma is favored based on location and TTF-1
staining. The tumor is high-grade. Dr. ___
___ were
informed on the diagnosis on ___ by Dr. ___.
CT HEAD ___
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect or acute
large vascular territory infarction. Prominent ventricles and
sulci suggest age-related atrophy. Periventricular white matter
hypodensities are consistent with chronic small vessel ischemic
disease. The basal cisterns appear patent and there is
preservation of gray-white differentiation.
No fracture is identified. The visualized paranasal sinuses,
mastoid air
cells and middle ear cavities are clear. Atherosclerotic mural
calcification of the internal carotid arteries is noted. The
globes are unremarkable.
IMPRESSION:
No acute intracranial process.
FDG-PET ___
INTERPRETATION:
Comparison is made to CT neck ___
HEAD/NECK: There is a large 5.9 x 4.3cm FDG avid (SUVMax 27.9)
cervical mass extending from the hyoid bone to the thoracic
inlet. There is no FDG avid cervical adenopathy.
CHEST: Multiple foci of FDG avidity in the lungs correspond to
ground glass
pulmonary opacities in the superior left lower lobe (image 80),
posterior right middle lobe and right lower lobe (image 87).
There is an 11 x 16mm solid nodule in the medial left lower lobe
which is not FDG avid (image 93).
ABDOMEN/PELVIS: There is a small volume of pneumoperitoneum.
There is mild FDG avidity and subcutaneous air surrounding the
gastrostomy tube tract (image 124). Dense gallstones layer in
the bladder.
MUSCULOSKELETAL: There are extensive degenerative changes at
the left
femoro-acetabular joint. Two pins traverse the left femoral
neck.
Physiologic uptake is seen in the brain, myocardium, salivary
glands, GI and GU tracts, liver and spleen.
IMPRESSION:
1. Large FDG avid cervical mass corresponding with known
malignancy. No evidence of FDG avid nodal metastasis.
2. Multi-focal FDG avid ground glass pulmonary opacities
suggestive of
pneumonia or aspiration pneumonitis.
3. 16mm non-FDG avid left lower lobe nodule.
4. Small volume pneumoperitoneum compatible with recent
gastrostomy placement.
Brief Hospital Course:
Ms. ___ is a ___ woman presenting with dysphagia s/p
microlaryngoscopy vocal
fold injection, esophageal dilation and cricopharyngeal Botox
without improvement.
#Squamous cell carcinoma: Ms. ___ presented with a 2 month
history of dysphagia, which was extensively worked up as an
outpatient. It was characterized by cricopharyngeal dysfunction,
esophageal spasm, and vocal paresis. She was s/p botox to upper
esophageal sphincter and cricopharyngeal botox and dilation.
Laryngeal EMG was suggestive of myasthenia picture but CT neck
showed thyroid mass. There was concern at one point of
paraneoplastic syndrome causing her dysphagia and she underwent
pheresis port placement, which was removed on transfer to OMED.
FNA of the mass revealed keratinizing squamous cell carcinoma.
She was unable to tolerate any PO intake, including her own
secretions. She underwent PEG tube placement on ___, was
started on tube feeds, and tolerated them well. She underwent
her first dose of chemotherapy with Cisplatin on ___ and
underwent mapping for XRT on ___.
- She will be continued on Cisplatin in the outpatient setting
with Dr. ___. However, she is discharged to rehab and
***She should receive her next scheduled dose of CISPLATIN while
in rehab. Her next dose is scheduled for ___
- She will follow up with radiation oncology on ___ for further radiation therapy planning.
Chemotherapy schedule: Cisplatin: C1D1 = ___. Administer on
days 1, 8, 15, 22, 29, 36 and 43. ___,
___ and ___.
# Headache: Chronic, likely tension headache given distribution
of pain and muscle spasm. Exacerbated by constant throat
clearing and expectoration of saliva. CT head without contrast
(___) showed no acute intracranial process. She was written
for Oxycodone-Acetaminophen Elixir PRN pain. MRI was
contraindicated due to possible metallic ear implants.
# Dysphagia: Secondary to neck mass. Patient unable to tolerate
PO intake and has a PEG tube in place. She receives bolus tube
feeds with:
Bolus tubefeeding: Isosource 1.5 Cal or Jevity 1.5 Full
strength; # of cc per feeding: 240 cc; # of feedings/day: 5
Advancement: Start at goal
Residual Check: Before each feeding Hold feeding for residual >=
: 200 ml
Flush w/100 ml water before & after each feeding
# Nausea: The patient developed nausea 4 days after her first
chemotherapy treatment with Cisplatin, likely a delayed response
to chemotherapy. ACS was considered though EKG was at baseline.
She was treated with Zofran and Compazine and should continue
with these while at ___.
*Transitional Issues*
1. Patient will need to receive next scheduled CISPLATIN
chemotherapy on ___ while in rehab.
2. Patient is scheduled for Radiation oncology appointment at
___ on ___ at 1pm in the ___
BASEMENT.
3. Treatment of nausea with Compazine and Zofran
Medications on Admission:
1. Levothyroxine Sodium 137 mcg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. OxycoDONE-Acetaminophen Elixir ___ mL PO Q6H:PRN pain
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. OxycoDONE-Acetaminophen Elixir ___ mL PO Q6H:PRN pain
RX *oxycodone-acetaminophen [Roxicet] 5 mg-325 mg/5 mL ___ mL
PEG every six (6) hours Disp #*1 Bottle Refills:*3
3. Levothyroxine Sodium 137 mcg PO DAILY
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Squamous cell carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at the ___
___ ___. You came to the hospital because of
difficulty swallowing. A CT scan showed a neck mass. A biopsy
was taken showing keratinizing squamous cell carcinoma. Due your
swallowing issues you had a PEG tube placed to provide
nutrition. You were seen by the Radiation Oncology team who
noted that you are a candidate for radiation therapy and you
underwent a simulation/mapping with them. You underwent a PET/CT
scan for staging of your cancer.
From this point on the treatment for your cancer is performed in
the outpatient setting. You will follow up with Dr. ___
in clinic for chemotherapy and with the radiation oncologist for
outpatient management of radiation therapy. You will receive
your next dose of chemotherapy with Cisplatin while in rehab.
The chemotherapy can cause nausea (both immediately and a
delayed response). This can be treated with zofran as you need
it.
Thank you for allowing us to be a part of your care,
Your ___ team.
Followup Instructions:
___
|
19900626-DS-9 | 19,900,626 | 21,246,742 | DS | 9 | 2152-04-25 00:00:00 | 2152-04-27 12:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
paper tape
Attending: ___
Chief Complaint:
Abdominal distension
Major Surgical or Invasive Procedure:
Diagnostic and therapeutic paracentesis ___
History of Present Illness:
Mr. ___ is a ___ year old with history of CAD s/p CABG, PVD
s/p bilateral fem-pop bypass, and hepatitis C as well as
alcohol-induced cirrhosis complicated by two episodes of HE and
grade 1 esophageal varices on EGD ___ presenting to ___
with increased abdominal swelling. Pt reports that since his
diuretics were decreased to lasix 20mg and spironolactone 50mg
in clinic ___, he has not a gradual increase in abdominal
distension. He also reports pain associated with a right
inguinal hernia when standing that improves when lying down. Pt
also reports some lower extremity swelling, which is new. Pt
denies any confusion, melena, BRBPR, hematemesis, fevers,
chills, cough, dysuria, hematuria.
In the ED, pt's VS were 97.8 66 107/63 18 100%. Pt's labs were
notable for a TBili 8.0 increased from 6.6, stable Na at 131,
BUN/Cr ___, INR 1.9, H/H 11.5/33.9, plts 88. Pt underwent
diagnostic paracentesis with 202 WBCs and 15% polys.
On transfer to the floor, pt's VS were 98.0 72 127/56 18 100% on
RA. Pt denies abdominal pain while lying in bed, but reports
his abdomen is much more distended than usual. Pt reports two
episodes of HE since being diagnosed with cirrhosis ___ months
ago. Denies history of bleeding or SBP.
Past Medical History:
1. Atrial fibrillation, previously on Coumadin, currently off
Coumadin.
2. Aortic stenosis.
3. Vitamin D deficiency.
4. Multiple basal cell carcinoma of the skin, recently treated
with local topical treatment two weeks ago and status post Mohs
surgery on his shoulder lesion and is scheduled for another Mohs
surgery for his upper lip lesion due to having another BCC.
5. Genotype I/II hepatitis C, failed on treatment of ribavirin
and interferon therapy.
6. Hyperlipidemia.
7. Peripheral neuropathy.
8. Ischemic colitis.
9. Cirrhosis due to alcohol and hepatitis C as above.
10. Left renal artery stenosis.
11. Severe superior mesenteric arterial stenosis.
12. Heart murmur.
13. Neck pain.
14. Myocardial infarction in ___, status post bypass
surgery.
15. Peripheral arterial disease.
16. Reflux esophagitis.
17. Diabetes.
18. Vitamin B12 deficiency.
19. Colonic polyp with high-grade dysplasia in the ascending
colon polyp as above.
Social History:
___
Family History:
Father - HCV cirrhosis
Physical Exam:
ADMISSION LABS:
==============
General: NAD, somewhat cachectic appearing
HEENT: NCAT, PERRL, EOMI
Neck: JVP flat
CV: S1 S2 RRR no m/r/g
Lungs: CTAB w/r/r
Abdomen: Soft, non-tender, distended, normoactive BS
GU: deferred
Ext: trace edema in ___ bilaterally
Neuro: ___ strength, SILT
Skin: Spider angiomata
DISCHARGE LABS:
================
VS: 98.1 110/57 70 18 97% on RA
General: NAD, somewhat cachectic appearing
HEENT: NCAT, PERRL, EOMI
Neck: JVP flat
CV: S1 S2 RRR no m/r/g
Lungs: CTAB w/r/r
Abdomen: Soft, non-tender, distended, normoactive BS
GU: deferred
Ext: trace edema in ___ bilaterally
Neuro: ___ strength, SILT, positive asterixis
Skin: Spider angiomata
Pertinent Results:
ADMISSION LABS:
=============
___:00AM BLOOD WBC-6.7 RBC-3.03* Hgb-11.5* Hct-33.9*
MCV-112* MCH-37.9* MCHC-33.9 RDW-15.5 Plt Ct-88*
___ 11:00AM BLOOD Neuts-76.7* Lymphs-16.5* Monos-5.5
Eos-0.8 Baso-0.6
___ 11:53AM BLOOD ___ PTT-40.8* ___
___ 11:00AM BLOOD Glucose-157* UreaN-18 Creat-1.0 Na-131*
K-4.4 Cl-99 HCO3-25 AnGap-11
___ 11:00AM BLOOD ALT-38 AST-71* AlkPhos-108 TotBili-8.0*
___ 11:00AM BLOOD Albumin-2.4*
___ 06:20AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9
___ 11:15AM BLOOD Lactate-2.8*
DISCHARGE LABS:
==============
___ 06:20AM BLOOD WBC-4.7 RBC-2.56* Hgb-9.9* Hct-28.2*
MCV-110* MCH-38.7* MCHC-35.1* RDW-15.6* Plt Ct-72*
___ 06:20AM BLOOD ___ PTT-44.1* ___
___ 06:20AM BLOOD Glucose-125* UreaN-19 Creat-0.8 Na-131*
K-4.2 Cl-100 HCO3-26 AnGap-9
___ 06:20AM BLOOD ALT-32 AST-58* LD(LDH)-246 AlkPhos-100
TotBili-5.1*
___ 06:20AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9
URINE:
=======
___ 04:25PM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:25PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-6.0 Leuks-MOD
___ 04:25PM URINE RBC-1 WBC-27* Bacteri-FEW Yeast-NONE
Epi-1 TransE-1
___ 04:25PM URINE CastHy-198*
___ 04:25PM URINE AmorphX-OCC
___ 04:25PM URINE WBC Clm-RARE Mucous-FEW
PERITONEAL FLUID:
================
___ 01:30PM ASCITES WBC-206* RBC-472* Polys-51* Lymphs-15*
Monos-0 Plasma-1* Mesothe-2* Macroph-31*
___ 01:30PM ASCITES TotPro-0.7 Glucose-160
micro
___ 1:30 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
blood cx x 2 pending
STUDIES:
========
ECG: Normal sinus rhythm. Possible prior inferior wall
myocardial infarction. Borderline Q-T interval prolongation. No
previous tracing available for comparison.
CXR
Low lung volumes with streaky bibasilar opacities, most likely
atelectasis. Otherwise, no acute cardiopulmonary process.
RUQ ultrasound
1. Cirrhotic liver without focal concerning lesion. Sequela of
portal
hypertension including splenomegaly and moderate four-quadrant
ascites.
2. Doppler assessment demonstrates patency of all visualized
veins with slow reversed flow in the left portal vein. Please
note midline including portal confluence and splenic vein is
obscured by bowel gas.
Echo
The left atrial volume index is moderately increased. The
interatrial septum is dynamic/borderline aneurysmal. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF=70%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are moderately thickened. There is moderate aortic
valve stenosis (valve area 1.0cm2). No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Normal biventricular systolic function. Moderate
calcific aortic valve stenosis. Moderate pulmonary artery
hypertension. Mildly dilated aortic root.
diagnostic and therapeutic paracentesis
Uneventful diagnostic and therapeutic paracentesis yielding 1.9
L of clear, straw-colored ascitic fluid.
Brief Hospital Course:
___ year old M with CAD, PVD, HCV/EtOH cirrhosis presenting with
worsening ascites in the setting of recent decrease in diuretic
dose
ACUTE ISSUES:
============
# ASCITES: Pt presented with a history of ascites difficult to
control with diuretics secondary to hyponatremia. Pt's diuretic
dosing had recently been reduced to lasix 20mg and
spironolactone 50mg daily in the setting of hyponatremia to 127.
Pt presented to ___ with worsening abdominal distension and
an improved serum sodium of 131. Pt underwent a diagnostic
paracentesis in the ___ ED, which did not show evidence of
SBP. The following day, pt underwent therapeutic and diagnostic
paracentesis with ___ and 1.9L of ascitic fluid was removed,
again without evidence of SBP. Post-procedure, pt was
discharged home with follow up in the transplant ___
clinic. Pt was continued on his home lasix and spironolactone
dosing, and will likely need weekly therapeutic paracenteses as
an outpatient given pt's propensity to develop hyponatremia at
higher diuretic doses.
# HEPATIC ENCEPHALOPATHY: Pt presented with a history of two
episodes of HE. Takes lactulose and rifaximin at home. Pt was
noted to have some asterixis on exam, however pt did not
demonstrate evidence confusion of altered mental status. Pt's
home lactulose and rifaximin were continued. In addition, pt's
bentyl for abdominal discomfort with lactulose was continued.
# CIRRHOSIS: Pt presented with cirrhosis secondary to HCV and
alcohol, not currently listed given severe vasculopathy. MELD
21 on admission. RUQ ultrasound demonstrated cirrhotic
morphology of the liver with patent PV. As discussed above, pt
was continued on his home diuretics, lactulose and rifaximin.
Pt was treated with SBP prophylaxis given no prior history.
# INGUINAL AND PERIUMBILICAL HERNIA: Pt presented with right
inguinal and periumbilical hernias. Exam did not demonstrate
evidence of ischemia or entrapment. Pt will follow up with
transplant surgery as an outpatient for evaluation for possible
hernia repair.
# Aortic stenosis: Pt presented with a history of AS, and TTE
was performed which demonstrated normal biventricular systolic
function, moderate calcific aortic valve stenosis, moderate
pulmonary artery hypertension, and a mildly dilated aortic root.
CHRONIC ISSUES:
===============
# CAD/PVD: Continued home ASA
# TYPE 2 DM: Continued home insulin
# ATRIAL FIBRILLATION: Continued home metoprolol, continued home
ASA
# SMOKER: Continued home bupropion
# NEUROPATHY: Continued home gabapentin
TRANSITIONAL ISSUES:
===================
# Pt will likely need weekly paracenteses
# Pt will follow up with transplant surgery as outpatient for
possible hernia repair
# Pt will follow up with transplant hepatology as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DiCYCLOmine 20 mg PO TID
2. Pantoprazole 40 mg PO Q12H
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Aspirin EC 81 mg PO DAILY
5. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
6. BuPROPion (Sustained Release) 150 mg PO QAM
7. Cialis (tadalafil) 20 mg oral PRN intercourse
8. Furosemide 20 mg PO DAILY
9. Spironolactone 50 mg PO DAILY
10. Lactulose 30 mL PO TID
11. Rifaximin 550 mg PO BID
12. Gabapentin 300 mg PO BID
13. Glargine 48 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. DiCYCLOmine 20 mg PO TID
RX *dicyclomine 20 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
4. Gabapentin 300 mg PO BID
5. Furosemide 20 mg PO DAILY
6. Glargine 48 Units Bedtime
7. Lactulose 30 mL PO TID
8. Metoprolol Succinate XL 12.5 mg PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Rifaximin 550 mg PO BID
11. Spironolactone 50 mg PO DAILY
12. Cialis (tadalafil) 20 mg oral PRN intercourse
13. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: acites
secondary diagnosis: Hepatitis C cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you while you were admitted to the
hospital. You were admitted with abdominal distension. We
performed a paracentesis to help improve your symptoms. We found
no evidence of infection (although some of the tests were
pending at the time you were discharged).
Please take your medications as prescribed or follow up with
your doctors as ___.
Followup Instructions:
___
|
19900689-DS-6 | 19,900,689 | 26,824,053 | DS | 6 | 2189-06-14 00:00:00 | 2189-06-20 01:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Morphine
Attending: ___.
Chief Complaint:
Stab wounds x6
Major Surgical or Invasive Procedure:
Left pigtail catheter placement (___)
History of Present Illness:
___ with unknown past medical history who presents as a transfer
from ___ with multiple stab wounds. Stab 6 times
in the posterior neck, back, left axilla. He has been
hemodynamically stable. He reports that he witnessed a man
assaulting a woman and broke broke them up. Later in the day he
encountered this man again who is an acquaintance of his, who
then stabbed him six times. Per EMS he waved down a bystander
who transported him to ___. At ___ he
underwent chest x-ray and pelvis x-ray and received 2 L normal
saline. Arrives here by EMS ground transport. Patient is alert
and awake. Triggered on arrival as trauma stat. Patient reports
tetanus shot last ___ years ago. Denies any medical history.
Complains of pain at stab wound sites which include left chest
left arm and posterior neck. No other complaints.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam
HR: 91/57 BP: 95 Resp: 18 O2 Sat: 98% on 2 L Normal
Constitutional: Gen: Uncomfortable alert and oriented
HEENT: EOMI Neck: Collar in place: With collar removed, there is
a 1 cm horizontal linear laceration over posterior neck,
nonpulsatile, no expanding hematoma, hemostasis achieved,
nontender over midline C-spine Resp: Crepitus appreciated over
left chest, no flail chest, breath sounds equal and bilateral, 3
stab wounds approximately 1 cm horizontal linear located over
left chest and left shoulder, hemostasis achieved for all stab
wounds, axilla is investigated and no evidence of stab wound
Upper extremity: Intact sensation over axillary nerve
distribution, intact radial median ulnar nerve motor and sensory
function, tenderness over proximal stab wound, nontender over
the remainder of humerus and forearm, palpable radial pulse and
intact distal sensation and cap refill
Back: No midline tenderness Perineum: No appreciable stab wounds
in GU or perineal area
CV: Normal heart sounds Abd: Soft, nondistended, single 1 cm
linear horizontal stab wound over left upper quadrant, no active
bleeding hemostasis achieved
Flank: No CVAT b/l ___: Intact distal pulses, compartments soft,
no cyanosis
Skin: Warm and dry Neuro: Speech fluent, CN grossly intact,
moving extremities spontaneously with normal ROM and no
limitation
Heme: No petechiae
Discharge Physical Exam
Vitals- T 97.8, BP 121 / 72, HR 80, RR 18, O2 Sat 96% (RA)
Gen: NAD, AxOx3
Card: RRR, no m/r/g
Pulm: Normal WOB, +CTAB, equal breath sounds bilaterally, no
wheezes or crackles; occlusive dressing to L anterior chest in
place, with scant serosanguineous staining, mildly TTP over
superior aspect, no crepitus
Abd: Soft, non-tender, non-distended
Wounds: Stab wounds to abdomen and posterior neck c/d/i, open to
air; stab wounds to L scapula c/d/i, closed with staples
Ext: No edema, warm well-perfused
Pertinent Results:
___ 10:05PM BLOOD WBC-17.6* RBC-4.44* Hgb-13.7 Hct-41.6
MCV-94 MCH-30.9 MCHC-32.9 RDW-12.5 RDWSD-42.8 Plt ___
___ 10:05PM BLOOD Neuts-87.1* Lymphs-7.0* Monos-4.8*
Eos-0.1* Baso-0.4 Im ___ AbsNeut-15.38* AbsLymp-1.23
AbsMono-0.85* AbsEos-0.01* AbsBaso-0.07
___ 10:05PM BLOOD ___ PTT-20.7* ___
___ 10:05PM BLOOD Plt ___
___ 02:49AM BLOOD Glucose-103* UreaN-8 Creat-1.0 Na-139
K-4.3 Cl-103 HCO3-19* AnGap-17
___ 10:05PM BLOOD Lipase-11
___ 02:49AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.6
___ 10:05PM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
___ 10:11PM BLOOD Glucose-88 Lactate-4.4* Creat-1.3* Na-143
K-3.7 Cl-106 calHCO3-24
___ 03:03AM BLOOD Lactate-1.9
___ 03:03AM BLOOD freeCa-1.07*
___ 07:05AM BLOOD WBC-4.8 RBC-3.87* Hgb-11.9* Hct-36.8*
MCV-95 MCH-30.7 MCHC-32.3 RDW-13.1 RDWSD-45.3 Plt ___
___ 07:05AM BLOOD Glucose-104* UreaN-17 Creat-0.9 Na-142
K-4.1 Cl-104 HCO3-24 AnGap-14
___ 07:05AM BLOOD Calcium-8.7 Phos-5.2* Mg-2.0
Trauma CXR (___)
Nonspecific patchy opacities at the left lung base. Left-sided
subcutaneous emphysema.
CTA Neck (___)
The carotidandvertebral arteries and their major branches are
patent with no evidence of stenoses or dissection.
- No fracture identified. Normal spinal alignment.
-Shallow left apical pneumothorax.
-Subcutaneous emphysema overlying the left lateral chest wall
extending superiorly along the left scalene and
sternocleidomastoid muscles. Gas is noted around the left
vertebral artery at the level of C5 and in the adjacent the left
epidural space.
CT Chest/Abdomen/Pelvis (___)
Left lateral chest wall stab wound site with associated lung
laceration (02:56), small left pneumothorax (___:23), and small
left hemothorax (2:81), as well as mildly displaced complete
anterior left fifth rib fracture (605:127) at entry. Locules of
gas track along the right anterior abdominal wall at site of
stab wound without CT evidence of intra-abdominal entry. Please
see separate CTA neck for neck findings.
CXR (___)
Mild pulmonary edema is new. Heterogeneous opacification
persists at the left lung base but has not worsened, consistent
with stable contusion or aspiration. There has been no change
since the chest CT 2 hours earlier to suggest an increase in
either small left pneumothorax or a small left pleural
effusion. One separated rib fracture is clear, anterior left
fifth, with adjacent subcutaneous emphysema, unchanged.
CXR (___)
Moderate left pneumothorax is substantially larger. Left
pleural effusion IS small if any. Left basal consolidation is
more pronounced, perhaps atelectasis from displacement by the
larger pneumothorax. Right basal atelectasis is mild,
reflecting ipsilateral mediastinal shift.
CXR (___)
Small left pneumothorax has decreased substantially following
insertion of a basal pigtail pleural drainage catheter. Left
basal consolidation is nevertheless more pronounced now than it
was earlier in the day, presumably worsening atelectasis. Left
pleural effusion minimal if any. Heart size
normal. Right lung grossly clear.
CXR (___)
Left pigtail catheter is in place. There is left apical
pneumothorax, small. Heart size and mediastinum are stable. Left
retrocardiac atelectasis is unchanged. Right lung is overall
clear.
R Hand XR (___)
Mildly displaced fracture of the dorsal base of the distal fifth
phalanx with mild flexion deformity, concerning for mallet
finger. Likely chronic changes related to waist fracture of the
scaphoid. Recommend correlation for pain in the anatomic
snuffbox and considering dedicated views of the wrist.
CXR (___)
There has been interval repositioning of the left pleural
pigtail catheter. No discrete pneumothorax is identified.
Retrocardiac atelectasis is unchanged. No large pleural
effusion. The size of the cardiac silhouette is within normal
limits. Unchanged cortical irregularity of the distal right
clavicle at the
acromioclavicular joint.
R Wrist XR (___)
There is again seen osseous irregularity and spurring about the
scaphoid waist suggestive of prior old injury. However, please
correlate with any history of prior trauma and acute pain. On
the lateral view, there is a well corticated density along the
volar aspect of the wrist joint and another calcific density
dorsal to the capitate. Small dystrophic calcification is seen
superior to the expected location the TFCC on the AP view.
There are mild degenerative changes of the first CMC joint with
minimal joint space narrowing spurring. No definite acute
fractures or dislocations are seen.
CXR (___)
Apical 1.5 cm pneumothorax. Stable position of the left
drainage pigtail catheter.
CXR (___)
Left-sided pigtail catheter is unchanged. There is a small left
apical pneumothorax. Lungs are low volume with bibasilar
atelectasis. Cardiomediastinal silhouette is stable. There is
subsegmental atelectasis in the right lower lobe.
CXR (___)
Comparison to ___. The left pleural pigtail
catheter is in stable position. The left pneumothorax has
minimally decreased. There is no evidence of tension. Stable
retrocardiac atelectasis. No pleural effusions. No pulmonary
edema. No pneumonia.
Brief Hospital Course:
Patient is a ___ yo M, who presented as a transfer from ___
___ s/p multiple stab wounds (as detailed in HPI). Patient
triggered on arrival as trauma stat for multiple stab wounds.
Complaining of left chest, posterior neck, and left arm pain.
Initial SBP 91 per EMS report, on immediate repeat on our
telemetry, SBP 110s. Patient was alert and oriented, with C
collar in place. Primary trauma survey notable for crepitus over
the left chest, but otherwise unremarkable and with equal breath
sounds bilaterally. Secondary survey notable for 1 cm horizontal
linear laceration over posterior neck (hemostasis achieved), 3
stab wounds approximately 1 cm horizontal linear located over
left chest and left shoulder (hemostasis achieved), single 1 cm
linear horizontal stab wound over left upper quadrant
(hemostasis achieved). E-fast negative. Portable chest x-ray
with no evidence of obvious pneumothorax. Patient then underwent
CT head, C spine, CTA neck, and CT torso. CTA demonstrated
subcutaneous emphysema overlying the left lateral chest wall
extending superiorly along the left scalene and
sternocleidomastoid muscles, with gas around the left vertebral
artery at the level of C5 and in the adjacent the left epidural
space. No vascular injury. C collar was replaced as a precaution
pending final read of the imaging. CT chest/abdomen/pelvis
showed left lateral chest wall stab wound site with associated
lung laceration, small left pneumothorax, and small left
hemothorax, and mildly displaced complete anterior left fifth
rib fracture at entry. Locules of gas were noted tracking along
the right anterior abdominal wall at site of stab wound without
CT evidence of intra-abdominal entry.
Patient's lacerations on his left shoulder and chest were
irrigated with copious amounts of sterile saline, washed with
Betadine, and closed with skin stapler. Laceration on the left
midaxillary line closed with 4 staples. Three lacerations in the
posterior shoulder closed with 3 staples each. Abdominal wound
and posterior neck wound remained open per Trauma Surgery
recommendations. Given the findings of trace pneumothorax but no
respiratory distress with hemodynamic stability, chest tube
placement was deferred and the patient was admitted to Trauma
Surgery to the TSICU.
The patient had stable O2 requirements of 2 L NC overnight after
admission to the ___, but AM CXR showed increased pneumothorax
and a left pigtail catheter was placed with immediate escape of
air. CXR confirmed appropriate placement. The patient was
otherwise doing well, and was deemed appropriate for step down
to the floor that morning of HD2. The final read of the CTA neck
confirmed no acute fracture and appropriate alignment, and his C
collar was clinically cleared. On tertiary survey on the evening
of HD2, the patient was noted to have bruising to the right ___
digit with tenderness to palpation and tenderness to palpation
over the right wrist at the anatomic snuffbox. A right hand XR
was ordered on HD3, which demonstrated a mildly displaced
fracture of the dorsal base of the distal fifth phalanx with
mild flexion deformity (concerning for mallet finger), and
likely chronic changes related to waist fracture of the
scaphoid. Hand Surgery was consulted, and a dedicated right
wrist XR was ordered.
The patient was seen by Hand Surgery on HD3, and given the
tenderness over the right anatomic snuffbox, was placed in a
thumb spica splint for ___ days until outpatient follow up
with repeat imaging. For ___ digit distal phalanx fracture, the
digit was taped in extension and instructed to keep the splint
in place for 6 weeks. If the splint is to be removed, the
patient was counseled on keeping his right fifth DIP in
extension. Dedicated right wrist XR showed osseous irregularity
and spurring about the scaphoid waist suggestive of prior old
injury, with no acute fracture or dislocation.
On HD3, the pigtail catheter was also put to water seal, with no
pneumothorax identified on repeat CXR. On HD4, repeat CXR showed
a small apical 1.5 cm pneumothorax after the chest tube was kept
to water seal overnight, but given its small size, the patient
was advanced to a clamp trial. Repeat CXR after 4 hr clamp trial
showed no change in pneumothorax, and the chest tube remained
clamped overnight. On HD 5, repeat CXR after overnight clamp
trial showed minimal decrease in the pneumothorax, and the
pigtail was pulled and an occlusive dressing placed.
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 ___
The patient was seen by Social Work, who determined he was safe
for discharge to home. The patient was evaluated by ___ and OT,
who recommended home with no services. The patient was then
deemed ready for discharge to home. 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 ___ He was
scheduled for outpatient follow up with the ___ (for
removal of his staples and follow up of his left 5th rib
fracture) and his PCP, and provided with the phone number for
the Hand Surgery clinic to arrange follow up ___ days after
discharge with repeat imaging.
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 - Mild/Fever
Please do not exceed 3gm in a 24 hour period.
2. Docusate Sodium 100 mg PO BID
Hold for loose stool.
3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
Please take with food. Alternate with Tylenol for pain.
4. Lidocaine 5% Patch 1 PTCH TD QAM left rib fx's
Please apply to affected area. On for 12 hours, off for 12
hours.
RX *lidocaine [Lidocaine Pain Relief] 4 % Please apply to
affected area. once a day Disp #*7 Patch Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
Please take lowest effective dose and wean as tolerated.
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*12 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
Hold for loose stool.
Discharge Disposition:
Home
Discharge Diagnosis:
Left 5th rib fracture
Left apical pneumothorax
Stab wounds x5
Right ___ distal phalanx avulsion fracture (mallet finger)
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 ___ after
a trauma with multiple stab wounds and a left 5th rib fracture.
Your stab wounds were not found to be deep, and were managed
conservatively. Your stab wounds were cleaned out, some were
closed with staples or covered with clean dry gauze. On imaging,
you were found to have a small amount of air in your chest due
to the rib fracture, and a chest tube was placed to remove it.
Repeat chest x-rays showed your lung was fully expanded, and
your chest tube was pulled on hospital day 4 without issue. CT
of your head/neck showed no fractures, and you were cleared from
the C-collar.
You were also found to have bruising of your right ___ finger
and tenderness over the base of your right thumb, and an XR
showed a fracture of your ___ finger. You were seen by Hand
Surgery, and they gave you a splint for your thumb and taped
your ___ finger. Keep your splint in place until you are seen by
the hand service in follow up. You were seen and evaluated by
Physical Therapy and Occupational Therapy, and they have cleared
you for discharge to home with no further services. You were
seen by Social Work, and they gave you resources about acute
stress and determined you were safe for discharge to home.
You are now tolerating a full diet, ambulating independently,
voiding without issue, breathing comfortably on room air, and
your pain is well-controlled on pain medications. You are now
deemed ready for discharge. Please follow the instructions below
to continue your recovery:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
RIB FRACTURES:
* Your injury caused a left 5th 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).
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 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 wounds are 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 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 For your chest tube dressing, tomorrow you may shower with
your water proof dressing.
o You may remove the chest tube dressing 3 days after your
discharge from the hospital.
o Your wounds may be slightly red around the staples. This is
normal.
o You may gently wash away dried material around your wounds.
o Avoid direct sun exposure to the wound area.
o Do not use any ointments on the wound 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.
MEDICATIONS:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed. If you have any questions
about what medicine to take or not to take, please call your
surgeon.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
|
19900867-DS-14 | 19,900,867 | 25,731,044 | DS | 14 | 2166-11-07 00:00:00 | 2166-11-07 14:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
___: Left hip hemiarthroplasty
History of Present Illness:
___ male history of hypertension, prostate cancer, left
patella fracture status post ORIF ___, ___ who
presents with left hip pain status post mechanical fall.
Patient
was walking home from the assisted living facility in which his
wife with dementia resides, when he tripped and fell on the
sidewalk today. He tried to get up and then fell again. He was
unable to bear weight on his left side. EMS brought him into
the
hospital for evaluation. He currently complains of pain "all
over". He is accompanied by his son who states that he has been
recently seen by neurology for evaluation of his cognitive
decline. He denies any numbness or tingling in his left lower
extremity. Positive head strike, negative loss of
consciousness.
Patient son states that he has been prescribed some home
medications, however he has not been taking any.
Past Medical History:
HTN, prostate cancer, MGUS, PUD, depression
Social History:
___
Family History:
non-contributory
Physical Exam:
Exam:
Vitals: ___ 0451 Temp: 98.1 PO BP: 129/73 R Lying HR: 95
RR:
18 O2 sat: 97% O2 delivery: Ra
General: Well-appearing, NAD
Resp: Normal WOB, symmetric chest rise
CV: Extremities WWP
MSK:
Left Lower Extremity:
SILT ___ distributions
Firing ___, FHL, TA, GSC
Incisional dressing clean dry and intact
Pertinent Results:
___ 07:07AM BLOOD WBC-7.6 RBC-3.39* Hgb-10.7* Hct-32.4*
MCV-96 MCH-31.6 MCHC-33.0 RDW-12.2 RDWSD-42.7 Plt Ct-86*
___ 07:07AM BLOOD Glucose-131* UreaN-22* Creat-1.0 Na-140
K-3.8 Cl-108 HCO3-23 AnGap-9*
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left hip hemiarthroplasty, 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
weightbearing as tolerated in the left extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 10 mg PO DAILY
2. Guaifenesin-CODEINE Phosphate 5 mL PO Q4H:PRN cough
3. LORazepam 0.5 mg PO Q6H:PRN anxiety
4. TraZODone 50 mg PO QHS:PRN Insomnia
5. Valsartan 80 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous Once nightly
Disp #*30 Syringe Refills:*0
5. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Third Line
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet by mouth Every 4 hours as needed
Disp #*25 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY constipation
8. Senna 17.2 mg PO HS
9. Citalopram 10 mg PO DAILY
10. Guaifenesin-CODEINE Phosphate 5 mL PO Q4H:PRN cough
11. LORazepam 0.5 mg PO Q6H:PRN anxiety
12. TraZODone 50 mg PO QHS:PRN Insomnia
13. Valsartan 80 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
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:
-Weightbearing as tolerated left lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- 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
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Treatments Frequency:
Skin staples in place, to be removed at 2-week follow-up
Followup Instructions:
___
|
19900961-DS-11 | 19,900,961 | 24,410,305 | DS | 11 | 2154-02-16 00:00:00 | 2154-02-16 23:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
atorvastatin / pravastatin
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ - Cardiac catheterization with coronary angiography
___ - 1. Coronary artery bypass graft x4, left internal
mammary artery to left anterior descending artery, saphenous
vein graft to distal right coronary artery, and saphenous vein
sequential graft to distal circumflex and ramus artery
History of Present Illness:
Mr. ___ is a ___ year old male with a history of coronary
artery disease status post non-ST elevation myocardial
infarction in ___levation myocardial infarction in
___. He presented with chest pressure and pain radiating to jaw
and teeth for 3 days. He reports that he got up to answer the
door a few days ago and experienced chest pain and heaviness in
his legs. He took an aspirin and the symptoms resolved. The
exact same symptoms occurred again the following day when he was
doing yard work, and again resolved with rest. On the day of
admission, he was getting ready for church and experienced the
same symptoms again, but this time at rest. He also reported
that during this episode the pain radiated to his jaw/teeth,
which is how his chest pain felt during his prior ACS events.
During all of these episodes he denied shortness of breath,
nausea, abdominal pain, or diaphoresis. In the ED he was given
sublingual nitroglycerin and heparin drip. A cardiac
catheterization demonstrated multivessel coronary artery
disease. Cardiac surgery was consulted for surgical
revascularization.
Past Medical History:
Coronary Artery Disease s/p prior PCI
Depression
Diabetes Mellitus Type II
Hyperlipidemia
Non-ST Elevation Myocardial Infarction, ___levation Myocardial Infarction, ___
Social History:
___
Family History:
Aunt - DM, ___ failure
Mother - ___ CA, DM, CAD with CABG x3 in her ___, CKD
Father - HTN, HLD
Uncle - DM, CAD with triple bypass
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VITALS:98.2 PO 130/70 L Lying 60 18 100 RA
Admission weight: 84.1 kg (185.41 lb)
GENERAL: WDWN. Pleasant, in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no appreciable JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, overweight but 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:
==========================
Pertinent Results:
Transthoracic Echocardiogram ___
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the basal
inferior and mid inferolateral walls. The remaining segments
contract normally (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
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction
c/w CAD (RCA territory). Mild mitral regurgitation. Compared
with the prior rest images from the stress echo study (images
reviewed) of ___ the regional dysfunction is new.
Cardiac Catheterization ___
Dominance: Right
LMCA: focal eccentric calcification and distal tapering.
LAD: calcified, eccentric ostial 65% stenosis followed by mild
plaquing in the proximal-mid LAD. The stent in the LAD had mild
in-stent restenosis. The distal LAD had mild plaquing. The
apical LAD had a 70% bifurcation lesion at the terminal
mustache. There were septal collaterals to the RPDA.
RI: proximal 50% diffuse bifurcation lesion.
LCX: stented, proximal edge 90% tubular stenosis with
underfilling of
the stented CX with likely at least moderate in-stent
restenosis. The LPL had a proximal 80% tubular stenosis.
RCA: mild plaquing proximally to 30%. The mid RCA was 65%
stenosed. The distal AV groove RCA had a 90% bifurcation lesion
extending from the distal RCA before the RPDA into the RPDA.
RPL1 and RPL2 were short. The RPL3 was longer and tortuous.
Transesophageal Echocardiogram ___
PRE BYPASS The left atrium is dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. The right atrium is dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. There
is mild global left ventricular hypokinesis (LVEF = 45 %). The
right ventricular cavity is dilated with borderline normal free
wall function. There are simple atheroma in the ascending aorta.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate (___) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Tricuspid valve prolapse is present. There is no
pericardial effusion. Dr. ___ was notified in person
of the results in the operating room at the time of the study.
POST BYPASS The patient is in sinus rhythm. There is normal
biventricular systolic function. Valvular function is unchanged
from the prebypass exam. The thoracic aorta is intact after
decannulation.
___ 05:34AM BLOOD WBC-9.0 RBC-2.94* Hgb-8.4* Hct-25.7*
MCV-87 MCH-28.6 MCHC-32.7 RDW-12.4 RDWSD-39.4 Plt ___
___ 04:00AM BLOOD ___ PTT-26.2 ___
___ 05:34AM BLOOD Glucose-153* UreaN-22* Creat-0.9 Na-142
K-4.2 Cl-103 HCO3-29 AnGap-10
___ ___ M ___ ___
Radiology Report CHEST (PA & LAT) Study Date of ___ 10:29
AM
Final Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with s/p CABG// eval postop changes
IMPRESSION:
In comparison with the study of ___, the right IJ catheter
tip remains at the level of the carina. Bibasilar
opacifications again are consistent with atelectatic changes.
There may be a small right pleural effusion.
No evidence of pneumothorax.
Brief Hospital Course:
He ruled in for non-ST elevation myocardial infarction with a
peak troponin of 0.95. He agreed to receive cell saver
transfusion. He was taken to the operating room on ___ and
underwent coronary artery bypass grafting x 4. Please see
operative note for full details. He tolerated the procedure well
and was transferred to the CVICU in stable condition for
recovery and invasive monitoring.
He weaned from sedation, awoke neurologically intact and was
extubated later that day. He was weaned from inotropic and
vasopressor support. Beta blocker was initiated and he was
diuresed toward his preoperative weight. He remained
hemodynamically stable and was transferred to the telemetry
floor for further recovery. He was evaluated by the physical
therapy service for assistance with strength and mobility. He
repeatedly got dizzy after taking Dilaudid so this was
discontinued and he was changed to tramadol for pain. By the
time of discharge on POD #5 he was ambulating freely, the wound
was healing, and pain was controlled with oral analgesics. He
was discharged to home in good condition with appropriate follow
up instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO BID
3. glimepiride 2 mg oral DAILY
4. Sildenafil 20 mg PO DAILY:PRN sexual activity
5. Aspirin 81 mg PO DAILY
6. Rosuvastatin Calcium 5 mg PO QPM
Discharge Medications:
1. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0
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. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
4. Furosemide 20 mg PO DAILY Duration: 5 Days
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
5. Metoprolol Tartrate 25 mg PO TID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
6. Potassium Chloride 20 mEq PO DAILY Duration: 5 Doses
RX *potassium chloride 20 mEq 1 tablet(s) by mouth once a day
Disp #*5 Tablet Refills:*0
7. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*50 Tablet Refills:*0
8. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
9. Rosuvastatin Calcium 10 mg PO QPM
RX *rosuvastatin [Crestor] 10 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
10. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
11. glimepiride 2 mg oral DAILY
RX *glimepiride [Amaryl] 2 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
12. Sildenafil 20 mg PO DAILY:PRN sexual activity
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Coronary Artery Disease
Non-ST Elevation Myocardial Infarction
Secondary diagnoses:
Diabetes Mellitus Type II
Hyperlipidemia
Non-ST Elevation Myocardial Infarction, ___
ST Elevation Myocardial Infarction, ___
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Discharge Instructions
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
19900981-DS-12 | 19,900,981 | 26,885,641 | DS | 12 | 2167-06-05 00:00:00 | 2167-06-06 17:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / bacitracin
Attending: ___.
Chief Complaint:
chest pain, dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ y/o male with a history of sickle cell disease
and "big heart and murmur" who presents with sudden onset chest
pain and dyspnea at 3PM yesterday. Pt describes heart
palpitations occurring at 3p on ___, accompanied by SOB,
diaphoresis, tachycardia that was constant and unremitting until
2 pm. Localizes pain onto L precordium, sharp quality, radiating
down both arm, no relief with 8 mg Dilaudid PO, no aggravating
or releiving factors identified, including position or
breathing. States this is unlike sickle cell crises he has had
in the past (usually back and knees), denies ever having had
chest pain in the past. Denies fevers or chills. His last
sickle cell crisis and last transfusion was about 6 weeks ago.
In the ED, initial VS were 8 98.6 66 117/68 16 94% ra. Labs were
notable for WBC 12.1 (44% PMNs), H/H 22.1/7.2,
Diagnosis:
ED Course (labs, imaging, interventions, consults):
[x] labs: crit 22
[x] retic count
[x] cross 2 units
[x] pain meds- diluadid control
[x] cxr: no infiltrate
[x] abx for possible acute chest syndrome
[x] ekg: sinus 59, normal axis, no st elevation, LVH, normal
intervals
[x] d-dimer: 4000
[x] trop: 0.05
[x] CTA: lingula stuff, no PE
[x] Fluids: received 4L of IVF
Disposition/Pending: admit medicine for acute chest syndrome
from sickle cell, IVF, pain control
Admission Vitals:
Ground glass nodule in lingula that will need to be followed up
in 6 months with CT scan.
On the floor, VS were: 97.7 T 64 P ___ BP 18 R 94% ra O2 sat
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. sinus tenderness, rhinorrhea or congestion. Denies cough,
shortness of breath. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Currently denies cp, SOB, tachycardia. Endorses mild HA, states
that this is usual in hospital setting, frontal, not accompanied
by aura, usually treated with Tylenol.
Past Medical History:
"Big heart"
"Murmur"
Sickle cell
Iron overload d/t multiple transfusions
Social History:
___
Family History:
Brother, passed away @ ___ from complications from BMT for sickle
cell anemia.
Diabetes in extended family but not immediate.
Physical Exam:
INITIAL PHYSICAL EXAM
Vitals: T:97.7 BP: 141/83 P: 64 R: 18 O2: 94%
General: Alert, oriented, no acute distress
HEENT: Mild Sclera icterius, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, Systolic II/VI murmur, ?diastolic
murmur nest appreciated at LUSB, heave appreciated, laterally
displaced PMI, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes appreciated, no c/c/e
Neuro: AAOx3, full range of motion
DISCHARGED PHYSICAL EXAM
VS 98.4 109/58 69 16 98%RA
General: Alert, oriented, no acute distress
HEENT: MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, Systolic II/VI murmur best
appreciated at LUSB. Heave palpation at midclavicular line. No
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes appreciated, no c/c/e
Neuro: AAOx3, full range of motion
Pertinent Results:
INITIAL LABS
-------------------
___ 08:24PM BLOOD WBC-11.6* RBC-2.29* Hgb-7.5* Hct-22.7*
MCV-99* MCH-32.8* MCHC-33.1 RDW-21.8* Plt ___
___ 08:24PM BLOOD Neuts-48* Bands-0 Lymphs-45* Monos-3
Eos-4 Baso-0 ___ Myelos-0 NRBC-1*
___ 08:24PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-2+
Macrocy-3+ Microcy-NORMAL Polychr-2+ Ovalocy-OCCASIONAL
Target-OCCASIONAL Sickle-2+ How-Jol-OCCASIONAL
Ellipto-OCCASIONAL
___ 08:24PM BLOOD Plt Smr-NORMAL Plt ___
___ 08:24PM BLOOD Ret Man-12.8*
___ 08:24PM BLOOD Glucose-103* UreaN-10 Creat-0.5 Na-136
K-4.1 Cl-103 HCO3-28 AnGap-9
___ 08:24PM BLOOD LD(LDH)-710*
___ 10:20PM BLOOD cTropnT-0.05*
___ 08:24PM BLOOD Hapto-<5*
___ 10:39PM BLOOD Lactate-0.7 Na-139 K-3.7 Cl-102
___ 11:30PM URINE cocaine-NEG
PERTINENT LABS
---------------
___ 10:20PM BLOOD cTropnT-0.05*
___ 08:30AM BLOOD CK-MB-19* MB Indx-10.7*
___ 05:25PM BLOOD cTropnT-0.45*
___ 12:43AM BLOOD CK-MB-8 cTropnT-0.44*
___ 08:30AM BLOOD CK-MB-5 cTropnT-0.41*
___ 08:30AM BLOOD Ret Man-26.2*
___ 10:20PM BLOOD D-Dimer-4003*
IMAGING:
----------
<b> Cardiovascular ReportECGStudy Date of ___ 7:51:32
___ </b>
Sinus bradycardia. Prominent precordial voltage and
inferolateral Q waves
which may be consistent with hypertrophy. The extent of R wave
prominence in
the precordial leads seems greater than expected for age.
Clinical correlation
is suggested. No previous tracing available for comparison.
Read ___
___
___
<b> Study Date of ___ 10:34 ___ Radiology Report
CHEST (PA & LAT) </b>
FINDINGS: No definite focal consolidation is seen. No large
pleural
effusion. The cardiac silhouette is at least mildly enlarged.
No
pneumothorax. No overt pulmonary edema. Subtle early
appearance of
eight-shaped vertebra involving the thoracic spine, correlate
with history of
sickle cell disease. Right upper quadrant surgical clips are
from presumed
cholecystectomy.
IMPRESSION: Mildly enlarged cardiac silhouette without overt
pulmonary edema.
<b> ___ CXR: Final Report </b>
INDICATION: Chest pain and shortness of breath. Evaluate for
PE. The
patient has history of sickle cell disease.
COMPARISON: None.
TECHNIQUE: Contiguous helical MDCT images were obtained through
the chest
after administration of 100 cc of Omnipaque IV contrast.
Multiplanar axial,
coronal, sagittal and maximum intensity projection oblique
images were
generated.
TOTAL BODY DLP: 149 mGy-cm.
FINDINGS: There is no supraclavicular, axillary, or mediastinal
lymphadenopathy. A borderline 1 cm right hilar lymph node is of
unclear
clinical significance. The heart is mildly enlarged, but
without pericardial
effusion. The aorta and main pulmonary arteries are normal in
caliber. There
are no appreciable atherosclerotic calcifications of the
coronary arteries.
There is no pleural effusion or pneumothorax. There is mild
bibasilar
atelectasis. 7 mm irregular opacity in the right upper lobe may
reflect
scarring. There is an indeterminant 9 mm ground-glass opacity
in the lingula
(3:125). The airways are patent to the subsegmental level.
<b> CTA CHEST </b>
: The aorta and great vessels are normally opacified. The
pulmonary
arteries are opacified to the subsegmental level without
evidence of pulmonary
embolism.
OSSEOUS STRUCTURES: H-shaped appearance of the vertebrae is
compatible with
known sickle cell disease.
This study is not designed for evaluation of the
subdiaphragmatic structures;
however, the spleen is shrunken to 2.9 x 1.1 cm and compatible
with
auto-infarction.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Mild cardiomegaly.
3. 9 mm ground-glass opacity in the lingula should be followed
up in six
months.
4. H-shaped vertebrae and auto infarction of the spleen
compatible with known
sickle cell disease.
The study and the report were reviewed by the staff radiologist.
<b> ___ 9:11:04 ___ ECG </b>
Artifact is present. Sinus rhythm. There are Q waves in the
inferior leads
consistent with infarction. There are Q waves in the
anterolateral leads and
an early transition consistent with posterior extension of the
infarction.
Compared to the previous tracing of ___ QRS voltages are
less.
Read ___.
___
___
<b> ___ TRANSTHORACIC ECHO </b>
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.6 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1
cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1
cm
Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.7 cm
Left Ventricle - Fractional Shortening: 0.38 >= 0.29
Left Ventricle - Ejection Fraction: 64% >= 55%
Left Ventricle - Stroke Volume: 91 ml/beat
Left Ventricle - Cardiac Output: 5.47 L/min
Left Ventricle - Cardiac Index: 3.49 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.16 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.10 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 7 < 13
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 3.0 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 24
Aortic Valve - LVOT diam: 2.2 cm
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 1.50
Mitral Valve - E Wave deceleration time: 183 ms 140-250 ms
TR Gradient (+ RA = PASP): 19 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Mild ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. No ASD
by 2D or color Doppler. Normal IVC diameter (<=2.1cm) with <50%
decrease with sniff (estimated RA pressure ___ mmHg).
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity. Normal regional LV systolic function. Overall normal
LVEF (>55%). Estimated cardiac index is normal (>=2.5L/min/m2).
TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. No MVP. No MR.
___ VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is ___ mmHg.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal. Quantitative (biplane) LVEF = 64 %.
The estimated cardiac index is normal (>=2.5L/min/m2). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Moderately dilated left ventricle with normal
global/regional biventricular systolic function
LAB RESULTS ON DISCHARGE:
___ 08:30AM BLOOD WBC-8.7 RBC-2.23* Hgb-7.0* Hct-22.1*
MCV-99* MCH-31.3 MCHC-31.6 RDW-20.3* Plt ___
___ 08:30AM BLOOD Neuts-32* Bands-0 Lymphs-58* Monos-5
Eos-4 Baso-0 Atyps-1* ___ Myelos-0 NRBC-4*
___ 08:30AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-2+
Macrocy-3+ Microcy-NORMAL Polychr-2+ Ovalocy-2+ Sickle-2+
Stipple-OCCASIONAL How-Jol-OCCASIONAL Ellipto-1+
___ 08:30AM BLOOD ___ PTT-27.0 ___
___ 08:30AM BLOOD Plt Smr-NORMAL Plt ___
___ 08:30AM BLOOD Ret Man-26.2*
___ 08:30AM BLOOD Glucose-92 UreaN-8 Creat-0.6 Na-141 K-3.8
Cl-106 HCO3-27 AnGap-12
___ 08:30AM BLOOD ALT-33 AST-73* LD(LDH)-621* CK(CPK)-70
AlkPhos-62 TotBili-2.9*
___ 08:30AM BLOOD CK-MB-5 cTropnT-0.41*
___ 08:30AM BLOOD Calcium-8.7 Phos-4.8* Mg-2.1
___ 12:44PM URINE cocaine-NEG
Brief Hospital Course:
___ yo M with a history of sickle cell disease who presented with
sudden onset chest pain with radiation down his arms and
dyspnea, found to have elevated troponin.
ACTIVE ISSUES
# Chest pain/NSTEMI: The patient's initial story was concerning
for cardiac etiology and troponin peaked at 0.45. CTA was
negative for PE. It's unclear whether the patient's myocardial
infarction was secondary to plaque rupture or vaso-occlusion due
to sickling. EKG showed old q-waves but no acute changes. The
chest pain resolved shortly after admission without any
intervention. Patient was discharged on aspirin and statin for
now due to possibility that this was a plaque rupture MI. He
will follow-up with cardiology to discuss stress testing as an
outpatient.
#Sickle cell: Pt presented with Hct ~22, which per pt is
baseline; however, reticulocyte count was markedly elevated
(26.2) and TBili and Hapto is low, implying increased hemolysis
consistent with sickle cell crisis. Patient placed on
maintenance IV fluids, Hydroxyurea 500 mg qd, Hydromorphone 4 mg
PO prn pain, 5 mg Folic acid, O2 NC.
TRANSITIONAL ISSUES
[] CXR revealed 9 mm ground-glass opacity in the lingula. Should
have follow-up imaging in six months.
[] Cardiology to arrange subsequent stress testing to determine
likelihood of ACS versus other etiologies of chest pain
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FerrouSul (ferrous sulfate) 325 mg (65 mg iron) oral daily
2. FoLIC Acid 1 mg PO DAILY
3. HYDROmorphone (Dilaudid) 4 mg PO QID:PRN pain
4. ALPRAZolam Dose is Unknown PO Frequency is Unknown
5. Ibuprofen 400 mg PO Q6H:PRN pain
6. Senna 8.6 mg PO BID:PRN constipation
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Hydroxyurea 500 mg PO BID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. FoLIC Acid 0 mg PO DAILY
3. HYDROmorphone (Dilaudid) 4 mg PO QID:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth QID:PRN Disp #*120
Tablet Refills:*0
4. Hydroxyurea 500 mg PO BID
5. Ibuprofen 400 mg PO Q6H:PRN pain
6. Senna 8.6 mg PO BID:PRN constipation
7. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. ALPRAZolam 0 mg PO Frequency is Unknown
10. FerrouSul (ferrous sulfate) 325 mg (65 mg iron) oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: NSTEMI
SECONDARY DIAGNOSIS: 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 in
with chest pain. You were found to have a high troponin level
which measures heart damage. We gave you aspirin and
atorvastatin for your chest pain, and treated your sickle cell
with fluids, and other medications to reduce sickling and
promote blood cell production. We consulted cardiology regarding
your care, and they would like you to follow up with them.
Followup Instructions:
___
|
19900981-DS-14 | 19,900,981 | 25,189,471 | DS | 14 | 2167-11-21 00:00:00 | 2167-11-22 17:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / bacitracin
Attending: ___.
Chief Complaint:
pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ pmHx sickle cell anemia requiring admissions ___ who
presents with diffuse pain. He states that yesterday, he began
experiencing sudden diffuse pain worst on his chest. Denies
nausea, vomiting, fever or chills. He states that his pain has
improved significantly. He continues to have ___ (improved from
___ R sided chest pain that was originally constant, but now
intermittent and worsened by movement. He also has b/l knee and
back pain, also improved from previously. He is also finished
with a 10d course azithromycin prescribed to him by her primary
care physician for SOB, productive cough, and rhinnorhea over
the past several weeks. His symptoms has improved and he
continues to have mild productive cough.
Most recently hospitalized ___ for sickle cell crisis and
transfused 1 unit.
In the ED, initial vitals were: 100 85 122/50 16 83% ra. He was
given 2L IVFs, 2g cefepime x2, 1mg dilaudid x3, and ketorlac
30mg. Initial labs were significant for WBC 14.1, H/H 6.9/18.9,
neg troponin, lactate 1.3, ALT 42, AST 145, AP 65, LDH 1232, T
bili 4.8, Dbili 0.6, haptop <5, retic 13.8. CXR showed subtle
opacity at the base of the right lung.
Past Medical History:
- Sickle cell anemia. Diagnosed around age ___. Most recent pain
crisis ___, generally has ___ times per year. Does not recall
prior episodes of acute chest, but has had pneumonias.
- NSTEMI, hospitalized at ___ ___. Troponin in 0.4 range,
positive MB and MBI.
- Iron overload, on deferasirox
- History of several episodes of pneumonia, further details
unknown. In ___ this led to ICU stay; no history of
intubations.
- Asthma, diagnosed in childhood, no inhalers x years
- Vitamin D deficiency
No history of VTE, liver disease, autoimmune disease.
PSHx:
- Cholecystectomy
Social History:
___
Family History:
Mother has seizure disorder
Brother, passed away @ ___ from complications from BMT for sickle
cell anemia.
Diabetes in extended family but not immediate.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:98.1 BP:106/56 P:71 R:18 O2:99/3L
General: Alert, oriented, lying in bed in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
throughout, + heave
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rash
Neuro: AOx3. CN2-12 intact
DISCHARGE PHYSICAL EXAM:
Vitals: T:97.3 BP:113/69 P:74 R:16 O2:94 RA
General: Alert, oriented, sitting in bed in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
throughout, rubs, gallops. +heave.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rash
Neuro: AOx3. CN2-12 intact
Pertinent Results:
ADMISSION LABS:
___ 12:00AM BLOOD WBC-14.1* RBC-1.99* Hgb-6.9* Hct-18.9*
MCV-95 MCH-34.7* MCHC-36.5* RDW-22.5* Plt ___
___ 12:00AM BLOOD Neuts-57 Bands-0 ___ Monos-3 Eos-8*
Baso-0 ___ Myelos-0 NRBC-1*
___ 12:00AM BLOOD Plt Smr-NORMAL Plt ___
___ 12:00AM BLOOD Ret Man-13.8*
___ 12:00AM BLOOD Glucose-110* UreaN-12 Creat-0.7 Na-138
K-4.4 Cl-101 HCO3-28 AnGap-13
___ 12:00AM BLOOD ALT-42* AST-145* LD(LDH)-1232* AlkPhos-65
TotBili-4.8* DirBili-0.6* IndBili-4.2
___ 12:00AM BLOOD Lipase-54
___ 12:00AM BLOOD cTropnT-<0.01
___ 12:00AM BLOOD Albumin-4.1 Calcium-9.7 Phos-5.0* Mg-2.2
___ 12:00AM BLOOD Hapto-<5*
___ 12:10AM BLOOD Lactate-1.3
___ portable CXR: Slightly low lung volumes. Subtle opacity at
the base of the right lung could represent atelectasis however
infection should be considered in the appropriate clinical
setting. Recommend followup chest radiograph for further
evaluation if clinically indicated.
___ PA/Lat:
As compared to the previous radiograph, a pre-existing
bilateral parenchymal opacities at the lung bases have
incompletely resolved. Minimal remnant opacities are still
visualized. No pleural effusions. No pulmonary edema. Moderate
cardiomegaly persists.
DISCHARGE LABS:
___ 06:12AM BLOOD WBC-9.5 RBC-2.43*# Hgb-7.9*# Hct-22.8*#
MCV-94 MCH-32.5* MCHC-34.6 RDW-21.3* Plt ___
___ 06:12AM BLOOD ___ PTT-27.3 ___
___ 06:12AM BLOOD Glucose-92 UreaN-11 Creat-0.5 Na-140
K-4.3 Cl-108 HCO3-26 AnGap-10
___ 06:12AM BLOOD LD(LDH)-854*
___ 06:12AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ with a PMHx of sickle cell disease and
NSTEMI who presented with diffuse pain and hypoxia consistent
with pain crisis likely secondary to pneumonia which improved
with IVFs, pain control, supplemental O2 and transfusion of
PRBCs.
# Sickle cell crisis: Patient presented with severe pain found
to have hypoxia to 83% on RA and Hgb 6.9 (baseline) with
elevated Tbili, LFTs, LDH and retic count consistent with
hemolysis. CXR showed likely pneumonia for which he was started
on ceftriaxone (was previously on azithromycin as outpatient
making atypical organisms causing this presentation less
likely). He was given 1u prbcs on ___ drop in Hgb to 6.1 on
___. Pain improved with this transfusion as well as IV
dilaudid, IVFs and supplemental O2. Patient remained afebrile
during hospital course and was discharged on home pain regimen
and was switched to cefpodixime to complete 5d course of
antibiotics. He was weaned to RA by day of discharge. Home
hydroxyurea and folate supplementation was continued.
# H/O NSTEMI: Continued home ASA and atorvastatin
TRANSITIONAL ISSUES:
- received 1U RBC ___, pretreated with benadryl
- Discharged on cefpodixime 200mg BID, last day ___.
- Discharged on 4mg dilaudid q4-6h prn (home regimen)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. FoLIC Acid 1 mg PO DAILY
5. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain
6. Hydroxyurea 1000 mg PO DAILY
7. Senna 8.6 mg PO BID:PRN constipation
8. Lactulose 10 mL PO Q12H:PRN constipation
9. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
10. Exjade (deferasirox) 250 mg oral BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. FoLIC Acid 1 mg PO DAILY
5. Hydroxyurea 1000 mg PO DAILY
6. Senna 8.6 mg PO BID:PRN constipation
7. Exjade (deferasirox) 250 mg oral BID
8. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain
9. Lactulose 10 mL PO Q12H:PRN constipation
10. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
11. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 4 Doses
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*4
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
SICKLE CELL CRISIS
PNEUMONIA
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 for low hemoglobin levels and pain. Your pain
crisis was treated with a IV pain medications, IV fluids, oxygen
and a blood transfusion. Your blood counts were low while you
were in the hospital for which you received a blood transfusion.
You pain crisis may have been triggered by an infection and you
were started on an antibiotic. Please continue to take it twice
a day. You already received today's dose in the hospital but
will need to take the antibiotic twice a day on ___ and ___
to complete your course. Please follow up with your PCP ___
after discharge.
We wish you all the best,
Your ___ Care team
Followup Instructions:
___
|
19900981-DS-15 | 19,900,981 | 27,544,733 | DS | 15 | 2167-12-22 00:00:00 | 2167-12-23 20:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / bacitracin
Attending: ___
Chief Complaint:
HMED ADMISSION NOTE
___
___
CC: chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with sickle cell disease who presents with sickle cell
crisis x4 days.
He states he developed pain 4 days prior. Pain right sided
throughout torso and left side by neck. Denies left sided chest
pain. In contrast to regular flares, the pain location is
diffierent (often chest and joints). Given difficulties with
pain controled he decided to present to ED. He also reports
cough with green sputum. Denies shortness of breath.
In the ED, initial vitals were: Pain: 9, T 100.9, HR 87, BP
123/69, RR 16, SvO2 95% RA. He had CXR which showed LLL opacity
and he was treated with CTX and azithromycin. He was also given
2L NS and 4mg total of IV dilaudid. He was admitted to medicine
for further evaluation and management.
Currently, he feels similar to presentation with ___ pain. He
denies other symptoms. Denies bleeding or constipation.
ROS: Per above. Otherwise negative.
Past Medical History:
- Sickle cell anemia. Diagnosed around age ___. Most recent pain
crisis ___, generally has ___ times per year. complicated by
osteonecrosis and priapism.
- NSTEMI, hospitalized at ___ ___. Troponin in 0.4 range,
positive MB and MBI.
- Iron overload, on deferasirox.
- History of several episodes of pneumonia, further details
unknown. In ___ this led to ICU stay; no history of
intubations.
- Asthma, diagnosed in childhood, resolved.
- Vitamin D deficiency.
- Cholecystectomy.
Social History:
___
Family History:
Mother has seizure disorder. Brother, passed away @ ___ from
complications from BMT for sickle cell anemia. Diabetes in
extended family but not immediate.
Physical Exam:
Vitals: 98.0 107/49, 68, 20, 90 RA
Pain: ___
General: No distress, in bed
HEENT: Sclera icteric MMM
Neck: supple, JVP not elevated, no LAD
Chest: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, tender to palp over right chest wall and left neck
CV: RR, nl rate, soft systolic murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rash
Neuro: AOx3. CN2-12 intact, no deficits noted on conversation.
Discharge:
T 97.8 110/60 ___ 18 93-95% RA ___ pain
General: Well appearing in NAD
HEENT: Sclera icteric MMM
Neck: supple, JVP not elevated, no LAD
Chest: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, tender to palp over right chest wall improved compared
to yesterday
CV: RR, Loud S1 and S2, holosystolic murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rash
Neuro: AOx3. CN2-12 intact, no deficits noted on conversation.
Pertinent Results:
___ 01:15AM BLOOD WBC-12.1* RBC-1.88* Hgb-6.2* Hct-17.3*#
MCV-92 MCH-33.2* MCHC-36.0* RDW-21.2* Plt ___
___ 01:15AM BLOOD Neuts-48.6* ___ Monos-6.3
Eos-4.1* Baso-0.3
___ 01:15AM BLOOD Ret Man-16.6*
___ 01:15AM BLOOD Glucose-90 UreaN-16 Creat-0.7 Na-133
K-4.0 Cl-98 HCO3-26 AnGap-13
___ 01:15AM BLOOD ALT-45* AST-93* AlkPhos-71 TotBili-4.1*
___ 01:15AM BLOOD Albumin-3.8 Calcium-8.5 Phos-5.1* Mg-2.1
___ 01:23AM BLOOD Lactate-1.1
Discharge labs:
___ 06:55AM BLOOD Hgb-7.3* Hct-19.9*
___ 06:45AM BLOOD Glucose-82 UreaN-13 Creat-0.5 Na-137
K-4.3 Cl-104 HCO3-26 AnGap-11
___ 06:45AM BLOOD LD(LDH)-711* TotBili-3.4*
___ 06:45AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.0
CXR: Subtly increased density at the posterior left lung base
suspicious for
pneumonia versus acute chest syndrome.
Blood cultures: NGTD
Brief Hospital Course:
___ with sickle cell disease who presents with pain crisis and
concern for acute chest syndrome vs bacterial pneumonia.
# Acute chest syndrome vs bacterial pneumonia:
# Sickle cell crisis:
Pt presented with symptoms of sickle cell crisis with increased
pain over his right side. CXRay revealed a small infiltrate
that was indicative of acute chest syndrome vs bacterial
pneumonia. Pt had evidence of hemolysis worse than baseline
suggestive of sickle cell crisis. His hemoglobin nadired to 5.7,
at baseline about 7, and he was transfused one unit with good
response. He was treated with levofloxacin and will complete a 6
day course. He was treated with IV dilaudid, toradol, tylenol,
supplemental oxygen, incentive spirometry, hydroxyurea, and
folate. By discharge, he was satting 93-95% on RA. The pt was
discharged on his home pain regimen. He will discuss use of
long acting narcotic agents with short acting for breakthrough
with his PCP
# ___ NSTEMI:
Continue home medications.
# Constipation:
Continue home bowel regimen.
Transitional: To follow up with PCP and hematologist
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. FoLIC Acid 1 mg PO DAILY
5. Hydroxyurea 1000 mg PO DAILY
6. Senna 8.6 mg PO BID:PRN constipation
7. Exjade (deferasirox) 250 mg oral BID
8. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain
9. Lactulose 10 mL PO Q12H:PRN constipation
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Exjade (deferasirox) 250 mg oral BID
6. FoLIC Acid 1 mg PO DAILY
7. Hydroxyurea 1000 mg PO DAILY
8. Lactulose 10 mL PO Q12H:PRN constipation
9. Senna 8.6 mg PO BID:PRN constipation
10. Vitamin D 1000 UNIT PO DAILY
11. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*3
Tablet Refills:*0
12. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Acute chest syndrome
Sickle cell pain crisis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a sickle cell pain crisis and acute chest
syndrome. You were treated with narcotics, fluids, antibiotics,
and 1 unit of packed red blood cells. You should complete your
antibiotic course which you should take through ___
Followup Instructions:
___
|
19900981-DS-17 | 19,900,981 | 22,537,206 | DS | 17 | 2168-02-09 00:00:00 | 2168-02-10 01:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / bacitracin
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y.o. man with sickle cell disease previously complicated by
osteonecrosis and priaprism and multiple episodes of acute pain
crises and NSTEMI in ___ presents with L-sided chest pain
and hand pain. Patient states he was in his usual state of
health, had a blood transfusion earlier today, when suddenly
started experiencing pain. Denies fever/chills, dyspnea,
additional pain or symptoms. He reports this presentation feels
different from his pain crises which usually manifest as back
and bilateral knee pain.
In the ED, the patient's VS were T:98.4 BP: Rt arm 126/72, Lt
arm 120/75 mmHg supine, HR 52 bpm, RR 15, O2: 95 % on RA. CXR
was notable for a small right pleural effusion but not PNA. CTA
was negative for PE. EKG was notable for NSR, LVH, no ischemic
changes. Trop 0.01 -> 0.62-> 0.74. CTA negative for PE.
Presentation concerning for NSTEMI, patient was started on ASA,
Atorvastatin, and heparin gtt. Patient was started on
supplemental O2, IV fluids, and Dilaudid. H/H was stable at H/H
stable 10.3/29.6 and did not require any transfusions.
On the floor, the patient endorsed improving, but continued ___
chest pain at rest. He was continued on IV fluids, supplemental
O2, and nitro gtt. He was continued on heparin gtt and started
on PCA Dilaudid.
Past Medical History:
-Sickle cell disease c/b priapism and osteonecrosis
-s/p NSTEMI ___
-Iron overload, on deferasirox.
-s/p several episodes of pneumonia. In ___ this led to ICU
stay; no history of
intubations.
-Hx of Asthma,
-Vitamin D deficiency.
-Mild pulmonary hypertension
Social History:
___
Family History:
Brother died at age ___ from complications
of bone marrow transplant. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death
Physical Exam:
ON ADMISSION:
VS: T 98.8 HR 67 BP 116/57 RR 18 SpO2 97% RA
GENERAL: Tired-appeaering in mild distress
HEENT: Sclera incterus. MMM, no oropharyngeal lesions.
NECK: Supple, no JVD, no cervical lymphadenopathy.
CARDIAC: RRR, no m,r,g. Normal S1 and S2.
CHEST: Pain is no reproducible on palpation of chest wall. No
wheezing, crackles, or rhonci.
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
NEURO: CN II-XII grossly intact. Full UE and ___ strength and
sensation bilaterally.
ON DISCHARGE:
VS: Tmax 98.1 Tc 98.1 HR 50-60s BP 100-120s/50-70s RR ___ SpO2
96-97% RA, Wt (50.6 kg)
I/O 24h 3550/3075, 8h ___
GENERAL: Tired-appearing, NAD
HEENT: Sclera incterus. MMM, no oropharyngeal lesions.
NECK: Supple, no JVD, no cervical lymphadenopathy.
CARDIAC: RRR, no m,r,g. Normal S1 and S2.
CHEST: Normal respiratory effort. No wheezing, crackles, or
rhonci.
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
NEURO: CN II-XII grossly intact. Full UE and ___ strength and
sensation bilaterally.
Pertinent Results:
ADMISSION LABS:
___ 04:00AM PLT COUNT-332
___ 04:00AM HYPOCHROM-1+ ANISOCYT-3+ POIKILOCY-3+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-1+ TARGET-1+ SICKLE-2+
SCHISTOCY-OCCASIONAL BURR-OCCASIONAL TEARDROP-OCCASIONAL
___ 04:00AM NEUTS-34.7* LYMPHS-53.2* MONOS-6.0 EOS-5.4*
BASOS-0.8
___ 04:00AM WBC-11.7* RBC-3.21*# HGB-10.3*# HCT-29.6*#
MCV-92 MCH-32.1* MCHC-34.9 RDW-23.5*
___ 04:00AM cTropnT-<0.01
___ 04:00AM estGFR-Using this
___ 04:00AM GLUCOSE-115* UREA N-15 CREAT-0.8 SODIUM-138
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-29 ANION GAP-15
___ 04:02AM LACTATE-1.1
___ 04:02AM ___ COMMENTS-GREEN
___ 09:40AM cTropnT-0.62*
___ 03:33PM cTropnT-0.74*
___ 11:30PM PTT-31.6
___ 09:07AM BLOOD CK-MB-14* cTropnT-0.53*
___ 03:33PM BLOOD cTropnT-0.74*
___ 09:40AM BLOOD cTropnT-0.62*
___ 09:07AM BLOOD LD(LDH)-766* TotBili-2.5*
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-7.8 RBC-2.73* Hgb-8.6* Hct-25.2*
MCV-92 MCH-31.6 MCHC-34.2 RDW-20.5* Plt ___
___ 08:00AM BLOOD Glucose-96 UreaN-12 Creat-0.5 Na-138
K-4.3 Cl-106 HCO3-22 AnGap-14
___ 08:00AM BLOOD Calcium-8.8 Phos-4.5 Mg-1.9
IMAGING:
TTE ___
Conclusions
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity is mildly dilated. Overall
left ventricular systolic function is mildly depressed (LVEF= 45
%) with mild global hypokinesis most prominent in the mid to
distal inferior/infero-lateral walls. There is no ventricular
septal defect. Right ventricular chamber size is normal. with
borderline normal free wall function. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
estimated pulmonary artery systolic pressure is normal. There is
a trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of ___, LV
systolic dysfunction is new.
CTA ___
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Ill-defined nodular opacities within the right middle and
lower lobes may
represent early pneumonia.
3. Moderate to severe cardiomegaly.
4. Small right greater than left layering simple pleural
effusions.
5. Anterior mediastinal soft tissue may represent thymic
hyperplasia,
unchanged since prior exam.
TTE ___
Conclusions
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity is mildly dilated. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The estimated cardiac
index is normal (>=2.5L/min/m2). 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. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
estimated pulmonary artery systolic pressure is normal. There is
a very small pericardial effusion.
IMPRESSION: Mild left ventricular cavity dilation with normal
regional and global biventricular systolic function.
Compared with the report of the prior study (images unavailable
for review) of ___, regional left ventricular systolic
function apears normal and trace aortic regurgitation is now
seen.
If clinically indicated, a cardiac MRI would be better able to
assess regional left ventricular function and to assess for
possible prior infarction of the inferior wall.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
___ y.o. man with sickle cell disease previously complicated by
osteonecrosis and priaprism and multiple episodes of acute pain
crises and NSTEMI in ___ presents with L-sided chest pain
and hand pain and found to have NSTEMI.
# Chest Pain/NSTEMI: Patient presenting with chest pain. EKG
without ST segment changes. Trop 0.01 -> 0.62-> 0.74->0.5. CTA
negative for PE. TTE mildly depressed (LVEF= 45 %) with mild
global hypokinesis most prominent in the mid to distal
inferior/infero-lateral walls. Concerning for NSTEMI with the
focal hypokinesis but unclear if coronary or microvascular
event. He was medically treated with heparin infusion for 48
hours and continued on his home aspirin as well as atorvastatin
80mg daily. Patient declined to undergo LHC during this
hospitalization and preferred to be followed as outpatient by
his cardiology clinic. He was discharged on aspirin and
atorvastatin.
# Sickle Cell Disease/Pain Crisis: Patient's pain crises usually
manifest as back and knee pain. Current pain appears to be
different. Neuro exam unremarkable for weakness, making CVA less
likely. No obvious trigger, H/H stable 10.3/___.6, LDH 848, TBili
4.0. He was given IV fluids, supplemental O2 and dilaudid PCA
for pain control. He was continued on his home hydroxyurea and
deferasirox. His pain resolved by day of discharge.
CHRONIC ISSUES:
#Sinus Bradycardia: Likely from chronic narcotic use. NSR with
HR ___ on admission. Improved with tapering of narcotics.
TRANSITIONAL ISSUES:
[]CODE STATUS: Full
[]Patient has PCP, ___, and Hematology followup
[]Will need continued discussion of need for left heart
catheterization
[]Patient's home Morphine (MS ___ and Diluadid were resumed
at discharge
[]Please follow up final TTE read from ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Exjade (deferasirox) 250 mg oral BID
6. FoLIC Acid 1 mg PO DAILY
7. Hydroxyurea 1000 mg PO DAILY
8. Lactulose 15 mL PO Q12H:PRN constipation
9. Morphine SR (MS ___ 30 mg PO QAM
10. Morphine SR (MS ___ 15 mg PO QHS
11. Senna 8.6 mg PO BID:PRN constipation
12. Vitamin D 1000 UNIT PO DAILY
13. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain
14. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
3. Atorvastatin 40 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Exjade (deferasirox) 250 mg oral BID
6. FoLIC Acid 1 mg PO DAILY
7. Hydroxyurea 1000 mg PO DAILY
8. Lactulose 15 mL PO Q12H:PRN constipation
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. Vitamin D 1000 UNIT PO DAILY
12. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain
13. Morphine SR (MS ___ 30 mg PO QAM
14. Morphine SR (MS ___ 15 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Non-ST Elevation Myocardial Infarction (NSTEMI)
Sickle Cell Pain Crisis
Secondary:
Sinus Bradycardia
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
the ___. As you know, you were
admitted with chest and left arm pain. We did tests which showed
some heart injury and possibly a small heart attack likely from
not enough oxygen due to your sickle cell disease. We treated
you with oxygen, fluids, and pain medications. We also have you
aspirin, cholesterol medications, and a blood thinner called
heparin. We did an ultrasound which showed decreased pumping
function and some areas of heart muscle not moving well. We
repeated the heart ultrasound which showed the decreased
function had not improved.
Please take your medications as instructed. Please followup with
your primary care doctor and cardiologist regarding a possible
left heart catheterization to see if there is a blockage in one
of your coronary arteries. Please also follow up with your
hematologist. If you develop any chest pain, back pain,
shortness of breath, palpitations, or lightheartedness, please
seek medical attention urgently.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19900981-DS-20 | 19,900,981 | 25,012,902 | DS | 20 | 2169-09-15 00:00:00 | 2169-09-18 09:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / bacitracin
Attending: ___.
Chief Complaint:
low back pain x 24 hours
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with hx of sickle cell disease complicated by NSTEMI,
recurrent sick cell crises, iron overload, priapism presenting
with low back and bilateral knee pain x24 hours.
Pt reports being rear ended while driving at 5 pm on ___. He
noted onset of low back pain at 9:30 pm after MVA. He describes
the pain as tightness, then evolved into sharp pain. He took his
home pain medication through the night without significant
relief. At baseline he takes MS contin 30 mg BID, and dilaudid 4
mg PO eight times daily. He increased the dose to dilaudid x3
tabs without significant relief. He tried an electric heat pad,
hot shower, all without relief. At 1:45 am he took another
dilaudid tablet without relief. Pain reached a maximum of ___,
sharp in quality. Pain exacerbated by movement. He endorses
bilateral knee pain, which started at 3 am on day of
presentation, sharp, not relieved by dilaudid, worse with
movement, although low back pain is the most bothersome pain.
Denies cough, chest pain, SOB, fevers, chills. Denies abdominal
pain, diarrhea, constipation, weakness in his legs,
parasthesias. He notes that his low back and knees is typical
location of pain for his sick cell crises.
With respect to his sickle cell disease, he is followed by ___
hematology, although his appointments are intermittent. His
transfusion threshold is Hb<6.0.
In the ___ ED:
VS 98.3, 81->57, 136/83->96/57 (stable x3 checks), 90% RA -> 98%
RA
Labs notable for WBC 12.9, Hb 5.4, plt 213, Na 135, Cr 0.6,
TnT<0.01
LDH 1343, retic pending
INR 1.2
CXR without definite infiltrate
Received:
NS 500 cc x1
Dilaudid 1 mg IV x3
Ketorolac 15 mg IV x1
Diphenhydramine 25 mg IV x1
On arrival to the floor, he endorses ___ pain despite dilaudid
2 mg IV. He denies chest pain, SOB, abdominal pain, cough.
ROS: all else negative
Past Medical History:
Per OMR, confirmed with pt and from chart review:
-Sickle cell disease c/b priapism - followed at ___ with
irregular visits
-s/p NSTEMI ___
-Iron overload, on deferasirox.
-s/p several episodes of pneumonia. In ___ this led to ICU
stay; no history of intubations.
-Hx of childhood asthma
-Vitamin D deficiency.
Social History:
___
Family History:
Brother died at age ___ years from complications of bone marrow
transplant. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death. Father with sickle
cell ?trait.
Physical Exam:
ADMISSION EXAM:
VS 98.2 PO 115 / 64 57 16 95 2L NC
Gen: Thin male standing up in his room to get his phone charger
from his bag, NAD, alert, interactive
HEENT: PERRL, EOMI, clear oropharynx, anicteric sclera
Neck: Supple, bilateral submandibular lymph nodes <1 cm in
diameter, nontender, smooth, mobile; no supraclavicular
adenopathy
CV: RRR, ___ systolic murmur loudest at LUSB, no rubs or gallops
Lungs: CTAB, no wheeze, rales, or rhonchi
Abd: soft, nontender, nondistended, normoactive bowel sounds, no
rebound or guarding, no hepatomegaly
GU: No foley
Back: TTP over lumbar spine, no step off or point tenderness
Ext: WWP, no clubbing, cyanosis or edema. TTP over bilateral
knees without effusion, erythema, or warm. Multiple well healed
ulcers over distal LEs, most notably at bilateral malleoli,
lateral>medial, with areas of hypopigmentation at site of healed
ulcers. Ulcer at posterior R ankle with scab in place, no
surrounding erythema or active drainage. 2+ DPs bilaterally
Neuro: strength ___ in ___ bilaterally, sensation intact to light
touch bilaterally, otherwise grossly intact
DISCHARGE EXAM:
Vital Signs: 98.2PO 107 / 69 51 16 96 1L
GEN: Alert, NAD
HEENT: NC/AT
CV: RRR, ___ systolic murmur throughout
PULM: CTA B
GI: S/NT/ND, BS present
BACK: TTP over the lumbar spine and paraspinal regions
EXT: no tenderness/edema/erythema noted on bilateral knee exam,
no ___ edema, no calf tenderness
NEURO: ___ strength in the bilateral ___
Pertinent Results:
Admission Labs:
___ 02:54PM BLOOD WBC-12.9* RBC-1.68* Hgb-5.4* Hct-15.6*
MCV-93 MCH-32.1* MCHC-34.6 RDW-29.0* RDWSD-84.2* Plt ___
___ 02:54PM BLOOD Neuts-57 Bands-0 ___ Monos-1*
Eos-13* Baso-0 ___ Myelos-0 NRBC-7* AbsNeut-7.35*
AbsLymp-3.74* AbsMono-0.13* AbsEos-1.68* AbsBaso-0.00*
___ 02:54PM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-2+
Macrocy-OCCASIONAL Microcy-NORMAL Polychr-2+ Ovalocy-2+
Sickle-3+ Burr-OCCASIONAL Stipple-1+ Tear Dr-1+ Fragmen-1+
Ellipto-2+
___ 02:54PM BLOOD Ret Man-24.0* Abs Ret-0.40*
___ 02:54PM BLOOD Glucose-113* UreaN-9 Creat-0.6 Na-135
K-4.5 Cl-105 HCO3-24 AnGap-11
___ 05:31PM BLOOD ALT-29 AST-112* AlkPhos-71 TotBili-4.0*
DirBili-0.5* IndBili-3.5
___ 05:31PM BLOOD cTropnT-<0.01
Discharge Labs:
___ 04:45AM BLOOD WBC-11.4* RBC-2.22*# Hgb-6.8*# Hct-19.2*
MCV-87 MCH-30.6 MCHC-35.4 RDW-28.1* RDWSD-78.4* Plt ___
___ 04:45AM BLOOD Ret Man-15.8* Abs Ret-0.35*
___ 04:45AM BLOOD Glucose-90 UreaN-9 Creat-0.5 Na-138 K-4.4
Cl-104 HCO3-27 AnGap-11
___ 04:45AM BLOOD ALT-29 AST-100* LD(LDH)-1008* AlkPhos-71
TotBili-3.9*
___ 04:45AM BLOOD Calcium-8.7 Phos-5.0* Mg-2.2
___ 04:45AM BLOOD Hapto-<10*
___ 06:03PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:03PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 08:22PM URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
___ 08:22PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:22PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.5 Leuks-NEG
UCx x 2 - No Growth
BCx x 2 - NGTD, final pending
Brief Hospital Course:
___ with hx of sickle cell disease complicated by NSTEMI,
recurrent sick cell crises, iron overload, priapism presenting
with low back and bilateral knee pain x24 hours.
This was felt to likely reflect vasoocclusive crisis in setting
of known sickle cell disease. Trigger may be stress related to
MVA. No suggestion of infection or ACS on initial workup. No
evidence of acute chest syndrome. Pain could also have been
related to musculoskeletal strain in the setting of recent MVA.
Of note, on presentation, Hgb < 6 (transfusion goal is 6). He
was transfused 1 unit of pRBCs with bump in H/H. Pain largely
resolved with this treatment. He was discharged on HD2. At the
time of discharge, pain was controlled on his home pain regimen.
He was instructed to follow up closely with his PCP and
hematologist.
Of note, pt does have chronic hypoxia. Last seen by Dr. ___
___ ___, at which time she advised repeat ABG on RA with
simultaneous recording of pulse oximetry, and
carboxy/methemoglobin measurements, V/Q scan to evaluate for
chronic macro/microthrombotic disease. VQ scan done in ___ and
interpreted as low probability for PE. At risk for pulmonary
hypertension in setting of sickle cell disease. He should follow
up in pulmonary clinic.
Also, per PCP ___, "CT scan ___ and ___ with RUL
ground glass and left lingular nodule. ___, CT per my
conversation with radiology said lesions are stable. Nonsmoker
with low malignancy risk." Plan was for additional chest CT,
which may be done as outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Bisacodyl 5 mg PO DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. FoLIC Acid 1 mg PO DAILY
6. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain
7. Morphine SR (MS ___ 30 mg PO BID
8. Senna 8.6 mg PO BID:PRN constipation
9. Vitamin D ___ UNIT PO DAILY
10. Desonide 0.05% Cream 1 Appl TP DAILY
11. Exjade (deferasirox) 250 mg oral BID
12. Lactulose 15 mL PO BID:PRN constipation
13. Omeprazole 20 mg PO DAILY
14. Hydroxyurea 500 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Bisacodyl 5 mg PO DAILY:PRN constipation
4. Desonide 0.05% Cream 1 Appl TP DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Exjade (deferasirox) 250 mg oral BID
7. FoLIC Acid 1 mg PO DAILY
8. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain
9. Hydroxyurea 500 mg PO DAILY
10. Lactulose 15 mL PO BID:PRN constipation
11. Morphine SR (MS ___ 30 mg PO BID
12. Omeprazole 20 mg PO DAILY
13. Senna 8.6 mg PO BID:PRN constipation
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Sickle cell pain crisis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital with pain in your lower back and
both of your knees. This was consistent with prior pain crises
from your sickle cell disease. The trigger for your pain crisis
was felt to likely be your recent car collision. You were given
a blood transfusion with significant improvement in your
symptoms. You are now being discharged home.
Followup Instructions:
___
|
19900981-DS-22 | 19,900,981 | 22,451,108 | DS | 22 | 2169-10-26 00:00:00 | 2169-10-26 16:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / bacitracin
Attending: ___.
Chief Complaint:
back pain, leg pain, epistaxis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with history of sickle cell disease complicated by NSTEMI,
recurrent sickle cell crises, iron overload, priapism presenting
with low back pain, leg pain, and epistaxis.
Pt with multiple admissions for back pain/leg pain in the last
few months c/w vasoocclusive crises. Was just recently
hospitalized here ___ for similar symptoms of back
pain/leg pain and recurrent epistaxis, found to have Hb: 4.9 on
admission felt to be VOC. Pt reports symptoms improved with
transfusion to Hb: 6.2. However, upon attempting to transition
to PO abx the morning after admission, pt decided to leave AMA.
Since discharge, pt has c/o ongoing back pain/leg pain and
epistaxis. At this point, epistaxis has been off and on x2
weeks. He had received Afrin in the ED with some improvement
but epistaxis has since been recurrent.
He denies fevers, chills, chest pain, worsening shortness of
breath, dysuria/hematuria, abdominal pain, n/v, or any other
acute symptoms other than stated above.
In the ED, VS: 99.2, 82, 120/70, 93% on RA
Labs revealed Hb: 4.3, WBC: 13.6, Cr: at baseline at 0.6.
CXR unremarkable and CT head (obtained for mild headache)
negative for acute bleed
___ give 1L NS, cefepime, dilaudid and admitted for management of
acute VOC.
ROS: 10-point ROS negative as noted above.
Past Medical History:
-Sickle cell disease c/b priapism - followed at ___ with
irregular visits
-s/p NSTEMI ___
-Iron overload, on deferasirox.
-s/p several episodes of pneumonia. In ___ this led to ICU
stay; no history of intubations.
-Hx of childhood asthma
-Vitamin D deficiency.
Social History:
___
Family History:
Brother died at age ___ years from complications of bone marrow
transplant. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death. Father with sickle
cell ?trait.
Physical Exam:
Admission Exam:
Vital Signs: 98.3, 55, 114/68, 97% on 2L
General: Cachetic, resting in bed in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Skin: no rashes, no lesions
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally,
Psych: normal mood and affect
Discharge Exam:
Vitals: 98.4 PO 106 / 54 69 16 93 RA
Ambulatory Sat: 94-96% RA
Pain Scale: ___ lower back
General: Patient appears much better today he is moing around
more easily, he is in good humor, making better eye contact and
smiling.
HEENT: Sclera anicteric, MMM, oropharynx clear, no epistaxis
Neck: supple, JVP low, no LAD appreciated
Lungs: Clear to auscultation bilaterally, moving air well and
symmetrically, no wheezes, rales or rhonchi appreciated
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality,
no murmurs, rubs or gallops appreciated
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds throughout, no rebound or guarding
Ext: Warm, well perfused, chronic ulcerations appear largely
stable
Neuro: CN2-12 grossly in tact, motor and sensory function
grossly
intact in bilateral UE and ___, symmetric
Pertinent Results:
ADMISSION LABS:
___ 05:55AM BLOOD WBC-13.6* RBC-1.46*# Hgb-4.3*# Hct-13.2*#
MCV-90 MCH-29.5 MCHC-32.6 RDW-25.2* RDWSD-77.9* Plt ___
___ 05:55AM BLOOD Glucose-103* UreaN-22* Creat-0.6 Na-137
K-4.0 Cl-101 HCO3-26 AnGap-14
___ 05:55AM BLOOD ALT-35 AST-99* LD(LDH)-832* AlkPhos-67
TotBili-2.7*
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-8.2 RBC-2.71* Hgb-7.9* Hct-23.4*
MCV-86 MCH-29.2 MCHC-33.8 RDW-19.9* RDWSD-61.4* Plt ___
___ 07:50AM BLOOD UreaN-19 Creat-0.6 Na-142 K-5.2* Cl-105
HCO3-30 AnGap-12
___ 07:50AM BLOOD LD(LDH)-997* TotBili-3.8*
Reports:
CXR ___:
Stable moderate cardiomegaly without evidence of pulmonary
edema.
CT head ___:
1. No intracranial hemorrhage or CT evidence of infarct. Please
note, MRI is more sensitive if clinical concern for stroke is
high.
2. Sinus disease as described.
Thoracic X-Ray ___
No radiographic evidence of interval fracture
Brief Hospital Course:
___ man with sickle cell disease complicated by multiple VOC's,
NSTEMI x2, presenting with back pain, leg pain, epistaxis, and
Hb: 4.3 1 week after AMA discharge from ___ medicine likely
___ recurrent/inadequately treated VOC.
# Sickle Cell Vasoocclusive Crisis:
Back pain and leg pain similar to prior episodes of VOC in
setting of objective findings of hemolysis with Hb of 4.3,
elevated LDH, TBili and Hapto <10. No signs of infection and Cx
negative. No evidence of acute chest syndrome without
infiltrates
on CXR or chest pain. Left AMA from ___ appx 1 week ago and
did not f/u for repeat ___ despite MD recommendations otherwise.
No signs of infection throughout admission (UA, CXR negative, pt
afebrile, resolved leukocytosis and no localizing symptoms). For
initial presenting Hb he was transfused two units pRBCs with
appropriate bump in H/H. Pain was controlled with Dilaudid PCA
which was increased to 0.18 q6min, no basal, Toradol 15mg q6H
and initially home MS contin which was then increased to 45 mg
PO Q12H given reported poor outpatient pain control at baseline.
Daily hemolysis labs revealed ongoing improvement in hemolysis
with time, oxygen, blood transfusion and hydration with
hypotonic fluids ___ NS) as maintenance. No antibiotics were
given due to lack of evidence for infectious source and no
evidence of acute chest syndrome. Folate was increased to 5mg po
daily and we discussed reinitiation of hydroxyurea. He has not
been taking Hydroxyurea for some time, though has
been on in the past. Obviously important he restart this
medication at some point though he is resistant to due to leg
ulcerations. Hematology was consulted who overall agreed with
plan but recommended against starting Hydroxyurea in house while
in acute VOC. We also discussed with patient regarding obtaining
home O2, has pulmonary hypertension already and was supposed to
follow up with Dr. ___ specialist) but never did. Home
O2 may reduce risk of recurrent VOC by reducing risk of
hypoxemia though patient adamant against home O2, however
ambulatory sats while inpatient were 94-96% on RA. With time and
conservative care his crisis resolved and pain was controlled
with higher dose of PO Morphine SR 45mg PO BID. He was
discharged with instructions to restart Hydroxyurea, presciption
provided, and follow up with Dr. ___.
# Epistaxis:
Reportedly evaluated by heme/onc in the recent past and felt to
be anterior bleed. No e/o ongoing bleed during inpatient stay.
Acute blood loss could also be contributing to VOC. Given a
script for Afrin per patients request on discharge.
# Hypoxemia:
Chronic hypoxemia thought related to pulmonary HTN. Not on home
O2, baseline sats low 90's on RA. As above, resistant to using
home O2. Supplemental O2 while in house though he remained in
94-96% range while on RA even with ambulation.
CHRONIC ISSUES:
===============
# Hx of NSTEMI:
In the setting of acute sickle crisis, unclear to me that he
needs to be on a statin since unlikely acute plaque rupture,
however he has been taking as an outpatient. Continued home
atorvastatin and aspirin
# GERD:
Continued omeprazole
Transitional Issues:
- Name of health care proxy: ___ (mother) Phone
number: ___
- ___ to restart Hydroxyurea though he is resitant to
taking this medication due to ulcerations. Provided a script and
has follow up scheduled with hematologist
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Bisacodyl 5 mg PO DAILY:PRN constipation
4. Desonide 0.05% Cream 1 Appl TP DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. FoLIC Acid 1 mg PO DAILY
7. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain
8. Morphine SR (MS ___ 30 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. Vitamin D ___ UNIT PO DAILY
12. Exjade (deferasirox) 250 mg oral BID
13. Lactulose 15 mL PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Hydroxyurea 500 mg PO DAILY
RX *hydroxyurea 500 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
3. FoLIC Acid 5 mg PO DAILY
RX *folic acid 1 mg 5 tablet(s) by mouth Daily Disp #*150 Tablet
Refills:*0
4. Morphine SR (MS ___ 45 mg PO BID
RX *morphine 15 mg 3 tablet(s) by mouth twice a day Disp #*45
Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO DAILY
7. Bisacodyl 5 mg PO DAILY:PRN constipation
8. Desonide 0.05% Cream 1 Appl TP DAILY
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Exjade (deferasirox) 250 mg oral BID
11. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain
12. Lactulose 15 mL PO BID:PRN constipation
13. Omeprazole 20 mg PO DAILY
14. Senna 8.6 mg PO BID:PRN constipation
15. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Active:
- Sickle cell crisis
- Vasoclusive crisis
Chronic:
- Prior NSTEMI secondary to acute chest syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
It was a pleasure treating you during this hospitalization. You
were admitted to ___ with back pain and significant anemia
both consistent with vaso-occlusive crisis secondary to sick
cell disease. You were treated with pain medications, oxygen and
fluids until the crisis improved. You were seen by our
hematology team and also received a couple blood transfusions.
It is vitally important that you follow up with Dr. ___
routine care and to restart Hydroxyurea per discussion with her.
Please be sure to keep your appointments as listed below.
Followup Instructions:
___
|
19900981-DS-23 | 19,900,981 | 25,565,157 | DS | 23 | 2169-11-01 00:00:00 | 2169-11-01 21:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / bacitracin / vancomycin
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman with Hgb-SS disease,
recently admitted for pneumonia, who presented with 2 days of
severe abdominal pain, fevers and lightheadedness, with
diarrhea.
Starting 2 days prior to admission, he was feeling constipated.
He took a bowel regimen, but after that, felt abdominal pain,
fevers and lightheadedness, with diarrhea. There was no blood in
the stool, but he also had nausea, vomiting and decreased PO
intake.
In the ED, initial vitals: T 100.2, pain ___, P 92, BP
132/83, R 18, SpO2 99%/RA
- Exam notable for: not documented.
- Labs were notable for: WBC 25.6, Hb 7.1, haptoglobin <10,
LDH 1030, TB 4.1 (DB 0.4), reticulocyte count 6.8, INR 1.2,
lactate 0.8
- CT Abdomen/Pelvis notable for [1.] Wall thickening of the
colon in the region of the splenic flexure, a watershed area, is
concerning for ischemic colitis. Infectious causes for colitis
may also be a possibility. [2.] Mild peribronchovascular opacity
in the left lower lobe could represent atelectasis or early
infection.
- CXR with very slight retrocardiac opacity which is
potentially atelectasis. If persistent clinical concern,
consider PA and lateral for further characterization.
- Patient was given: NS x? L, Vancomycin (1.3g out of 1.5 -
stopped for reaction, developed itchiness and burning sensation.
No visible hives or rash. No airway involvement), Zosyn 4.5 g,
Flagyl 500 mg
- Surgery was consulted: benign exam, colitis c/w sickle cell
crisis. Recommend admission to medicine, hydration, tx of
pneumonia, and clear liquids. Will follow.
- Hematology was consulted: no indication for exchange
pheresis. Pain control, IV hydration, transfuse to Hb >7,
antibiotics for colitis.
On arrival to the MICU, his abdominal pain has improved, he is
just fatigued.
Past Medical History:
- Sickle Cell disease (Hgb SS), c/b priapism - followed at ___
- History of NSTEMI, ___
- Iron overload, on deferasirox
- History of multiple pneumonias, with history of ICU stays,
though no intubations
- History of childhood asthma
- Vitamin D deficiency
Social History:
___
Family History:
Brother - died at age ___ from complications of BM transplant.
Father - sickle cell trait.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 99.1 P 74 BP 110/57 R 14 SpO2 100%/RA
GENERAL: fatigued, in no distress
HEENT: PERRL, anicteric sclera, pink conjunctiva, dry mucous
membranes
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, normal S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, normal bowel sounds, mild tenderness in
periumbilical region and LUQ, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Exam on Discharge:
VITALS: 97.7 136/71 53 18 95% RA
GEN: Thin gentleman, lying in bed, comfortable
HEENT: EOMI, sclerae anicteric, MMM, OP clear
NECK: No LAD, no JVD
CARDIAC: RRR, no M/R/G
PULM: normal effort, no accessory muscle use, LCTAB
GI: soft, NT, ND, NABS
MSK: No visible joint effusions or deformities, no knee pain to
palpation
DERM: No visible rash. No jaundice.
NEURO: AAOx3, moving all extremities with purpose
PSYCH: Somewhat of a flattened affect
EXTREMITIES: WWP, no edema
Pertinent Results:
ADMISSION LABS:
================
___ 08:48AM BLOOD WBC-25.6*# RBC-2.42* Hgb-7.1* Hct-21.3*
MCV-88 MCH-29.3 MCHC-33.3 RDW-18.1* RDWSD-57.7* Plt ___
___ 08:48AM BLOOD Neuts-79.6* Lymphs-9.3* Monos-9.6
Eos-0.0* Baso-0.2 NRBC-0.2* Im ___ AbsNeut-20.39*#
AbsLymp-2.38 AbsMono-2.46* AbsEos-0.00* AbsBaso-0.04
___ 08:48AM BLOOD ___ PTT-27.3 ___
___ 08:48AM BLOOD Ret Aut-6.8* Abs Ret-0.16*
___ 08:48AM BLOOD Glucose-111* UreaN-30* Creat-0.8 Na-136
K-4.7 Cl-97 HCO3-21* AnGap-23*
___ 08:48AM BLOOD ALT-38 AST-81* LD(LDH)-1030* AlkPhos-73
TotBili-4.1* DirBili-0.4* IndBili-3.7
___ 08:48AM BLOOD Lipase-18
___ 08:48AM BLOOD Albumin-3.7 Calcium-8.6 Phos-5.3* Mg-2.4
___ 08:48AM BLOOD Hapto-<10*
MICROBIOLOGY:
==============
___ BLOOD CX: No growth as of discharge
___ URINE CX: Negative
___ Stool studies:
___ 3:15 pm STOOL Site: STOOL CONSISTENCY: NOT
APPLICABLE
Source: Stool.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Pending):
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
___ C.diff negative
IMAGING:
========
___ CHEST X-RAY
Very slight retrocardiac opacity which is potentially
atelectasis. If
persistent clinical concern, consider PA and lateral for further
characterization.
___ CT ABDOMEN/PELVIS
1. Wall thickening of the colon in the region of the splenic
flexure, a
watershed area, is concerning for ischemic colitis. Infectious
causes for
colitis may also be a possibility.
2. Mild peribronchovascular opacity in the left lower lobe could
represent
atelectasis or early infection.
DISCHARGE LABS:
===============
___ 06:45AM BLOOD WBC-10.0 RBC-2.74* Hgb-8.0* Hct-24.3*
MCV-89 MCH-29.2 MCHC-32.9 RDW-17.4* RDWSD-55.8* Plt ___
___ 06:45AM BLOOD Glucose-87 UreaN-10 Creat-0.5 Na-141
K-3.9 Cl-107 HCO3-25 AnGap-13
___ 06:45AM BLOOD Calcium-8.7 Phos-5.2* Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ year old man with Hb SS disease who presents
with abdominal pain & diarrhea, as well as leukocytosis and
anemia, with evidence of colitis on CT abdomen/pelvis.
ACTIVE ISSUES
# Colitis: Etiology thought to be infectious vs. ischemic. No
blood in stool and guaiac negative in ED. Fevers and
leukocytosis favored infectious etiology (though possibly
ischemic vs vaso-occlusive crisis). Distribution favored
watershed infarct. Abdomen rather benign on exam. Surgery
evaluated patient in ED and recommended conservative medical
management. Patient was given aggressive IV hydration, as well
as empiric ciprofloxacin and metronidazole to cover for possible
infectious colitis. C. diff PCR was negative. Stool studies
pending on discharge, though diarrhea (initially present on
admission) resolved with antibiotic therapy. He tolerated
regular diet prior to discharge. Leukocytosis resolved. He is
discharged with plan for 7 days of antibiotic therapy through
___.
# Sickle cell disease
# Vaso-occlusive crisis
# Pain crisis: Patient presented with anemia, diffuse body pain,
and evidence of hemolysis with low haptoglobin, elevated LDH &
indirect bilirubin and reticulocytosis. There was no evidence of
cerebral or coronary involvement; as such, exchange pheresis not
performed on admission. Patient received IVF hydration, and
transfused 2uPRBC given his anemia for goal Hgb>7. Pain managed
with PO Tylenol, PO hydromorphone, and ketorolac. After transfer
from FICU to the medicine floor he had worsening bone pain and
was treated for one day on PCA. His pain quickly improved and he
was transitioned back to his home pain regimen, which he
tolerated well prior to discharge. Of note, he has not reliably
been taking hydroxyurea as an outpatient. The patient's primary
hematologist was emailed on discharge to discuss timing of
re-initiation and PCP ___.
Transitional:
- Continue cipro/flagyl through ___
- Awaiting recommendation from hematology regarding timing of
re-initiation of hydroxyurea
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Bisacodyl 5 mg PO DAILY:PRN constipation
4. Desonide 0.05% Cream 1 Appl TP DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. FoLIC Acid 5 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Senna 8.6 mg PO BID:PRN constipation
9. Exjade (deferasirox) 250 mg oral BID
10. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain
11. Lactulose 15 mL PO BID:PRN constipation
12. Vitamin D ___ UNIT PO DAILY
13. Morphine SR (MS ___ 45 mg PO BID
14. Acetaminophen 1000 mg PO TID
15. Hydroxyurea 500 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*11 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*17 Tablet Refills:*0
3. Acetaminophen 1000 mg PO TID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO DAILY
6. Bisacodyl 5 mg PO DAILY:PRN constipation
7. Desonide 0.05% Cream 1 Appl TP DAILY
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Exjade (deferasirox) 250 mg oral BID
10. FoLIC Acid 5 mg PO DAILY
11. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain
12. Hydroxyurea 500 mg PO DAILY
13. Lactulose 15 mL PO BID:PRN constipation
14. Morphine SR (MS ___ 45 mg PO BID
15. Omeprazole 20 mg PO DAILY
16. Senna 8.6 mg PO BID:PRN constipation
17. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Colitis (infectious)
Sickle cell anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with abdominal pain and an exacerbation of
your sickle cell anemia. You were found to have an infection of
your colon (colitis) and this likely caused your pain crisis.
You were initially admitted to the ICU but were ultimately
transferred to the general medical floor where you continued to
improve. You will be discharged to complete a course of
antibiotics for your colitis. You will resume your home pain
regimen.
It was a pleasure to be a part of your care!
Your ___ treatment team
Followup Instructions:
___
|
19900981-DS-26 | 19,900,981 | 24,317,150 | DS | 26 | 2171-06-03 00:00:00 | 2171-06-06 13:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / bacitracin / vancomycin
Attending: ___.
Chief Complaint:
Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with SCD (not on hydroxyurea) who presents
with extreme back pain requiring ICU admission for SVT to 160s
and Ketamine gtt and found to have acute chest syndrome during
his inpatient stay.
He reported to the ED that he began to experience lower back
pain one day prior to admission. It then spread to multiple
joints, most prominently his knees. Of note, on arrival to ___,
he only reported having had pain in back. Pain was ___. He
takes dilaudid 4mg 10x/day at home for his pain, and per review
of outpatient records, this has not been providing him with
adequate pain relief. He denies any shortness of breath, chest
pain, or fevers. He has had chronic lower extremity ulcers and
was seen by dermatology ___ who prescribed dicloxacillin 500mg
q6h x7 days for infection.
Of note, he has had inconsistent follow-up with hematology and
is not on hydroxyurea as an outpatient due to concerns regarding
side effects, and per chart review, believes his brother (who
had received a BM transplant) may have died from a hydroxyurea
complication. He is prescribed deferasirox for iron overload
from numerous transfusions. Per chart review, he has also been
having housing difficulties recently, and it appears he may be
inconsistently filling his medications.
In ED initial VS: 97.1, 88, 142/77, 24, 93% RA, had reported
runs of SVT to 170
Labs significant for: WBC 30.5, Hgb 5.9, Plt 201, Trp <0.01, Cr
0.8, LDH 1496, TB 4.8, Lactate 1.3
He received: 5mg IV dilaudid, 30mg ketorolac, 1L LR, 500mg
azithromycin, and was started on a ketamine gtt.
He was started on O2 for a pulse ox reading of 84 on room air
and admitted to the MICU with concern for acute chest syndrome.
Imaging notable for:
- CXR: No acute intrathroacic process. Stable moderate
cardiomegaly
Consults: None
VS prior to transfer: 98.2, 88, 127/71, 16, 99% 5L NC
On arrival to the MICU, he was in visible pain and unable to
provide much history. He denied any chest pain and endorsed low
and mid back pain.
Past Medical History:
- Sickle Cell disease (Hgb SS), c/b priapism - followed at ___
- History of NSTEMI, ___
- Iron overload, on deferasirox
- History of multiple pneumonias, with history of ICU stays,
though no intubations
- History of childhood asthma
- Vitamin D deficiency
Social History:
___
Family History:
Brother - died at age ___ from complications of BM transplant.
Father - sickle cell trait.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VITALS: Reviewed in metavision
GENERAL: Alert, appears in pain, answers questions with one word
answers
HEENT: Sclera anicteric
NECK: supple
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, ___ systolic murmur
at base
ABD: Soft, nt, nd
EXT: Warm, well perfused, no clubbing, cyanosis or edema.
SKIN: RLE ulcer wrapped in clean, dry bandage
NEURO: Alert
DISCHARGE PHYSICAL EXAM
=======================
VITALS: Temp: 98.7 PO BP: 152/77 HR: 63 RR: 18 O2 sat: 98% O2
delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: Alert, lying in bed, talkative.
HEENT: Sclera anicteric.
NECK: Supple, no JVD.
CHEST: No TTP to anterolateral chest wall.
CV: Regular rate and rhythm, normal S1 S2, ___ systolic murmur
at
apex, without appreciable radiation.
PULM: Decreased breath sounds at bases, no crackles noted.
ABD: Soft, non tender, non distended, normoactive bowel sounds.
EXT: Warm and well perfused; no clubbing, cyanosis or edema.
SKIN: RLE ulcer wrapped in bandage, CDI.
NEURO: Alert, oriented, no gross focal deficits.
Pertinent Results:
ADMISSION LABS:
===============
___ 01:50AM BLOOD WBC-30.5* RBC-1.82* Hgb-5.9* Hct-16.7*
MCV-92 MCH-32.4* MCHC-35.3 RDW-27.2* RDWSD-82.1* Plt ___
___ 01:50AM BLOOD Neuts-75.9* Lymphs-13.8* Monos-6.1
Eos-0.2* Baso-0.5 NRBC-7.3* Im ___ AbsNeut-23.16*
AbsLymp-4.19* AbsMono-1.86* AbsEos-0.05 AbsBaso-0.14*
___ 01:50AM BLOOD Hypochr-NORMAL Anisocy-3+* Poiklo-3+*
Macrocy-1+* Microcy-1+* Polychr-2+* Ovalocy-1+* Target-1+*
Sickle-3+* Schisto-1+* How-Jol-1+*
___ 01:50AM BLOOD Plt Smr-NORMAL Plt ___
___ 01:50AM BLOOD Ret Man-25.0* Abs Ret-0.46*
___ 01:50AM BLOOD Glucose-191* UreaN-11 Creat-0.8 Na-137
K-4.7 Cl-100 HCO3-22 AnGap-15
___ 01:50AM BLOOD ALT-51* AST-200* LD(LDH)-1496* AlkPhos-97
TotBili-4.8* DirBili-0.9* IndBili-3.9
___ 01:50AM BLOOD cTropnT-<0.01
___ 02:55PM BLOOD Calcium-8.3* Phos-4.3 Mg-2.1
___ 01:50AM BLOOD Hapto-<10*
___ 03:17AM BLOOD Lactate-1.3
DISCHARGE LABS:
==============
___ 06:15AM BLOOD WBC: 12.7* RBC: 3.38* Hgb: 9.9* Hct:
28.7*
MCV: 85 MCH: 29.3 MCHC: 34.5 RDW: 18.6* RDWSD: 56.9* Plt Ct:
503*
___ 06:15AM BLOOD Glucose: 105* UreaN: 10 Creat: 0.5 Na:
139
K: 4.3 Cl: 104 HCO3: 21* AnGap: 14
___ 06:15AM BLOOD Calcium: 8.5 Phos: 4.8* Mg: 2.1
IMAGING:
==========
___ CHEST (PORTABLE AP)
In comparison with the study ___, the there is little
change.
Continued enlargement of the cardiac silhouette with
indistinctness of
pulmonary vessels consistent with elevated pulmonary venous
pressure.
Retrocardiac opacification with obscuration of the hemidiaphragm
is consistent with substantial volume loss in the left lower
lobe and probable pleural effusion. There is probably also a
small effusion at the right base. Although no focal
consolidation is identified, given the changes described above
would be extremely difficult to exclude superimposed
aspiration/pneumonia in the appropriate clinical setting,
especially in the absence of a lateral view.
___ CTA CHEST
1. No evidence of pulmonary embolism in the main, right, left,
lobar or
segmental pulmonary arteries.
2. Small bilateral pleural effusions.
3. Opacification of the lung parenchyma in the lower lobes may
be secondary to compressive atelectasis although acute chest
syndrome cannot be excluded.
4. Global cardiomegaly, bony sclerosis, H-shaped vertebral
bodies and absence of the spleen consistent with sequela of
sickle cell disease.
MICRO:
=====
No pertinent culture data; UCx and Blood Cx negative
MRSA swab nares negative
Brief Hospital Course:
___ with SCD not on hydroxyurea due to patient preference who
presented with low and mid back pain consistent with acute pain
crisis. He was admitted to the MICU for pain control. Upon
arrival to the floor, patient developed severe right-sided chest
pain and back pain with O2 sat <90%. CT chest showed bilateral
lower lobe consolidations, and he met criteria for moderate
severity acute chest syndrome.
ACUTE ISSUES
#CHEST PAIN
#ACUTE CHEST SYNDROME, MODERATE SEVERITY
Patient complaining of new onset of sharp pleuritic pain on
___. CTA notable for focal b/l lower lobe consolidations. Given
CTA findings and clinical status (chest pain, dyspnea,
hypoxemia), patient met criteria for acute chest syndrome of the
moderate type. From ___, patient received 2g IV
ceftriaxone and 250mg PO azithromycin. From ___, patient
received 2g IV cefepime (after spiking a fever) and 250mg PO
azithromycin. He received 2U PRBCs on ___ and 2U PRBCs on ___
with marked improvement in his symptoms. He was stable on room
air with improvement in his pain to baseline on ___.
#ACUTE PAIN CRISIS, SICKLE CELL DISEASE:
On admission, he had significant back pain consistent with acute
pain crisis. His pain was managed initially with dilaudid PCA
and ketamine gtt, but he was able to wean off the ketamine while
in ICU. He was weaned off PCA dilaudid on ___. At time of
discharge, he was only requiring PO dilaudid. He also received
Tylenol and toradol during his hospital course.
#LEUKOCYTOSIS: Suspect reactive in setting of acute pain crisis.
Culture data was negative.
#ANEMIA: Patient received 4 total simple transfusions of pRBC
after Hgb fell to 4.6. Patient's Hgb 9.9 at time of discharged.
#HYPOXEMIA (RESOLVED):
The patient had O2 sats <90% and was put on 2L NC. At time of
discharge, the patient was sat 97-99% on room air.
CHRONIC ISSUES
#RLE ULCER:
Has a history of chronic ulcers. He was seen by dermatology
___ and prescribed dicloxacillin for 7 days for infection.
Outpatient culture from wound grew MSSA. Dicloxacillin was
discontinued on ___ as the patient was on treatment on
ceftriaxone and azithromycin for PNA.
#H/O NSTEMI: Years ago due to SCD. He is continuing to take his
home aspirin and atorvastatin.
#Malnutrition: He is clinically malnourished and needs to be
encouraged to keep up with his caloric and protein requirements
during his acute hospitalization.
TRANSITIONAL ISSUES:
======================
- ___ checked, no concerning prescription patterns. Provided
dilaudid refill prescription for two days of pain medications.
Patient will call primary care provider on ___ for follow up
appointment and prescription refill.
- Hematology oncology will arrange for follow up after
discharge. They will address chronic issues including
hydroxyurea and PO iron chelation.
- Patient has dermatology follow up after discharge for care of
his RLE ulceration.
- Consider outpatient liver MRI to quantify his iron overload.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. HYDROmorphone (Dilaudid) 4 mg PO 10X/DAY
4. Jadenu (deferasirox) 360 mg oral BID
Discharge Medications:
1. FoLIC Acid 5 mg PO DAILY
RX *folic acid 1 mg 5 tablet(s) by mouth daily Disp #*150 Tablet
Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. HYDROmorphone (Dilaudid) 4 mg PO 10X/DAY
RX *hydromorphone 4 mg 1 tablet(s) by mouth every three (3)
hours Disp #*20 Tablet Refills:*0
5. Jadenu (deferasirox) 360 mg oral BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
# Moderate type, acute chest syndrome
# Acute hypoxic respiratory failure
# Sickle cell disease
# Acute pain crisis
SECONDARY
=========
# RLE ulcer
# Anemia
# Leukocytosis
# Iron Overload
# Malnutrition
Discharge Condition:
Mr. ___ was alert, talkative, and at his usual state of health
upon discharge. He was able to ambulate well and had no
difficulties with his ADLs.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
You came in with severe back pain caused by your sickle cell
disease.
WHAT HAPPENED TO ME IN THE HOSPITAL?
You required care in the Intensive Care Unit and received
fluids, blood products, and folic acid.
You then developed chest pain that was worse with deep breaths
and were found to have an infection in your lungs. You received
5 days of antibiotics for treatment of the infection.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
You should follow up with the Hematology team to ensure that you
are recovering well from this hospital course.
You should follow up with the Dermatology team for management of
your right leg ulcer.
Please call your primary care doctor on ___ to ensure follow
up.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19901190-DS-18 | 19,901,190 | 22,988,121 | DS | 18 | 2147-02-23 00:00:00 | 2147-02-23 18:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
BRBPR, diarrhea, abd pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with type II diabetes, hypertension, hyperlipidema, alcohol
abuse and hypothyroidism presenting with abdominal pain, bloody
diarrhea and emesis. Her symptoms started suddenly approximately
24 hours prior to admission. She awoke from sleep with abdominal
pain and subsequently experienced large volume diarrhea followed
by BRBPR. The pain was mostly in her lower quadrants and sharp.
She experienced emesis of foodstuff after a small meal. She
continues to experience some degree of blood per rectum, but no
further large volume diarrhea. The patient was ill approximately
1.5 weeks ago with a GI illness which affected her entire
family, but from which she recovered.
In the ED intial vitals were: 99.1 96 170/93 16 99% RA.
- Labs were significant for Lactate 6.1->2.2, WBC 16.4, AST/ALT
___
- Patient was given IVFs, IV Cipro/Flagyl, Dilaudid 1mg IV x2,
Zofran, and Percocet.
- Vitals prior to transfer were: 75 135/56 20 96% RA
On the floor, the patient reports improved abdominal pain. She
still has a small amount of blood per rectum. She does not have
nausea.
Past Medical History:
-type II diabetes (last A1C ___ 9.9)
-alcohol abuse
-hypertension
-hyperlipidemia
-hypothyroidism
Social History:
___
Family History:
(Per ___ records) Family History: family history includes
Alcoholism in her brother, father, and sister; CAD/PVD in her
mother; Cancer - ___ (age of onset: ___) in her father; and
___ in her mother.
Physical Exam:
On admission:
Vitals - T: 98 BP: 120/60 HR: 70 RR: 18 02 sat: 98% RA
GENERAL: NAD, flushed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, fair dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, soft systolic murmur, no R/G
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mild tenderness in b/l lower
quadrants, no rebound/guarding, no hepatosplenomegaly
RECTAL: enlarged but nonthrombosed external hemorrhoids, normal
tone, no masses, soft, stool, guaic positive
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
On discharge:
VS: 99.5/97.1 71 141/66 16 100% RA
GEN: NAD, pleasant
HEENT: anicteric sclera, MMM, OP clear
RESP: CTAB, no w/r/r
CV: RR, S1+S2, nmrg
ABD: SNTND, normoactive BS
EXT: wwp, no c/c/e
Pertinent Results:
=======================
Labs:
=======================
___ 06:10PM BLOOD WBC-16.4* RBC-5.49* Hgb-16.8* Hct-49.0*
MCV-89 MCH-30.6 MCHC-34.3 RDW-13.0 Plt ___
___ 07:43AM BLOOD WBC-7.3 RBC-4.14* Hgb-13.2 Hct-38.1
MCV-92 MCH-31.9 MCHC-34.7 RDW-12.8 Plt ___
___ 06:10PM BLOOD Neuts-80.7* Lymphs-13.9* Monos-4.9
Eos-0.1 Baso-0.4
___ 06:10PM BLOOD ___ PTT-28.3 ___
___ 06:10PM BLOOD Glucose-321* UreaN-10 Creat-0.8 Na-133
K-5.0 Cl-92* HCO3-24 AnGap-22*
___ 07:43AM BLOOD Glucose-158* UreaN-7 Creat-0.7 Na-143
K-3.8 Cl-107 HCO3-26 AnGap-14
___ 06:10PM BLOOD ALT-67* AST-63* AlkPhos-99 TotBili-0.6
___ 07:17AM BLOOD ALT-40 AST-34 CK(CPK)-121 AlkPhos-73
TotBili-0.7
___ 07:17AM BLOOD Lipase-52
___ 07:17AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:10PM BLOOD Albumin-4.8
___ 07:17AM BLOOD Calcium-7.8* Phos-2.2* Mg-1.2*
___ 07:43AM BLOOD Calcium-7.7* Phos-2.5* Mg-2.1
___ 06:39PM BLOOD Lactate-6.1*
___ 07:19PM BLOOD Lactate-4.0*
___ 10:12PM BLOOD Lactate-2.2*
___ 10:56AM BLOOD Lactate-2.0
___ 08:33AM BLOOD Lactate-1.6
___ 09:55PM URINE Color-Straw Appear-Clear Sp ___
___ 09:55PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 09:55PM URINE RBC-7* WBC-0 Bacteri-NONE Yeast-NONE
Epi-2
___ 09:55PM URINE Mucous-RARE
=======================
Labs:
=======================
___ blood cultures x 2: no growth to date
___ 9:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
=======================
Imaging:
=======================
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 8:29 ___
IMPRESSION:
Colitis involving primarily the descending ___ and proximal
sigmoid ___, likely infectious or inflammatory in etiology.
Ischemic colitis is much less likely given the extent of
inflammation.
Brief Hospital Course:
___ with T2DM, HTN, HLD, hypothyroidism who presents with BRBPR,
emesis and abd pain - likely ischemic colitis.
.
.
Acute Issues
========
# COLITIS/BRBPR: Pt presented with rapid onset abdominal pain
and rectal bleeding; leukocytosis and elevated lactate
consistent with ischemic colitis, likely to due to reduced
perfusion in setting of recent GI illness (~1.5 weeks prior to
admission). Was given IV fluids and analgesics. Pain improved
considerably. Was initially treated with cipro/flagyl, which was
discontinued during admission. Lactate normalized and blood per
rectum resolved. Was tolerating po well prior to discharge.
- Should have colonoscopy ___ weeks after discharge.
.
# DMII: Home metformin was held on admission. Pt was treated
with insulin sliding scale. Given lactic acidosis likely from
ischemic colitis, metformin was discontinued. Prior to
discharge, she was started on glipizide 5mg BID. Should follow
up as outpt for continued DM monitoring and management.
.
.
Chronic Issues
=========
# HTN: Home lisinopril was held on admission in setting of GI
bleed and likely hypoperfusion. Restarted on discharge.
.
# HLD: Continued on simvastatin. Aspirin was held on admission
due to GI bleed. Restarted on discharge.
.
# HYPOTHYROIDISM: Continued on levothyroxine.
.
#ALCOHOL ABUSE: The patient reports 1 pint of alcohol per day.
She has no evidence chronic liver disease. Was monitored on
CIWA, but did not require treatment for alcohol withdrawal.
.
#TOBACCO USE: Patient counseled on tobacco abuse.
.
.
Transitional issues
============
-Follow up with PCP ___ 1 week for continued DM monitoring
and management
-Pt should have colonoscopy a few weeks after discharge
-Pt should stay well hydrated to help prevent recurrence of
ischemic colitis
-Code: Full
-Emergency Contact: ___ (son) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Levothyroxine Sodium 25 mcg PO DAILY
6. TraZODone 50-100 mg PO HS:PRN insomnia
7. Gabapentin 300 mg PO TID:PRN unknown
Discharge Medications:
1. Levothyroxine Sodium 25 mcg PO DAILY
2. Simvastatin 20 mg PO DAILY
3. TraZODone 50-100 mg PO HS:PRN insomnia
4. GlipiZIDE 5 mg PO BID
RX *glipizide 5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Gabapentin 300 mg PO TID:PRN unknown
7. Lisinopril 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Ischmic colitis
Secondary:
-DM
-Hypertension
-Hyperlipidemia
-Hypothyroidism
-Alcohol use
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. You were hospitalized due to
abdominal pain and rectal bleeding. Your symptoms were most
likely due to ischemic colitis, which is damage to the ___ due
to reduced blood flow. This likely was triggered by dehydration
from your recent gastrointestinal illness. You were treated with
medications to control your pain and given fluids to help
improve blood flow to your ___. Your diabetes medication was
changed from metformin to glipizide 5mg twice daily. You should
take this medication before breakfast and dinner, but do not
take it prior to a mealtime if you will skip that meal. Please
monitor your blood sugar, as low blood sugar can occur with this
medication. Please take your medications as prescribed, and
attend a follow up appointment with your primary care physician
within the next week. We also recommend a colonoscopy within the
next month after you leave the hospital. Please drink plenty of
fluid to stay well hydrated, which will help prevent recurrence
of ischemic colitis.
Pleasy stay well hydrated
You should follow up with your PCP and get ___ referral for a
colonoscopy one month after discharge.
Followup Instructions:
___
|
19901288-DS-5 | 19,901,288 | 24,808,650 | DS | 5 | 2139-01-14 00:00:00 | 2139-01-14 11:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right knee pain
Major Surgical or Invasive Procedure:
irrigation and drainage, liner exchange
History of Present Illness:
___ w/ hx of R TKA ___, ___ and L TKA ___, ___
___ w/ recent hx of fever and difficulty ambulating on RLE.
Pt was evaluated at ___ and had R knee aspirated
which produced 60 cc of pink, turbid fluid w/ WBC ___, RBC
<1000 and no crystals. He received PO Bactrim and 2 g Ancef at
OSH. He is currently under section 35 for IVDU abuse.
Past Medical History:
PMH: Hypothyroidism, HTN, partial paralysis of left side d/t
cord compression, Hep C, depression
Pshx: ACDF C5-C6, L TKA ___, Lap Chole, Hernia repair, knee
arthroscopy, Carpal tunnel release, trigger finger release.
Social History:
___
Family History:
Non-contributory
Physical Exam:
Exam on discharge:
Exam:
VS: AVSS
Gen: Breathing comfortably on RA.
MSK:
RLE:
-Dressing clean, dry, and intact
-Knee swelling improving, incision c/d/I
-Can actively range knee to full extension, ___ degrees flexion
-Fires ___
-SILT s/s/sp/dp/t nerve distributions distally
-Foot warm, well perfused
Pertinent Results:
___ 04:52AM BLOOD WBC-9.9 RBC-3.12* Hgb-9.9* Hct-31.1*
MCV-100* MCH-31.7 MCHC-31.8* RDW-13.7 RDWSD-50.0* Plt ___
___ 08:00PM BLOOD WBC-18.2*# RBC-3.99* Hgb-12.6* Hct-39.4*
MCV-99* MCH-31.6 MCHC-32.0 RDW-14.1 RDWSD-51.2* Plt ___
___ 08:00PM BLOOD Neuts-78.4* Lymphs-10.3* Monos-9.8
Eos-0.7* Baso-0.2 Im ___ AbsNeut-14.31*# AbsLymp-1.88
AbsMono-1.78* AbsEos-0.12 AbsBaso-0.04
___ 06:55AM BLOOD Glucose-144* UreaN-15 Creat-0.7 Na-140
K-4.6 Cl-103 HCO3-25 AnGap-12
___ 04:59PM BLOOD ALT-20 AST-17 AlkPhos-61 TotBili-0.2
___ 04:59PM BLOOD Albumin-3.4*
___ 06:55AM BLOOD Albumin-3.2* Calcium-8.3* Phos-2.9 Mg-2.1
Iron-37*
___ 06:55AM BLOOD calTIBC-224* TRF-172*
___ 06:20PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 06:55AM BLOOD CRP-192.5*
___ 06:20PM BLOOD HIV Ab-NEG
___ 06:20PM BLOOD HCV Ab-POS*
___ 06:20PM BLOOD HCV VL-NOT DETECT
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right septic knee and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for irrigation and drainage, liner exchange, 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.
Infectious disease was consulted for evaluation and antibiotic
recommendations. Cultures were followed and appropriate
antibiotic coverage was started. Please see discharge
instructions for their recommendations. A PICC line was placed.
The patient worked with ___ to evaluate function and safety. 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
weightbearing as tolerated in the right lower extremity, and
will be discharged on Aspirin BID 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:
Active Medication list as of ___:
Medications - Prescription
ATENOLOL - atenolol 25 mg tablet. 1 tablet(s) by mouth daily -
(Prescribed by Other Provider)
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D2] - Vitamin D2 50,000
unit
capsule. 1 capsule(s) by mouth weekly - (Prescribed by Other
Provider)
GABAPENTIN - gabapentin 800 mg tablet. 1 tablet(s) by mouth
three
times daily *** NOTE CHANGE IN TABLET STRENGTH AND INSTRUCTIONS
***
IBUPROFEN - ibuprofen 800 mg tablet. 1 tablet(s) by mouth three
times a day as needed for pain
LEVOTHYROXINE - levothyroxine 200 mcg tablet. 1 tablet(s) by
mouth daily - (Prescribed by Other Provider)
LEVOTHYROXINE - levothyroxine 25 mcg tablet. 1 tablet(s) by
mouth
daily - (Prescribed by Other Provider)
OXYCODONE - oxycodone 5 mg tablet. 1 tablet(s) by mouth Daily
VENLAFAXINE [EFFEXOR XR] - Effexor XR 75 mg capsule,extended
release. one capsule(s) by mouth daily fpr pain
Medications - OTC
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - Vitamin B-12
1,000
mcg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other
Provider)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Aspirin 81 mg PO BID Duration: 4 Weeks
3. CeFAZolin 2 g IV Q8H Duration: 6 Weeks
Length of treatment: ___
4. Docusate Sodium 100 mg PO BID
5. Nicotine Patch 21 mg TD DAILY
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
7. Rifampin 450 mg PO Q12H
Continue for 6 months after IV Cefazolin is stopped.
8. Senna 8.6 mg PO BID
9. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
10. Atenolol 25 mg PO DAILY
11. Gabapentin 800 mg PO TID
12. Levothyroxine Sodium 200 mcg PO DAILY
13. Venlafaxine XR 75 mg PO DAILY
14.Infectious Disease
-Continue Cefazolin 2g IV q8 hours for 6 weeks (___)
-Add rifampin 450mg PO BID with plan to continue for 6 months
after Cefazolin completed
-When cefazolin completed would add Levofloxacin for 6 months
-Patient should have weekly CBC w/diff, BUN/Cr for safety labs
-Would monitor patient's QT while on rifampin
Discharge Disposition:
Extended Care
Discharge Diagnosis:
right septic knee
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weightbearing as tolerated right 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 Aspirin BID daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Physical Therapy:
-weightbearing as tolerated; activity as tolerated
Treatments Frequency:
-staples to remain in place until follow up visit
Followup Instructions:
___
|
19901341-DS-14 | 19,901,341 | 23,906,609 | DS | 14 | 2169-09-05 00:00:00 | 2169-09-05 19:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Levaquin / Bactrim / Penicillins / Tetracyclines / codeine
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Dophoff placement ___
History of Present Illness:
Patient is a ___ year old chronically malnourished woman with
history of anorexia/bulimia, surreptitious laxative use,
hypothyroidism, and chronic kidney disease, who is admitted for
bilateral flank pain, dysuria and fevers.
Patient was last admitted to ___ in ___ for complications
of anorexia/Bulimia/eating disorder including ___ on CKD,
hypothyroidism and metabolic abnormalities. She was discharged
with follow up with renal and endocrinology. ___ then she has
been non compliant with her appointments. No labs in the system
to document labs in the interim. Family thinks she has not been
taking any of her meds in the interim. SHe lives in an assisted
living facility by herself.
She reports for the past 10 days, she has had flank pain, R>L,
associated with dysuria, subjective fever/chills and urinary
frequency. Denies constipation, diarrhea, melena, bright red
blood per rectum, vomiting. Denies cough, dyspnea, palpitations.
Brought in by family.
In the ED, initial VS were: 97.3 82 ___ 100% RA
ED physical exam was recorded as:
Immaciated-appearing
+CVAT on left
ED labs were notable for:
UA positive for ___, 57 WBC, mod bact
Na 130
BUN 110, Cr 3.9
Lactate:1.7
Ca: 11.2 Mg: 3.3 P: 9.5
Lip: 1832
WBC 10
Imaging showed:
Bilateral nonobstructing kidney stones and evidence of
medullary
nephrocalcinosis without hydronephrosis or obstructing ureteral
stone.
2. Pancreatic calcification involving the uncinate process may
reflect chronic
pancreatitis.
3. Osteopenia with healed sacral and lower rib fractures.
4. Atrophic body wall consistent with provided history of
anorexia
EKG showed no signs of pericarditis
Patient was given:
___ 10:21 IVF NS ___ Started
___ 10:43 IV Ondansetron 4 mg ___
___ 12:50 IVF NS 1 mL ___ Stopped (2h ___
___ 14:09 IV CeftriaXONE ___ Started
___ 14:59 IV CeftriaXONE 1 g ___ Stopped
(___)
___ 15:00 IVF NS ___ Started 150 mL/hr
___ 16:20 IV Morphine Sulfate 4 mg ___
___ 16:30 IV Ondansetron 4 mg ___
Transfer VS were: 98.7 73 150/79 14 99% RA
REVIEW OF SYSTEMS:
A ten point ROS was conducted and was negative except as above
in the HPI.
Past Medical History:
# Anorexia/bulimia - longstanding, chronic laxative abuse
# CKD stage IV
# Hypothyroidism
# Osteoporosis
# s/p CCY
Social History:
___
Family History:
Brother died of colon CA in his ___. Lynch syndrome
Physical Exam:
On Admission:
Gen: severely cachectic woman, bitemporal wasting, severe muscle
wasting, appears fatigued
Eyes: EOMI, sclerae anicteric
ENT: dry mucous membranes, OP clear
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: Fragile skin with multiple bruises diffusely. 1cm ulcer on
left shin. Neuro: AAOx3. No facial droop. No asterixis
Psych: Flat affect, psychomotor slowing
Discharge:
97.9126 / ___
Gen: Emaciated female, laying in bed in NAD
HEENT: Bitemporal wasting, EOMI, sclerae anicteric, OP clear
NECK: No LAD, no JVD
CARDIAC: RR, no M/R/G
PULM: normal effort, no accessory muscle use, CTAB
GI: cachectic, soft, not tender to palpation, no distention, BS+
MSK: No joint effusions, deformities, + severe muscle wasting
DERM: No visible rash. No jaundice. Pale. Skin lesions on b/l
shins are dressed.
NEURO: Awake and alert, oriented x3, clear speech
PSYCH: calm, cooperative
Pertinent Results:
On Admission:
___ 07:17PM ___ PO2-105 PCO2-18* PH-7.12* TOTAL
CO2-6* BASE XS--21 COMMENTS-GREEN TOP
___ 06:50PM GLUCOSE-66* UREA N-101* CREAT-3.6*
SODIUM-128* POTASSIUM-3.2* CHLORIDE-94* TOTAL CO2-5* ANION
GAP-32*
___ 12:36PM URINE HOURS-RANDOM
___ 12:36PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:36PM URINE RBC-0 WBC-57* BACTERIA-MOD YEAST-NONE
EPI-<1 TRANS EPI-1
___ 10:00AM ALT(SGPT)-22 AST(SGOT)-28 ALK PHOS-141* TOT
BILI-0.4
___ 10:00AM NEUTS-83.9* LYMPHS-9.8* MONOS-5.2 EOS-0.1*
BASOS-0.4 IM ___ AbsNeut-8.69*# AbsLymp-1.02* AbsMono-0.54
AbsEos-0.01* AbsBaso-0.04
Pertinent Interval:
___ 07:15AM BLOOD calTIBC-191* Ferritn-559* TRF-147*
___ 02:30AM BLOOD TSH-0.04*
___ 07:15AM BLOOD PTH-170*
___ 07:15AM BLOOD T4-2.7*
___ 04:51AM BLOOD WBC-10.3* RBC-2.27* Hgb-7.0* Hct-22.4*
MCV-99* MCH-30.8 MCHC-31.3* RDW-15.1 RDWSD-53.8* Plt ___
___ 06:03AM BLOOD Glucose-87 UreaN-70* Creat-1.2* Na-139
K-5.0 Cl-101 HCO3-27 ___ Blood and urine cultures negative
Imaging:
___ CT A/P
1. Bilateral nonobstructing kidney stones and evidence of
medullary
nephrocalcinosis without hydronephrosis or obstructing ureteral
stone.
2. Pancreatic calcification involving the uncinate process may
reflect chronic pancreatitis.
3. Osteopenia with healed sacral and lower rib fractures.
4. Atrophic body wall consistent with provided history of
anorexia.
___ ECHO:
he left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
tricuspid valve leaflets are mildly thickened. There is no
pericardial effusion.
CXR:
FINDINGS:
A Dobhoff tube is seen in the left stomach. The lungs appear
clear without focal consolidation. There is no pulmonary edema,
pneumothorax, or pleural effusion. The cardiomediastinal
silhouette and hilar contours appear normal. There is diffuse
regular thickening of the small bowel loops in the visualized
upper abdomen, which can be seen in hypoproteinemia. There is
paucity of soft tissues/fat, possibly due to malnutrition.
IMPRESSION:
The Dobhoff tube is seen in the left stomach.
Discharge labs:
___ 06:50AM BLOOD WBC-7.4 RBC-2.30* Hgb-7.5* Hct-24.6*
MCV-107* MCH-32.6* MCHC-30.5* RDW-18.1* RDWSD-67.7* Plt ___
___ 06:45AM BLOOD Glucose-87 UreaN-109* Creat-1.2* Na-134
K-4.9 Cl-94* HCO3-25 AnGap-20
___ 06:45AM BLOOD Calcium-9.8 Phos-6.7* Mg-3.4*
Brief Hospital Course:
Ms. ___ is a ___ year old woman with history of
anorexia/bulimia, surreptitious laxative use, hypothyroidism,
and chronic kidney disease, who is admitted for bilateral flank
pain, dysuria and fevers, admitted for management of UTI and
severe anion gap metabolic acidosis, with course notable for
severe malnutrition requiring Dobhoff placement and monitoring
in the ICU for re-feeding syndrome.
#SEVERE PROTEIN CALORIE MALNUTRITION:
Patient presented weighing 28 kg with a BMI of 10. Presentation
secondary to long standing history of anorexia/bulimia. She was
initiated on tube feeds and high risk for re-feeding syndrome.
Given the severity of her illness she was at high risk for
mortality during this admission. This was communicated to the
patient and family. Multidisciplinary team meeting was held with
psychiatry, nutrition, social work, and nursing staff. She was
admitted to the ICU for strict monitoring, electrolytes were
repleted as needed, and there were no major complications. She
was transferred to the medical floor where tube feeds were
continued. She pulled out her dobhoff tube and refused to have
it replaced. Extensive discussions were held with the patient,
her HCP and her sister. Given her long-standing refusal to
receive appropriate psychiatric treatment and persistent refusal
to have dobhoff replaced decision was made to discharge home on
hospice services. Discussed ___ form with patient, HCP and
sister. She did not want to sign a ___ form, family to
discuss with her further.
-Discharged to home hospice
-Counseled family on importance of signing ___ form
___ on CKD, stage IV-V:
CKD stage IV-V due to microvascular disease and tubular atrophy
resulting from chronic hypokalemia and other electrolyte
abnormalities. She has not had follow up in over ___ year. Current
creatinine is an underestimation of the
severity of her renal failure in light of her low muscle mass.
Acidemia resolved with bicarbonate drip and creatinine
continued to improve over the hospitalization to 0.9-1.2.
#HYPERCALCEMIA:
Patient initially presented with hypercalcemia, likely secondary
to severe dehydration. Resolved with fluids.
#ANEMIA:
Patient presented with hemoglobin of 11, then to 6.6 after IVF
repletion. Likely secondary to bone marrow suppression in the
setting of severe malnutrition. No evidence of bleed at this
time. Required 4 units of blood during her prior admission ___
year ago. Given 1 unit with good response and then held stable
between Hgb 7 to 9.
#HYPOTHYROIDISM:
Patient presents with low TSH, low T4. Concern at this time for
central hypothyroidism vs anorexia related thyroid dysfunction.
During her last admission she was evaluated by endocrinology
given similar presentation who at that time felt that she had
anorexia-related hypothyroidism. Her previous dose of exogenous
levothyroxine was actually acting to raise her metabolic rate
and worsen her malnutrition. She was seen by endocrine who
recommended increased dose Levothyroxine to ensure adequate
absorption given that she was on tube feeds. Once tube feeds
were stopped she was put back on Levothyroxine 75 mcg daily.
-Consider repeat thyroid function tests in two weeks if within
goals of care
# ACUTE TOXIC ENCEPHALOPATHY - due to malnutrition, electrolyte
abnormalities, hypothyroidism. She displayed poor insight into
her condition. For this reason, her HCP was activated who
assisted in the medical decision making. Mental status slowly
improved to baseline.
#Dispo: home with hospice services
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Ascorbic Acid ___ mg PO DAILY
3. biotin 5000 mcg oral DAILY
4. Multivitamins W/minerals 1 TAB PO DAILY
5. OLANZapine 2.5 mg PO QHS
6. Sodium Bicarbonate 1300 mg PO BID
7. Simethicone 40-80 mg PO QID Gas pain
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
9. Sertraline 50 mg PO DAILY
10. Pyridoxine 50 mg PO DAILY neuropathy
11. Pravastatin 20 mg PO QPM
12. Pancrelipase 5000 1 CAP PO TID W/MEALS
13. Levothyroxine Sodium 37.5 mcg PO DAILY
14. Sodium Chloride 1 gm PO TID
15. Polyethylene Glycol 17 g PO BID
16. Calcium Carbonate 500 mg PO QID:PRN heartburn
17. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
Discharge Medications:
1. Calcium Carbonate 500 mg PO QID:PRN heartburn
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Pancrelipase 5000 1 CAP PO TID W/MEALS
7. Sertraline 50 mg PO DAILY
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
9. Simethicone 40-80 mg PO QID Gas pain
10. Sodium Bicarbonate 1300 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1 Anorexia Nervosa
2. Severe protein calorie malnutrition
3 Chronic kidney disease
4. Hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with severe malnutrition due to anorexia. You
had to spend a few days in the ICU to become stabilized. You
were then placed on the eating disorder protocol and required a
feeding tube and tube feeds. You removed the tube and said you
did not want a tube again. You are being discharged to home
with hospice services to focus on your comfort.
Followup Instructions:
___
|
Subsets and Splits